Social health insurance consolidation and urban-rural inequality in utilization and financial risk protection in China

Impact of medical insurance integration on reducing urban-rural health disparity: Evidence from China

The urban-rural health disparity poses a significant challenge for countries worldwide. China encounters substantial disparities in healthcare services and health outcomes between urban and rural regions. In 2015, the Chinese government integrated the medical insurance schemes for urban and rural residents into a unified program, with the goal of mitigating the disparities and enhancing the sustainability and efficiency of the medical insurance system. Using data from the China Health and Retirement Longitudinal Study (CHARLS), we explored the impact of this integration on health outcomes and the health disparity between urban and rural residents, employing a triple difference approach with propensity score matching. We found that both urban and rural residents benefited from the medical insurance reform, experiencing improvements in their health outcomes to some extent. Urban residents reported better self-reported health, while rural residents exhibited improved health in terms of both self-reported health and number of diagnosed diseases. Notably, the disparity in activities of daily living (ADL) difficulties decreased. However, we also observed a worsening trend in ADL difficulties, especially among the elderly and the working population. This underscores the urgent need for further attention to health behaviors and healthcare resource allocation to these socio-demographic groups.

Urban-Rural Health Insurance Integration and China's Rural Household Savings

Background

A linchpin to realizing the internal circulation (referring to the domestic cycle of production, distribution and consumption) is reducing residents' saving rate and expanding the domestic needs. However, rural residents in China demonstrate a strong propensity to save money.

Methods

In light of practical characteristics of urban-rural health integration promoted in different places, the three-phase data (from 2014 to 2018) and the dual difference-in-differences model of the China Labor-force Dynamics Survey (CLDS) are used to empirically investigate the impact of urban-rural health insurance integration on rural household savings.

Results

Research reveals that urban-rural health integration can reduce the health risks and medical risks facing rural households, thus weakening the motivation of precautionary savings. The analysis of heterogeneity reveals that the integration of urban-rural health insurance significantly influences the savings rates of households headed by older individuals, particularly women, with lower levels of educational attainment. Besides, the single-tier health insurance system can have a more significant impact, whereas the multi-tier insurance system may not significantly affect the savings rate.

Conclusion

Based on the aforesaid research conclusions, this article believes that in order to reduce the savings rate of rural households and expand consumption, the health insurance system should be further improved.

Medical insurance, vulnerability to poverty, and wealth inequality

Background

China has made remarkable achievements in alleviating poverty under its current poverty standards. Despite these immense successes, the challenge of consolidating these achievements remains. In reality, health risks are among the significant factors causing rural households to fall into poverty, and medical insurance is the significant factor mitigating household vulnerability to poverty. Therefore, alleviating or guarding against households falling into poverty is essential.

Methods

This paper establishes a multi-equilibrium model that incorporates heterogeneous health risks and medical insurance. Through parameter calibration and value function iteration, numerical solutions are derived.

Results

Heterogeneous health risks significantly increase poverty vulnerability and wealth inequality in rural households. Medical insurance, through its investment incentives and loss compensation effects, efficiently mitigates these issues, especially benefiting those in poorer health. Furthermore, the dual-slanted compensation policy efficiently mitigates the adverse effects of "reverse redistribution."

Conclusion

Medical insurance effectively mitigates household vulnerability to poverty and wealth inequality. Government departments must establish health records for residents. By recognizing variations in health conditions, these departments can provide households with poorer health conditions with a higher medical expense compensation ratio. In addition, the government should further focus medical expense reimbursements toward households on the cusp of escaping poverty to ensure that they are not plunged back (or further) into poverty due to medical expenses.

Does basic medical insurance promote public health? Evidence from China family panel study

Background

To promote common prosperity, China government has devoted much financial resources to the basic medical insurance system, it is of great significance to improve the health level of the insured groups to prevent them from returning to poverty due to illness. Whether or not the basic medical insurance can improve health status is an important policy issue after China has win the absolute poverty alleviation movement.

Methods

Based on the data of China Family Panel Studies this paper constructs a strong balanced panel data with two levels information, which including variables from family level and personal level. This paper uses the panel data fixed effect model and propensity score matching model to analysis.

Results

This paper finds that after controlling the family and personal confounding variables, the basic medical insurance has positive effect toward health status. With propensity score matching model, this paper finds that there is causality between basic medical insurance and public health.

