Carlos Arriaga Costa 1 Economia da Segurança Social Unidade 08 - Procura e oferta de segurança social. Modelos de segurança social.

Carlos Arriaga Costa2 Uma protecção social Uma protecção social eficiente deve contribuir para um welfare condigno! eficiente deve contribuir para um welfare condigno! Que oferta de protecção social? Que oferta de protecção social? Como reage a procura?

Carlos Arriaga Costa3. Descrever variaveis da oferta de protecção social e da procura.. Compreender a elasticidade da oferta e da procura na protecção social relativamente ao preço dos serviços de protecção social. compreender os equilíbrios em protecção social Resultados de aprendizagem desta unidade

Carlos Arriaga Costa4 Interacções da oferta e da procura A construção das funções de oferta da protecção social levanta problemas de ordem metodológica e conceptual: A construção das funções de oferta da protecção social levanta problemas de ordem metodológica e conceptual: 1. O seguro de doença provoca um estimulo mas também um racionamento na procura de cuidados de saúde. 1. O seguro de doença provoca um estimulo mas também um racionamento na procura de cuidados de saúde. A evolução das cotizações de saúde e de prestações de reforma explicam-se em parte por considerações eleitorais. A evolução das cotizações de saúde e de prestações de reforma explicam-se em parte por considerações eleitorais.

Carlos Arriaga Costa5 Interacções da oferta e da procura Como surge a oferta de protecção social? Como surge a oferta de protecção social? Que produtos estão incluídos nessa oferta? Que produtos estão incluídos nessa oferta? Como se mede a oferta? Como se mede a oferta? Em que consistem os preços dos serviços oferecidos? Em que consistem os preços dos serviços oferecidos?

Carlos Arriaga Costa6 Estimulo e racionamento da procura A oferta e procura de um bem subvencionado com preço administrativo fixado pode levar a um racionamento da procura ou da oferta. A oferta e procura de um bem subvencionado com preço administrativo fixado pode levar a um racionamento da procura ou da oferta. A oferta e procura de cuidados subvencionados a preços livres pode levar a uma desslocação da curva de procura para a direita ( o preço aumenta e a procura tambem) A oferta e procura de cuidados subvencionados a preços livres pode levar a uma desslocação da curva de procura para a direita ( o preço aumenta e a procura tambem)

Carlos Arriaga Costa7 Q0 * Bem subvencionado Q1 M3 M2 P0 P preço procura oferta Preços administrativos subvencionados

Carlos Arriaga Costa8 P PREÇO PAGO AO PRODUTOR DE UM BEM DE SAUDE FIXADO ADMNISTRATIVAMENTE P PREÇO PAGO AO PRODUTOR DE UM BEM DE SAUDE FIXADO ADMNISTRATIVAMENTE M TAXA MODERADORA (pago pelo consumidor) M TAXA MODERADORA (pago pelo consumidor) P-M Pago pelo seguro ou pelo Estado e funciona como uma subvenção que faz diminuir o preço pago pelo consumidor P-M Pago pelo seguro ou pelo Estado e funciona como uma subvenção que faz diminuir o preço pago pelo consumidor

Carlos Arriaga Costa9 O problema fiscal Em consequência da despesa publica nos anos 1970s e 1980s, os paises europeus são caracterizados por: Em consequência da despesa publica nos anos 1970s e 1980s, os paises europeus são caracterizados por: –Divida publica elevada. –Impostos elevados para financiar o welfare state. Devido a um crescimento mais lento que o previsto e uma taxa de desemprego crescente na maior parte dos paises europeus, as reformas fiscais requeridas pelo tratado de Maastricht têm sido difíceis de implementar. Em consequência: Devido a um crescimento mais lento que o previsto e uma taxa de desemprego crescente na maior parte dos paises europeus, as reformas fiscais requeridas pelo tratado de Maastricht têm sido difíceis de implementar. Em consequência: –A maior parte das alterações têm sido de curto prazo. Em alguns casos simples ajustamentos contabilísticos. Os problemas fiscais de longo prazo não têm sido resolvidos.

