Wang Hong, Zhang Licheng, Yip Winnie, Hsiao William
Yale University School of Medicine New Haven, CT 06520, USA.
Soc Sci Med. 2006 Sep;63(5):1236-45. doi: 10.1016/j.socscimed.2006.03.008. Epub 2006 Apr 24.
This study examines adverse selection in a subsidized voluntary health insurance scheme, the Rural Mutual Health Care (RMHC) scheme, in a poor rural area of China. The study was made possible by a unique longitudinal data set: the total sample includes 3492 rural residents from 1020 households. Logistic regression was employed for the data analysis. The results show that although this subsidized scheme achieved a considerable high enrollment rate of 71% of rural residents, adverse selection still exists. In general, individuals with worse health status are more likely to enroll in RMHC than individuals with better health status. Although the household is set as the enrollment unit for the RMHC for the purpose of reducing adverse selection, nearly 1/3 of enrolled households are actually only partially enrolled. Furthermore, we found that adverse selection mainly occurs in partially enrolled households. The non-enrolled individuals in partially enrolled households have the best health status, while the enrolled individuals in partially enrolled households have the worst health status. Pre-RMHC, medical expenditure for enrolled individuals in partially enrolled households was 206.6 yuan per capita per year, which is 1.7 times as much as the pre-RMHC medical expenditure for non-enrolled individuals in partially enrolled households. The study also reveals that the pre-enrolled medical expenditure per capita per year of enrolled individuals was 9.6% higher than the pre-enrolled medical expenditure of all residents, including both enrolled and non-enrolled individuals. In conclusion, although the subsidized RMHC scheme reached a very high enrollment rate and the household is set as the enrollment unit for the purpose of reducing adverse selection, adverse selection still exists, especially within partially enrolled households. Voluntary RMHC will not be financially sustainable if the adverse selection is not fully taken into account.
本研究考察了中国贫困农村地区一项补贴型自愿医疗保险计划——农村互助医疗（RMHC）计划中的逆向选择问题。该研究借助一组独特的纵向数据集得以开展：总样本包括来自1020户家庭的3492名农村居民。数据分析采用了逻辑回归。结果显示，尽管这项补贴计划实现了相当高的参保率，71%的农村居民参保，但逆向选择依然存在。总体而言，健康状况较差的个体比健康状况较好的个体更有可能参加农村互助医疗。尽管为了减少逆向选择，将家庭设定为农村互助医疗的参保单位，但近三分之一的参保家庭实际上只是部分家庭成员参保。此外，我们发现逆向选择主要发生在部分参保家庭中。部分参保家庭中未参保的个体健康状况最佳，而部分参保家庭中已参保的个体健康状况最差。在参加农村互助医疗之前，部分参保家庭中已参保个体的人均医疗支出为每年206.6元，是部分参保家庭中未参保个体参加农村互助医疗之前人均医疗支出的1.7倍。该研究还表明，已参保个体的参保前人均年度医疗支出比所有居民（包括已参保和未参保个体）的参保前医疗支出高9.6%。总之，尽管补贴型农村互助医疗计划实现了很高的参保率，并且为了减少逆向选择将家庭设定为参保单位，但逆向选择仍然存在，尤其是在部分参保家庭中。如果不完全考虑逆向选择问题，自愿参加的农村互助医疗在财务上将不可持续。
