医保减贫视角下中老年慢性呼吸道疾病患者的健康贫困特征与影响因素研究

背景　在我国，慢性呼吸道疾病（CRD）已成为影响中老年人健康状况的主要慢性病之一，长期的医疗费用支出给其及家庭造成巨大的经济负担，使其陷入贫困的风险增大。在医保制度实现人口宽度全民覆盖的背景下，是否有效缓解了中老年CRD患者的疾病负担，减轻了因病致贫风险（IME）等问题已然成为掣肘社会可持续发展的焦点问题。目的　通过多维度分析，系统把脉和精准锁定我国中老年CRD患者这一健康贫困高危群体发生致贫的脆弱特征及影响因素。方法　本研究于2019年7月利用2015年中国健康与养老追踪调查（CHARLS）微观数据，以920户（2 106例）中老年CRD患者为调查对象，采用WHO推荐的灾难性卫生支出（CHE）、IME方法测算其疾病经济负担，并采用多因素Logistic回归分析中老年CRD患者发生CHE的影响因素。结果　920户家庭总体CHE发生率为20.65%（190/920），IME发生率为7.83%（72/920），其中合并3种及以上慢性病的家庭CHE发生率最高，为44.00%（11/25）。不同性别、受教育程度、自评健康状况户主，家庭是否有住院患者、合并其他慢性病种类，户主参加保险类型CHE发生率比较，差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示：户主为女性、受教育程度为高中及以上、家庭有住院患者、合并3种及以上慢性病、其他和未参保户主是灾难性卫生支出高发的影响因素（P<0.05）。结论　CRD患者自身健康能力的缺失，叠加住院、合并其他类慢性病等多种健康脆弱性，加剧CHE发生风险。现有医保制度，仅保障了老年CRD患者进入卫生领域的权利，缺乏对CRD患者中，其他和未参保家庭、新型农村合作医疗保险参保家庭的制度倾斜和贫困人口的精准锁定，需进一步加强对高卫生服务利用群体的医保覆盖深度与高度，加强基本医保、大病医保、医疗救助与疾病应急救助等多路径健康保障体系的协调与统一。

Health Poverty Characteristics and Influencing Factors of Middle-aged and Elderly Patients with Chronic Respiratory Diseases from the Perspective of Poverty Reduction by Medical Insurance

Background　The chronic respiratory disease（CRD） has become one of the major chronic diseases affecting the health of middle-aged and elderly people in China. The long-term medical expenditure causes a huge economic burden on the elderly and their families，increasing the risk of falling into poverty. In the context of the universal coverage of medical insurance，whether the existing medical insurance system has effectively alleviated the disease burden of patients with CRD and reduced the risk of poverty caused by diseases has become a public concern on the sustainable development of society. Objective　To systematically identify and analyze the vulnerable characteristics and influencing factors of middle-aged and elderly patients with CRD，the high-risk group of health poverty，through multi-dimensional analysis. Methods　Using the microdata from 2015 China Health and Retirement Longitudinal Study（CHARLS），920 households（2 106 cases） of middle-aged and elderly patients with CRD were investigated. The methods recommended by the World Health Organization were adopted to calculate the catastrophic health expenditure（CHE）and the impoverishment by medical expenses（IME）. The influencing factors were analyzed by multivariate Logistic regression. Results　The overall CHE incidence rate was 20.65%（190/920） and the IME incidence rate was 7.83%（72/920）. The incidence rate of CHE was highest in families with more than 3 kinds of chronic diseases at 44.00%（11/25）. There were significant differences in the incidence of CHE among heads of household with different gender, education level，self-rated health status, whether there were inpatients in the family，and other chronic diseases．Multivariate Logistic regression analysis results showed that female heads of households，high school or above，having inpatient family members，combined with more than 3 types of chronic diseases，and uninsured households were the factors affecting the high incidence of CHE（P<0.05）. Conclusion　The lack of health ability combined with multiple health vulnerabilities，such as hospitalization and chronic diseases，aggravates the risk of CHE among patients with CRD. The existing medical insurance system only guarantees the right of elderly CRD patients to obtain medical resources，but it lacks the system tilt for uninsured households and insured households in new rural cooperative medical system，and accurate identification of the poor among CRD patients. Moreover，it is necessary to further strengthen the depth and range of medical insurance coverage for groups with high utilization rate of health services. The coordination and unification of multi-path health protections such as basic medical insurance，critical illness insurance，medical assistance，and emergency medical assistance should be promoted.