WHO執行委員會於2005年提出了“全民覆蓋”概念，也稱作為“全民健康保險覆蓋”或“全民醫保”，即每個國家通過建立良好籌資的保障體系，保證所有公民能夠在可負擔的水平上獲得必要的衛生服務。
基本介紹
- 中文名：我國全民醫保推進下城鎮地區衛生籌資的效應分析
- 類別：效應分析
- 對象：城鎮衛生
- 國家：中國
中文摘要,外文摘要,
中文摘要
一、研究背景
WHO執行委員會於2005年提出了“全民覆蓋”概念，也稱作為“全民健康保險覆蓋”或“全民醫保”，即每個國家通過建立良好籌資的保障體系，保證所有公民能夠在可負擔的水平上獲得必要的衛生服務。2010年，WHO進一步為“全民醫保”的實現制定了操作指南，對任何一個國家來說，無論其發展水平，“全民醫保”都應是其政策制定的優先目標。“全民醫保”的實施需要解答政府、社會、個人應當怎樣籌集資金來支付所發生的衛生服務，從而保證個人能夠負擔得起所需要的服務。由此可見，“全民醫保”的基礎是建立良好的衛生籌資體系。
衛生籌資...>> 詳細
WHO執行委員會於2005年提出了“全民覆蓋”概念，也稱作為“全民健康保險覆蓋”或“全民醫保”，即每個國家通過建立良好籌資的保障體系，保證所有公民能夠在可負擔的水平上獲得必要的衛生服務。2010年，WHO進一步為“全民醫保”的實現制定了操作指南，對任何一個國家來說，無論其發展水平，“全民醫保”都應是其政策制定的優先目標。“全民醫保”的實施需要解答政府、社會、個人應當怎樣籌集資金來支付所發生的衛生服務，從而保證個人能夠負擔得起所需要的服務。由此可見，“全民醫保”的基礎是建立良好的衛生籌資體系。
衛生籌資...>> 詳細
一、研究背景
WHO執行委員會於2005年提出了“全民覆蓋”概念，也稱作為“全民健康保險覆蓋”或“全民醫保”，即每個國家通過建立良好籌資的保障體系，保證所有公民能夠在可負擔的水平上獲得必要的衛生服務。2010年，WHO進一步為“全民醫保”的實現制定了操作指南，對任何一個國家來說，無論其發展水平，“全民醫保”都應是其政策制定的優先目標。“全民醫保”的實施需要解答政府、社會、個人應當怎樣籌集資金來支付所發生的衛生服務，從而保證個人能夠負擔得起所需要的服務。由此可見，“全民醫保”的基礎是建立良好的衛生籌資體系。
衛生籌資體系通過稅收、社會醫療保險等形式籌集社會公共資源，在不同健康狀況、不同支付能力的人群中進行分攤，並利用這些籌集的資源向衛生服務提供方購買服務。衛生籌資的目標之一是使不同人群間經濟負擔趨向於公平。籌資公平性可分為水平公平和垂直公平：水平公平是指具有相同支付能力的人應支付相同的費用；垂直公平是指具有不同支付能力的人支付的衛生費用不同，支付能力高的人應該支付更多的費用。在全民醫保實施下採取合理的籌資方式，能夠有效地起到保障個人或家庭財務風險的作用，使人們在有衛生服務需求時能及時獲得服務，最終促進人群的總體健康水平，達到“全民健康”的目的。
新中國的醫療保障制度建立至今已有60餘年，回顧其歷史，從建國後的公費、勞保醫療制度、農村合作醫療制度到後來的城鎮職工/居民醫療保險制度、新型農村合作醫療制度，我國的醫保制度經歷了起起落落的幾個階段。在全民醫保的開展之前，我國醫保覆蓋面較低，看病貴、看病難問題突出，個人現金支付的比例不斷上升，成為衛生籌資的主要問題。WHO2000年的報告表明，當時我國的衛生籌資公平性在191個成員國中排在188位，衛生籌資公平性非常不理想。而在2009年的新醫改之後，我國開始了“全民醫保”的全面推進。雖然在制度建設、籌資水平、保障水平等問題上還存在諸多挑戰，但“全民醫保”的基本實現已經成為現實。
21世紀初我國衛生籌資公平性的下降引起了國內許多學者的重視，湧現了許多以衛生籌資及其公平性作為重點內容的研究，在理論上及分析評價方法上都取得了較大進展。2003年之後，隨著新農合的改革以及城鎮職工基本醫療保險的不斷推進，我國衛生籌資的公平性有了明顯改善。關於新農合的研究表明，新農合改善了各個收入層次人群的衛生服務利用，降低了農民的災難性衛生支出風險。而針對我國城鎮地區人群的衛生籌資研究主要反映的是城鎮居民醫保實施前的情況，現有研究缺乏對新形勢下，有其是新醫改實施後城鎮地區衛生籌資的評價。並且現有研究利用專門針對城鎮地區人群衛生服務利用及籌資狀況的數據較少。因此，評估新醫改啟動後“全民醫保”基本實現的前提下，我國城鎮地區衛生籌資及公平性現狀以及評價城鎮地區醫保改革帶來的影響是非常重要的。
二、研究目的
本研究以我國推進“全民醫保”過程中實行城鎮居民基本醫療保險改革的典型試點城市為樣本，結合衛生改革的籌資理論，以城鎮居民家庭為視角，通過對居民衛生服務利用以及家庭經濟狀況、生活支出的考察，評估和研究我國城鎮地區在基本實現“全民醫保”後，當前衛生籌資體系下城鎮人群衛生服務利用與衛生籌資公平性及財務風險保護情況的變化，為城鎮地區基本醫療保險制度的發展和完善提供現實參考。具體目標包括：
1．基於衛生改革的籌資理論，描述分析我國“全民醫保”制度在城鎮地區的發展、挑戰和存在的問題，以及全民醫保制度的籌資體系現狀；
2．實證分析全民醫保背景下城鎮人群的衛生服務利用及公平性現狀；
3．實證分析全民醫保背景下城鎮人群的衛生籌資及公平性現狀；
4．實證分析全民醫保背景下城鎮人群的財務風險保護現狀；
5．實證分析全民醫保背景下城鎮人群的健康水平及促進現狀；
6．針對分析結果提出改善我國現有城鎮醫保制度籌資方式的建議。
三、研究方法
(一)衛生籌資體系的效應分析框架
本研究將衛生系統強化的監測和評價框架與衛生改革發展框架相結合，同時捨去原有框架中針對供方的評價內容，來評價和分析我國全民醫保推進下衛生籌資體系的效應。利用家庭衛生服務調查的實證數據，對“全民醫保推進”——“城鎮居民衛生服務利用、籌資公平性評價”——“城鎮居民健康狀況、財務風險保護的影響”這一結果鏈進行綜合考察和評價。
(二)資料來源
1．抽樣調查
本研究根據中國各省市不同的地理位置和經濟發展狀況，選擇第一批居民醫保試點城市中的西部和東部城市各一個作為研究對象，並根據項目開展、資料獲取的可行性，在西部試點城市中選擇陝兩省寶雞市作為樣本城市，在東部試點城市中選擇浙江省杭州市作為樣本城市。採取多階段分層隨機抽樣的方法，在兩個城市中隨機選取一定數量的居民家庭，並以家庭中全體城鎮戶籍居民為調查對象(常住非戶籍居民不納入調查)，作為我國城鎮地區居民的樣本代表，分析其衛生服務利用及籌資現狀。本研究通過連續三年(2009、2010、2011)的入戶調查，對兩個樣本城市家庭成員的相關衛生服務利用及籌資數據進行連續性收集和監測。同時調查根據第一輪調查進行回訪的原則，考察同一家庭在三年內的變化情況。
2．二手資料收集
包括查閱國內外全民醫保及衛生籌資研究，回顧中央政府、寶雞市和杭州市政府關於城鎮地區醫療保險制度實施、推進等重要政策檔案，以及查找世界衛生組織網站、國家衛生部、人力資源與社會保障部、樣本市衛生局、勞動及社會保障局等主要政府部門數據統計結果。
(三)分析方法
1．文獻回顧及歸納
對收集的文獻及政策檔案等二手資料進行歸納和總結，分析我國醫保體系的發展過程及“全民醫保”實施的必然性，以及衛生籌資系統的現狀。
2．衛生服務利用及衛生籌資的公平性分析
通過比率比較、Gini係數、集中指數、衛生服務利用的標準化及水平不公平指數、 Kakwani指數等對樣本居民的衛生服務利用和衛生籌資公平性做實證分析。
3．財務風險保護分析
測算災難性衛生支出發生率，分析家庭遭遇災難性衛生支出打擊的嚴重程度等，反映現有醫保及衛生籌資系統下人群受財務風險保護的強度。
4．人群健康狀況分析
以歐洲五維健康量表(EQ-5D)進行測量，描述15歲及以上居民的健康相關生命質量，考察居民健康水平的變化。
5．統計分析工具
家庭入戶調查資料以Epidata 3.1進行錄入，並導入SPSS 18.0進行統計分析。
四、研究結果
(一)新醫改實施對我國全民醫保建設和衛生籌資系統完善起到了重要作用
在新醫改實施前，我國的衛生系統和衛生籌資上存在著個人支出負擔較重、醫療保險保障不足、資源配置和利用效率較低、地區及制度間衛生籌資不公平的問題。隨著2009年開始的新醫改實施，我國首次明確了“全民醫保”的目標，在新醫改實施下我國衛生籌資體系也發生了重要的改變，從籌資來源和籌資形式上來說，新醫改下衛生籌資的重要目標是放大政府財政籌資和社會保險籌資的功能，其目的是要降低個人現金支付的比例，符合了全民醫保衛生籌資體系建設的要求，值得稱道。
(二)我國已建立基本的全民醫保體系且覆蓋面較廣、制度建立較完善
本研究以杭州和寶雞作為東部城市中西部城市的樣本代表，調查顯示兩城市的基本醫保覆蓋面已達到95%以上，樣本城市的城鎮基本醫保的覆蓋情況非常良好，從覆蓋面上來說基本達到了全民醫保的要求，顯現了新醫改後全民醫保取得的巨大成就。從兩個城市的醫保制度運行情況、籌資方式及保障待遇上來看，目前的城鎮基本醫保制度能夠針對不同的人群設計不同的籌資及保障方式。兩個城市作為城鎮居民醫保改革試點的第一批城市，居民醫保的政策也在這幾年間不斷的調整，籌資水平和保障待遇逐步提高，表現了政府盡最大可能來減輕居民的醫療經濟負擔的決心。
(三)不同地區間、不同醫保制度間的衛生籌資及保障待遇差異明顯
我國目前不同地區的醫保採取屬地化管理，各地社會經濟發展水平的差異使不同地區間的籌資及保障待遇差距明顯。保障待遇方面杭州兩類城鎮基本保險的門診保障水平都較高，寶雞的城鎮基本醫保則主要是“保大病”，門診方面的補償待遇較低。此外，居民醫保的籌資主要由政府財政投入，籌資水平遠不如職工醫保，因而導致兩類醫保人群在保障待遇上的差距。無論從地區差異還是制度差異來說，我國目前的全民醫保還僅處於最基本的階段，不同人群的差距容易造成不公平的現象。
(四)不同地區及醫保參保人群間的門診及住院服務利用存在差異
由於杭州和寶雞在衛生籌資及醫保保障制度上的差異，使兩個城市居民的門診和住院服務利用產生了較大的區別。杭州的衛生籌資水平較高，對門診的保障力度較大，因而杭州的門診服務利用率較高。而寶雞在門診方面的籌資水平較低，保障水平也較低，制約了寶雞居民門診服務的使用。但住院率上則呈相反的情況，寶雞年住院率反而高於杭州，反映出寶雞居民由於住院保障力度相對門診高，可能發生多利用住院服務來治療原本能夠通過門診治療的疾病，導致了住院率的上升。本研究利用衛生服務標準化的方法計算了門診和住院次數的集中指數和HIwv指標，結果反映近三年來兩個樣本城市門診服務利用在不同經濟水平人群中的公平性較為良好，但住院服務利用上兩個城市都存在不公平的現象，經濟水平高的人群能更多的使用住院服務。目前的全民醫保體系和衛生籌資水平對住院服務的使用並沒有起到根本性的改善。