Conclusion

Basic medical insurance has a significant health effect, that is, basic medical insurance has a significant positive impact on individual self-rated health. Participating in basic medical insurance can significantly improve the ability of families to face risk shocks, promote the accumulation of health capital in families, promote the diversification of livelihood strategies, and effectively prevent the occurrence of returning to poverty due to illness.

Does the integration of urban and rural health insurance influence the functional limitations of the middle-aged and elderly in rural China?

In January 2016, the Chinese government integrated the two systems of urban resident basic medical insurance and new rural cooperative medical system to establish a unified Urban and Rural Resident Medical Insurance. The integration of medical insurance is purported to enhance access for the rural population; however, a dearth of literature exists regarding its effect on functional impairment among middle-aged and elderly residing in rural areas. This study aims to evaluate the impact of urban-rural health insurance integration on functional limitation among middle-aged and elderly individuals in rural China. A longitudinal survey was conducted among 7855 middle-aged and elderly individuals in rural China. Using a nonequivalent control group pretest-posttest design, we exploit these policy changes to evaluate their impact on middle-aged and elderly individuals' functional limitation. The results showed that the integration of urban and rural health insurance systems was significantly associated with reduced functional limitation (Odds ratio .742; 95%CI 0.603, 0.914) among middle-aged and elderly individuals in rural China. Our findings also indicate that prevalent behaviors such as tobacco use, and alcohol consumption may exacerbate functional limitation among middle-aged and elderly individuals. These findings suggest that the integration of urban and rural health insurance systems can have a positive impact on the functional limitation of middle-aged and elderly individuals in rural China and could be an important factor in improving the health and well-being of middle-aged and elderly individuals in rural areas.

Trends in health service needs, utilization, and non-communicable chronic diseases burden of older adults in China: evidence from the 1993 to 2018 National Health Service Survey

BACKGROUND

Aging is associated with an increased prevalence of non-communicable chronic diseases (NCDs), functional impairments, and diverse demands for health services. This study analyzed the trends in older adults' needs and utilization of health services from 1993 to 2018 in China, as well as chronic disease-related economic burdens.

METHODS

The research data were collected from the six cross-sectional National Health Service Survey (NHSS), implemented every 5 years from 1993 to 2018. A multi-stage stratified random cluster sampling method has been adopted in the NHSS. The data on the older population's socio-economic characteristics, health service needs, and utilization were collected from the 6 waves National Health Service Survey (NHSS) 1993-2018. In the 2013 and 2018 NHSSs, EQ-5D-3L and visual analogue scale were used to evaluate the health condition. And the prevalence of NCDs and related Out-of-pocket (OOP) expenditures were collected. Functional dependency and impairment were collected in 2018. The Katz Activities of Daily Living scale was used to evaluate six functions, including self-feeding, dressing, bathing, transferring, toilet hygiene, and controlling bowel movements.

RESULTS

The two-week morbidity rate and prevalence of NCDs showed a rapid upward trend in older adults. With the development of health system reform and universal health insurance coverage, older adults' two-week medical consultation rate increased from 25.6% in 1993 to 40.1% in 2018, and the hospitalization rate rose from 6.1% to 24.9%. The difference in health service needs and utilization between urban and rural areas decreased, and the hospitalization rate in rural areas (26.3%) exceeded that in urban areas (23.6%) for the first time in 2018. Functional independence become more severe as aged. The proportion of severe functional impairment was 6.9% and 2% in the group aged 80 or over and group 70-79 years, respectively. Regarding disability status, 32.5% had hearing problems and 31.4% had visual impairment. The highest prevalence rates of NCDs in older adults were found in hypertension (36.9%), followed by diabetes (10.6%), cerebrovascular disease (5.4%), ischemic heart disease (4.5%), and intervertebral disc disease (4.2%). The average annual OOP expenditures attributed to NCDs increased from ¥2481.8 RMB in 2013 to ¥8255.9 RMB in 2018 for older adults. About 90.7% of older adults prefer to live in the residential community, leading to the demands for preventive healthcare (30.4%), medical treatment (14.1%), and elderly education (8.6%).

CONCLUSION

The elevated risks of age-related impairments and chronic morbidities, and increased demands for preventive healthcare are critical public health issues. Policymakers should strengthen primary healthcare and move towards integrated delivery to improve access and quality of care for older adults. The integration of healthcare and social security constitutes an adaptive trend in meeting the multi-level demands of an aging society.

