我国城乡健康与医疗不平等的动态演进以及新农合的影响效应研究：度量、分解与制度优化

Although Chinese health status has been considerably improved with sustained and rapid economic growth, official statistical data show that the inequalities in health and health care between the urban and the rural area are expanding. The impact of the NCMS on inequality reduction remains unknown. Due to the heterogeneity between the urban and the rural area, different source of sampling by years, and time effects, limitations may occur in the evaluation by using such the macro data, and the results may not accurate. In addition, How to measure the inequalities between the urban and the rural areas and decompose valid scales is currently far from final conclusion among experts. Therefore, the aim of this study is to add value on this issue by solving the following problems: First, at the macro-level, to describe the characteristics and trends of health and health care inequalities between the urban and the rural and to analyze determinants of the inequalities including constructive diversity between the urban and the rural and stock and increment of health capital; Second, at the micro-level, to construct counterfactual analysis framework and decompose scales of urban-to-rural inequalities in health and health care by using Oaxaca-Blinder and Neuman-Oaxaca method, to objectively measure severity of the inequalities and it's dynamic evolution process; Third, to evaluate the impact and the mechanism of NCMS on inequality reduction by using DID model, then to propose strategies on systematic optimization; Finally, based on the results from the empirical research and policy simulation, to make policy recommendations on how to optimize the design of the NCMS with the goal to reduce inequalities in health and health care between the urban and the rural.

随着经济的快速增长与医疗体制改革的深化，我国的总体健康水平有了显著提升，但统计数字显示的城乡不平等却在持续扩大。由于上述宏观数据无法剔除城乡异质性、样本差异和时间效应，未必能够反映真实的城乡健康与医疗不平等现状。那么，如何准确度量我国真实的城乡健康与医疗不平等？新农合在其中的影响效应如何？对以上问题的研究具有重要的现实意义和理论价值。 鉴于此，本研究试图解决以下几个问题：第一，宏观层面，描述城乡健康与医疗不平等的事实特征，从健康存量和增量差异的视角分析城乡不平等的原因；第二，微观层面，构建反事实分析框架，运用Oaxaca-Blinder和Neuman-Oaxaca方法分解健康与医疗的城乡不平等和城乡不公平，客观测度城乡不公平程度及其动态演进，了解城乡不平等的过往与现状；第三，构建效果评价的DID模型，分析新农合对城乡不公平的多阶段持续作用及其作用机制，并提出优化新农合制度的政策建议。

背景：虽然近年来我国城乡人口的健康水平不断提升，但城乡不平等现象却依然普遍存在。基于此，本研究在反事实分析框架下实证测度城乡医疗不平等的动态演进，分解不平等中的制度差异，分析医疗保障制度在其中的作用，并给出优化建议。.方法：运用1993-2011CHNS7轮调查的混合横截面数据，建立反事实分析框架，运用虚拟变量法、Oaxaca-Blinder分解、分位数分解、添加交互项的Multinomial logistic回归等方法多维度测度城乡医疗不平等的程度及时空特征。在此基础上，展开问卷调查，结合条件估价法、Heckit两阶段模型及分位数分解，从筹资和补偿两个阶段测度医疗保障制度对城乡不平等的效果。.结果： 1993-2011年，医疗保健利用的多数宏观指标对比都存在显著的城乡差距，差距呈现持续缩小趋势。反事实分析表明，矫正混杂因素的城乡医疗保健利用仍存在显著差异，在2000年后城乡不平等呈现明显的下降趋势。其中，城乡不公平在各年份均大于从均值观察到的城乡差异，并且SES效应加剧了由户籍带来的制度差异，宏观数字实际上是低估了城乡不公平的程度。对城乡就医选择行为的进一步研究显示，比起患病后不采取任何治疗措施，城镇居民选择自我治疗、门诊治疗、住院治疗的概率分别是农村居民的3.24、2.23、4.77倍。城乡差距在1993-2011期间有显著的缩小趋势， 2011年三种医疗利用的城乡差距仅为1993年的33.3%、35.5%、9.6%。分地区的研究结果显示，西部大多数地区在医疗保健需求收入弹性上的城乡差异呈明显的下降趋势，中、东部地区的城乡差异则以扩大为主。因此，全国广泛开展以减小城乡不平等为主要目的的统筹城乡医疗保障改革，其效果评估显示：统筹城乡医保制度保障了保障了福利更多的分配给农村居民。其中，阶梯式自由选择的模式不仅在缩小医保补偿差异、促进城乡医疗利用平等上更具优越性，也更符合筹资意愿的分布规律。