(五)城鎮地區醫療費用個人承擔比例仍較高且存在地區和制度間的差異
數據結果顯示了由東西部城市社會經濟水平的差異所導致的醫療費用水平上的差距，這一差距在住院費用上體現的更加明顯。從醫療費用個人承擔比例上看，杭州的門診保障待遇水平較高，個人需要承擔的自付費用比例僅在35%左右；寶雞的門診補償待遇則較低，尤其是居民醫保基本上沒有實質性的醫保報銷，基本上全部依靠個人自付來承擔。住院保障上兩個城市之間的差異較小，杭州個人承擔的比例在40%左右，寶雞個人承擔比例在45%左右。從個人承擔比例上看我國全民醫保就保障力度而言仍然處於非常基礎的水平。而比較兩類城鎮基本醫保制度，結果顯示職工醫保無論是門診還是住院其個人承擔的比例都比居民醫保要低。不同地區和醫保制度間的差距，意味著城鎮地區衛生籌資存在水平不公平現象。
(六)城鎮地區衛生籌資的公平性及累進性較差
通過各類衛生支出集中指數、各類經濟能力衡量標準的Gini係數以及Kakwani指數等指標來評價目前我國城鎮地區衛生籌資的公平性，結果顯示新醫改實施後全民醫保體系下我國目前城鎮地區的衛生籌資仍然屬於累退性。各類Kakwani指數都呈負值說明衛生籌資在低經濟水平家庭中的比重要高於其所對應的經濟能力的比重，對於低經濟水平家庭來說衛生籌資的負擔更重。通過再分配效應分析，結果表明籌資後的經濟水平分布比籌資前的不公平程度加劇，衛生籌資的累退性帶來的不公平也容易引起災難性衛生支出的發生，從而影響人群的生活水平和健康狀況。
(七)城鎮地區家庭災難性衛生支出發生率仍較高
數據結果顯示杭州的災難性衛生支出發生率在11%左右，寶雞的發生率為15%左右，這一結果表明目前我國家庭的現金衛生支出對家庭生活水平帶來的負面影響較大，雖然全民醫保的覆蓋面較廣，但通過衛生籌資並沒有給家庭的財務風險帶來較好的保障。災難性衛生支出家庭的生活水平明顯低於未發生災難性衛生支出的家庭，其衛生支出占家庭消費支出的比例平均在60%，與界定標準40%的差距較大。是否發生災難性衛生支出的集中指數顯示了災難性衛生支出的發生比較偏向於低經濟水平的家庭，低水平家庭的財務風險保護狀況較為不理想。
(八)城鎮地區人群健康狀況變化未顯示明顯的改善
利用EQ-5D量表對調查人群的健康相關生命質量進行評價，總體上EQ-5D的VAS得分和指數得分反映杭州和寶雞城鎮居民的平均健康水平尚處於良好的水平。考慮到本研究三年間採用回訪的方式進行調查，可能受回訪居民年齡增長帶來的健康水平下降的影響，EQ-5D兩類得分都顯示了三年間略有降低的情況。現有結果說明新醫改實施後的三年內，全民醫保的覆蓋並沒有給城鎮居民帶來實質性的健康狀況改善，居民主觀上並未認為自己的健康水平有所提高。需要指出的是由於政策對於健康狀況的改善效應有箕滯後性，在新醫改實施後的前三年短時期內，通過調查數據反映出的居民自我認知狀況尚不能充分反映真實的健康狀況改變，仍需要通過長期的監測來評價居民的健康狀況改善。
五、政策建議
(一)加大政府投入和提高社會保險籌資水平，降低醫療費用個人承擔比例
新醫改實施後的近3年政府已經投入8500億元用於衛生事業發展，但從城鎮地區居民的服務利用和衛生籌資變化上看，投入仍然沒有根本改變居民衛生籌資的不公平狀況。因此，政府的大力投入應當繼續保持，不僅需要保證居民的參保，還需要進一步提高居民的醫保保障待遇，進一步降低衛生籌資中個人承擔的比例。
(二)在提高衛生籌資公平性的同時注重衛生籌資的配置和使用效率
在目前衛生籌資資源有限的情況下，政府應堅定不移的支持基層衛生機構的發展，支持公共衛生服務、基本衛生服務、基本藥物的提供，同時探索供方支付方式改革、需方過度服務需求的控制等，通過與衛生籌資相關的各類配套政策的實施和管理，促進衛生籌資的效率，提高全民醫保體系的保障力度和衛生籌資的公平性。
(三)推動城鄉統籌和制度統籌，提升統籌層次，縮小區域性差異和制度性差異
不同城市間的區域差異和不同醫保制度之間的差異是造成衛生籌資水平不公平的重要原因。政府應著重對中西部城市或其他社會經濟水平較低的區域的財政投入，縮小不同區域間的保障水平差距；同時繼續提高居民醫保的保障水平，使其向職工醫保的保障待遇靠攏，尤其針對居民醫保門診的保障應逐步提高補償水平，縮小不同醫保人群的保障待遇差距。
(四)在醫保籌資中引入累進性的籌資機制
目前我國衛生籌資體系的累退性，一部分原因是醫療保障制度實施中並沒有根據個人的經濟水平採取不同的籌資比例，因此需要建立符合公平要求的醫療保障籌資機制，做到政策向低收入者和貧困人群傾斜。
(五)強化醫療救助作用，重點幫助災難性衛生支出家庭
災難性支出家庭對於衛生籌資公平性的影響非常大，降低災難性支出家庭的比例可以明顯改善家庭衛生籌資的公平性。目前我國的醫療救助制度已經發展相對較為成熟，通過對災難性衛生支出的測算，可以更好的有針對性的發揮醫療救助制度對弱勢人群的保障力度。此外，不僅要強化醫療救助的事後救助，還要建立醫療救助的事先救助，幫助面臨高額醫療費用家庭接受所需要的醫療服務。
(六)樹立全民醫保和衛生籌資公平性理念，加強監測與評估
對於全民醫保費用和服務保障維度的實現，不能只停留在關注醫保政策範圍內醫療費用報銷比例和醫療費用實際報銷比例，而是需要著眼於衛生籌資的整體，關注整個衛生籌資體系的籌資結構和籌資效應。因此需要建立對於我國衛生籌資體系的監測與分析機制，使其成為衛生系統績效評估的重要組成部分。
【關鍵字】全民醫保；衛生籌資；城鎮地區；公平性
WHO執行委員會於2005年提出了“全民覆蓋”概念，也稱作為“全民健康保險覆蓋”或“全民醫保”，即每個國家通過建立良好籌資的保障體系，保證所有公民能夠在可負擔的水平上獲得必要的衛生服務。2010年，WHO進一步為“全民醫保”的實現制定了操作指南，對任何一個國家來說，無論其發展水平，“全民醫保”都應是其政策制定的優先目標。“全民醫保”的實施需要解答政府、社會、個人應當怎樣籌集資金來支付所發生的衛生服務，從而保證個人能夠負擔得起所需要的服務。由此可見，“全民醫保”的基礎是建立良好的衛生籌資體系。
衛生籌資體系通過稅收、社會醫療保險等形式籌集社會公共資源，在不同健康狀況、不同支付能力的人群中進行分攤，並利用這些籌集的資源向衛生服務提供方購買服務。衛生籌資的目標之一是使不同人群間經濟負擔趨向於公平。籌資公平性可分為水平公平和垂直公平：水平公平是指具有相同支付能力的人應支付相同的費用；垂直公平是指具有不同支付能力的人支付的衛生費用不同，支付能力高的人應該支付更多的費用。在全民醫保實施下採取合理的籌資方式，能夠有效地起到保障個人或家庭財務風險的作用，使人們在有衛生服務需求時能及時獲得服務，最終促進人群的總體健康水平，達到“全民健康”的目的。
新中國的醫療保障制度建立至今已有60餘年，回顧其歷史，從建國後的公費、勞保醫療制度、農村合作醫療制度到後來的城鎮職工/居民醫療保險制度、新型農村合作醫療制度，我國的醫保制度經歷了起起落落的幾個階段。在全民醫保的開展之前，我國醫保覆蓋面較低，看病貴、看病難問題突出，個人現金支付的比例不斷上升，成為衛生籌資的主要問題。WHO2000年的報告表明，當時我國的衛生籌資公平性在191個成員國中排在188位，衛生籌資公平性非常不理想。而在2009年的新醫改之後，我國開始了“全民醫保”的全面推進。雖然在制度建設、籌資水平、保障水平等問題上還存在諸多挑戰，但“全民醫保”的基本實現已經成為現實。
21世紀初我國衛生籌資公平性的下降引起了國內許多學者的重視，湧現了許多以衛生籌資及其公平性作為重點內容的研究，在理論上及分析評價方法上都取得了較大進展。2003年之後，隨著新農合的改革以及城鎮職工基本醫療保險的不斷推進，我國衛生籌資的公平性有了明顯改善。關於新農合的研究表明，新農合改善了各個收入層次人群的衛生服務利用，降低了農民的災難性衛生支出風險。而針對我國城鎮地區人群的衛生籌資研究主要反映的是城鎮居民醫保實施前的情況，現有研究缺乏對新形勢下，有其是新醫改實施後城鎮地區衛生籌資的評價。並且現有研究利用專門針對城鎮地區人群衛生服務利用及籌資狀況的數據較少。因此，評估新醫改啟動後“全民醫保”基本實現的前提下，我國城鎮地區衛生籌資及公平性現狀以及評價城鎮地區醫保改革帶來的影響是非常重要的。
二、研究目的
本研究以我國推進“全民醫保”過程中實行城鎮居民基本醫療保險改革的典型試點城市為樣本，結合衛生改革的籌資理論，以城鎮居民家庭為視角，通過對居民衛生服務利用以及家庭經濟狀況、生活支出的考察，評估和研究我國城鎮地區在基本實現“全民醫保”後，當前衛生籌資體系下城鎮人群衛生服務利用與衛生籌資公平性及財務風險保護情況的變化，為城鎮地區基本醫療保險制度的發展和完善提供現實參考。具體目標包括：
1．基於衛生改革的籌資理論，描述分析我國“全民醫保”制度在城鎮地區的發展、挑戰和存在的問題，以及全民醫保制度的籌資體系現狀；
2．實證分析全民醫保背景下城鎮人群的衛生服務利用及公平性現狀；
3．實證分析全民醫保背景下城鎮人群的衛生籌資及公平性現狀；
4．實證分析全民醫保背景下城鎮人群的財務風險保護現狀；
5．實證分析全民醫保背景下城鎮人群的健康水平及促進現狀；
6．針對分析結果提出改善我國現有城鎮醫保制度籌資方式的建議。
三、研究方法
(一)衛生籌資體系的效應分析框架
本研究將衛生系統強化的監測和評價框架與衛生改革發展框架相結合，同時捨去原有框架中針對供方的評價內容，來評價和分析我國全民醫保推進下衛生籌資體系的效應。利用家庭衛生服務調查的實證數據，對“全民醫保推進”——“城鎮居民衛生服務利用、籌資公平性評價”——“城鎮居民健康狀況、財務風險保護的影響”這一結果鏈進行綜合考察和評價。
(二)資料來源
1．抽樣調查
本研究根據中國各省市不同的地理位置和經濟發展狀況，選擇第一批居民醫保試點城市中的西部和東部城市各一個作為研究對象，並根據項目開展、資料獲取的可行性，在西部試點城市中選擇陝兩省寶雞市作為樣本城市，在東部試點城市中選擇浙江省杭州市作為樣本城市。採取多階段分層隨機抽樣的方法，在兩個城市中隨機選取一定數量的居民家庭，並以家庭中全體城鎮戶籍居民為調查對象(常住非戶籍居民不納入調查)，作為我國城鎮地區居民的樣本代表，分析其衛生服務利用及籌資現狀。本研究通過連續三年(2009、2010、2011)的入戶調查，對兩個樣本城市家庭成員的相關衛生服務利用及籌資數據進行連續性收集和監測。同時調查根據第一輪調查進行回訪的原則，考察同一家庭在三年內的變化情況。
2．二手資料收集
