Does the critical illness insurance reduce patients' financial burden and benefit the poor more: a comprehensive evaluation in rural area of China

Can Social Health Insurance Improve Mental Health? An Analysis of Supplementary High-Cost Illness Insurance in China

OBJECTIVES

China introduced an innovative Supplementary High-Cost Illness Insurance (SHCII) program to enhance existing social health insurance by providing extra financial support for individuals facing catastrophic illnesses in 2015. The SHCII has notably increased access to healthcare and alleviated financial strain for economically disadvantaged individuals. However, there is a lack of information regarding the program's impact on the mental health of its beneficiaries. This study aims to assess the impact of SHCII on the mental well-being of middle-aged and older individuals.

METHODS

Using data from the China Health and Retirement Longitudinal Study (2011, 2013, 2015, and 2018), this study examined how SHCII affects mental health among middle-aged and older individuals in China using propensity score matching with the time-varying difference-in-differences method.

RESULTS

We found that SHCII implementation can significantly reduce the Center for Epidemiologic Studies-Depression Scale scores of middle-aged and older individuals. This reduction was more pronounced among older individuals with poor self-rated health, chronic disease, and low household wealth when compared to their counterparts.

DISCUSSION

The implementation of SHCII has had a significant and positive impact on mental health outcomes. We recommend that governments consider expanding the program to other areas within China, focusing especially on the most economically disadvantaged segments of the population.

Association Between Temporary Employment and Gradient Health Outcomes Among Chinese Workers

Temporary workers' health problems in China have raised concerns recently. This study aimed to assess the relationship between temporary employment and three health outcomes with gradient severity and explore mediating mechanisms. Data was obtained from a national cross-sectional survey (China General Social Survey 2018). Compared with regular workers, temporary workers reported more frequent mood disorders (β = 0.197) and disturbance of daily activities (β = 0.132), however, there was no significant difference in serious health risks (inpatient treatment) between temporary and regular workers. Income poverty, subjective social status, and family relative socioeconomic status were significant mediators. The results suggest that temporary workers have higher general health risks, and economic deprivation is the main mechanism. Therefore, Chinese policymakers should provide more inclusive preventive health services beyond the existing health care system focused on critical illness to reduce the general health risks of grassroots workers.

Healthcare Expenditures among the Elderly in China: The Role of Catastrophic Medical Insurance

China has been piloting the catastrophic medical insurance (CMI) program since 2012 and rolled it out nationally in 2016 to reduce the incidence of catastrophic health expenditure among Chinese residents. Few studies have been conducted to determine its effect on healthcare expenditures, particularly among the elderly. The purpose of this study is to examine the effect of CMI on healthcare expenditures among China's elderly population. The data for this study were derived from 4 waves of the Chinese Longitudinal Healthy Longevity Survey, which included 344 and 1199 individuals in the treatment and control groups, respectively. To examine the effect of CMI on healthcare expenditures among the elderly, we used difference-in-differences and fixed-effects models. Additionally, a heterogeneity analysis was used to examine the differences in the impact of CMI on different groups. Finally, we confirmed the robustness of the results using robustness and placebo tests. CMI increased total health and out-of-pocket expenditures significantly, as well as inpatient and corresponding out-of-pocket expenditures. The reassults of the heterogeneity analysis indicated that CMI had a greater impact on elderly residents of rural areas. Economic burden protection has been enhanced for low-income groups and patients with serious diseases over the last two years. Our research indicated that CMI can promote the use of inpatient medical services for the elderly to a certain extent. Targeted measures such as expanding the CMI compensation list, establishing a more precise compensation scheme, and specific diseases associated with high healthcare expenditures can be considered in the practice of CMI implementation.

Participating in health insurance and health improvements for the relatively poor population: A propensity score analysis

This study examined the causal relationship between participation in the New Rural Cooperative Medical Scheme (NRCMS) and health status among relatively poor population in rural China. Data were obtained from the China Family Panel Studies (CFPS) conducted in 2018, which contained 4,507 samples. This study used propensity score matching (PSM) to examine the net effect of participation in the NRCMS on the health of the relatively poor population, and this effect was tested for equilibrium using nearest neighbor matching, radius matching, and kernel matching. This study showed that participation in the NRCMS has a significant and positive effect on the health status of the relatively poor population and the positive health effect may come from three channels, including the increased frequency of physical activity, the fact that an individual is more likely to seek medical care at a lower level of visit, and a plan to reduce health care expenditures.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China

Background

The Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China.

