Urban-rural differences in the association between access to healthcare and health outcomes among older adults in China

Healthcare is inarguably one of the most well-known and widely studied determinants of health [1‐4]. Adequate access to healthcare is especially critical to older adults who require greater levels of treatment and care to manage disease and prolong survival [5]. Indeed, a number of studies have shown that adequate access to medical services significantly improves the health and longevity of older adults [4, 6‐12]. Previous studies have also suggested that access to healthcare varies across different segments of the population—e.g., by age, sex, race, and urban-rural residence [13‐15]. However, much of this research is based on Western nations and few studies have examined the impact of access to healthcare on health outcomes in developing nations such as China. Moreover, it is largely unknown whether access to healthcare has similar benefits in urban and rural areas in China where there are well-known disparities in socioeconomic status and other risks/resources [7, 16, 17].

Since 1950, China has implemented a dual-system of social welfare in urban and rural areas [7]. As a result, the healthcare system in rural areas is entirely different from the healthcare system in urban areas [14, 16‐23]. In rural areas, the current healthcare insurance system is the New Cooperative Medical Scheme (NCMS), which was launched in the early 2000s after the old cooperative medical scheme collapsed following economic reforms in the late 1970s [24, 25]. In urban China, the current health insurance system, or urban medical schemes (UMS), mainly consists of the Urban Employer-sponsored Medical Scheme (UEMS, for urban employees) and the Urban Resident Medical Scheme (URMS, for urban residents without UEMS). The UEMS system was launched in 1999 and was mainly a modification of the free public medical scheme that existed in the planned economy. The URMS system is relatively new and implemented nationally in 2010 after a three-year pilot program [26‐28].

Previous studies have demonstrated significant urban-rural differences in access to and utilization of healthcare in China. For example, research shows that older adults from rural areas in China are less likely to use inpatient services and more likely to rely on in-home medical care than their urban counterparts [18, 20]. Considering the unique systems of stratification and healthcare in China and the limited research on urban-rural differential in links between healthcare assess and health outcomes, the purpose of the current study is to investigate whether the association between access to healthcare and health outcomes varies by urban-rural residence among older Chinese. Using nationally representative longitudinal data from China, we examined whether and to what extent adequate access to healthcare was related to disability, cognitive impairment, and all-cause mortality among older adults residing in urban and rural areas. The implications of the findings are discussed in the context of rapidly aging societies such as China and the need for sustainable healthcare resources for older adults.

Table 1 presents the weighted distributions of the total sample and by urban-rural residence. Although the reported access to healthcare was generally high among all CLHLS respondents, older adults in rural areas were nearly twice as likely as older adults in urban areas to report inadequate access to healthcare (9.1% vs. 5.4%; p < 0.01) during the period 2005–2014. Overall, older adults in rural areas had lower levels of SES, were more likely to smoke, spend less time on leisure activities, and had lower levels of ADL disability than older adults in urban areas. Nearly half of rural older adults (47.4%) were enrolled in NCMS and an additional 7.2% were enrolled in the MS insurance program. Among urban older adults, almost a quarter were enrolled in NCMS (24.9%) and more than a third (37.6%) were enrolled in one of three urban healthcare insurance programs.

Table 2 reports the odds ratios (ORs) for IADL disability associated with inadequate access to healthcare by urban and rural residence. Results show that inadequate access to healthcare was associated with 79% (OR = 1.79; p < 0.001) higher odds of IADL disability among older adults in urban areas and a 130% (OR = 2.30; p < 0.001) higher odds among older adults in rural areas when taking into account sociodemographic factors in Model I. The ORs remained largely unchanged when further taking into account enrollment in the national health insurance programs (Model II). We also found that there was no association between enrollment in urban medical schemes and the prevalence of IADL disability. Further adjustment for health behaviors in Model III shows that the ORs were partially attenuated for older adults in urban (OR = 1.58; p < 0.05) and rural (OR = 1.95; p < 0.001) areas.