包括查閱國內外全民醫保及衛生籌資研究，回顧中央政府、寶雞市和杭州市政府關於城鎮地區醫療保險制度實施、推進等重要政策檔案，以及查找世界衛生組織網站、國家衛生部、人力資源與社會保障部、樣本市衛生局、勞動及社會保障局等主要政府部門數據統計結果。
(三)分析方法
1．文獻回顧及歸納
對收集的文獻及政策檔案等二手資料進行歸納和總結，分析我國醫保體系的發展過程及“全民醫保”實施的必然性，以及衛生籌資系統的現狀。
2．衛生服務利用及衛生籌資的公平性分析
通過比率比較、Gini係數、集中指數、衛生服務利用的標準化及水平不公平指數、 Kakwani指數等對樣本居民的衛生服務利用和衛生籌資公平性做實證分析。
3．財務風險保護分析
測算災難性衛生支出發生率，分析家庭遭遇災難性衛生支出打擊的嚴重程度等，反映現有醫保及衛生籌資系統下人群受財務風險保護的強度。
4．人群健康狀況分析
以歐洲五維健康量表(EQ-5D)進行測量，描述15歲及以上居民的健康相關生命質量，考察居民健康水平的變化。
5．統計分析工具
家庭入戶調查資料以Epidata 3.1進行錄入，並導入SPSS 18.0進行統計分析。
四、研究結果
(一)新醫改實施對我國全民醫保建設和衛生籌資系統完善起到了重要作用
在新醫改實施前，我國的衛生系統和衛生籌資上存在著個人支出負擔較重、醫療保險保障不足、資源配置和利用效率較低、地區及制度間衛生籌資不公平的問題。隨著2009年開始的新醫改實施，我國首次明確了“全民醫保”的目標，在新醫改實施下我國衛生籌資體系也發生了重要的改變，從籌資來源和籌資形式上來說，新醫改下衛生籌資的重要目標是放大政府財政籌資和社會保險籌資的功能，其目的是要降低個人現金支付的比例，符合了全民醫保衛生籌資體系建設的要求，值得稱道。
(二)我國已建立基本的全民醫保體系且覆蓋面較廣、制度建立較完善
本研究以杭州和寶雞作為東部城市中西部城市的樣本代表，調查顯示兩城市的基本醫保覆蓋面已達到95%以上，樣本城市的城鎮基本醫保的覆蓋情況非常良好，從覆蓋面上來說基本達到了全民醫保的要求，顯現了新醫改後全民醫保取得的巨大成就。從兩個城市的醫保制度運行情況、籌資方式及保障待遇上來看，目前的城鎮基本醫保制度能夠針對不同的人群設計不同的籌資及保障方式。兩個城市作為城鎮居民醫保改革試點的第一批城市，居民醫保的政策也在這幾年間不斷的調整，籌資水平和保障待遇逐步提高，表現了政府盡最大可能來減輕居民的醫療經濟負擔的決心。
(三)不同地區間、不同醫保制度間的衛生籌資及保障待遇差異明顯
我國目前不同地區的醫保採取屬地化管理，各地社會經濟發展水平的差異使不同地區間的籌資及保障待遇差距明顯。保障待遇方面杭州兩類城鎮基本保險的門診保障水平都較高，寶雞的城鎮基本醫保則主要是“保大病”，門診方面的補償待遇較低。此外，居民醫保的籌資主要由政府財政投入，籌資水平遠不如職工醫保，因而導致兩類醫保人群在保障待遇上的差距。無論從地區差異還是制度差異來說，我國目前的全民醫保還僅處於最基本的階段，不同人群的差距容易造成不公平的現象。
(四)不同地區及醫保參保人群間的門診及住院服務利用存在差異
由於杭州和寶雞在衛生籌資及醫保保障制度上的差異，使兩個城市居民的門診和住院服務利用產生了較大的區別。杭州的衛生籌資水平較高，對門診的保障力度較大，因而杭州的門診服務利用率較高。而寶雞在門診方面的籌資水平較低，保障水平也較低，制約了寶雞居民門診服務的使用。但住院率上則呈相反的情況，寶雞年住院率反而高於杭州，反映出寶雞居民由於住院保障力度相對門診高，可能發生多利用住院服務來治療原本能夠通過門診治療的疾病，導致了住院率的上升。本研究利用衛生服務標準化的方法計算了門診和住院次數的集中指數和HIwv指標，結果反映近三年來兩個樣本城市門診服務利用在不同經濟水平人群中的公平性較為良好，但住院服務利用上兩個城市都存在不公平的現象，經濟水平高的人群能更多的使用住院服務。目前的全民醫保體系和衛生籌資水平對住院服務的使用並沒有起到根本性的改善。
(五)城鎮地區醫療費用個人承擔比例仍較高且存在地區和制度間的差異
數據結果顯示了由東西部城市社會經濟水平的差異所導致的醫療費用水平上的差距，這一差距在住院費用上體現的更加明顯。從醫療費用個人承擔比例上看，杭州的門診保障待遇水平較高，個人需要承擔的自付費用比例僅在35%左右；寶雞的門診補償待遇則較低，尤其是居民醫保基本上沒有實質性的醫保報銷，基本上全部依靠個人自付來承擔。住院保障上兩個城市之間的差異較小，杭州個人承擔的比例在40%左右，寶雞個人承擔比例在45%左右。從個人承擔比例上看我國全民醫保就保障力度而言仍然處於非常基礎的水平。而比較兩類城鎮基本醫保制度，結果顯示職工醫保無論是門診還是住院其個人承擔的比例都比居民醫保要低。不同地區和醫保制度間的差距，意味著城鎮地區衛生籌資存在水平不公平現象。
(六)城鎮地區衛生籌資的公平性及累進性較差
通過各類衛生支出集中指數、各類經濟能力衡量標準的Gini係數以及Kakwani指數等指標來評價目前我國城鎮地區衛生籌資的公平性，結果顯示新醫改實施後全民醫保體系下我國目前城鎮地區的衛生籌資仍然屬於累退性。各類Kakwani指數都呈負值說明衛生籌資在低經濟水平家庭中的比重要高於其所對應的經濟能力的比重，對於低經濟水平家庭來說衛生籌資的負擔更重。通過再分配效應分析，結果表明籌資後的經濟水平分布比籌資前的不公平程度加劇，衛生籌資的累退性帶來的不公平也容易引起災難性衛生支出的發生，從而影響人群的生活水平和健康狀況。
(七)城鎮地區家庭災難性衛生支出發生率仍較高
數據結果顯示杭州的災難性衛生支出發生率在11%左右，寶雞的發生率為15%左右，這一結果表明目前我國家庭的現金衛生支出對家庭生活水平帶來的負面影響較大，雖然全民醫保的覆蓋面較廣，但通過衛生籌資並沒有給家庭的財務風險帶來較好的保障。災難性衛生支出家庭的生活水平明顯低於未發生災難性衛生支出的家庭，其衛生支出占家庭消費支出的比例平均在60%，與界定標準40%的差距較大。是否發生災難性衛生支出的集中指數顯示了災難性衛生支出的發生比較偏向於低經濟水平的家庭，低水平家庭的財務風險保護狀況較為不理想。
(八)城鎮地區人群健康狀況變化未顯示明顯的改善
利用EQ-5D量表對調查人群的健康相關生命質量進行評價，總體上EQ-5D的VAS得分和指數得分反映杭州和寶雞城鎮居民的平均健康水平尚處於良好的水平。考慮到本研究三年間採用回訪的方式進行調查，可能受回訪居民年齡增長帶來的健康水平下降的影響，EQ-5D兩類得分都顯示了三年間略有降低的情況。現有結果說明新醫改實施後的三年內，全民醫保的覆蓋並沒有給城鎮居民帶來實質性的健康狀況改善，居民主觀上並未認為自己的健康水平有所提高。需要指出的是由於政策對於健康狀況的改善效應有箕滯後性，在新醫改實施後的前三年短時期內，通過調查數據反映出的居民自我認知狀況尚不能充分反映真實的健康狀況改變，仍需要通過長期的監測來評價居民的健康狀況改善。
五、政策建議
(一)加大政府投入和提高社會保險籌資水平，降低醫療費用個人承擔比例
新醫改實施後的近3年政府已經投入8500億元用於衛生事業發展，但從城鎮地區居民的服務利用和衛生籌資變化上看，投入仍然沒有根本改變居民衛生籌資的不公平狀況。因此，政府的大力投入應當繼續保持，不僅需要保證居民的參保，還需要進一步提高居民的醫保保障待遇，進一步降低衛生籌資中個人承擔的比例。
(二)在提高衛生籌資公平性的同時注重衛生籌資的配置和使用效率
在目前衛生籌資資源有限的情況下，政府應堅定不移的支持基層衛生機構的發展，支持公共衛生服務、基本衛生服務、基本藥物的提供，同時探索供方支付方式改革、需方過度服務需求的控制等，通過與衛生籌資相關的各類配套政策的實施和管理，促進衛生籌資的效率，提高全民醫保體系的保障力度和衛生籌資的公平性。
(三)推動城鄉統籌和制度統籌，提升統籌層次，縮小區域性差異和制度性差異
不同城市間的區域差異和不同醫保制度之間的差異是造成衛生籌資水平不公平的重要原因。政府應著重對中西部城市或其他社會經濟水平較低的區域的財政投入，縮小不同區域間的保障水平差距；同時繼續提高居民醫保的保障水平，使其向職工醫保的保障待遇靠攏，尤其針對居民醫保門診的保障應逐步提高補償水平，縮小不同醫保人群的保障待遇差距。
(四)在醫保籌資中引入累進性的籌資機制
目前我國衛生籌資體系的累退性，一部分原因是醫療保障制度實施中並沒有根據個人的經濟水平採取不同的籌資比例，因此需要建立符合公平要求的醫療保障籌資機制，做到政策向低收入者和貧困人群傾斜。
(五)強化醫療救助作用，重點幫助災難性衛生支出家庭
災難性支出家庭對於衛生籌資公平性的影響非常大，降低災難性支出家庭的比例可以明顯改善家庭衛生籌資的公平性。目前我國的醫療救助制度已經發展相對較為成熟，通過對災難性衛生支出的測算，可以更好的有針對性的發揮醫療救助制度對弱勢人群的保障力度。此外，不僅要強化醫療救助的事後救助，還要建立醫療救助的事先救助，幫助面臨高額醫療費用家庭接受所需要的醫療服務。
(六)樹立全民醫保和衛生籌資公平性理念，加強監測與評估
對於全民醫保費用和服務保障維度的實現，不能只停留在關注醫保政策範圍內醫療費用報銷比例和醫療費用實際報銷比例，而是需要著眼於衛生籌資的整體，關注整個衛生籌資體系的籌資結構和籌資效應。因此需要建立對於我國衛生籌資體系的監測與分析機制，使其成為衛生系統績效評估的重要組成部分。
【關鍵字】全民醫保；衛生籌資；城鎮地區；公平性
外文摘要
Background
WHO Executive Committee proposed the concept of ''Universal Coverage'' in 2005, also known as ''Universal Health Insurance Coverage'' or ''Universal Health Coverage''. It refers to countries ensuring all citizens to obtain the necessary health services under an affordable level through the establishment of a good financed insurance system. In 2010, WHO further developed an operation guide for achieving universal health coverage. For any country regardless of their development ...>> 詳細
