Demand for and Supply of Supplementary Health Insurance in Shanghai Wen Chen 1, Xiaohua Ying 1, Shanlian Hu 1, Guozhen Sun 2, Li Luo 1, Wenwei Tang 2 1 School of Public Health, Fudan University, Shanghai 200032, People s Republic of China 2 Shanghai Bureau of Medical Insurance, Shanghai 200040, People s Republic of China SUMMARY Background A new basic health plan was implemented in Shanghai on Jan 1, 2001, covering 6.8 million employees. Supplementary health insurance was encouraged by the government to meet the employees different demand for health services based on basic benefit package enslaved to general socioeconomic situation. The study aimed to measure the demand for and supply of supplementary health insurance and explore policy options to promote this market, as a model for other parts of China and elsewhere. Methods Take-it-or-leave-it (TIOLI) and open-ended question methods of contingent valuation in questionnaire survey were employed to investigate the employee s willingness-to-pay for supplementary packages designed according to the framework of Shanghai s basic health plan. Another questionnaire was used to obtain the employer s intent and willingness-to-pay for supplementary health plan. Potential insurers including NGOs and commercial companies were visited in the study. Results It s showed that these supplementary packages were of different attributes, the demand for which depended not only on their characteristics including the probability of the risk event occurring and the magnitude of the loss resulting from the health event, plan price, and the employee s family income, but also on the employee s insurance cognition, attitudes and obtained information concerned. The price elasticity of the demand ranged from 0.59 to 3.84. The state-owned enterprises were reluctant to provide subsidy for the employees enrollment in supplementary health plans. The insurers were short of technology and information necessary to provide appropriate supplementary health plan tightly linking up with basic health plan. Conclusions The market for supplementary health insurance was generally out-of-order and certain incentives were required to fill the gap between the employees willingness-to-pay and the supply. It s also necessary for the government to define and regulate the 1
market. Basic health plan should be adjusted with the development of supplementary health insurance. INTRODUCTION By the end of the 1980s, the labor insurance scheme covered all employees and retirees, and their dependents, of state-owned enterprises and most workers in collective-owned enterprises and the welfare insurance scheme was responsible for the payment of medical care expenditures of government employees, retirees, disabled veterans, university teachers and students in Chinese urban areas. Because of no incentives to control medical expenditures and their limited ability to spread risk [1], the health insurance system had to be rebuilt to give the access to basic health care to everyone with the economic transition. At the end of 1998, on the basis of the experiences from the reform trials of Zhenjiang and Jiujiang cities, a new framework of basic health insurance for urban employees was initiated by the Ministry of Labor and Social Security, which was appointed to take charge of health insurance reform by the new State Council. The new plan was characterized by the principle of basic healthcare provision and extensive coverage for urban population [2] which meant to guarantee the equitable access to basic benefit package for all employees in the urban areas. A mixed financing mechanism including government, employer and employee contributions was required to establish. The operation pattern combining social solidarity fund and personal medical savings account (MSA) was highlighted by the central government. The basic benefit package covered by social solidarity fund was generally defined through benefit exclusions on pharmaceuticals, medical procedures and facilities and the instruments of deductible (10 percent of the employees average wage), coinsurance, and expenditure ceiling (4 times of the employees average wage). To cover the gap between basic social health insurance and actual medical expenditures, establishing and developing supplementary health insurance was encouraged by the new national health reform plan. In Shanghai, a new basic health insurance plan was launched on Jan 1, 2001 based on five-year reform experience, which gradually extended through the coverage of original labor insurance beneficiaries to covering government employees and then to all urban employees, and through hospitalization insurance to covering catastrophic outpatient visits and then to the establishment of MSAs. By the end of 2001, 6.8 million employees, of which had 2.3 million retirees, had been covered by the social health plan, approximately 50% of population in Shanghai. According to Shanghai s plan [3], the employee had to pay the contribution of 2 percent of his wage into his own MSA and the employer paid the amount equaling to 8 percent of the employees 2
