《财政学》（第8版）课件：lecture6 The Health Care Market and Government

1、LECTURE 6The Health Care Market ,Government and social securitySocial Insurance社会保险 为个人提供保险以帮助其抵御不利事件的政府计划ExamplesMedicaid：公共医疗补助制Medicare：老年保健医疗制Social Security：社会保障Unemployment Compensation：失业保障How Health Insurance Works保险费(Insurance premium) -人们为什么愿意在保险上花钱?期望值：Expected ValueExpected value (EV) =

2、(probability of outcome 1) * (Payout in outcome 1) + (probability of outcome 2)*(Payout in outcome 2) + + (probability of outcome n)*(Payout in outcome n)Expected Value ComputationDraw cards from deck of cardsDraw heart and receive $12Draw spade, diamond or club and lose $4Probability of drawing hea

3、rt = 13/52 = Probability of drawing spade, diamond or club = 39/52 = EV = (1/4)($12) + (3/4)(-$4) = $0Why Buy Insurance?保险选择Insurance Options收入Income健康概率Probability of Staying Healthy生病概率Probability of Getting Sick生病损失Lost Income if She Gets Sick(A)(B)(C)Income if She Stays HealthyIncome if She Gets

4、 SickExpected ValueOption 1: No Insurance$50,0009 in 101 in 10$30,000$50,000$20,000$47,000Option 2: Full Insurance ($3,000 premium to cover $30,000 in losses$50,0009 in 101 in 10$30,000$47,000$47,000$47,000Why People Buy InsuranceIncomeUtility20,00047,00050,000UAUCUDUBDCBAWhy People Buy Insurance：co

5、nclusion精算公平保费( Actuarially Fair Insurance Premium )：投保人支付的正好足以弥补损失的期望值，即损失的期望值风险平滑( Risk Smoothing )：减少高收入年的收入以防其他年度的收入下降基本结论：如果收入的边际效用递减，则一个人有精算公平保险可供选择时，就会购买全险以防生病造成的收入损失Do People Buy Insurance with Loading Fees?The Role of Risk Pooling参保人数较少时参保人数较多时结论：参加保险的人越多，其支出越可预测（Law of large numbers）Advers

6、e Selection in the Health Insurance Market不对称信息(Asymmetric information)：可能导致逆向选择经验费率(Experience rating)：即差别保费，缺点是可能出现不公平问题团体费率(Community rating)：向某一由不同健康风险的个人组成的团体收取统一保费，缺点是无效率(A)(B)(C)(D)(E)(F)Expected Benefit Expected Benefit Expected Benefit Minus PremiumMinus PremiumMinus PremiumInsurance BuyerP

7、robability of Getting SickLost Income if SickExpected Lost Income(Differential Premiums)(Premium = $3,000)(Premium = $4,500)Emily1 in 5 (High Risk)$30,000 $6,000 $0$3,000$1,500Jacob1 in 5 (High Risk)$30,000 $6,000 $0$3,000$1,500Emma1 in 5 (High Risk)$30,000 $6,000 $0$3,000$1,500Michael1 in 5 (High R

8、isk)$30,000 $6,000 $0$3,000$1,500Madison1 in 5 (High Risk)$30,000 $6,000 $0$3,000$1,500Joshua1 in 10 (Low Risk)$30,000 $3,000 $0$0 -$1,500Olivia1 in 10 (Low Risk)$30,000 $3,000 $0$0 -$1,500Matthew1 in 10 (Low Risk)$30,000 $3,000 $0$0 -$1,500Hannah1 in 10 (Low Risk)$30,000 $3,000 $0$0 -$1,500Ethan1 i

9、n 10 (Low Risk)$30,000 $3,000 $0$0 -$1,500Insurers Net Profits$0 -$15,000$0 Insurance and Moral Hazard道德风险Moral hazard：一项保险计划通过弥补保健成本越使风险平滑化，它导致无效率的保健滥用程度越大扣除额Deductible：保险公司在赔付之前，个人每年必须支付的保健成本数共同支付Co-payment：即向医疗服务支付的一笔固定数额共同保险Co-insurance费率：即由投保人支付医疗费用总额的一定比例Moral HazardMedical services per yearPr

10、ice per unitDmSmM1M00P0.2P0abhdeadweight lossAdditional Considerations医疗服务的价格弹性：对价格确有弹性道德风险证明政府干预是合理的吗?政府保单也是第三方支付Third Party Payment保健市场的信息不对称可以作为政府介入的理由吗？介入可能导致无效率。保健的外部性Externalities：通过不具有外部性Do We Want Efficient Provision of Health Care?政府提供保健的合理性可能是：家长主义(Paternalism)未保险者问题Who are the uninsured?D