WHO Executive Committee proposed the concept of ''Universal Coverage'' in 2005, also known as ''Universal Health Insurance Coverage'' or ''Universal Health Coverage''. It refers to countries ensuring all citizens to obtain the necessary health services under an affordable level through the establishment of a good financed insurance system. In 2010, WHO further developed an operation guide for achieving universal health coverage. For any country regardless of their development ...>> 詳細
Background
WHO Executive Committee proposed the concept of ''Universal Coverage'' in 2005, also known as ''Universal Health Insurance Coverage'' or ''Universal Health Coverage''. It refers to countries ensuring all citizens to obtain the necessary health services under an affordable level through the establishment of a good financed insurance system. In 2010, WHO further developed an operation guide for achieving universal health coverage. For any country regardless of their development level, universal health coverage should be the priority objectives of its policy-making. The implementation of universal health coverage needs to answer the question that how to raise funds to pay for health services from government, society and individuals and to ensure individuals being able to afford those services. Thus, the basis of ''universal coverage'' is to establish a good health financing system.
A health financing system raises public resources through taxation, social health insurance and other forms, shares them in individuals with different health status and ability to pay, and uses these resources to purchase services from health service providers. One of the objectives of health financing is to make the economic burden between different groups of people tend to be fair. Equity in health financing can be divided into horizontal equity and vertical equity. Horizontal equity means those have same ability to pay should pay the same fees. Vertical equity means people with different ability to pay should bear different health costs. Adopting reasonable means of financing when implementing universal health coverage can effectively protect the financial risk so that people can use services timely when they have the health service needs, and ultimately promote the overall health of population and achieve the goal of ''health for all''.
The medical insurance system in China has established for more than 60 years. Reviewing its history, the system has undergone several stages from public funded medical care, labor protection medical care, the rural cooperative medical system to the urban employees / residents basic medical insurance (UEBMI / URBMI), the new rural cooperative medical care system (NCMS). Before the promotion of universal health coverage, the low health insurance coverage in China and the increasing proportion of out-of-pocket (OOP) payments become the main problems in health financing. In 2000, WHO report shows that China''s equity in health financing ranked 188 in the 191 member states, which was far from ideal. After a new healthcare reform in 2009, China began to comprehensively promote universal health coverage. Although there are still many challenges in the system construction, funding levels, protection levels and other issues, the basic achieving of universal health coverage has become a reality.
In the early 21st century, the declining of equity in health financing aroused the attention of many domestic scholars. The emergence of researches focusing on health financing and equity had made great progresses both in theory and the analysis methods. After 2003, the equity in health financing in China has been significantly improved as to the reform of the new rural cooperative medical care system and urban employees basic medical insurance. Studies on new rural cooperative medical care system showed that it improved health services utilization for people with different income levels and reduced farmers'' catastrophic health expenditure (CHE) risk. Studies on health financing in China''s urban areas reflected the situation prior to the implementation of urban residents basic medical insurance. There are few existing researches focusing on the new situation, especially after the implementation of the new healthcare reform. And less existing researches used data of health services utilization and the financing status specifically for urban areas. Therefore, it is important to assess the current situation of equity in health financing and the impact of insurance reform under the background of universal health coverage after the new healthcare reform in China''s urban areas.