Methods

A total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality.

Results

The horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and −28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: −73.51 and −54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: −4.60 and −0.90%, respectively.

Conclusions

The findings showed that the “equal treatment in equal need” principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

Does Health Insurance Lead to Improvement of Health Status Among Chinese Rural Adults? Evidence From the China Family Panel Studies

The purpose of this study is to examine the causal relationship between the New Rural Cooperative Medical Scheme (NRCMS) and health status among Chinese rural adults. The data were drawn from China Family Panel Studies performed in 2016, involving 2,093 rural adults. Furthermore, this study employed k-nearest neighbor matching out of propensity score matching (PSM) to investigate the impact of NRCMS on health status among rural adults. Moreover, radius matching, kernel matching, and nearest-neighbor matching within caliper out of PSM were adopted to conduct sensitivity analyses. This study demonstrates that NRCMS enrollment has had a significant and positive effect on the self-assessed and mental health of rural adults, and the health effect shows significant age and income disparities. Moreover, the positive health effect may result from 2 channels, including the increase of health services utilization and the fact that adults with NRCMS are more likely to seek health care in lower-level medical institutions.

Benefit of China's Social Health Insurance Schemes: Trend Analysis and Associated Factors Since Health Reform

With the deepening of health insurance reform in China, the integration of social health insurance schemes was put on the agenda. This paper aims to illustrate the achievements and the gaps in integration by demonstrating the trends in benefits available from the three social health insurance schemes, as well as the influencing factors. Data were drawn from the three waves of the China Health and Nutrition Survey (2009, 2011, 2015) undertaken since health reforms commenced. χ2, Kruskal-Wallis test, and the Two-Part model were employed in the analysis. The overall reimbursement rate of the Urban Employee Basic Medical Insurance (UEBMI) is higher than that of Urban Resident Basic Medical Insurance (URBMI) or the New Rural Cooperative Medical Scheme (NRCMS) (p < 0.001), but the gap has narrowed since health reform began in 2009. Both the outpatient and inpatient reimbursement amounts have increased through the URBMI and NRCMS. Illness severity, higher institutional level, and inpatient service were associated with significant increases in the amount of reimbursement received across the three survey waves. The health reform improved benefits covered by the URBMI and NRCMS, but gaps with the UEBMI still exist. The government should consider more the release of health benefits and how to lead toward healthcare equity.

Economic crisis of rural patients insured with critical illness insurance: Do working-age patients have higher financial burden?

Working-age patients are generally found to have higher healthcare expenditure than elder. China implemented critical illness insurance (CII) in 2012 to decrease the medical expenditure of patients. The aim of this study was to determine if the economic burden of rural working-age patients with CII was more serious than other age groups. A questionnaire survey was undertaken in two counties of central and western China in 2017. Comprehensive financial measurement was used, including direct costs, indirect costs and medical debt rate. All data collected were used for descriptive statistics and multivariate variance analysis. Linear regression with random effect analysis upon area was used to evaluate the differences in ages. A total of 834 rural patients were surveyed in this study. Patients aged 18-44 years had the highest lodging and food payments (3,838 Chinese Yuan [CNY]), work loss (15,350 CNY) and medical debt rate (83.24%). Patients who were of working age, sought health services out of counties, had longer length of stay, and were diagnosed with chronic illness had higher healthcare expenditure. Rural working-age patients with CII had higher direct and indirect costs, which were attributed to medical debt. The increased service capability of hospitals in counties and improved medical financial assistance may also be issues of concern.

Effect of critical illness insurance on the medical expenditures of rural patients in China: an interrupted time series study for universal health insurance coverage

OBJECTIVE

The objective of this study is to determine if critical illness insurance (CII) promotes the universal health coverage to reduce out-of-pocket (OOP) medical expenditures and improve the effective reimbursement rate (ERR) in rural China.