Effects of basic medical insurance integration on subjective wellbeing of residents in China: empirical evidence from a quasi-experiment

Introduction

Enhancing the wellbeing of residents through universal health coverage (UHC) is a long-term policy goal for China. In 2016, China integrated the New Rural Cooperative Medical Scheme (NRCMS) and the Urban Resident Basic Medical Insurance (URBMI) into the Urban and Rural Resident Basic Medical Insurance (URRBMI) to address the problem of fragmentation.

Objective

The objective of this study was to investigate whether the integration of basic medical insurance had an impact on the subjective wellbeing of Chinese residents.

Methods

Using the China Household Finance Survey data of 2015 and 2019, we empirically estimated the influence of the integration of basic medical insurance on Chinese residents through the difference-in-difference method based on propensity score matching (PSM-DID).

Results

Our findings indicate that the integration of basic medical insurance improved the subjective wellbeing of the insured population. Additionally, through heterogeneity testing, we validated that the integration increased the subjective wellbeing of residents from less developed regions in West China and rural areas, as well as those with older adult dependents. However, the subjective wellbeing of low-income groups, who were expected to benefit more from the URRBMI, did not improve significantly, at least in the short term.

Conclusion

According to our research, the integration of basic medical insurance in China supports the country's objective of achieving equality and providing universal benefits for its residents. The introduction of the URRBMI has had a positive impact on the subjective wellbeing of insured individuals. This is particularly beneficial for disadvantaged groups in less developed regions, as well as for residents with older adult dependents. However, the subjective wellbeing of the middle-income group has improved significantly, whereas that of the low-income group, despite being the intended beneficiaries of the integration, did not show significant improvement.

Recommendations

From a funding perspective, we recommend establishing a dynamic adjustment funding system that links residents' medical insurance funding standards with their disposable income. Regarding the utilization of the URRBMI, the benefit packages should be expanded, particularly by covering more outpatient services through risk pooling. We call for further research with additional data and continued efforts on improving wellbeing of residents, particularly for disadvantaged populations.

Effects of multimorbidity patterns and socioeconomic status on catastrophic health expenditure of widowed older adults in China

Background

The high multimorbidity and lower socioeconomic status (SES) of older adults, can lead to catastrophic health expenditures (CHEs) for older adults' households. However, whether widowed older adults will bear such a financial burden has yet to be explored. The aim of this study was to investigate the influence of multimorbidity patterns and SES on CHE in Chinese widowed older adults.

Methods

Data was obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS). This is a cross-sectional study. A total of 1,721 widowed participants aged 60 years and older were enrolled in the study. Latent class analysis was performed based on 14 self-reported chronic diseases to identify multimorbidity patterns. The logistic model and Tobit model were used to analyze the influence of multimorbidity patterns and SES on the incidence and intensity of CHE, respectively.

Results

About 36.72% of widowed older adults generated CHE. The incidence and intensity of CHE were significantly higher in the cardiovascular class and multisystem class than in the minimal disease class in multimorbidity patterns (cardiovascular class, multisystem class, and minimal disease class). Among SES-related indicators (education, occupation and household per capita income), respondents with a middle school and above education level were more likely to generate CHE compared to those who were illiterate. Respondents who were in the unemployed group were more likely to generate CHE compared to agricultural workers. In addition, respondents aged 70-79 years old, geographically located in the east, having other medical insurance, or having fewer family members are more likely to generate CHE and have higher CHE intensity.

Conclusion

Widowed older adults are at high risk for CHE, especially those in the cardiovascular and multisystem disease classes, and those with low SES. Several mainstream health insurances do not provide significant relief. In addition, attention should be paid to the high-risk characteristics associated with CHE. It is necessary to carry out the popularization of chronic disease knowledge, improve the medical insurance system and medical service level, and provide more policy preferences and social support to widowed older adults.

Does the immediate reimbursement of medical insurance reduce the socioeconomic inequality in health among the floating population? Evidence from China

BACKGROUND

Enhancing health intervention for floating populations has become an essential aspect of public health around the world. China launched a policy reform aimed at implementing immediate reimbursement for trans-provincial inpatient treatments. The objective of this study was to investigate the effects of this policy change on socioeconomic inequality in health among the floating population.

METHODS

This study used two waves of individual-level data from the China Migrants Dynamic Survey (CMDS) collected in 2017 and 2018 as well as administrative hospital data at the city level. The sample included 122061 individuals and 262 cities. Under a quasi-experimental research design, we built up the framework to employ the generalized and multi-period difference-in-differences estimation strategy. We used the number of qualified hospitals that could provide immediate reimbursement to represent the degree and intensity of the implementation of this policy change. We also calculated the Wagstaff Index (WI) to measure socioeconomic inequality in health.