Objectives
This study chose the typical pilot cities implementing the urban residents basic medical insurance reform as samples. Combined with the theory of financing in health reform, we took the perspective of urban households and investigated the utilization of health services and family economic conditions. The objective was to assess the changes in utilization of health services, equity in health financing and the protection of financial risk of urban populations in the current health financing system after the basic achieving of universal health coverage. Policy suggestions would be provided to promote the development of the basic medical insurance system in urban areas.
Specific objectives include:
1. Based on the theory of financing in the health reform, describing and analyzing the development, challenges and existing problems of universal health coverage in China, as well as the current situation of health financing system;
2. Empirical Analysis on the current situation of utilization of health services and its equity in urban areas;
3. Empirical Analysis on the current situation of health financing and its equity in urban areas;
4. Empirical Analysis on the current situation of financial risk protection in urban areas;
5. Empirical Analysis on the current situation of individuals'' health level in urban areas;
6. Providing suggestions and recommendations to improve the financing of the existing urban medical insurance system based on the analysis results.
Methods
1. The effect analysis framework of health financing system
In this study, we combined the framework of monitoring and evaluation of health system strengthening and the framework of health reform and development and discarded the evaluation indices of supplier side to evaluate and analyze the effect of health financing under the background of universal health coverage. Using the empirical data from the family health service survey, we inspected and evaluated the results chain from ''promotion of universal health coverage'', ''assessment of equity in health services utilization and health financing'', to ''assessment of impact on the health status and financial risk protection''.
2. Data Source
Household Survey
Based on the different geographical and economic development between Chinese provinces and the feasibility of data acquisition, we chose Hangzhou as the sample of eastern cities and Baoji as the sample of western cities from those first pilot cities having URBMI reform. We adopted a multi-stage stratified random sampling method to randomly select a certain number of households in the two cities and investigated all permanent residents in these families as samples of residents living in urban areas in China. In this study, household survey was organized in three consecutive years (2009, 2010, 2011). Data of health service utilizations and financing of family members was collected for continuous monitoring. The survey tried to revisit the same family in three years to control the impact of changes in populations.
Literature and policy data collection
International and domestic researches on universal health coverage and health financing were searched and collected. Important policy documents of the implementation and promotion of insurance system from central government, Baoji and Hangzhou municipal government were reviewed, as well as statistical data from the World Health Organization, the Ministry of Health, the Ministry of Human Resources and Social Security, Municipal Bureau of Health, Bureau of Labor and social Security and other government departments.
3. Analytical Methods
Literature review and summarizing
Through summarizing the collected literature, policy documents and other secondary data, the development of China''s health insurance system, the inevitability of implementation of universal health coverage as well as the current situation of the health financing system were analyzed.
Analysis on equity in health service utilizations and health financing
Ratios comparison, Gini coefficient, concentration index, standardization of utilization of health services and HIwv, Kakwani index etc. were used to empirically analyze the equity in health service utilizations and health financing of resident samples.