total wage, of which 2 percent was taken into local additional insurance fund, the amount equivalent to 0.5% to 1.5% of the employees average wage of last year was put into the employee s MSA according to his age group and 4% or 4.5% into the retiree s, and the others were allocate into the unified solidarity fund. The retirees did not need to pay the contribution himself. For all outpatient and emergency visits, the employee firstly used his MSA to pay for the medical bill within the benefit package, when he ran out of the MSA, he had to pay for the entire bill out-of-pocket up to 10 percent of the employees average wage of last year (1,400 yuan RMB in 2001). After that limit, he only paid parts of medical expenditures with the co-payment rate of 30% to 50% according to his age group. The others would be paid for by the local additional fund. The retiree had a deductible of 2 percent of the employees average wage of last year and 10% to 20% of co-payment rate for different level of hospital visits. As for inpatient stay, the insured had a deductible amounting to 10 percent of average wage of last year in one year, and then was required to pay for 15% medical bill. When the hospitalization bill was beyond the ceiling of 4 times of average wage of last year (56,000 yuan RMB in 2001), the additional fund would pay for 80% of medical bill for him. The retiree had a deductible of 5% of average wage of last year and a co-payment rate of 8% (see graph 1). The employees retired after 2001 would have a higher deductible and co-payment rate. Some supplementary-like health insurance plans have existed in Shanghai, such as mandatory additional insurance fund held by the local Bureau of Medical Insurance and mutual security funds held by municipal labor union and some enterprises. Many commercial insurance plans for inpatient, surgical operations and catastrophic diseases are also providing the duplicate coverage for the urban employees. All these plans, to some extent, improve risk sharing and meet employees demand for different level of health care. On account of the lack of the evidence on the employee s demand for supplementary health insurance, there exist market failures. Indemnity insurance plans for catastrophic diseases and hospitalization, for example, are commonly observed in the market. Overall loss ratios for the insurers are generally low, while loss ratios of commercial plans additional to life insurance seem particularly high for the purpose to attract the enrollee. Group enrollment is often employed to avoid the uncertainty of individual risk. The market for supplementary health insurance is not clearly defined, especially for commercial insurance companies, which brings about duplicate coverage for parts of employees and decline the financing capacity and efficiency of resource utilization. International experiences have told us that private supplemental coverage can have spillover effects, increasing the cost of public coverage [4]. During the transition from health welfare system to multi-level health insurance system, the research questions produced for Shanghai were: do the employees demand supplementary health insurance? and how much are the employees and employers willingness-to-pay for 3
these supplementary health insurance plan? The purpose of the study was to measure the demand for and supply of supplementary health insurance and explore policy options to promote this market. METHODS On the basis of the framework of social health insurance plan in Shanghai, five packages were designed to measure the employees and their employers potential demand for supplementary health insurance. As showed by graph 1, package A was assigned to cover the employee s out-of-pocket payment for medical bill beyond hospitalization expenditures ceiling; package B was designed to cover the employee s co-payment between deductible and ceiling of inpatient medical expenditures; and package C was to cover the employee s co-payment of outpatient medical spending beyond the sum of deductible and the amount of his MSA. To maintain the cost containment role of the deductible for outpatient visits, package D was appointed to cover 60% of the deductible of outpatient coverage to balance the gain of risk sharing and deadweight loss from moral hazard [5]. At last, package E was designed to cover medical expenditures beyond basic benefit package, including pharmaceuticals and examination items that social health insurance plan did not pay for. D C Outpatient expenditures MSA Deductible Co-payment of 30%~50% (50%~70% by additional fund) B A Inpatient expenditures Deductible Co-payment of 15% (85% by solidarity fund) Co-payment of 20% (80% by additional fund) Ceiling Graph 1. Framework of basic health insurance plan in Shanghai Sample enterprises were chosen according to economic situation from three districts of different socioeconomic characteristics, including state-owned enterprises and joint venture. About 100 employees in one department or production unit were picked from every sample enterprise to take questionnaire and interview survey. At last, 1,164 employees were investigated in 11 enterprises, including 7 state-owned enterprises and 4 companies. Questionnaire survey was employed to obtain every sampled employee s 4
