ch12Healthandhealthcare(福利经济学-牛津大学Barr)

2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Chapter12:HealthandhealthcareBarr:EconomicsoftheWelfareState:4e2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Organizationofthechapter1.Introduction2.Aims3.Methods4.AssessmentoftheUKsystemofhealthcare5.Reform6.Conclusion2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.1.Introduction•Theviewthat‘healthcareandeducationarebasicrightsandthereforeshouldbeprovidedbythestate’isillogicalbecausethewords‘andtherefore’donotfollowfromtheinitialpremise.Ifhealthcare,etc.,arebasicrights,thensoisfood,whichisprovidedwellenoughbytheprivatesector•TheNationalHealthService(NHS)ismainlypubliclyfundedandmainlypubliclyorganised•Why?2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.2.Aims2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.2.1ConceptsTheobjective:improvedhealth•Sourcesofgoodhealth•Income/wealth•Individualchoice•Aperson’senvironment•Accesstohealthcare•Inheritance,e.g.physicaloremotionalstrength•Thushealthoutcomesdonotdependonlyonaccesstohealthcare2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Instrumentalobjectives:efficiencyandequity•Efficiency:ifwespentnothingonhealth,peoplewoulddieunnecessarily;ifwespentthewholeofGDPonhealthcare,therewouldbenofoodandwewoulddieofstarvation.Theoptimalquantityliessomewherebetween•Equity:nounambiguousdefinition2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.2.2.Measuringcostsandbenefits•Measuringcosts:feasible,thoughnotwithoutitsproblems•Benefitsarehardtoquantify:•Healthishardtomeasure•Causalityiscomplex•Improvedhealthishardtovalue2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.3.Methods3.1.Theoreticalargumentsforintervention1:Efficiency2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.1)Informationproblems•Areindividualswell-informedaboutthenatureoftheproduct?•Muchinformationiscomplex•Mistakenchoicecanbecostly•Theremaynotbetimetoacquireinformation•Arepeoplewell-informedaboutprices?•Arepeoplewell-informedaboutthefuture?2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.2)InsuranceproblemsPremium=(1+α)pL2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Conditionsunderwhichcompetitiveinsurancewillbeefficient1Probabilitiesmustbeindependent2Probabilitymustbelessthanone3Probabilitymustbeknownorestimable4Noadverseselection5Nomoralhazard•Endogenousprobability•Third-partypaymentproblem2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Actuarialmedicalinsurance:Whateconomictheorypredicts•Gapsincoverage•Chronic/congenitalhealthproblems•Theelderly•Maternity•Uninsuredrisk-averseindividuals•Explodingcosts2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.3)Theremainingassumptions•Competition.•Ismedicalcarecompetitive•Howusefuliscompetition?•Externalities•Increasingreturnstoscale2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.3.2.Theoreticalargumentsforintervention2:Equity•Horizontalequity•Verticalequity•Theroleofgiving2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.3.3.Typesofintervention•Puremarketprovision.•Mixedpublic/privateinvolvement•Publicproduction,allocation,andfinance2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.4.AssessmentoftheUKsystemofhealthcare2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.4.1.Institutions•TheoperationoftheNHS–Production•Primaryhealthcare•Hospitalsandcommunityhealthservices–Theindividualconsumptiondecision–Finance•PrimaryCareTrustsandgeneralpractitioners•Hospitalsandconsultants–Theaggregateproductiondecision,i.e.settingbudgetlimits•Privatehealthcare:asmallsectorinvolvingslightlymorethan10%ofthepopulation2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.4.2.Assessment1:EfficiencyTheNHS:agenuinestrategy•Demandside:•Decisionsabouttreatmentaremadebydoctors•Treatmentistax-financedandfreeatpointofuse•Supplyside:•Doctorsarenotpaidafeeforservice•HealthcareisrationedbytheNHSbudgetandbyadministrativemeans2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.4.3.Assessment2:Equity•Theunimportanceofincomeindeterminingaccesstohealthcare•Thesystemallowsactiononthedistributionofhealthcarebyregion•Outcomes•Thedistributionofhealth•Thedistributionofhealthcare•RedistributiveeffectsoftheNHS2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.5.Reform2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.5.1.Mainlyprivateapproaches:example,theUSAProblemswithprivatemedicalinsurance:•Highandrisingcosts•Gapsincoverage•Unequalaccess2HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Healthspending,variouscountries,2001Healthspendingperhead,US$PPPHealthspending,percentofGDPCanadaFranceSwedenUKUSA2,7922,5612,2701,9924,8879.79.58.77.613.92HigherEducation©OxfordUniversityPress,2005.Allrightsreserved.Attemptstocontaincosts•Diagnosis-relatedgroups(DRGs)•Preferredproviderorganizations(PPOs)•Healthmaintenanceorganizations(HMOs)•A‘firm’ofdoctors;memberspayinsurancecontributionstotheHMO,wh