STUDY DESIGN

The 5-year monthly hospitalisation data, starting 2 years before the CII (ie, the 'intervention') began, were collected. Interrupted time series analysis models were used to evaluate the immediate and gradual effects of CII on OOP payment and ERR.

SETTING

The study was conducted in Xiantao County, Hubei Province, China.

PARTICIPANTS

A total of 511 221 inpatients within 5 years were included in the analysis.

RESULTS

In 2016, 100 288 patients received in-patient services, among which 4137 benefited from CII. After the implementation of CII, OOP expenses increased 32.2% (95% CI 24.8% to 39.5%, p<0.001). Compared with the preintervention periods, the trend changes decline at a rate of 0.7% per month after the implementation of CII. Similarly, a significant decrease was observed in log ERR after the intervention started. The rate of level change is 16% change (95% CI -20.0% to -12.1%, p<0.001).

CONCLUSION

CII did not decrease the OOP payments of rural inpatients in 2011-2016 periods. The limited extents of population coverage and financing resources can be attributed to these results. Therefore, the Chinese government must urgently raise the funds of CII and improve the CII policy reimbursement rate.

Unmet Healthcare Needs, Catastrophic Health Expenditure, and Health in South Korea's Universal Healthcare System: Progression Towards Improving Equity by NHI Type and Income Level

This study examined the effects of healthcare inequality on personal health. It aimed to determine how health insurance type and income level influence catastrophic health expenditure and unmet healthcare needs among South Koreans. Unbalanced Korean Health Panel data from 2011 to 2015, including 33,374 adults, were used. A time-trend and panel regression analysis were performed. The first to identify changes in the main variables and, the second, mediating effects of unmet healthcare needs and catastrophic health expenditure on the relationship between health insurance type, income level, and health status. The independent variables were: high-, middle-, low-income employee insured, high-, middle-, low-income self-employed insured, and medical aid. The dependent variable was health status, and the mediators were unmet needs and catastrophic health expenditure. The medical aid beneficiaries and low-income self-employed insured groups demonstrated a higher probability of reporting poor health status than the high-income, insured group (15.6%, 2.2%, and 2.3%, respectively). Participants who experienced unmet healthcare needs or catastrophic health expenditure were 10.7% and 5.6% higher probability of reporting poor health, respectively (Sobel test: p < 0.001). National policy reforms could improve healthcare equality by integrating insurance premiums based on income among private-sector employees and self-employed individuals within the health insurance network.

Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China

BACKGROUND

Medical debt is a persistent global issue and a crucial and effective indicator of long-term family medical financial burden. This paper fills a research gap on the incidence and causes of medical debt in Chinese low- and middle-income households.

METHOD

Data were obtained from the 2015 China Household Finance Survey, with medical debt measured as borrowings from families, friends and third parties. Tobit regression models were used to analyze the data. The concentration index was employed to measure the extent of socioeconomic inequality in medical debt incidence.

RESULTS

We found that 2.42% of middle-income families had medical debt, averaging US$6278.25, or 0.56 times average household yearly income and 3.92% of low-income families had medical debts averaging US$5419.88, which was equivalent to 2.49 times average household yearly income. The concentration index for low and middle-income families' medical debt was significantly pro-poor. Medical debt impoverished about 10% of all non-poverty households and pushed poverty households deeper into poverty. While catastrophic health expenditure (CHE) was the single most important factor in medical debt, age, education, and health status of householder, hospitalization and types of medical insurance were also significant factors determining medical debt.

CONCLUSIONS

Using a narrow definition of medical debt, the incidence of medical debt in Chinese low- and middle-income households was relatively low. But, once medical debt happened, it imposed a long-term financial burden on medical indebted families, tipping many low and middle-income households into poverty and imposing on households several years of debt repayments. Further studies need to use broader definitions of medical debt to better assess the long-term financial impact of medical debt on Chinese families. Policy makers need to modify China's basic medical insurance schemes to manage out-of-pocket, medical debt and CHE and to take account of pre-existing medical debt.