Carlos Arriaga Costa10 Limites sobre a política fiscal: Limites sobre a política fiscal: –Significante sobre o imposto de capitais. –Principio geral – a taxa de imposição deve estarbrelacionada com a elasticidade da oferta. –A globalização tem aumentado elasticidade da oferta de capital devido à forte mobilidade de capital –Menos importante quando o imposto é baseado mais na cidadania do que na residencia e quando há uma forte percepção da cidadania por parte da população. Todavia, com a globalização existe uma maior flexibilidade no que respeita à cidanania e à residência. –A globalização tem aumentado a elasticidade de oferta de trabalhadores qualificados mas essa elasticidade tende a ser menor que a elasticidade de oferta de capital. Globalização e os limites à redistribuição

Carlos Arriaga Costa11 Globalização e os limites à redistribuição O efeito pode ser perverso pois há um elemento importante na redistribuição nos programas do sector público: O efeito pode ser perverso pois há um elemento importante na redistribuição nos programas do sector público: –Segurança social (pensões de velhice) e cuidados de saude. –Pode contribuir para forçar a privatização de funções públicas. Implicações importantes no desenvolvimento das sociedades: Implicações importantes no desenvolvimento das sociedades: Pode afectar o bem estar social e o crescimento económico. Pode afectar o bem estar social e o crescimento económico. –Actividades com potencial são tambem as de maior risco, tomadas de posição em risco podem afectar a segurança social…

Carlos Arriaga Costa12 Sistemas de pensões e de saude generosos associados a um envelhecimento da população causaram: Sistemas de pensões e de saude generosos associados a um envelhecimento da população causaram: –Um passivo crescente no sistema de pagamentos de pensões do sector publico –Um passivo crescente no sistema de pagamentos de despesas de saude do sector publico –Problemas no financiamento do welfare state o qual é dificil de eliminar devido a interesses vários.

Carlos Arriaga Costa13 Procura de protecção social A procura de serviços de saude é menos elastica que de outros bens A procura de serviços de saude é menos elastica que de outros bens Quanto maior a oferta tambem maior a procura... Quanto maior a oferta tambem maior a procura... Depende mais de uma situação estrutural que conjuntural Depende mais de uma situação estrutural que conjuntural

Carlos Arriaga Costa14 Procura de protecção social - Função de procura de serviços de saude (estudo empírico : An Economic Analysis of Health Care in China, Gregory C Chow, Princeton University,June 8, 2006) The amount of health care services measured in 1995 prices q = health care expenditure /relative price index of health care service table The amount of health care services measured in 1995 prices q = health care expenditure /relative price index of health care service table table Regression of lnq on lny and lnp based on the 9 annual observations from 1995 to 2003 yields: Regression of lnq on lny and lnp based on the 9 annual observations from 1995 to 2003 yields: lnq =1.194(.382) lny–0.730(.241) lnp–4.831(4.027) lnq =1.194(.382) lny–0.730(.241) lnp–4.831(4.027) R2/s = 0.620/ (1) R2/s = 0.620/ (1) next next next

Carlos Arriaga Costa15 2. Changes in Health Care System §Institutions before 1980’s 2. Changes in Health Care System §Institutions before 1980’s A cost-effective three-tear health care system improved the health of the Chinese people: A cost-effective three-tear health care system improved the health of the Chinese people:.reduction of diseases.reduction of diseases.decline in the annual death rate.decline in the annual death rate 17 per 1000 population in 1952→6.34 per 1000 in per 1000 population in 1952→6.34 per 1000 in 1980.increase in life expectancy.increase in life expectancy early 1950s: 40.8 years→ early 1960s: 49.5 years → late 1970s: early 1950s: 40.8 years→ early 1960s: 49.5 years → late 1970s: 65.3 years 65.3 years

Carlos Arriaga Costa16 § Institutions since 1980’s § Institutions since 1980’s Rural: Rural:.Privatization of farming led essentially to the abandonment of public health provided by the government..Privatization of farming led essentially to the abandonment of public health provided by the government. Urban: Urban:.Privatization of state-owned enterprises was a very slow process that took over two decades..Privatization of state-owned enterprises was a very slow process that took over two decades..The government tried to provide a substitute for the public provision of health care through the state-owned enterprises..The government tried to provide a substitute for the public provision of health care through the state-owned enterprises.

