| Since the 20 th century,the world has witnessed substantial healthcare reforms,and the poor performance of health investment has become the common problem for governments around the world.Meanwhile,the healthcare reform in China is also in the process.It had been oriented by the market in China from 1980 s to the early 21 th century,which,however,led to the potential difficulties and high expense in medical care in the later stage.While the new reform policies enforced after 2003,especially after 2009,highlight government orientation,non-profit and fairness.But there are still some principal contradictions in Chinese medical field haven't been solved,which are mainly reflected in the constant rise of medical expense,little improvement of people's health status as well as less access to medical care service for low-income residents.Therefore,further healthcare reform proves quite necessary for the social development and harmony in China,which is closely related to the rural development and the well-being of rural residents.Under the circumstances of ever-increasing number of aged population in rural areas before prosperity,the constant rise in medical expense and rapid changes of disease patterns become the severe challenge for the middle-aged and elderly residents.As a result,the constant improvement of basic medical insurance(BMI)system,effective control of healthcare expense rise and the promotion of compensation level will be beneficial to the aging society.As important parts of the healthcare system reform in China,the following perspectives are closely related to the vital interests of rural residents: How can we make a comprehensive evaluation of the BMI system for rural residents and its positive as well as negative effects;Weighing the welfare loss and gains,is the present insurance payment optimal? Is it necessary to keep raising the reimbursement rate of the medical insurance for rural residents? Does the rising medical cost caused by the insurance bring about the moral risks for the suppliers or the demanders? What is the function of the doctor,hospital and medicine in it? What are the effects of prepaid payment system reform to control the constant rise of medical cost? Have all intended targets been achieved? What are the guarantee effects of the insurance on the catastrophic medical expenditure? Are they beneficial to improve the medical service utilization for the low-income groups? The answers to the above questions not only become the focus of attention for the government,but provide valuable reference for coordinating the development of the BMI system in urban and rural areas.Given the above questions,based on the data of CHARLS and the welfare maximization theory of social insurance,the dissertation started with the investigation of moral hazard of the BMI for rural residents,then estimated the amount of behavioral distortion caused by it.Besides,the moral risks faced by the suppliers and demanders,liquidity effects and price effects were given in-depth discussion and the consumption smoothing effects of the insurance were identified according to the quasi-experimental data.Finally,the optimum reimbursement ratio is calculated with the optimal policy formula,which would provide some reference for the policy-making and medical insurance reform.Main researches covered by the dissertation are as follows:1.Research on the total amount of the moral hazard of the BMI.No pre-event moral risks were found in the BMI system for rural residents by the panel probit model;No endogeneity was found from their participation in insurance by IVprobit and Hauseman tests.With the usage of sample selection model and two-sector model,the relationship was researched between overall outpatient service insurance,overall hospitalization insurance and the medical service demand of rural residents,which were all covered by the BMI.The results showed that the outpatient probability of insured residents was 4.3% higher than the non-insured ones,and the utilization rate of hospitalization services was increased by 4.0%;When the reimbursement rate of outpatients was risen to 10%,the outpatient expenditure was increased by 7.7%.As shown in the sample,the average outpatient cost was 719 Yuan per person,which meant the cost would increase by 55.4 Yuan per person;Once the hospitalization reimbursement rate was increased by 10%,the hospitalization expenditure would increase by 3.82%.As shown in the sample,the average hospitalization expenditure was 7034 Yuan,which meant the cost would increase by 268.7 Yuan.Meanwhile,the medical insurance,medicine and hospitals were the main channels for the rise of medical expenditure.2.Evaluate the effects of prepaid payment system(PPS)and separate the moral hazard between suppliers and demanders.A natural experiment was conducted while the payment pattern of new rural cooperative medical system(NCMS)developed from experimental reform stage to the comprehensive promotion stage in 2012.The analysis of DID model showed that compared with the non-participants,PPS made the inpatient cost decrease by 65%,which