11、oes health insurance improve healthHigh Health Care CostsCauses of Health Care Cost Inflation美国老龄化The Graying of America收入增长Income Growth医疗服务质量改进Improvements in Quality商品平均主义Commodity Egalitarianism：每个人都应该得到基本的公共医疗服务Private Health Insurance美国大部分的私人健康保险是通过雇主为员工提供的，是雇主对雇员的一种福利原因是联邦政府为雇主提供健康保险提供了隐性补贴雇主

12、提供健康保险的优缺点Increase the risk poolReduce adverse selectionLower administrative costsJob lockCost Control and Private Insurance按费用补偿制度或一次一付医疗费制度【Cost-based reimbursement (fee-for-service)】管理保健(Managed care)按人头补偿制Capitation-based reimbursement卫生保健组织Health Maintenance Organizations (HMOs)优先提供者组织Preferred

13、 Provider Organizations (PPOs)服务点计划Point-of-service (POS)Medicare: OverviewSOURCE: Centers for Medicare and Medicaid Services 2005a.Expenditures on Medicare as a Share of GDPReal expenditures on MedicareMedicare: Overview医疗保险：向65岁以上的老人和伤残人提供的健康保险，其主要原因是增加老年人获得高质量保健服务的机会。一个人在65岁前不能领取医疗保险金；该计划由联邦政府管理。

14、由四部分组成：Part A Hospital insurance (HI)：强制。筹资：通过工薪税筹资，雇主雇员各一半，适用于全部收入How Medicare WorksPart B Supplementary medical insurance (SMI)：对医院之外的医生、医生订购的用品及提供的医疗服务付费。是自愿的。筹资：General revenues fund SMIPart C Medicare Advantage医疗保险优惠计划Prescription Drug BenefitPart D Prescription Drug Benefit必须按月支付保费Monthly prem

15、ium低扣除额Low deductible甜圈饼洞Donut hole对高成本支出提供慷慨资助Generous coverage for high costsCost Control Under Medicare诊后支付制度Medicares retrospective payment system预支付制度Medicares prospective payment system疾病诊断相关组Diagnosis related groups资源性相对价值标准制度Resource-based relative value scale system医疗保险的管理保健Medicare Managed

16、 CareMedicare: Impacts on Spending and HealthExpenditures on health care for the elderly：导致支出大量增加Health outcomes：减少了老年人的风险，但对老年人的健康状态影响不明显Medicaid: Overview医疗补助Medicaid：是对低收入者的最大政府支出计划。由联邦与州共同管理，共同筹资，联邦以一般收入提供配套。State Childrens Health Insurance Program各州必须提供最低补助金，以支付主要医疗服务的费用。领取率Take-up rate不高存在Crow

17、ding out效应SOURCE: Centers for Medicare and Medicaid Services 2005a.Expenditures on Medicaid as a Share of GDPReal expenditures on MedicaidHealth Care Reform个人托管Individual mandates健康储蓄账户Health savings accountsCatastrophic insurance policy单一支付者Single payerSources: Expenditure data from Social Security

18、 Trustees 2006. CPI data from Department of Labors Bureau of Labor Statistics. GDP data from Department of Commerces Bureau of Economic Analysis.Expenditures on social security as a Share of GDPReal expenditures on social securityWhy Have Social Security?社会保障的运作方式年金市场与消费平滑化年金Annuity消费平滑化Consumption

19、smoothing逆向选择与年金市场不对称信息Asymmetric information逆向选择Adverse selectionOther Justifications缺乏远见Lack of foresight and paternalism道德风险Moral hazard节省决策成本Economize on decision-making and administrative costs收入分配Income Redistribution改善老年人的经济地位Improve the Economic Status of the AgedFully Funded PlanPeriod 1Per

20、iod 2Period 3Period 4contributebenefitscontributebenefitscontributebenefitsThe GreatestGenerationThe Baby BoomGenerationGeneration XWorkRetireDeadUnbornWorkWorkRetireStillDeadDeadChildhoodChildhoodRetireEach generations benefits based on deposits it made during working life plus accumulated interest

21、Period 1Period 2Period 3Period 4The GreatestGenerationThe Baby BoomGenerationGeneration XWorkRetireDeadUnbornWorkWorkRetireStillDeadDeadChildhoodChildhoodRetirecontributebenefitscontributebenefitscontributebenefitsbenefitsPay As You Go (or Unfunded) System0Each generations benefits come from tax pay