Analysis on financial risk protection
Catastrophic health expenditure incidence and severity of catastrophic health expenditure were estimated to reflect the strength of the financial risk protection in the population under the existing health insurance and health financing system.
Analysis on health status of sample populations
Health related quality of life of residents aged 15 and over was measured by EQ-5D scales to evaluate the changes of the health status of urban residents.
Statistical analysis tools
Household survey data was input by Epidata 3.1 and was imported into SPSS 18.0 to run statistical analysis.
Results
1. The implementation of new healthcare reform played an important role in improving the construction of universal health coverage and health financing system in China
Prior to the implementation of the new healthcare reform, there were problems of inequality such as heavy burden of OOP payment, lack of medical insurance, low efficiency of resource allocation and use, regional and inter-system inequality in health financing in China''s health systems and health financing system. After the implementation of the new healthcare reform in 2009, China established the goal of universal health coverage. China''s health financing system has also undergone a significant change in the sources of funding and financing forms. In the new healthcare reform, the important objective of health financing was to enlarge the function of government financial funding and financing of social insurance. Its purpose was to reduce the proportion of individual OOP payments. The goal of reform, in line with the requirements of the health financing system for universal health coverage, was praiseworthy.
2. China has established a basic universal health coverage system with wide coverage and good system construction
In this study, Hangzhou and Baoji were chosen as the representative samples of eastern and midwestern cities. Until 2011, the survey shows the basic health insurance coverage in the two cities has reached 95%, which refers to the wide urban basic medical insurance coverage basically reaching the requirements of universal health coverage, revealing the tremendous achievements of the new healthcare reform. From the operation status, financing forms and security benefits of insurance systems in these two cities, the current systems were designed with different financing and benefit methods for different groups of people. The policies of URBMI in these two pilot cities were adjusted constantly in the past few years to gradually increase the level of financing and security benefits. This showed government''s great determination to mitigate the medical and economic burden of the residents at the greatest extent.
3. Significant differences in health financing and security benefits were found between different regions, and different insurance systems
The medical insurance systems in different areas were managed by local government, which resulting the obvious gap of financing and security benefits between different regions caused by differences in the levels of social and economic development. Two types of urban basic insurances in Hangzhou both had higher security benefits at out-patient level, while the urban basic health insurance in Baoji was designed to mainly reimburse the in-patient services causing low compensation for out-patient services. In addition, the financing of URBMI was mainly from the investment of government budget funding and the financing level was far lower than UEBMI, which results the gap of the security benefits between two types of insurances. In terms of regional differences or inter-system differences, universal health coverage in China was carried out to be at the basic stage which can cause inequality between different groups of people.
4. There were disparities in the utilization of outpatient and inpatient services among people in different regions and with different insurances
Due to the differences in the health financing and security benefits of medical insurances between Hangzhou and Baoji, residents in these two cities had great differences in the utilization of outpatient and inpatient services. The health financing level was higher and the extent of protection in outpatient services was greater, thus a higher utilization of outpatient services was found in Hangzhou. The level of outpatient financing and protection was lower, which restricted residents to use outpatient services in Baoji. But the situation of hospitalization rate was the opposite. Year hospitalization rates in Baoji were higher than Hangzhou, reflecting that it may occur more utilization of hospital services to treat the outpatient diseases because of the relatively higher security benefit level for inpatient services than outpatient services in Baoji which resulting the increasing of hospitalization rate. We used methods of standardization of health services utilization to calculate the standardized outpatient and inpatient treatment times and analyzed the concentration index and HIwv index. The results showed that the equity in outpatient services utilization was good between populations with different economic levels in the past three years in two sampled cities, but hospital services utilization in the two cities was relatively unfair because population with higher economic levels used more hospital services. Current universal health coverage and health financing system did not make a fundamental improvement in the use of hospital services.
5. The proportion of OOP payment in medical expenses was still high in urban areas and differences between regions and insurance systems still existed
The data results showed that the gap between the levels of medical expenses caused by the differences of socio-economic development levels between eastern and western cities, which was more obvious in the cost of hospitalization. Based on the proportion of OOP payment in medical expenses, the level of security benefits for outpatient services was higher in Hangzhou and the proportion of OOP payment was only about 35%. The compensation for outpatient treatment was lower in Baoji, especially for population with URBMI who basically had no reimbursement and relied on OOP payment to pay for outpatient services. The difference between reimbursement levels for hospitalization services was small between the two cities. The proportion of OOP payment was about 40% in Hangzhou, while in Baoji the proportion was about 45%. From the international experiences, the proportion of OOP payment in inpatient treatment costs was just barely reached the standard level of 40% in China''s urban areas, which means our universal health coverage was still at a very basic level. Comparing the two urban basic medical insurance system, the results showed that people with UEBMI had lower proportion of OOP payment whether in outpatient costs or inpatient costs than those with URBMI. The gap between different regions and health insurance systems meant the inequality in health financing in urban areas.
6. The equity and progressivity in health financing were poor in urban areas
This study used concentration index of health expenditures, Gini coefficients calculated using different measurement of economic level and Kakwani index and other indicators to evaluate the equity in health financing in China''s urban areas. The results showed that the health financing system was still regressive under the universal health coverage system after the implementation of the new healthcare reform in China''s urban areas. Various types of Kakwani indices were negative showing that the proportion of health financing in families with low economic level was higher than their corresponding proportion of family economic capacity which means the burden of health financing was heavier for families with low economic level. The results of redistributive effects analysis showed that the inequality in economic level distribution after health financing was larger than the distribution before financing. Regressivity of health financing also would more easily lead to occurrence of catastrophic health expenditure, thus affecting people''s living standards and health status.
7. The incidence of household catastrophic health expenditures was still high in urban areas
The data showed that the incidence of catastrophic health expenditures was about 11% in Hangzhou while about 15% in Baoji, which means the OOP health expenditures have a great negative impact on the family life. Although the universal health coverage was widely expanded, health financing didn''t lead to better protection of family''s financial risk. The living standard of families with catastrophic health expenditure was significantly lower than those without catastrophic health expenditure. The proportion of health expenditures in household consumption expenditures was about 60% in those families with CHE, much higher than the standard of 40%. The concentration index of catastrophic health expenditure occurrence showed the occurrence of CHE in favor of the families with low economic level which means the protection of financial risk for those poor families was less ideal.
8. People''s health status was not significantly improved in urban areas
This study used the EQ-5D scale to evaluate the health-related quality of life of surveyed population. The results showed that the overall EQ-5D VAS scores and EQ-5D index scores reflecting a good situation of average health status of urban residents in Hangzhou and Baoji. Regarding the revisit in three years, the survey may be affected by the decline of health level caused by the increased residents'' age so that the two types of EQ-5D scores slightly decreased in the past three years. The existing results indicated that within three years after the implementation of the new healthcare reform, universal health coverage didn''t substantially improve health status of urban residents and residents subjectively did not think their health levels had increased. It should be noted that due to the lag of improvement effect of policies on health status, self-cognitive health status of urban residents in a short time after the implementation of new healthcare reform reflected by the survey could not fully indicate the true state of health changes, which still need to be evaluated by long-term monitoring.
Suggestions
1. Government financial investment should be increased and the level of social insurance financing should be improved to decrease the proportion of OOP payments in medical expenses
In the past three years after the implementation of the new healthcare reform, government had invested 850 billion yuan for health system development, but investment did not fundamentally improve the inequality in residents'' health financing regarding the changes in residents'' health services utilization and health financing in urban areas. Therefore, the government should continue to invest the health system to not only ensure residents getting insured, but also further improve security benefits of basic medical insurances and reduce the proportion of OOP payments in health financing.
2. The efficiency of allocation and utilization of health resources should be focused when improving the equity in health financing
With the limited health resources, the government should support the development of primary health organizations, the delivery of public health services, basic health services and essential drugs, while exploring the payment reform for supply-side and controlling excessive demand for demand-side. Government should also promote the efficiency of health financing to improve the security benefits of the current universal health coverage system and equity in health financing through the implementation and management of various types of supporting policies relative to health financing.
3. Pooling between urban and rural areas and between different insurance systems should be promoted to enhance the pooling level and reduce the regional and inter-system differences
The differences between the different cities and different health insurance systems were the important reason causing inequality in health financing. Government should input more financial investment to the midwestem cities or other areas with lower socio-economic level to narrow the gap of security benefits between different regions. Meanwhile the security benefit level of URBMI should also be improved to move closer to the level of UEBMI, especially for the reimbursement level of outpatient services.
