گسترش بیمه سلامت دولتی و تقاضا برای بیمه درمانی خصوصی در مناطق روستایی چین

This paper examines the impact of the New Cooperative Medical Scheme (NCMS) on private health insurance purchasing decisions in rural China, using longitudinal data from the China Health and Nutrition Survey (CHNS, 2000–2006). A Difference-in-difference (DID) approach is employed to estimate NCMS effects. The overall effects of NCMS were modest, but differed for adults and children. We find that adults were 2.1% more likely to purchase private health insurance when NCMS became available. NCMS had a larger positive effect on adult private coverage in higher income groups and in communities with a preexisting health care financing system, known as the Cooperative Medical Scheme (CMS). We also find evidence suggesting that NCMS crowded out child private health insurance, especially in lower income groups. However, this finding is not robust to controlling for other covariates including household characteristics and availability of private insurance in the community. For both adults and children, risk preferences and socio-economic status, including income and education, are important predictors of private insurance take-up. We find no evidence for adverse selection in the demand for private health insurance.

Since the initiation of market reforms in the 1980s, China's growing economy has resulted in an extraordinary reduction in poverty, lifting approximately 500 million of people out of poverty (World Bank, 2002). The sharp decline in the rural poor accounted for 75 to 80% of the drop in the national poverty rate during the period 1981–2001 (Ravallion & Chen, 2007). Nevertheless, the development of China's health care system lagged far behind its economic growth (World Bank, 1997 and Eggleston et al., 2008). Inadequate government investment in the health care sector, combined with rapidly escalating medical costs, increased the burden of individual out-of-pocket health expenditures from 23.2% of total medical expenditures to 49.3% by 2006 (China Statistical Yearbook, 2008). Moreover, over 90% of the 0.9 billion rural population were uninsured in 1998 (Liu, 2004a). Soaring out-of-pocket medical expenses have not only become a direct financial threat to low-income rural residents, but also created a financial barrier to health care access, thus contributing to the cycle of poverty associated with poor health (Liu, Rao and Hsiao, 2003, Hennock, 2007 and Yip and Hsiao, 2009). To address this problem, in 2003 the Chinese government began to re-establish the health care system in rural China, implementing a nationwide project known as the New Cooperative Medical Scheme (NCMS). The NCMS replaced the old village-based rural health financing system, known as the Cooperative Medical Scheme (CMS). The NCMS was first implemented in 304 pilot rural counties from 31 provinces, then expanded to 620 counties (about 22% of all rural counties) in 2005 (Liu, 2004b and World Bank, 2005), and aims at covering all rural counties by the end of 2010. The NCMS seeks to provide low-cost basic health care services, including inpatient, catastrophic, and some types of outpatient care, but it cannot finance full health protection for the entire rural population (Central Committee of CPC, 2009). Additional diversified supplemental medical insurance, such as private health insurance programs, are required to satisfy different medical care needs beyond those covered by the NCMS (Bhattacharjya & Sapra, 2008). Since its launch in the 1980s, the private health insurance industry has remained relatively small. As shown in Fig. 1, private health insurance premiums experienced rapid growth beginning around 2003. Although private health insurance premiums amounted to 24.2 billion RMB in 2003, it only accounted for 3.6% of national health care expenditures (Guo & Duan, 2007). There are nearly 100 private insurers of different sizes and complexities, offering over 700 health insurance products in the market (Guo and Duan, 2007 and Bhattacharjya and Sapra, 2008). However, these private health insurance products mainly focus on inpatient care and catastrophic coverage, and typically do not include long-term care coverage and disability income insurance (Wang, 2009). In 2003, only 6% of urban and 8% of rural residents were covered by private health insurance (Swiss Re, 2007).

With the launch and expansion of the New Cooperative Medical Scheme (NCMS), individual demand for private health insurance has been changing in rural China. In this study we employ the difference-in-difference method to empirically examine the impact of NCMS on individual demand for private health insurance coverage. This paper is among the first to empirically identify the relationship between the developing NCMS and private health insurance in rural China. The overall effects of NCMS on private health insurance purchases have been modest, but differ for adults and children. Adults were 2.1% more likely to purchase private health insurance when public health insurance became available. The NCMS had a larger positive effect on adult private coverage in higher income groups and in communities with a prior history of CMS. The positive relationship between the implementation of NCMS and private purchases of health insurance by adults may reflect the supply and demand factors described earlier in the Introduction, and the fact that these two types of insurances are differentiated. In contrast, we find some evidence suggesting that NCMS crowded out child private health insurance, especially in lower income groups, although these estimates become insignificant in the full model specification. The reason for the differential effect of NCMS on adult and child private health insurance demand may reflect the preexisting availability of private health insurance for students in many communities. Since the 1990s, local private insurers began introducing some student health insurance programs with low premiums and limited coverage, through school administration in rural areas of China (Mao, 2005 and Zhu et al., 2008). This explains why children attending school have more private coverage than other children, as shown in Table 5. But with the availability of NCMS in rural China, parents may have substituted this in favor of preexisting private insurance for their children, as NCMS offers similar coverage and benefits but lower premiums (Zhu et al., 2008). This explanation is consistent with our findings that NCMS has a crowding-out effect on child private coverage, especially among low-income households. For both adults and children, risk preferences and socio-economic status, including income and education, are important predictors of private insurance take-up. We find no evidence for adverse selection in the demand for private health insurance. It must be acknowledged that this study is subject to two potential limitations. First, our empirical identification hinges on the exogeneity of NCMS at the county level. If the government takes private coverage into account when expanding NCMS, this could lead to biased estimates of the relationship between these two systems. However, this endogenous legislation scenario may not be problematic in our context, since we examine individual demand for private insurance and also control for the availability of private insurance at the community level. Moreover, Lei and Lin (2009) find that counties implementing NCMS differ little from non-NCMS counties in their observable characteristics in the CHNS sample. Using the DID method, we also control for the time-invariant unobservable differences between the treated and untreated communities. Second, due to data limitations, the measure of NCMS is constructed based on survey questions related to the presence and history of cooperative insurance at the communities, with no direct distinction between old and new schemes. Reporting bias may exist if the respondents, the community head or community health workers, mistakenly consider the NCMS the same as old CMS, which would lead to an underestimate of the NCMS impact. Overall, our findings provide empirical evidence for a certain degree of complementarity between social health insurance system and private health insurance system for adults, and draws attention to the potential private crowd out from subsidized public programs for children, which may have important policy implications for the deepening health care system reform in China. It motivates further studies to better understand the underlying causes for both complementary and substitution effects of the NCMS among different groups. This research also raises the fundamental question of how the public sector should design programs to ensure access to basic health care for everyone, especially the poor and the vulnerable.