socioeconomic characteristics, including demographic, economic, health situations and healthcare utilization, cognition of and attitude to basic health insurance, and willingness-to-accept supplementary health insurance. In the second part of the survey, every employee was interviewed by the pre-trained interviewer to provide the information on personal understanding of basic health insurance plan, commercial insurance enrolment for him and his family, willingness-to-pay for the above five supplementary packages and his choice of packages preferred. Take-it-or-leave-it (TIOLI) method of contingent valuation [6,7] was used to investigate the employee s willingness-to-pay for the above first four supplementary packages and open-ended question method for package E. The starting point of package A to D was tested and adjusted after the pilot survey in one enterprise and the price range was defined according to the experience of the research team (table 1). The benefit of every package was elaborately introduced and depicted to the interviewee by the interviewer, especially for who did not clearly understand basic health insurance plan. The highest value of the employee s willingness-to-pay for every package was recorded during the interview. Table 1. Price ranges for the survey of the employee willingness-to-pay (yuan RMB) Package Starting point Price up Price down A 15 20 25 10 8 B 50 70 90 C 30 40 50 D 300 360 420 5 40 30 20 25 20 240 200 Another questionnaire was designed to investigate the employer s characteristics, financial situation, past and current spending on healthcare fringe benefits for the employees, and willingness-to-pay for the above supplementary packages. The employee s willingness-to-pay for every package could be interpreted as whether the employee was willing to enroll in a health plan defined by the package under different price level shown in table 1. A demand function could be established with logistic model for every package. The factors affecting the demand for health insurance mainly included the individual s risk-aversion, the probability of the risk event occurring, the magnitude of the loss resulting from the health event, the price of insurance, and the individual s income [8]. The individual s information about insurance benefits and attitudes toward to medical care and risk also had effects on 5
demand for supplementary health insurance [9,10]. In this study, personal socioeconomic indicators such as gender, age, education, working position, and personal cognition, knowledgeable information and attitudes toward insurance including rationality for self-paying for parts of premium and medical expenditures, having commercial insurance for himself and his family or not, and knowing outpatient/inpatient reimbursement of basic health insurance plan, were employed to reflect personal risk aversion. Personal risk probability and loss magnitude were substituted by the indicators including self-assessment of health status, having a chronic disease or not, having at least an outpatient visit within the last month or not, having an inpatient stay within half a year or not, and drug spending in pharmacy within the last three months. The family s average monthly income per capita and self-judgement for out-of-pocket parts of medical expenditures were used as the proxy of personal income situation (table 2). Other control variables contained beneficiary of original welfare insurance or not and package preferred or not. Two interactional terms were also put into the models to better mirror the demand of the employees with a chronic disease who took hospital visits, self-medication or no medication. To directly show the effects of all influencing factors on the demand probability for supplementary packages, marginal effects of every coefficient was calculated from logistic models [11]. The price elasticity of demand for every package was also measured. Municipal labor union and three insurance companies were visited by the researchers to understand the current situations of the operation and confronted problems of their plans marketed. RESULTS Basic characteristics of the employers and employees The minimal and maximal number of employees in 11 enterprises was 153 and 9,243, respectively. The ratio of the employer s health fringe benefits to the employees total wage amount ranged from 2% to 21% in 2000. After the implementation of new basic health insurance plan, as health fringe benefits spending with a certain proportion of the employees total wage amount, the enterprises with high ratio of fringe benefits decrease the current financial burden and those with lower ratio balanced health benefits spending between today and future. The employees surveyed averaged the age of 40.8, male 53.4%. Of which, 20.1% with the family s average monthly income per capita beyond 2,000 yuan RMB, 16.8%, 23.7%, 27.0%, and 12.3% with that income between 1,250 and 2,000, between 800 6
