Health care inequality under different medical insurance schemes in a socioeconomically underdeveloped region of China: a propensity score matching analysis

Since economic inequality is often accompanied by health inequalities, health care inequalities are increasingly becoming a hot issue on a global scale [1‐4]. As people pay attention to their own health, health care inequalities are getting more and more attention from the public. As a developing country with fast economic growth, China also faces the same problems as other countries in the world. According to the World Health Report in 2000, China’s overall health system performance ranked 144 out of 199 countries and the ranking of equity in health financing was third from last in the world [5]. There are two main reasons for this phenomenon. One of them is insufficient coverage of medical insurance [6], and the other is health care inequality. In the past 20 years, China has achieved a series of health reforms [7, 8]. It included further coverage of Urban Employees Basic Medical Insurance (UEBMI) and Urban Residents Basic Medical Insurance (URBMI). UEBMI is a social insurance system established in 1998 to compensate urban employees for economic losses due to disease risks. However, the elderly, children, students, and urban non-employed residents are not included in this scheme. Therefore, in order to reduce the medical expenses brought by the growing health needs of residents, URBMI has been implemented since 2007. The implementation of URBMI indeed makes up for the health care of some groups and improves health care inequalities. The coverage rate of medical insurance in China has exceeded 95% [9, 10]. But does this fast-developing insurance system mask undetectable health care inequalities and fail to achieve real health care inequalities? With the coverage of universal medical insurance in China, health care inequality has become more important and needs to be taken seriously. Health care inequality is mainly reflected in the imbalance between hospitalization expenses and hospitalization reimbursement, as well as inequalities under different medical insurance schemes in the use of medical resources and the choice of hospital types.

In today’s China, citizens can directly go to any level of hospital, but they are still more willing to choose high-level hospitals for treatment [11]. In order to alleviate the pressure on high-level hospitals, China has implemented grading diagnosis and treatment system, including a two-way referral system, to leave some patients with slight illness in low-level hospitals. However, it still cannot completely eliminate the phenomenon of “inverted pyramids” in China. In some cities, there are still many patients gathered in high-level hospitals to see a doctor [12]. Patients believe that they can get relatively better treatment in high-level hospitals [11]. In addition to focusing on better treatment, patients are also very concerned about medical expenses. So does the phenomenon of “inverted pyramids” exist in socioeconomically underdeveloped regions? Does the hospital with the most hospitalization expenses have the most hospitalization reimbursement? These issues are worthy exploring further.

Although the use of health care should be distributed equitably based on people’s needs rather than ability to pay [13], the current use of health care is unequal. Healthcare utilization is more beneficial to the rich [14]. The rich enjoy the relatively high-level healthcare utilization, while the poor have to choose lower-level services or even no money to get health care [15, 16]. So there is such a saying that it is difficult and expensive to see a doctor. Underdeveloped regions are relatively backward in economy. In these regions, the difficulty and high expense for getting medical treatment may be more serious. Therefore, the use of medical resources and the choice of hospital types may be different from those in ordinary regions and require more attention. Since different insurance schemes have an impact on healthcare utilization and costs [17, 18], it is worth considering whether different insurance schemes will have a greater impact on healthcare utilization, the choice of hospitals and healthcare cost in socioeconomically underdeveloped regions. Earlier studies focused more on ordinary regions and did not use propensity scores to reduce the effects of confounding factors [19‐22], which had increased bias in the research.

Medical inequality is easily hidden by economic development, so our aim was to explore whether there is an imbalance between hospitalization expenses and hospitalization reimbursement, and whether there are inequalities under different medical insurance schemes in healthcare utilization, the choice of hospital types and healthcare cost in a socioeconomically underdeveloped city of China. Our paper contributes to a certain theoretical basis for policy makers to pay more attention to health inequalities, thus eliminating the greater hidden dangers in the future.

Providing equal health care to every patient is the goal of all countries around the world. China is also making unremitting efforts to this end. In the past, China has made some progress in providing affordable and equitable basic medical services to the population, which has surpassed many developing countries. However, health care inequalities enjoyed by each subgroup of insurance enrollees still exist. This paper indicated the imbalance between hospitalization expenses and hospitalization reimbursement, and systematically estimated the impact of different medical insurance schemes on health care inequality in healthcare utilization, the choice of hospital types and healthcare cost in a socioeconomically underdeveloped city.