4. Progressive financing mechanisms could be introduced to the financing of health insurances.
The regressivity of the health financing system in China was partly due to that the current medical insurance system did not finance based on the individuals'' economic level. Therefore insurance financing mechanism which meeting the equity requirements need to be established so that policies would be beneficial to poor population.
5. The role of medical assistance system should be strengthened to focus on the help for families with catastrophic health expenditure
CHE families had great impact on equity in health financing. Reducing the proportion of catastrophic expenditures families can significantly improve the equity in health financing. China''s current medical assistance system had well developed. Estimate of catastrophic health expenditure can help to strengthen the role of medical assistance system to protect vulnerable populations. Furthermore, medical assistance should not only protect families after the happening of CHE, but also to help families to receive medical treatment when they facing high medical expenses.
6. Idea of universal health coverage and equity in health financing need to be established to strengthen the monitoring and evaluation
To achieve the cost and service dimension of universal health coverage, focus could not be just remained on the proportion of reimbursement of medical expenses and should be on health financing as a whole from the financing structure to the financing effects of the health financing system. Therefore, the mechanisms for monitoring and analysis of China''s health financing system need to be established and become an important part of health system performance assessment.
Keywords: Universal Health Coverage; Health Financing; China''s Urban Areas; Equity
WHO Executive Committee proposed the concept of ''Universal Coverage'' in 2005, also known as ''Universal Health Insurance Coverage'' or ''Universal Health Coverage''. It refers to countries ensuring all citizens to obtain the necessary health services under an affordable level through the establishment of a good financed insurance system. In 2010, WHO further developed an operation guide for achieving universal health coverage. For any country regardless of their development level, universal health coverage should be the priority objectives of its policy-making. The implementation of universal health coverage needs to answer the question that how to raise funds to pay for health services from government, society and individuals and to ensure individuals being able to afford those services. Thus, the basis of ''universal coverage'' is to establish a good health financing system.
A health financing system raises public resources through taxation, social health insurance and other forms, shares them in individuals with different health status and ability to pay, and uses these resources to purchase services from health service providers. One of the objectives of health financing is to make the economic burden between different groups of people tend to be fair. Equity in health financing can be divided into horizontal equity and vertical equity. Horizontal equity means those have same ability to pay should pay the same fees. Vertical equity means people with different ability to pay should bear different health costs. Adopting reasonable means of financing when implementing universal health coverage can effectively protect the financial risk so that people can use services timely when they have the health service needs, and ultimately promote the overall health of population and achieve the goal of ''health for all''.
The medical insurance system in China has established for more than 60 years. Reviewing its history, the system has undergone several stages from public funded medical care, labor protection medical care, the rural cooperative medical system to the urban employees / residents basic medical insurance (UEBMI / URBMI), the new rural cooperative medical care system (NCMS). Before the promotion of universal health coverage, the low health insurance coverage in China and the increasing proportion of out-of-pocket (OOP) payments become the main problems in health financing. In 2000, WHO report shows that China''s equity in health financing ranked 188 in the 191 member states, which was far from ideal. After a new healthcare reform in 2009, China began to comprehensively promote universal health coverage. Although there are still many challenges in the system construction, funding levels, protection levels and other issues, the basic achieving of universal health coverage has become a reality.
In the early 21st century, the declining of equity in health financing aroused the attention of many domestic scholars. The emergence of researches focusing on health financing and equity had made great progresses both in theory and the analysis methods. After 2003, the equity in health financing in China has been significantly improved as to the reform of the new rural cooperative medical care system and urban employees basic medical insurance. Studies on new rural cooperative medical care system showed that it improved health services utilization for people with different income levels and reduced farmers'' catastrophic health expenditure (CHE) risk. Studies on health financing in China''s urban areas reflected the situation prior to the implementation of urban residents basic medical insurance. There are few existing researches focusing on the new situation, especially after the implementation of the new healthcare reform. And less existing researches used data of health services utilization and the financing status specifically for urban areas. Therefore, it is important to assess the current situation of equity in health financing and the impact of insurance reform under the background of universal health coverage after the new healthcare reform in China''s urban areas.
Objectives
This study chose the typical pilot cities implementing the urban residents basic medical insurance reform as samples. Combined with the theory of financing in health reform, we took the perspective of urban households and investigated the utilization of health services and family economic conditions. The objective was to assess the changes in utilization of health services, equity in health financing and the protection of financial risk of urban populations in the current health financing system after the basic achieving of universal health coverage. Policy suggestions would be provided to promote the development of the basic medical insurance system in urban areas.
Specific objectives include:
1. Based on the theory of financing in the health reform, describing and analyzing the development, challenges and existing problems of universal health coverage in China, as well as the current situation of health financing system;
2. Empirical Analysis on the current situation of utilization of health services and its equity in urban areas;
3. Empirical Analysis on the current situation of health financing and its equity in urban areas;
4. Empirical Analysis on the current situation of financial risk protection in urban areas;
5. Empirical Analysis on the current situation of individuals'' health level in urban areas;
6. Providing suggestions and recommendations to improve the financing of the existing urban medical insurance system based on the analysis results.
Methods
1. The effect analysis framework of health financing system
In this study, we combined the framework of monitoring and evaluation of health system strengthening and the framework of health reform and development and discarded the evaluation indices of supplier side to evaluate and analyze the effect of health financing under the background of universal health coverage. Using the empirical data from the family health service survey, we inspected and evaluated the results chain from ''promotion of universal health coverage'', ''assessment of equity in health services utilization and health financing'', to ''assessment of impact on the health status and financial risk protection''.
2. Data Source
Household Survey
Based on the different geographical and economic development between Chinese provinces and the feasibility of data acquisition, we chose Hangzhou as the sample of eastern cities and Baoji as the sample of western cities from those first pilot cities having URBMI reform. We adopted a multi-stage stratified random sampling method to randomly select a certain number of households in the two cities and investigated all permanent residents in these families as samples of residents living in urban areas in China. In this study, household survey was organized in three consecutive years (2009, 2010, 2011). Data of health service utilizations and financing of family members was collected for continuous monitoring. The survey tried to revisit the same family in three years to control the impact of changes in populations.
Literature and policy data collection
International and domestic researches on universal health coverage and health financing were searched and collected. Important policy documents of the implementation and promotion of insurance system from central government, Baoji and Hangzhou municipal government were reviewed, as well as statistical data from the World Health Organization, the Ministry of Health, the Ministry of Human Resources and Social Security, Municipal Bureau of Health, Bureau of Labor and social Security and other government departments.
3. Analytical Methods
Literature review and summarizing
Through summarizing the collected literature, policy documents and other secondary data, the development of China''s health insurance system, the inevitability of implementation of universal health coverage as well as the current situation of the health financing system were analyzed.
Analysis on equity in health service utilizations and health financing
Ratios comparison, Gini coefficient, concentration index, standardization of utilization of health services and HIwv, Kakwani index etc. were used to empirically analyze the equity in health service utilizations and health financing of resident samples.
Analysis on financial risk protection
Catastrophic health expenditure incidence and severity of catastrophic health expenditure were estimated to reflect the strength of the financial risk protection in the population under the existing health insurance and health financing system.
Analysis on health status of sample populations
Health related quality of life of residents aged 15 and over was measured by EQ-5D scales to evaluate the changes of the health status of urban residents.
Statistical analysis tools
Household survey data was input by Epidata 3.1 and was imported into SPSS 18.0 to run statistical analysis.
Results
1. The implementation of new healthcare reform played an important role in improving the construction of universal health coverage and health financing system in China
Prior to the implementation of the new healthcare reform, there were problems of inequality such as heavy burden of OOP payment, lack of medical insurance, low efficiency of resource allocation and use, regional and inter-system inequality in health financing in China''s health systems and health financing system. After the implementation of the new healthcare reform in 2009, China established the goal of universal health coverage. China''s health financing system has also undergone a significant change in the sources of funding and financing forms. In the new healthcare reform, the important objective of health financing was to enlarge the function of government financial funding and financing of social insurance. Its purpose was to reduce the proportion of individual OOP payments. The goal of reform, in line with the requirements of the health financing system for universal health coverage, was praiseworthy.