Table 3 presents the ORs for ADL disability associated with inadequate access to healthcare by urban and rural residence. Results show that inadequate access to healthcare among rural older adults was associated with substantially higher rates of ADL disability after adjusting for sociodemographic factors (OR = 3.05; p < 0.001), enrollment in national health insurance (OR = 2.76; p < 0.001), and health behaviors (OR = 1.89; p < 0.001). In contrast, we found no significant differences in ADL disability associated with access to healthcare among older adults in urban areas. The results for cognitive impairment in Table 4 were largely similar with significantly higher odds in Model I (OR = 3.19; p < 0.001), Model II (OR = 2.94; p < 0.001), and Model III (OR = 2.37; p < 0.001) among rural older adults with inadequate access to healthcare compared to their counterparts with adequate access to healthcare. No significant differences in cognitive impairment associated with access to healthcare in urban areas were found.

Table 5 reports the hazard ratios (HRs) for the association between inadequate access to healthcare and mortality by urban-rural residence. When controlling for sociodemographics (Model I), we found that inadequate access to healthcare was associated with 30% (p < 0.001) higher risks of mortality among rural older adults and 36% (p < 0.001) higher risks for urban older adults. Further accounting for enrollment in national health insurance programs (Model II) only slightly attenuated the association between access to health care and mortality in both urban and rural areas. Although we found that enrollment in NCMS was associated with significant reductions in mortality, NCMS enrollment had little impact on the association between access to healthcare and mortality in urban and rural older adults. Enrollment in urban medical schemes almost had no association with mortality. However, after taking into account health behaviors (Model III) and health status (Model IV), inadequate access to healthcare was not significantly associated with mortality among older adults living in urban areas. In contrast, inadequate access to healthcare increased risks for mortality by 23% (p < 0.01) and 16% (p < 0.05) among those in rural areas.

This study examined the association between access to healthcare and multiple health outcomes in a large nationally representative longitudinal dataset of adults aged 65 and older in China. To our knowledge, this study was the first to investigate whether and to what extent inadequate access to healthcare is associated with physical disability, cognitive impairment, and mortality in urban and rural older adults in a developing country. We found that older adults with inadequate access to healthcare had significantly higher rates of IADL disability, ADL disability, cognitive impairment, and all-cause mortality compared with older adults with adequate access to care. The associations were stronger among older adults in rural areas than in urban areas; and the associations persisted despite adjusting for multiple demographic, socioeconomic, behavioral, and health-related factors.

Adequate access to healthcare is beneficial to health by facilitating timely and quality medical care to screen for and treat diseases in early stages, postponing declines in physiological function with illness, restoring immune function, and ultimately prolonging survival. We showed that access to healthcare has significant impact on multiple health outcomes in older adults and that inadequate access to healthcare is especially detrimental to the health of older adults residing in rural locations. Our findings build on previous studies that have shown associations between increases in health insurance coverage and health outcomes [9, 10, 44, 45] and studies that have shown associations between access to healthcare or health insurance and mortality among the elderly population [7], the elderly in urban areas [44], and among patients with specific diseases [12].

In rural China today, the majority of the older adults can access to healthcare and can receive medical treatment for their health problems. This is because the Chinese healthcare system has greatly improved in recent years, with coverage reaching more than 95% of the population as of 2015 in both urban and rural areas [26]. In most rural areas, local/village doctors and nurses are widely available and physician visits are relatively inexpensive and prescription medications are generally accessible [20]. Nevertheless, there are rural residents who do not have adequate access to healthcare and are often the most vulnerable, frail, and poorest older adults who are unable to receive preventative care and/or timely treatment(s). Although the healthcare system has been greatly improved in rural areas [46], the health insurance program in rural China is not as good (or beneficial) as programs in urban areas. In rural areas, financial barriers are often considered the underlying reasons for inadequate access to healthcare [16]—and largely attributable to the lack of pensions, lower income, higher out-of-pocket cost, and greater co-payments compared with urban areas [47]. Consequently, rural older adults may face disproportionately greater difficulties in getting adequate medical services when needed relative to their urban counterparts, which lead to a high heterogeneity in rural areas between those who are able to adequately access to healthcare and those who are not able to do so.

