Does Social Health Insurance System Ensure Equitable Access to Physician Visits and Hospital Admissions Among Older Adults in China? Evidence from 2014 China Family Panel Studies

Background and purpose: The systemic fragmentation of different health insurance plans inevitably undermines equitable access to health care envisioned in the Healthy China 2030 Blueprint. There are concerns that uninsured and rural residents are vulnerable to access care due to financial barriers in a shifted market-oriented health care system after China’s neoliberalism-induced economic reform.

Methods: Based on a representative sample of older adults (n=6,571) from 2014 China Family Panel Studies, this secondary analysis examined socioeconomic and psychophysical factors, particularly disparities in social health insurance status, that facilitate or impede physician visits and hospital admissions. Grounded in Andersen's behavioral framework, two series of logistic regression analyses were undertaken: one in a hierarchical manner among clusters of predisposing, enabling, health-need, and lifestyle-behavioral factors, and the other in a cross-referencing manner among uninsured populations, job-based and community-based insurance enrollees.

Results: After full adjustment, the negative associations between job-based insurance plans and outpatient care (Odds ratio [OR]=0.65, 95% confidence interval [CI]=0.44-0.96) reflect primarily on urban-rural disparities in self-medication. The positive association between the Urban Employee Basic Medical Insurance plan (OR=1.49, 95% CI=1.03, 2.14) with hospital admissions demonstrated the superior effect of job-based insurance on improved health care access. Besides the robust association between health insurance and health care use, there were other factors significantly influence access to care: being female (OR=0.68; 95% CI: 0.58-0.80), without a partner (OR=0.57; 95%CI: 0.47-0.69) were less likely to receive inpatient care. With respect to enabling factors, elders with a medium level of old-age income were more likely to access outpatient care (OR=1.25; 95% CI: 1.03-1.52). Family support from the spouse, adult children and other family members were all correlated to increased access to inpatient care in contrast to those without any caregiver (ORs=2.19-3.85, p’s<0.05). With the largest variance explained (Naegelkerke pseudo R²=0.24 for doctor visits; R²=0.26 for hospital admissions), health-need characteristics were the strongest determinants in use of health services: being depressed (OR=2.77, 95%CI=2.45-3.12), with functional limitations (OR=1.18, 95%CI=1.01-1.38), with chronic diseases (OR=1.80, 95% CI=1.59-2.03), and poor self-reported health status (OR=4.95, 95%CI=4.04-6.08) were all significantly related to increased outpatient and inpatient service utilization.

Conclusion and implications: This study sheds light on disparities in health care use among participants enrolled in divergent health insurance plans, identification of vulnerable groups of elders, and a multi-dimensional examination of Andersen’s framework of health care utilization in China. Given China’s aim to achieve universal insurance coverage in response to population aging, this study highlights that insurance-related inequities in health care utilization cannot be ameliorated unless the Chinese government can move beyond merging homogeneous insurance programs to unify the job- and community-based institutional divide.