and 1,250, between 450 and 800, and less than 450, respectively. 48.9% of the employees had purchased at least a commercial insurance plan for himself or his family, including life insurance with or without additional health benefits, family asset insurance, accident insurance, and health insurance. 48.7% employees considered rational for self-paying for parts of premium and medical expenditures (table 2). Table 2. Main variables (n=1,164 for not specified) Variables Means STD Dependent variable willingness-to-accept Package A (n=6,984) 0.76 0.43 Package B (n=6,984) 0.56 0.50 Package C (n=5,820) 0.20 0.40 Package D (n=5,820) 0.56 0.50 Willingness-to-pay for package E (yuan RMB) 47.8 81.5 Premium (yuan RMB) Package A 13.83 6.96 Package B 50.00 23.81 Package C 304.00 79.41 Package D 33.00 10.77 Male 0.53 0.50 Age Less than 35 0.19 0.40 35~45 0.46 0.50 Education Lower than high school 0.28 0.45 Higher than high school 0.22 0.41 Working position (others as control) Manager 0.21 0.41 Officer 0.25 0.43 Worker 0.38 0.49 Family s average monthly income per capita(800~1,250 yuan RMB as control) More than 3,500 0.07 0.25 2,000~3,500 0.13 0.34 1,250~2,000 0.17 0.37 450~800 0.27 0.44 Less than 450 0.12 0.33 Self-judgement for out-of-pocket burden of medical expenditures Difficulty 0.46 0.50 Cannot afford 0.20 0.40 Self-assessment of health status Good or very good 0.25 0.44 Poor or very poor 0.11 0.31 Having a chronic disease 0.52 0.50 Having at least an outpatient visit within the last month 0.40 0.49 Having a hospitalization stay within half a year 0.03 0.16 7
Drug spending in pharmacy within the last three months(yuan RMB) 84.43 142.48 Having commercial insurance for himself or his family 0.45 0.50 Rational for paying for parts of insurance premium and medical expenditures 0.49 0.50 Knowing outpatient reimbursement of basic health insurance plan 0.74 0.44 Knowing inpatient reimbursement of basic health insurance plan 0.58 0.49 Package preferred 0.36 0.48 Beneficiary of original welfare insurance 0.09 0.28 Having a chronic disease *having an outpatient visit within the last month 0.29 0.45 Having a chronic disease *drug spending in pharmacy within the last three months 60.16 134.93 (yuan) #: Dummy variable for the indicator without a unit. Demands for supplementary health insurance packages Under social health insurance, the companies paid more attention to the employees health benefits and were more willing to pay for supplementary health insurance, compared to state-owned enterprises. Some companies had purchased commercial health insurance plans for the employees. The state-owned enterprises were generally willing to pay additional proportion of the employees wage amount (2%), which was defined by basic health plan to be income tax-free, for some appropriate supplementary health plans if affordable. 64.4% of the employees were willing to participate in some forms of supplementary health plans, 22.7% of the interviewees would make the decision depending on actual situations, and the others were sure not to enroll in any supplementary health plan. No ability to pay the premiums was regarded by about 54% of the negativists as the main reason not taking supplementary coverage. 57.1% of the interviewees preferred the government to hold supplementary health plan, 28.1% for mutual security fund within an enterprise and only 3.5% for commercial plans. Generally from the employees demand functions for four supplementary health packages against deductible, co-payment and ceiling in basic health insurance plan (table 3), the marginal effects of insurance prices on the demand probabilities ranged from 0.25% to 3.22%, that meant the demand probabilities would rise by 0.25% to 3.22% with the insurance prices down every 1 yuan RMB. The demand increased with the raise of the family s average monthly income per capita and decreased for those considering difficulty or cannot afford to pay for out-of-pocket parts of medical 8
expenditures. The employees with the experience of a hospitalization stay within half a year and more spending in pharmacy within the last three months had a higher demand, but those outpatients within the last month showed a lower demand. The individuals with more knowledge and risk and insurance cognition tended to be higher demand. Male and young person with less than 35 years old was more willing to enroll in a supplementary health plan. There were some differences for the influencing factors between the four demand functions. Self-assessment of personal health status had differential effects on the demands. The demand probability of package A for those with good self-assessment was higher by 5 percentage points than for those with fair health status and those with poor self-assessment