The Impact of Catastrophic Expenditure on Health and Urban-Rural Inequality in China

Background: The development of the healthcare system in China remains relatively slow and insufficient, despite the rapid economic growth in the last two decades. Furthermore, social protection systems in China devote inadequate attention to access to healthcare services and health-related financial burdens. Older adults, who tend to have higher healthcare needs and higher financial burdens but fewer income resources than other age groups, continue to face higher barriers to these services, especially in rural areas. This problem has become particularly urgent as China now has the largest aging population and one of the highest aging rates in the world. Meanwhile, substantial inequalities exist between rural and urban older adults in terms of welfare benefits level, access to health care, quality of care, and financial resources to pay for healthcare services.

Methods: This paper used the China Health and Retirement Longitudinal Study 2011 and 2013 and a difference-in-differences approach to examine the association between the incidence of catastrophic health expenditure (CHE) and health-related quality of life (HRQoL) among urban and rural older adults in China. To distinguish the dynamic of CHE and generate rigorous estimates, we categorized the older adults into four groups: CHE entry group, non-CHE group, CHE exit group, and CHE persistent group. We divided these four groups into two panels: panel A compares the CHE entry group vs. the non-CHE group, and panel B compares the CHE exit group vs. the CHE persistent group.

Results: Overall, we found that entry into CHE was associated with poorer HRQoL while exiting CHE was associated with better HRQoL for older adults in China. The negative association between entry into CHE and HRQoL was more robust for physical health than mental health, while the positive association between exiting CHE and HRQoL was weak and sporadic for both physical and mental health. Compared to the non-CHE group, rural older adults in the CHE entry group saw their physical component score decrease by 0.89 units. Compared to rural older adults in the CHE persistent group, rural older adults in the CHE exit group saw their physical component score increase by 0.62 units. We found the effects of CHE on HRQoL to be more consistent among rural older adults than urban older adults in China.

Conclusions: To reduce the negative impacts of CHE on HRQoL among older adults in China, future policy reforms should consider the affordability, accessibility, and availability of medical care. First, the prevalence of CHE could be used as a tool to measure the effectiveness of public health insurance. Second, policymakers in China could consider establishing more clinics and equipping more well-educated physicians in rural areas and low-income urban areas. Third, preventive healthcare should be heavily reimbursed and encouraged among older adults. Finally, professional social work services, especially at the community level, should be implemented and expanded to improve older adults’ HRQoL based on different demands in urban and rural settings.