22、ments made by current workersPeriod 1Period 2Period 3Period 4The GreatestGenerationThe Baby BoomGenerationGeneration XWorkRetireDeadUnbornWorkWorkRetireStillDeadDeadChildhoodChildhoodRetirecontributebenefitscontributebenefitscontributebenefitsbenefitsTodays Partially Funded System0Baby Boomers and G

23、en X are also contributing to their own retirementBenefitsHow to calculate benefitsAIME (Average Indexed Monthly Earnings) average monthly earnings in 35 highest paid yearsWages indexed for inflationCeiling on AIME up to tax ceiling0Benefit StructureIf AIME $656 PIA = .90*AIMEIf $656 AIME $3955 PIA

24、= .90*$656 + .32*($3955-$656) + .15*(AIME - $3955) First Bend PointSecond Bend Point0Adjustments退休金每年按消费价格指数进行调整去取养老金的年龄：Normal retirement ageEarly retirement benefit reduced 5/9th of one percent a month for first 36 months preceding normal retirement ageLate retirement benefit increased 15/24th of

25、one percent a month0Adjustments依据家庭状况调整+50% for spouse or dependent childIf covered worker dies spouse receives 100% of workers benefit or spouses benefitDivorced spouse married at least 10 years gets spouse benefit if not remarried while covered worker alive收入检验与征税退休金Benefits reduced $1 for every $

26、2 earned above $12,480Individuals losing benefits may have later benefits increasedUp to 85% of benefits taxed for recipients with income above a base amount ($25,000 for single and $32,000 for married taxpayers.)FinancingFICA (Federal Insurance Contribution Act)2006 Social Security Tax ratesEmploye

27、e6.2% (OASI - 5.6%, DI - .6%) of first $94,200 of earnings on both employee and employerSelf-employed 12.4%2006 Medicare Tax rates1.45% on both employer and employee with no earnings ceilingWhy not fund Social Security through general tax revenues?0Distributional Issues精算公平收益Actuarially fair return代

28、际再分配Intergenerational redistributionTotal benefits = Nb * BTotal taxes = t * Nw * wIf total benefits = total taxes:Nb * B = t * Nw * w orB = t * (Nw/Nb) * wSocial Security Wealth for Representative IndividualsSource: Updated tables, furnished by C. Eugene Steuerle and Adam Carasso, 2006. See C. Euge

29、ne Stueuerle and Jon M. Bakija 1994 for original tables and methodology. All values expressed in 2006 dollars.Other Distributional Issues代内再分配Redistribution within a generation收入阶层间Differences by earnings寿命差异Differences by lifespan生活方式差异Differences by living arrangements家庭有收入者人数Differences by number

30、 of earners in the family规范性评价Normative evaluationThe Social Security Trust Fund社会保障与国民储蓄预算法对社会保障基金的处理Off budgetUnified budgetWorkerRetireeTrust Fund0Social Security and Savings BehaviorLife-cycle theory of savingsWealth Substitution EffectRetirement EffectBequest EffectBudget Constraint for Present

31、 and Future ConsumptionPresent consumption (c0)Future consumption (c1)NMI0I1DI0 - SI1 + (1+r) SS(1+r)SI1 - (1+r) BFB(1+r)BAt endowment point consumer neither saves nor borrowsUtility-maximizing Choice of Present and Future ConsumptionPresent consumption (c0)Future consumption (c1)NMI0I1E1c1*Ac0*Savi

32、ngCrowding out of private saving due to Social SecurityPresent consumption (c0)Future consumption (c1)NMI0I1E1c1*Ac0*RTI0T(1+r)TSaving before Social SecuritySaving after Social SecurityLong-Term Stresses on Social SecurityProjected revenues and projected costs of Social Security as share of Gross Do

33、mestic Product Source: Social Security Trustees 2006Long-Term Stresses on Social SecuritySince: B = t * (Nw/Nb) * wRearrange: t = (Nb/Nw) * (B/w)Dependency RatioReplacement RatioSocial Security ReformMaintain the Current SystemRaise the payroll taxRaise the Maximum Taxable Earnings LevelRaise the Re

34、tirement AgeReducing the Cost-of-Living AdjustmentChange the Benefit FormulaComparing the OptionsPrivatize the SystemPersonal Accounts个人帐户的优缺点Pros and cons of personal accountsEffect on SolvencyEffect on Saving分拆账户Carve-out accounts新增账户Add-on accountsRiskAdministrationDistribution外媒称中国现行社保制度“劫贫济富” 目前，我国社会养老保障体系已基本确立。除机关事业单位的退休制度外，我国的养老保险分为城镇居民社会养老保险、城镇职工基本养老保险、新型农村社会养老保险(下称“新农保”)三种。