means that the average inpatient cost for the participants had fallen by 1394.4 Yuan,but it is not significant to the outpatient cost control.71% of the increase in the outpatient expenditure caused by insurance was from the moral hazard of suppliers,and 29% from that of demanders;85% of the increase in the hospitalization expenditure caused by insurance was from hospitals and doctors,and 15% from rural residents.Evidently,moral risks were mainly from the suppliers of medical services.3.Evaluate the guarantee capability of BMI for catastrophic medical expenditureIt was found in the research that as to the rural residents whose 20% of average household income was spend on deductible hospitalization expense,the expense would reduce by 20.6% if the reimbursement ratio of BMI could be risen by 10%;as to those with 20% to 40%,the deductible medical expense dropped by 26.9%;but as to those with more than 40%,only 14.4% would fall.Obviously,the BMI didn't have enough guarantee capability for large medical costs,and it was mainly used to share the economic burden of hospitalization expense arisen from general diseases.Therefore,critical disease insurance is extremely necessary.4.Investigate the liquidity effects of BMIThe liquidity effects of BMI were evaluated according to three indexes,namely,risk sharing,satisfaction degree of medical services for low-income groups,and survival duration.The results indicated that insurance could reduce the hospitalization out-ofpocket expense by 33%,and the outpatient cost and inpatient expense respectively by 8.2% and 6.8%.However,insurance had no significant effect on the outpatient cost,and the outpatient and inpatient rate of low-income group.According to the single factor analysis of COX Model,insurance participation could help to reduce the mortality risk by 55%.But with more influence factors involved,insurance had no significant effect on the survival duration,which meant the health performance of insurance was limited.5.Study the consumption smoothing effects of BMI for rural residentsQuasi-experimental data was acquired on the basis of CHARLS data to analyze the effects of hospitalization reimbursement ratio of medical insurance on the consumption changes for the insured in morbid state.The results showed that once the hospitalization reimbursement ratio was increased by 10%,3.1% to 3.2% of the weekly household food consumption would be saved,and 1.38% to 1.44% of the aggregate consumption expenditure would be saved.Since the average hospitalization reimbursement ratio of the sample was 54%,the average food consumption of every hospitalization dropped by 8.4%,and the average annual gross consumption reduced by 9.5%.Without the hospitalization reimbursement policy,the food consumption would reduce by 25.6%,and the household gross consumption expenditure would reduce by 17.1% to 20.1%,which were respectively 3 times and twice more than the present level,which meant the welfare value of the insurance was high.6.High welfare value brought by the constant increase of the reimbursement ratio of BMIIn the sufficient statistic formula,the regression estimators of total moral hazard and consumption smoothing effects were used as substitution,and the protection targets were defined as the fluctuation of annual gross consumption expenditure to prevent diseases.When the risk aversion coefficient of rural residents was approximated between 4 and 5,the optimal reimbursement ratio was 67% to 83%,so that the present average hospitalization reimbursement ratio(54%)was less than it.Meanwhile,if the ratio was increased to 64%,the net gain of social welfare would be risen by 11.28 billion.If the risk aversion coefficient of rural residents was 3.5,the present reimbursement ratio was optimal.The main innovation points of the research are as follows:Firstly,the theoretical framework of the research is developed to the overall perspective.Presently,the literature on the effect evaluation of BMI policies mainly covers some aspect of the positive or negative influences of the insurance.In this research,the positive and negative influences of medical insurance system,marginal cost and income are studied with a unified theoretical framework,and the optimal insurance treatment is achieved,which is a promotion to the previous research.Secondly,a new research perspective is adopted on the new value of medical insurance.The consumption smoothing effects found in this research provide new empirical evidence for the insurance value..Thirdly,the research divides for the first time the contribution ratio of suppliers and demanders,and evaluates the effects of prepaid payment reform to control the moral hazard of suppliers.Total moral risks consisted of risks from both suppliers and demanders,and their respective contribution ratio was not clear previously,but the answer can be found in this dissertation.Besides,some empirical evidences are provided for the necessity and theoretical results of payment pattern reform,which are only explained theoretically now. |
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