2. China has established a basic universal health coverage system with wide coverage and good system construction
In this study, Hangzhou and Baoji were chosen as the representative samples of eastern and midwestern cities. Until 2011, the survey shows the basic health insurance coverage in the two cities has reached 95%, which refers to the wide urban basic medical insurance coverage basically reaching the requirements of universal health coverage, revealing the tremendous achievements of the new healthcare reform. From the operation status, financing forms and security benefits of insurance systems in these two cities, the current systems were designed with different financing and benefit methods for different groups of people. The policies of URBMI in these two pilot cities were adjusted constantly in the past few years to gradually increase the level of financing and security benefits. This showed government''s great determination to mitigate the medical and economic burden of the residents at the greatest extent.
3. Significant differences in health financing and security benefits were found between different regions, and different insurance systems
The medical insurance systems in different areas were managed by local government, which resulting the obvious gap of financing and security benefits between different regions caused by differences in the levels of social and economic development. Two types of urban basic insurances in Hangzhou both had higher security benefits at out-patient level, while the urban basic health insurance in Baoji was designed to mainly reimburse the in-patient services causing low compensation for out-patient services. In addition, the financing of URBMI was mainly from the investment of government budget funding and the financing level was far lower than UEBMI, which results the gap of the security benefits between two types of insurances. In terms of regional differences or inter-system differences, universal health coverage in China was carried out to be at the basic stage which can cause inequality between different groups of people.
4. There were disparities in the utilization of outpatient and inpatient services among people in different regions and with different insurances
Due to the differences in the health financing and security benefits of medical insurances between Hangzhou and Baoji, residents in these two cities had great differences in the utilization of outpatient and inpatient services. The health financing level was higher and the extent of protection in outpatient services was greater, thus a higher utilization of outpatient services was found in Hangzhou. The level of outpatient financing and protection was lower, which restricted residents to use outpatient services in Baoji. But the situation of hospitalization rate was the opposite. Year hospitalization rates in Baoji were higher than Hangzhou, reflecting that it may occur more utilization of hospital services to treat the outpatient diseases because of the relatively higher security benefit level for inpatient services than outpatient services in Baoji which resulting the increasing of hospitalization rate. We used methods of standardization of health services utilization to calculate the standardized outpatient and inpatient treatment times and analyzed the concentration index and HIwv index. The results showed that the equity in outpatient services utilization was good between populations with different economic levels in the past three years in two sampled cities, but hospital services utilization in the two cities was relatively unfair because population with higher economic levels used more hospital services. Current universal health coverage and health financing system did not make a fundamental improvement in the use of hospital services.
5. The proportion of OOP payment in medical expenses was still high in urban areas and differences between regions and insurance systems still existed
The data results showed that the gap between the levels of medical expenses caused by the differences of socio-economic development levels between eastern and western cities, which was more obvious in the cost of hospitalization. Based on the proportion of OOP payment in medical expenses, the level of security benefits for outpatient services was higher in Hangzhou and the proportion of OOP payment was only about 35%. The compensation for outpatient treatment was lower in Baoji, especially for population with URBMI who basically had no reimbursement and relied on OOP payment to pay for outpatient services. The difference between reimbursement levels for hospitalization services was small between the two cities. The proportion of OOP payment was about 40% in Hangzhou, while in Baoji the proportion was about 45%. From the international experiences, the proportion of OOP payment in inpatient treatment costs was just barely reached the standard level of 40% in China''s urban areas, which means our universal health coverage was still at a very basic level. Comparing the two urban basic medical insurance system, the results showed that people with UEBMI had lower proportion of OOP payment whether in outpatient costs or inpatient costs than those with URBMI. The gap between different regions and health insurance systems meant the inequality in health financing in urban areas.
6. The equity and progressivity in health financing were poor in urban areas
This study used concentration index of health expenditures, Gini coefficients calculated using different measurement of economic level and Kakwani index and other indicators to evaluate the equity in health financing in China''s urban areas. The results showed that the health financing system was still regressive under the universal health coverage system after the implementation of the new healthcare reform in China''s urban areas. Various types of Kakwani indices were negative showing that the proportion of health financing in families with low economic level was higher than their corresponding proportion of family economic capacity which means the burden of health financing was heavier for families with low economic level. The results of redistributive effects analysis showed that the inequality in economic level distribution after health financing was larger than the distribution before financing. Regressivity of health financing also would more easily lead to occurrence of catastrophic health expenditure, thus affecting people''s living standards and health status.
7. The incidence of household catastrophic health expenditures was still high in urban areas
The data showed that the incidence of catastrophic health expenditures was about 11% in Hangzhou while about 15% in Baoji, which means the OOP health expenditures have a great negative impact on the family life. Although the universal health coverage was widely expanded, health financing didn''t lead to better protection of family''s financial risk. The living standard of families with catastrophic health expenditure was significantly lower than those without catastrophic health expenditure. The proportion of health expenditures in household consumption expenditures was about 60% in those families with CHE, much higher than the standard of 40%. The concentration index of catastrophic health expenditure occurrence showed the occurrence of CHE in favor of the families with low economic level which means the protection of financial risk for those poor families was less ideal.
8. People''s health status was not significantly improved in urban areas
This study used the EQ-5D scale to evaluate the health-related quality of life of surveyed population. The results showed that the overall EQ-5D VAS scores and EQ-5D index scores reflecting a good situation of average health status of urban residents in Hangzhou and Baoji. Regarding the revisit in three years, the survey may be affected by the decline of health level caused by the increased residents'' age so that the two types of EQ-5D scores slightly decreased in the past three years. The existing results indicated that within three years after the implementation of the new healthcare reform, universal health coverage didn''t substantially improve health status of urban residents and residents subjectively did not think their health levels had increased. It should be noted that due to the lag of improvement effect of policies on health status, self-cognitive health status of urban residents in a short time after the implementation of new healthcare reform reflected by the survey could not fully indicate the true state of health changes, which still need to be evaluated by long-term monitoring.
Suggestions
1. Government financial investment should be increased and the level of social insurance financing should be improved to decrease the proportion of OOP payments in medical expenses
In the past three years after the implementation of the new healthcare reform, government had invested 850 billion yuan for health system development, but investment did not fundamentally improve the inequality in residents'' health financing regarding the changes in residents'' health services utilization and health financing in urban areas. Therefore, the government should continue to invest the health system to not only ensure residents getting insured, but also further improve security benefits of basic medical insurances and reduce the proportion of OOP payments in health financing.
2. The efficiency of allocation and utilization of health resources should be focused when improving the equity in health financing
With the limited health resources, the government should support the development of primary health organizations, the delivery of public health services, basic health services and essential drugs, while exploring the payment reform for supply-side and controlling excessive demand for demand-side. Government should also promote the efficiency of health financing to improve the security benefits of the current universal health coverage system and equity in health financing through the implementation and management of various types of supporting policies relative to health financing.
3. Pooling between urban and rural areas and between different insurance systems should be promoted to enhance the pooling level and reduce the regional and inter-system differences
The differences between the different cities and different health insurance systems were the important reason causing inequality in health financing. Government should input more financial investment to the midwestem cities or other areas with lower socio-economic level to narrow the gap of security benefits between different regions. Meanwhile the security benefit level of URBMI should also be improved to move closer to the level of UEBMI, especially for the reimbursement level of outpatient services.
4. Progressive financing mechanisms could be introduced to the financing of health insurances.
The regressivity of the health financing system in China was partly due to that the current medical insurance system did not finance based on the individuals'' economic level. Therefore insurance financing mechanism which meeting the equity requirements need to be established so that policies would be beneficial to poor population.
5. The role of medical assistance system should be strengthened to focus on the help for families with catastrophic health expenditure
CHE families had great impact on equity in health financing. Reducing the proportion of catastrophic expenditures families can significantly improve the equity in health financing. China''s current medical assistance system had well developed. Estimate of catastrophic health expenditure can help to strengthen the role of medical assistance system to protect vulnerable populations. Furthermore, medical assistance should not only protect families after the happening of CHE, but also to help families to receive medical treatment when they facing high medical expenses.
6. Idea of universal health coverage and equity in health financing need to be established to strengthen the monitoring and evaluation
To achieve the cost and service dimension of universal health coverage, focus could not be just remained on the proportion of reimbursement of medical expenses and should be on health financing as a whole from the financing structure to the financing effects of the health financing system. Therefore, the mechanisms for monitoring and analysis of China''s health financing system need to be established and become an important part of health system performance assessment.
Keywords: Universal Health Coverage; Health Financing; China''s Urban Areas; Equity