RESULTS

This policy change and income level had a negative joint impact on the health status of floating population (odds ratio = 0.955, P < 0.01), that is, the lower the income, the better the number of qualified hospitals' effect on health improvement. Furthermore, as the number of qualified tertiary hospitals increased, the health inequality would decrease significantly on average at the city level (P < 0.05). In addition, inpatient utilization as well as total expenditure and reimbursement significantly improved after the policy change, and the magnitude of increase was greater in the relatively lower-income group (P < 0.01). Finally, only inpatient spending could obtain immediate reimbursement in the early stage, thus, compared with primary care, these impacts were greater in tertiary care.

CONCLUSIONS

Our study revealed that after the implementation of immediate reimbursement, the floating population could obtain greater and more timely reimbursement, which significantly increased its inpatient utilization, promoted health, and reduced the health inequality caused by socioeconomic factors. These results suggest that a more accessible and friendly medical insurance scheme should be promoted for this group.

The impact of integrated urban and rural resident basic medical insurance on health service equity: Evidence from China

Background

Many countries and regions worldwide are improving their healthcare systems through the integration and unification of health insurance programs covering different groups of people. In China, the past 10 years has been the time when Chinese government promote the Urban and Rural Residents Basic Medical Insurance (URRBMI) by integrating the Urban Residents' Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS).

Objectives

To evaluate the impact of the URRBMI on equity in relation to health services.

Methods

The quantitative data used in this study were obtained from the CFPS 2014–2020 database, and all respondents with health insurance type UEBMI, URBMI, and NRCMS were included. UEBMI respondents were set as the control group and URBMI or NRCMS as the intervention group, and a DID method model was used to analyze the impact of integrating health insurance on health service utilization, costs and health status. Heterogeneity analysis was also conducted after stratifying the sample according to income level and chronic disease status. This was done to investigate whether there were differences in the effects of the integrated health insurance program across different social groups.

Results

The implementation of URRBMI is found to be associated with a significant increase in inpatient service utilization (OR = 1.51, P &lt; 0.01) among rural Chinese residents. Regression results by income stratum show that the utilization of inpatient services increased in rural areas for high-, middle- and low-income groups, with the fastest increase (OR = 1.78, P &lt; 0.05) emerging for low-income groups. Analysis by chronic disease status shows that rural residents with chronic disease are associated with a higher increase in hospitalization rates (OR = 1.64, P &lt; 0.01).

Conclusion

The implementation of URRBMI is found to have improved health insurance's ability to withstand risks and effectively improve access to health services for rural residents. In this regard, it can be considered as playing a positive role in bridging the gap in health service utilization between rural and urban areas and in improving regional equity.

The efficient moral hazard effect of health insurance: Evidence from the consolidation of urban and rural resident health insurance in China

Ex post moral hazard, the additional healthcare utilization induced by health insurance, can be decomposed into an efficient portion generated by the income effect and an inefficient portion caused by the substitution effect, which has been discussed theoretically, but few studies have provided evidence of the efficient moral hazard. In 2016, the Chinese government launched the consolidation of urban and rural resident health insurance at the national level. After the consolidation, insurance benefits for nearly 800 million rural residents got improved. This paper uses a nationally-representative sample of 30,972 individuals from the China Health and Retirement Longitudinal Study (2011-2018) and adopts a 2-step empirical approach with the difference-in-differences method and the fuzzy regression discontinuity design to estimate the efficient moral hazard in the consolidation among rural residents. We find that the price shock contained in the consolidation increases inpatient care utilization, and the corresponding price elasticity is between -0.68 and -0.62. Further analysis shows that the efficient moral hazard resulting in welfare gains accounts for 43.33%-66.36% of the additional healthcare utilization. These findings highlight the necessity of evaluating the efficient moral hazard when analyzing the cost-benefit of health insurance reform.

Economic growth and household energy footprint inequality in China

There are significant differences in energy footprints among individual households. This study uses an environmentally extended input-output approach to estimate the per capita household energy footprint (PCHEF) of 10 different income groups in China's 30 provinces and analyzes the heterogeneity of household consumption categories, and finally measures the energy equality of households in each province by measuring the energy footprint Gini coefficient (EF-Gini). It is found that the energy footprint of the top 10% income households accounted for about 22% of the national energy footprint in 2017, while the energy footprint of the bottom 40% income households accounted for only 24%. With the growth of China's economy, energy footprint inequality has declined spatially and temporally. Firstly, wealthier coastal regions have experienced greater convergence in their energy footprint than poorer inland regions. Secondly, China's household EF-Gini has declined from 0.38 in 2012 to 0.36 in 2017. This study shows that China's economic growth has not only raised household income levels, but also reduced energy footprint inequality.