Carlos Arriaga Costa17 Time-Series Data on Aggregate Demand for Health Care YearConsumer Price Index GDP Price index of healthcare Govern- ment revenue Total consumption expenditure Quantity of health services services

Carlos Arriaga Costa18 § Health Care Expenditures and Funding Resources § Health Care Expenditures and Funding Resources

Carlos Arriaga Costa19 Estimating Income Elasticity with Cross-section Data Regressing the log of medical expenditure per capita on the log of total expenditure per capita yields table : Regressing the log of medical expenditure per capita on the log of total expenditure per capita yields table : table total expenditure elasticity se Adj-R2 total expenditure elasticity se Adj-R2 Urban Urban Rural Rural Corresponding data for 2003 yield similar total expenditure elasticities. Corresponding data for 2003 yield similar total expenditure elasticities. next next next

Carlos Arriaga Costa20 Cross-section data on per capita health expenditure and total expenditure in 2002 Low income households Lower Middle income households Middle income households Upper middle income households High income households Urban: Total expenditur es Medicine and medical services Rural: Total expenditur es Medicine and medical services

Carlos Arriaga Costa21 Price Elasticity by Combining Cross- section and Time Series Data Take an average of and or as our estimate of income elasticity of demand for health care, which is close to the estimate based on time series data alone as reported in equation (1) Take an average of and or as our estimate of income elasticity of demand for health care, which is close to the estimate based on time series data alone as reported in equation (1) Use time series data to estimate the price elasticity : Use time series data to estimate the price elasticity : (lnq lny) = (.047) lnp (.033) (lnq lny) = (.047) lnp (.033) R2/s = / (2) R2/s = / (2) Price elasticity is Price elasticity is 0.636

Carlos Arriaga Costa22 Income and elasticity by Provincial Data for Urban and Rural Residents Adding lnp to both sides of equation (1) yields Adding lnp to both sides of equation (1) yields ln(pq) = c + a lny + (1- b) ln p + e ---- (3) ln(pq) = c + a lny + (1- b) ln p + e ---- (3) If the lnp on the right-hand side of (3) is uncorrelated with lny, using provincial data on health care expenditure from CSY 2005, we have : If the lnp on the right-hand side of (3) is uncorrelated with lny, using provincial data on health care expenditure from CSY 2005, we have : Urban: ln(pq) = (1.415) (0.154) lny R 2 = Urban: ln(pq) = (1.415) (0.154) lny R 2 = Rural: ln(pq) = (1.299) (0.163) lny R 2 = Rural: ln(pq) = (1.299) (0.163) lny R 2 = The average of the above two income elasticities is ( )/2= The average of the above two income elasticities is ( )/2=1.041.

Carlos Arriaga Costa23 § Inequality in Health Care Spending from Regression Analysis s(lnpq) = (a/R)s(lny) s(lnpq) = (a/R)s(lny) For urban residents across provinces, the factor a/R equals 0.919/0.742 or For rural residents it is 1.162/0.799 or (in 2004 ) For urban residents across provinces, the factor a/R equals 0.919/0.742 or For rural residents it is 1.162/0.799 or (in 2004 ) Inequality in medical expenditure is larger than inequality in income across provinces for both urban and rural residents. Inequality in medical expenditure is larger than inequality in income across provinces for both urban and rural residents. The ratio of inequality for rural residents is higher partly because the rural residents have a higher income elasticity of demand for medical expenditure. The ratio of inequality for rural residents is higher partly because the rural residents have a higher income elasticity of demand for medical expenditure.

Carlos Arriaga Costa24 4.Government’s Program for Health Care § On Demand Side "Decision on Health Reform and Development by the Central Party Committee and State Council." (January 15, 1997) "Decision on Health Reform and Development by the Central Party Committee and State Council." (January 15, 1997) Basic objective : to insure that every Chinese will have access to basic health protection. Basic objective : to insure that every Chinese will have access to basic health protection. Rural : to develop and improve CMS through education, by mobilizing more farmers to participate and gradually expanding its coverage; 40 yuan subsidy per account. Rural : to develop and improve CMS through education, by mobilizing more farmers to participate and gradually expanding its coverage; 40 yuan subsidy per account. Urban ： a basic medical insurance system was established in 1998, financed by 6 ％ of the wage bill of employing units and 2 ％ of the personal wages. Urban ： a basic medical insurance system was established in 1998, financed by 6 ％ of the wage bill of employing units and 2 ％ of the personal wages.

