Effects of health insurance integration on health care utilization and its equity among the mid-aged and elderly: evidence from China

Background: The fragmentation of health insurance schemes in China has undermined equity in access to health care. To achieve universal health coverage by 2020, the Chinese government has decided to consolidate three basic medical insurance schemes. This study aims to evaluate the effects of integrating Urban and Rural Residents Basic Medical Insurance schemes on health care utilization and its equity in China. Methods: The data for the years before (2013) and after (2015) the integration were obtained from the China Health and Retirement Longitudinal Study. Respondents in pilot provinces were considered as the treatment group, and those in other provinces were the control group. Difference-in-difference method was used to examine integration effects on probability and frequency of health care visits. Subgroup analysis across regions of residence (urban/rural) and income groups and concentration index were used to examine effects on equity in utilization. Results: The integration had no significant effects on probability of outpatient visits (beta = 0.01, P > 0.05), inpatient visits (beta = 0.01, P > 0.05), and unmet hospitalization needs (beta = 0.01, P > 0.05), while it had significant and positive effects on number of outpatient visits (beta = 0.62, P < 0.05) and inpatient visits (beta = 0.39, P < 0.01). Moreover, the integration had significant and positive effects on number of outpatient visits (beta = 0.77, P < 0.05) and inpatient visits (beta = 0.49, P < 0.01) for rural residents but no significant effects for urban residents. Furthermore, the integration led to an increase in the frequency of inpatient care utilization for the poor (beta = 0.78, P < 0.05) among the piloted provinces but had no significant effects for the rich (beta = 0.25, P > 0.05). The concentration index for frequency of inpatient visits turned into negative direction in integration group, while that in control group increased by 0.011. Conclusions: The findings suggest that the integration of fragmented health insurance schemes could promote access to and improve equity in health care utilization. Successful experiences of consolidating health insurance schemes in pilot provinces can provide valuable lessons for other provinces in China and other countries with similar fragmented schemes.