showed lower demand for package D by over 7 percentage points. The employees with a chronic disease were more willing to accept package C by 6.6 percentage points and showed no significant preference for other packages. The individuals with the complete knowledge of outpatient reimbursement of basic health plan were more willing to enroll in outpatient benefit coverage, while on the contrary for inpatient coverage. Table 3. Marginal effects of independent variables and price elasticity for every demand function (logistic model) A B C D Male 0.0336 * 0.1036 ** 0.1423 ** 0.0120 Age(older than 45 years old as control) Less than 35 0.0877 ** 0.0721 ** 0.1313 ** 0.0317 35~45 0.0090 0.0168 0.0091 0.0596 ** Education (high school as control) Lower than high school 0.0082 0.0055 0.0255 0.0073 Higher than high school 0.0475 * 0.0255 0.0268 0.0187 Working position (others as control) Manager 0.0248 0.0412 0.0549 * 0.0671 ** Officer 0.0324 0.0833 ** 0.0830 ** 0.0707 ** Worker 0.0005 0.0169 0.0540 * 0.0687 ** Premium (yuan RMB) 0.0322 ** 0.0133 ** 0.0244 ** 0.0025 ** Family s average monthly income per capita(800~1,250 yuan RMB as control) More than 3,500 0.0363 0.0441 0.0456 0.0428 2,000~3,500 0.1133 ** 0.0532 0.0707 * 0.0315 1,250~2,000 0.0317 0.0231 0.0030 0.0150 450~800 0.0126 0.0803 ** 0.0220 0.0390 * Less than 450 0.0844 ** 0.1872 ** 0.0983 ** 0.0053 Self-judgement for out-of-pocket burden of medical expenditures Difficulty 0.0106 0.0467 * 0.0523 ** 0.0529 ** Cannot afford 0.0063 0.0257 0.0782 ** 0.1352 ** Self-assessment of health status Good or very good 0.0520 ** 0.0226 0.0068 0.0255 Poor or very poor 0.0088 0.0299 0.0253 0.0708 ** 9
Having a chronic disease 0.0369 0.0323 0.0658 ** 0.0201 At least having an outpatient visit within the last month 0.0050 0.0610 * 0.0678 * 0.0065 Having a hospitalization stay within half a year 0.0377 0.1677 ** 0.0954 * 0.0246 Drug spending in pharmacy within the last three months(yuan RMB) 0.0002 * 0.00001 0.0004 ** 0.0004 ** Having commercial insurance for himself or his family 0.0843 ** 0.1132 ** 0.0977 ** 0.0429 ** Rational for paying for parts of insurance premium and medical expenditures 0.0667 ** 0.0227 0.0697 ** 0.0530 ** Knowing outpatient reimbursement of basic health insurance plan - - 0.0359 0.0424 ** Knowing inpatient reimbursement of basic health insurance plan 0.0106 0.0331 * - - Package preferred 0.0729 ** 0.0554 ** 0.0096 0.0975 ** Beneficiary of original welfare insurance 0.0211 0.0388 0.1261 ** 0.0337 Having a chronic disease *having an outpatient visit within the last month 0.0688 * 0.0166 0.0575 0.0189 Having a chronic disease *drug spending in pharmacy within the last three months 0.0001 0.0003 * 0.0002 0.0002 (yuan) Price elasticity 0.59 1.19 1.44 3.84 *: p<0.05; **: p<0.01. Package A covered catastrophic risk with very small probability, the demand for which mainly depended on the employees insurance cognition and attitudes. So, besides insurance price and the family s average monthly income per capita, the influencing factors included personal characteristics and insurance cognition, such as age, gender, high education, having commercial insurance for himself or his family, considering rational for self-paying for parts of premium and medical expenditures, and so on. The individuals who had self-assessment of good health status cared more about this kind of high expenditure risk, while those with a chronic disease and often took outpatient visits could decrease his concern on it, the demand probability comparatively lower by 6.9 percentage points. The price elasticity of demand for package A was 0.59. Package B covered hospitalization risk with small probability. Besides the above factors affecting the demand for package A, the experience of health service utilization would have more effect on the demand, especially those having an inpatient stay within the last half a year showed higher demand probability by 17 percentage points. The utilization of outpatient service within the last month, however, would decrease the demand. The employees who had a chronic disease and took self-medication confronted the bigger hospitalization risk and showed a higher demand probability, proportional to the amount of self-medication. Perhaps based on 10
imperfect information about hospitalization expenditures, the understanding of inpatient reimbursement of basic health plan made the probability of demand for package B down by 3.3 percentage points. The price elasticity of demand for package B was 1.19. Package C covered outpatient high expenditure risk with relatively small probability, with the similar characteristics for the demand function. Personal ability to self-pay for out-of-pocket parts of medical expenditures, whether having a chronic disease or not, and the utilization of outpatient service within the last month had more effect on the probability of demand than for package B. Different population groups, such as having different working positions and the government s or enterprise employees, showed