Carlos Arriaga Costa25 § On Supply Side In 2004 the government is in the process of allowing some hospitals in urban and rural areas to be run privately to reduce the burden to the government. In 2004 the government is in the process of allowing some hospitals in urban and rural areas to be run privately to reduce the burden to the government.

Carlos Arriaga Costa26 5. Supply of Health care and Prospects for Future Development § Constant Supply The amount of health care supplied remained approximately constant between 1989 and 2003(as with the quantity q in Table 2). The amount of health care supplied remained approximately constant between 1989 and 2003(as with the quantity q in Table 2).

Carlos Arriaga Costa27 Changeof No. ofDoctorsand No.Graduat es YearNumber of Doctors 1000’s Number of Graduates 1000’s Retirees (1/35 No. in year before) Estimated Increase in No. Doctors Actual Increase in No. Doctors Implie d % of Retire ment

Carlos Arriaga Costa28 § Shift of Health Resources from Rural to Urban Population In 2001 the number of health clinics in villages and townships was reduced by 1139; the number of doctors and health care personnel was reduced by 30,000. In 2001 the number of health clinics in villages and townships was reduced by 1139; the number of doctors and health care personnel was reduced by 30,000. From 1990 to 2000, government spending in total health care spending in rural areas was reduced from 12.5 percent to 6.6 percent. From 1990 to 2000, government spending in total health care spending in rural areas was reduced from 12.5 percent to 6.6 percent. The shifts in relative demand in favor of urban residents who could afford to pay and received more government funding for medical care resulted in the shifts of supply to the urban residents at the expense of rural residents. The shifts in relative demand in favor of urban residents who could afford to pay and received more government funding for medical care resulted in the shifts of supply to the urban residents at the expense of rural residents.

Carlos Arriaga Costa29 § Forecast of Rate of Increase in the Supply of Doctors Assuming the number of doctors in the next few years to be 2400 thousand (with 160 thousand graduates per year, and number of graduates to be 200 thousand per year. Assuming the number of doctors in the next few years to be 2400 thousand (with 160 thousand graduates per year, and number of graduates to be 200 thousand per year. The number retired will be 2400/35 = thousand, resulting in a net increase of 200 – = thousand, or a rate of increase of /2400 = The number retired will be 2400/35 = thousand, resulting in a net increase of 200 – = thousand, or a rate of increase of /2400 = After subtracting annual population increase of we obtain a rate of increase of This is substantially less than the increase in demand due to increase in real income. After subtracting annual population increase of we obtain a rate of increase of This is substantially less than the increase in demand due to increase in real income.

Carlos Arriaga Costa30 7. Conclusions We have estimated an income elasticity of demand for health services to be unity for urban population and slightly above unity for rural population, and a price elasticity of about 0.6 by combining cross-section and time-series data. We have estimated an income elasticity of demand for health services to be unity for urban population and slightly above unity for rural population, and a price elasticity of about 0.6 by combining cross-section and time-series data. Demand analysis can explain the increase in expenditure on healthcare and the increase in price as income increases given limited supply. It also explains the increase in the ratio of health expenditure to GDP. Demand analysis can explain the increase in expenditure on healthcare and the increase in price as income increases given limited supply. It also explains the increase in the ratio of health expenditure to GDP. There is large inequality in health expenditure per capita between the urban and the rural population associated with income inequality. There is large inequality in health expenditure per capita between the urban and the rural population associated with income inequality. Rapid increase in income and government support account for much better healthcare for the urban population. Rapid increase in income and government support account for much better healthcare for the urban population. A market economy in rural China fails to provide as much health care as under the former collectively managed and collectively paid system. The government is attempting to reintroduce features of this system, with results yet uncertain. A market economy in rural China fails to provide as much health care as under the former collectively managed and collectively paid system. The government is attempting to reintroduce features of this system, with results yet uncertain.