持续灾难性卫生支出测度、城乡差异与医疗保险阻断效应评估

以往文献对持续灾难性卫生支出天然属性的研究匮乏,导致相对贫困治理和医疗保障政策长远靶向目标规划缺失。文章将家庭医疗支出连年增加,重复发生灾难性卫生支出的过程定义为持续灾难性卫生支出,并在此基础上构建反映持续灾难性卫生支出发生率、发生深度以及发生时间等指数综合刻画持续灾难性卫生支出程度,利用中国微观数据（CFPS）进行动态测度和城乡分解,最后实证分析基本医疗保险对城乡家庭持续灾难性卫生支出的政策效果。研究发现,家庭持续灾难性卫生支出发生具有较强黏性,持续时间越长,摆脱难度越大,且农村持续灾难性卫生支出程度高于城镇,但城乡差距随持续时间逐渐缩小;与此同时,基本医疗保险能够显著阻断持续灾难性卫生支出,但阻断效应呈现较大的城乡差异,农村基本医疗保险在当期的阻断效应更明显,而长期来看城镇基本医疗保险的阻断效应则更强。文章结论为我国相对贫困治理和医疗保险制度优化提供了实证参考。

Durative Catastrophic Health Expenditure Measurement,Urban-Rural Differences and Blocking Effect of Medical Insurance

The shortage of research on the nature of the durative catastrophic health expenditure leads to the lack of long-term targeted planning for relative poverty governance and health care policies. In this paper,the internal conflict process in which the family medical expenditure increases year after year and the catastrophic health expenditure occurs repeatedly is defined as the durative catastrophic health expenditure. Based on the Alkire and Foster (2011) multidimensional poverty measurement method and the Foster (2009) duration analysis method,this paper constructs a range of indices reflecting the incidence,depth and duration of the durative catastrophic health expenditure to comprehensively describe the degree of the durative catastrophic health expenditure. And using the data of China Family Panel Studies (CFPS) from 2010 to 2018 to empirically analyze the blocking effect of the basic medical insurance on the durative catastrophic health expenditure,and further evaluates the long-term policy effect of the basic medical insurance through the double-fixed effect model. It is found that the occurrence ofthe durative catastrophic health expenditure for families has strong stickiness, and the longer the duration,the more difficult it is to get rid of it. And in terms of the indices on the incidence,depth and duration of the durative catastrophic health expenditure, the rural families are higher than urban families,but the urban-rural gap gradually narrows over time,which shows that rural families are still the focus of medical expenditure-based poverty governance in China. Meanwhile,the incidence,depth and duration of the durative catastrophic health expenditure for the insured families are lower compared with the families that do not participate in the basic medical insurance. The basic medical insurance can significantly block the durative catastrophic health expenditure,and the current blocking effect of the new rural cooperative medical system is more significant. The basic medical insurance has a long-term blocking effect on the durative catastrophic health expenditure of urban and rural families,and the longer the family has been continuously insured, the greater the long-term blocking effect will be. The long-term blocking effect of urban basic medical insurance is higher than that of the new rural cooperative medical system. It fully highlights the economic compensation and health maintenance functions of the basic medical insurance, which can effectively block the occurrence and further deepening of the durative catastrophic health expenditure of families. This paper also discusses the feasibility of embedding catastrophic health expenditure into multidimensional relative poverty and finds that the durative catastrophic health expenditure is highly compatible with the concept of multidimensional relative poverty. Therefore,this paper accordingly proposes that the government should pay more attention to the expenditure-based poverty governance and incorporate medical expenditure-based poverty into the overall framework of relative poverty governance. We should adhere to the early prevention-oriented hygiene and health work policy,and increases investment in urban and rural health work. Moreover, it is essential to continue to improve the protection degree of the basic medical insurance, which focuses on the protection of people who have just been out of poverty and are vulnerable to return to poverty. The conclusions of this paper provide the empirical reference for the relative poverty governance and medical insurance system optimization in China.