Effect of Critical Illness Insurance on Household Catastrophic Health Expenditure: The Latest Evidence from the National Health Service Survey in China

BACKGROUND

China fully implemented the critical illness insurance (CII) program in 2016 to alleviate the economic burden of diseases and reduce catastrophic health expenditure (CHE). With an aging society, it is necessary to analyze the extent of CHE among Chinese households and explore the effect of CII and other associated factors on CHE.

METHODS

Data were derived from the Sixth National Health Service Survey (NHSS, 2018) in Jiangsu Province. The incidence and intensity of CHE were calculated with a sample of 3660 households in urban and rural areas in Jiangsu Province, China. Logistic regression and multiple linear regression models were used for estimating the effect of CII and related factors on CHE.

RESULTS

The proportion of households with no one insured by CII was 50.08% (1833). At each given threshold, from 20% to 60%, the incidence and intensity were higher in rural households than in urban ones. CII implementation reduced the incidence of CHE but increased the intensity of CHE. Meanwhile, the number of household members insured by CII did not affect CHE incidence but significantly decreased CHE intensity. Socioeconomic factors, such as marital status, education, employment, registered type of household head, household income and size, chronic disease status, and health service utilization, significantly affected household CHE.

CONCLUSIONS

Policy effort should further focus on appropriate adjustments, such as dynamization of CII lists, medical cost control, increasing the CII coverage rate, and improving the reimbursement level to achieve the ultimate aim of using CII to protect Chinese households against financial risk caused by illness.

Trends in access to health services, financial protection and satisfaction between 2010 and 2016: Has China achieved the goals of its health system reform?

Guided by the principle of universal health coverage, China began its complex health system reform in 2009. Using data from the China Family Panel Studies (CFPS), this study assesses trends in healthcare utilization, financial protection, and satisfaction between 2010 and 2016. We use difference-in-means tests and regression analysis to evaluate overall trends and compare subsample results by urban/rural residence and income quartiles to examine changes in inequity. Our results show that China has achieved substantial improvements in access to healthcare services and financial protection since the health system reform in 2009. First, China has experienced a substantial increase in both inpatient and outpatient care utilization between 2010 and 2016. Second, people receive better financial protection by measures of health insurance coverage, inpatient reimbursement rate, the likelihood of incurring catastrophic health expenditure, and the likelihood of medical impoverishment. Third, inequity in financial protection by income quartiles has significantly decreased, though poorer groups remain more vulnerable. However, we do not observe a concurrent increase in satisfaction towards the health system. We also find that people are more willing to seek medical services in hospitals rather than primary care institutions. All these results suggest that China's ongoing health system reform should pay more attention to establishing a tiered health delivery system, strengthening financial protection for the poor, and increasing responsiveness to rising expectations.

Impact of Critical Illness Insurance on the Burden of High-Cost Rural Residents in Central China: An Interrupted Time Series Study

Critical illness insurance (CII) in China was introduced to protect high-cost groups from health expenditure shocks for the purpose of mutual aid. This study aimed to evaluate the impact of CII on the burden of high-cost groups in central rural China. Data were extracted from the basic medical insurance (BMI) hospitalization database of Xiantao City from January 2010 to December 2016. A total of 77,757 hospitalization records were included in our analysis. The out-of-pocket (OOP) expenses and reimbursement ratio (RR) were the two main outcome variables. Interrupted time series analysis with a segmented regression approach was adopted. Level and slope changes were reported to reflect short- and long-term effects, respectively. Results indicated that the number of high-cost inpatient visits, the average monthly hospitalization expenses, and OOP expenses per high-cost inpatient visit were increased after CII introduction. By contrast, the RR from BMI and non-reimbursable expenses ratio were decreased. The OOP expenses and RR covered by CII were higher than those uncovered. We estimated a significant level decrease in OOP expenses (p < 0.01) and rise in RR (p < 0.01), whereas the slope decreases of OOP expenses (p = 0.19) and rise of RR (p = 0.11) after the CII were non-significant. We concluded that the short-term effect of the CII policy is significant and contributes to decreasing OOP expenses and raising RR for high-cost groups, whereas the long-term effect is non-significant. These findings can be explained by increasing hospitalization expenses, many non-reimbursable expenses, low coverage for high-cost groups, and the unsustainability of the financing methods.