In a socioeconomically underdeveloped city, the phenomenon of “inverted pyramids” still exists. In the inherent misconceptions of many Chinese people, the need for hospitalization indicates a very serious disease, and high-level hospitals can get good treatment. At this time, people wanted to get the best treatment. Our results showed that first-level hospitals had highest hospitalization compensation ratios. But it was not the first thing they considered. As a result, most hospitalization expenses are still spent in tertiary-level hospitals. This is an abnormal phenomenon that leads to a failure to better allocate and utilize medical resources, thus causing a waste of medical resources. In terms of the choice of hospital types, UEBMI enrollees had higher outpatient visit rates in all hospital types than URBMI enrollees (p < 0.001). URBMI enrollees were less likely to use outpatient visit services, probably because URBMI enrollees were unable to get compensation from the insurance scheme and can only use their own money for outpatient visits. The money they have can only guarantee their basic life. So they usually try to minimize the use of outpatient visit services. Our results also indicated that UEBMI enrollees were more willing to receive hospitalization treatment in tertiary-level hospitals (p < 0.001), while those who receive hospitalization treatment in first-level hospitals are more likely to be enrolled in URBMI (p = 0.004). We can see that insured enrollees under different insurance schemes have inequalities in the choice of hospital types due to economic inequalities. However, this result is inconsistent with Zhou, et al. [26]. Zhou et al. [26] thought that UEBMI enrollees in Shaanxi Province may be more willing to go to lower-level hospitals for hospitalization. This further explains that the imbalance of hospitalization expenses and hospitalization compensation ratios may be more obvious in a socioeconomically underdeveloped city.

Healthcare utilization varies significantly by different insurance schemes. Insured enrollees in the UEBMI scheme had higher likelihood of healthcare utilization. This may be due to URBMI enrollees have relatively low incomes compared to the UEBMI enrollees. Only when URBMI enrollees have relatively serious illnesses can they go to the hospital for treatment. It showed that the inequalities in the use of medical resources are largely not based on differences in demand but on the economy. Although different insurance schemes target different groups, if there are always huge differences between different insurance schemes, this will bring greater hidden dangers in the future.

Inequalities in healthcare utilization also have left a huge mark on healthcare cost [27]. UEBMI enrollees had higher hospitalization expenses in any hospital type (p < 0.05). In addition, hospitalization compensation ratio of UEBMI enrollees was also significantly higher than that of URBMI enrollees (p < 0.001). Our findings are consistent with Zhang, et al. [28] in that UEBMI enrollees have the highest compensation ratios and compensation ratios of medical insurance vary significantly by schemes. From this perspective, there is no difference in the hospitalization compensation ratio between socioeconomically underdeveloped regions and ordinary regions. This may be due to the different reimbursement of different urban medical insurance schemes, which also reflects the existence of health care inequality and needs to be valued by government.

Similar to Dou et al. and Yu et al. [29, 30], we conclude that although China has successfully achieved the goal of providing medical insurance for almost the entire population, it faces the challenge of health care inequality. The challenge still continues, and policymakers should now make efforts to reduce health care inequality between subgroups of insurance enrollees. We offer some advices on the current medical insurance policy in socioeconomically underdeveloped regions. The grading diagnosis and treatment system should be further implemented to balance hospitalization expenses and hospitalization compensation ratios. Slight illnesses go to low-level hospitals, and then go to higher-level hospitals. If insurance enrollees participate in this system, the medical insurance reimbursement will increase relatively, and if not, it will fall. We also need to strengthen publicity, improve people’s awareness, and make health resources more rationally allocated and utilized. In order to achieve an equality of insurance benefits under different insurance schemes, a large amount of additional public funds is needed. The government can subsidize socioeconomically underdeveloped regions to expand the redistribution of resources.

There are some limitations in our study. By using matching techniques to increase the comparability between different insurance schemes, unobservable (unmatched) characteristics may affect the presented results. During the investigation, we collected data as comprehensively as possible. Completely ideal data is difficult to obtain. In addition, our study did not collect information on the existence of chronic diseases, the presence of special occupational diseases, pregnancy status, etc., which may affect the demand for healthcare utilization.

Healthcare utilization varies significantly by different insurance schemes. Insured enrollees in the UEBMI scheme had higher likelihood of healthcare utilization. Hospitalization expenses and hospitalization compensation ratios of UEBMI enrollees were also significantly higher than those of URBMI enrollees. Health care inequality is mainly reflected in the imbalance between hospitalization expenses and hospitalization compensation ratios, as well as inequalities under different medical insurance schemes in healthcare utilization, the choice of hospital types and healthcare cost in socioeconomically underdeveloped regions of China. We should conduct a targeted medical insurance reform for the socioeconomically underdeveloped regions, rather than applying templates of ordinary regions. Further efforts are needed in the future to provide equal health care for every patient.