Association between multimorbidity patterns and catastrophic health expenditure among Chinese older adults living alone

BACKGROUND

Multimorbidity is prevalent among older adults and may result in catastrophic health expenditures (CHEs) on older adults' households. However, whether older adults living alone suffer such a financial burden is unknown. We aimed to investigate the association between multimorbidity patterns and CHE in Chinese older adults living alone.

METHODS

We included 884 participants aged 60 years and over and living alone from the 2018 wave of the China Health and Retirement Longitudinal Study (CHARLS). Latent class analysis was performed to identify multimorbidity patterns based on 14 self-reported chronic diseases. The logit model and Tobit model were adopted to analyze the association of multimorbidity patterns with the incidence and intensity of CHE, respectively.

RESULTS

Approximately 20.2% of the older adults living alone experienced CHE. Among the four multimorbidity groups (minimal disease, cardiovascular, lung and asthma, and multisystem), the multisystem group and cardiovascular group had significantly higher incidence and intensity of CHE than the minimal disease group.

CONCLUSIONS

Older adults living alone had high risks of CHE, especially those belonging to the multisystem pattern and cardiovascular pattern. Integrated care should be adopted in the treatment of multimorbidity to reduce health costs. More elder services and social assistance should be provided to solitary older adults with certain patterns of multimorbidity.

Is air pollution politics or economics? Evidence from industrial heterogeneity

This paper checks the asymmetrical impact of Beijing's and Shanghai's air quality (AQ) on cross-industries stock returns (SR) by using the quantile-on-quantile (QQ) regression method. The major empirical findings as shown as followings. There are heterogeneous responses from SR to AQ within the same city. Different links are discovered for Beijing and Shanghai within the same industry. Air pollution does not have political or economic properties for all industries. Our research provides useful contributions compared with past literature. First of all, we distinguish whether air pollution is political or economic. Apart from psychology and physiology, government intervention and economic expectation are also important components in interpreting the influence from AQ to SR. Second, this study adequately considers the heterogeneity of industries. Industries differently react to the identical extrinsic shock, depending on the nature of their industry. Besides, the QQ approach captures quantile-varying relationship between variables, and does not need to consider structural fracture and time lag effects. The practical significance is that investors need to focus on national industrial policies, and avoiding biased decisions in stock market from air pollution.

Disease burden of ageing, sex and regional disparities and health resources allocation: a longitudinal analysis of 31 provinces in Mainland China

OBJECTIVES

To measure the disease burden of ageing based on age-related diseases (ARDs), the sex and regional disparities and the impact of health resources allocation on the burden in China.

DESIGN

A national comparative study based on Global Burden of Diseases Study estimates and China's routine official statistics.

SETTING AND PARTICIPANTS

Thirty-one provinces of Mainland China were included for analysis in the study. No individuals were involved.

METHODS

We first identified the ARDs and calculated the disability-adjusted life years (DALYs) of ARDs in 2016. We assessed the ARD burden disparities by province and sex and calculated the provincial ARD burden-adjusted age. We assessed historical changes between 1990 and 2016. Fixed effects regression models were adopted to evaluate the impact of health expenditures and health workforce indicators on the ARD burden in 2010-2016.

RESULTS

In 2016, China's total burden of ARDs was 15 703.7 DALYs (95% uncertainty intervals: 12 628.5, 18 406.2) per 100 000 population. Non-communicable diseases accounted for 91.9% of the burden. There were significant regional disparities. The leading five youngest provinces were Beijing, Guangdong, Shanghai, Zhejiang and Fujian, located on the east coast of China with an ARD burden-adjusted age below 40 years. After standardising the age structure, western provinces, including Tibet, Qinghai, Guizhou and Xinjiang, had the highest burden of ARDs. Males were disproportionately affected by ARDs. China's overall age-standardised ARD burden has decreased since 1990, and females and eastern provinces experienced the largest decline. Regression results showed that the urban-rural gap in health workforce density was positively associated with the ARD burdens.

CONCLUSION

Chronological age alone does not provide a strong enough basis for appropriate ageing resource planning or policymaking. In China, concerted efforts should be made to reduce the ARDs burden and its disparities. Health resources should be deliberately allocated to western provinces facing the greatest health challenges due to future ageing.