the differential probability of demand. The price elasticity of demand for package C was 1.44. Package D covered low-risk outpatient expenditures with big probability. The employees willingness to accept was relatively low because of the big probability and individual accurate expectation of health events occurring and the low additional utility from risk spreading. The demand depended on insurance price, the family s average monthly income per capita, self-judgement of the ability to self-pay for out-of-pocket medical expenditures, insurance cognition, understanding of outpatient reimbursement of basic health plan, working position, and medical expenditure burden potential from self-medication. The individuals with self-assessment of poor health status tended to pay more attention on high-expenditure risk and showed lower probability of demand for this package. The price elasticity of demand for package D was 3.84, full of elasticity. The employee s willingness-to-pay for package E averaged 47.8 yuan RMB, which seemed not proportionally match the extensive coverage of package E for prescription pharmaceuticals and examination beyond basic benefit package. Supply of supplementary health insurance Three plans covering catastrophic diseases, hospitalization for the employees and the retirees of the mutual security fund held by municipal labor union had covered 1.9, 2.5, and 2.2 million employees by the end of 2001, respectively. Because of the short history of NGOs and the lack of operation experience in health insurance, the government support on organization, technology, information, propaganda, and even financial assistance contributed to the success of mutual security fund. Certain mechanisms were being explored to promote the attainable development of non-for-profit mutual security funds deviated from the government support. It s known that Chinese insurance market has a huge potentiality and is experiencing 11
compelling growth. In health insurance, the difficulties from conception, technology and information made commercial companies focus on health plans additional on life insurance, indemnity insurance, and some groups of high-income population. It s rarely observed that health plans developed and marketed by commercial companies could tightly link up with basic health plan and meet the employees different health demand. Duplicate coverage was often seen on some employees. DISCUSSION AND RECOMMENDATIONS As an important part of urban health security system, supplementary health insurance aimed to meet the employees demand for different level of health services and also made a trade-off between the improvement of risk spreading and the containment of moral hazard on the basis of basic health plan. It s very important for supplementary health plan to tightly link up with basic social health insurance, advance the extent and the profundity of risk sharing of medical expenditures, and decline duplicate coverage with basic health plan and between different supplementary health plans, to furthest raise the utilization efficiency of health resources mobilized. Based on the framework of Shanghai s basic health plan, five supplementary packages were designed to measure the employees willingness-to-pay and establish the demand functions. The results showed that these supplementary packages were of different attributes, the demand for which depended not only on their characteristics including the probability of the risk event occurring and the magnitude of the loss resulting from the health event, plan price, and the employee s family income, but also on the employee s insurance cognition, attitudes and obtained information concerned. The price elasticity of the demand ranged from 0.59 to 3.84, which determined differential sensitivity of the demand for these packages to price. The state-owned enterprises were reluctant to provide subsidy for the employees enrollment in supplementary health plans. The insurers were short of technology and information necessary to provide appropriate supplementary health plan tightly linking up with basic health plan. In theory, insurance price determining the demand for health plan referred to loading charge [8], the margin between actual premium and expected spending for the insurer to pay for the benefits covered. The demand function was built for every supplementary package in this study, for which the preconcerted premium was able to substitute the insurance price because of the same pure premium for the identical package. The employee s willingness-to-pay for five supplementary health packages was simultaneously investigated in the field study, which implied the employee s 12
preference could influence the strength and significance exhibition of some variables affecting the demand, such as self-assessment of health status, having a chronic disease or not, and so on. The economic attributes for the supplementary packages elicited from this study, however, were not ultimately influenced. The price elasticities of demand tended to be stable on the condition of the combination change of dependent variables. Adverse selection was an important phenomenon of health insurance market failure [8]. It, however, was not revealed in the demand functions obtained from this study, that is ill-healthy person or who expected to utilize more health services did not tend to purchase more benefits covered. Only self-assessment of health status and no other objective health status indicator was adopted in the study, which could result in the insignificance of adverse selection from subjective difference of health status assessment. On the other hand, adverse selection may be manifested to different extent for the supplementary packages covering differential risks of medical expenditures. The demand functions elicited from this study showed the tendency of more motivation and influencing strength of adverse selection resulting from the more ability of the individual s consumption behaviors to determine medical expenditures. It needs further observation and research for adverse selection in supplementary health insurance market. Supplementary health insurance is a neonatal market-oriented mechanism of risk pooling in China. The promotion and regulation from health policy should adequately consider the attributes of different supplementary health plans. First of all, the market for supplementary health insurance should be clearly defined, where the qualification of the insurers, financial and nonfinancial standards for entry and operation, conditions for insurer exit, reporting requirements and examinations, and consumer protection should consist of the practices of government regulation [12,13]. Second, the propaganda and dissemination of basic health plan, composition and role of health insurance system, health investment conception, and personal health behaviors is useful to elevate the employee conception and cognition of health insurance and attitudes toward health insurance and healthcare utilization, to increase personal information about medical expenditures and risk awareness, and at last to indirectly raise the employee enrollment in supplementary health plans. The government should actively look after feasible incentives to urge the employers and employees to organize and participate in non-for-profit supplementary health plan the employees preferred. The supplementary health plan held by enterprises may fully consider the benefit attributes and the employee wish and set about the plan with higher willingness-to-accept and lower price elasticity, like package A in this study. The employer s spending on health fringe benefits may be used to provide the subsidy for the plan with higher price elasticity. At last, as a result of spillover effects of supplementary health insurance on basic health plan, the administration should make 13
timely adjustment on basic health plan and restrict the benefits provided by supplementary health plan to make a better tradeoff between the raise of risk pooling and the control of moral hazard. The cost containment of supplementary health insurance on the providers of health services depends on basic health plan. So, supplementary health insurance will be promoted from the results of cost decreasing resulting from the control of basic health plan on the providers. References: 1. Gu X.Y. and Tang S.L. Reform of the Chinese health care financing system. Health Policy 1995, 32: 181-191. 2. The State Council. The decision of the State Council on establishing basic health insurance system for urban employees. 1998 3. Shanghai Municipal Government. Basic health insurance plan for urban employees in Shanghai. October, 2000. 4. Selden T.M. More on the economic efficiency of mixed public/private insurance. Journal of Public Economics 1997, 66: 517-523. 5. Petretto A. Optimal social health insurance with supplementary private insurance. Journal of Health Economics, 1999, 18: 727-745. 6. Klose T. The contingent valuation method in health care. Health Policy 1999, 47: 97-123. 7. Diener A., o Brien B., and Gafni A. Health Care Contingent Valuation Studies: A Review and Classification of the Literature. Health Economics 1998, 7: 313-326. 8. Feldstein P.J. Health Care Economics (fifth edition). Delmar Publishers, 1998: 117-162. 9. Gertler P., Sturm R., and Davidson B. Information and the Demand for Supplemental Medical Insurance. NBER Working Paper, series No.4700, April 1994 10. Vistnes J.P. and Banthin J.S. The Demand for Medicare Supplemental Insurance Benefits: The Role of Attitude toward Medical Care and Risk. Inquiry 1997/98 Winter, 34: 311-324. 11. Gujarati D.N. Basic Econometrics, 3 rd edition. McGraw-Hill, 1995 12. Chollet D.J. and Lewis M. Private insurance: principles and practice. World Bank Discussion Paper 365: Innovations in Health Care Financing. Schieber G.J. (ed). Proceedings of a World Bank Conference, March 10-11, 1997: 77-114. 13. Wen Chen. Private health insurance and supplementary insurance. Chinese Health Resources 2001, 4(3): 135-137. 14