According to the 2005–2014 waves of the CLHLS, approximately 60% of rural older adults who reported inadequate access to healthcare expressed financial constraint as the main barrier to accessing medical services. Among urban older adults, only 45% expressed financial constraints to accessing care. Older adults in rural areas also face obstacles to care from family members (i.e., sons and daughters) who have increased migrated to urban areas for education and work opportunities [48]. In contrast, older adults in urban areas are more likely to use hospital services and generally benefit from higher quality of care, better medical facilities, and more advanced treatment options. Notwithstanding, these advantages in urban settings have been hampered by a rapidly growing elderly population and the over-utilization of medical services—which has led to longer waiting times, delayed treatments, and ultimately less timely and effective treatments [23, 26]. As a result, the health disparity between older adults with and without adequate access to healthcare in urban areas is less discernible than in rural areas.

A unique feature of the present study is the measure of (inadequate) access to healthcare. This approach is different from most previous studies that focused exclusively on whether having health insurance is associated with a given health outcome [9, 10, 41, 49‐53]. Although informative, researchers have argued that comparisons of health outcomes by basic categorizations of insured or uninsured make it difficult to determine the nature of the association—i.e., whether having insurance impacts health or whether health status impacts having insurance [41]. As such, this issue may explain, in part, why many previous studies in various settings find no significant association between having health insurance and mortality [49, 50, 54, 55]. The measure of inadequate access to healthcare used in the current study avoided such an issue of endogeneity.

One strength of our study was the simultaneous examination of multiple health outcomes associated with access to healthcare. We are aware of only one recent study that examined the association between enrollment in a health insurance program in China and several quality-of-life indicators [10]. We built on this research by demonstrating robust associations between access to healthcare and the prevalence of physical disability, cognitive impairment, and all-cause mortality. Moreover, we demonstrated that the associations were not uniform among urban and rural older adults after adjustment for several demographic, socioeconomic, behavioral, and health-related factors. Another strength of the study was the use of a large-scale nationally representative sample of older adults from a developing country that were examined over almost a 10-year period (2005–2014).

Our findings also have potentially important implications for improving access to healthcare in China. Given the high coverage rate of the three pillars of healthcare coverage in China (NCMS, UEMS, and URMS), these health insurance schemes have made most older adults enable to afford basic healthcare services when needed [24, 26]. However, there have been dramatic increases in the need and utilization of healthcare services due to a number of factors, including: (i) a rapidly aging population, (ii) a shortage of healthcare professionals, (iii) reduced familial caregiving due to smaller family size, (iv) sky-rocketing costs of medications and medical services, and (v) complicated reimbursement procedures for utilization. In addition, rural older adults face disproportionate challenges relative to their urban counterparts in obtaining timely and adequate medication due to high co-payments in NCMS. Based on the findings from this study, inadequate access to healthcare can be especially detrimental to health in rural areas. It is perhaps that increasing the benefits under NCMS or the unification of urban-rural healthcare programs could be viable strategies toward reducing health disparities faced by older adults in rural areas of China.

Despite the strengths of this study, we acknowledge several limitations. First, the measure of (in)adequate access to healthcare in this study is based on the respondents’ self-reported perceptions of access. We recognize that such self-assessments may not reflect actual access (or use) of healthcare and may be influenced by differences in background (e.g., age, sex, education), resources (e.g., income), and/or health status. Furthermore, respondents’ perceptions may be based on past experiences with healthcare—particularly among those without disability or impairment at the time of the survey. However, research suggests that self-perceived access to healthcare is highly aligned with actual use of healthcare services; including overall utilization, use of mental health services, routine checkups, and emergency care [4, 56, 57]. Therefore, we followed the existing literature by defining access to healthcare as a measure of obtaining needed healthcare services—rather than actual utilization—as an indicator of access to positive health outcomes [58]. Nevertheless, we encourage additional research with comparable (or alternative measures) of adequate access to healthcare to further validate and build on the current findings. A second limitation is that we did not consider the severity of each health outcome. Therefore, we acknowledge that individual needs for healthcare may differ according to the severity of the condition. Third, as the length of stay in the current residential status was not available in the CLHLS, we were not able to model the urban-rural residential change on the effect of inadequate access to healthcare. Research that includes such information is preferable in studying urban and rural disparities in access to healthcare. Finally, we could not control for potentially important factors related to healthcare use. For example, we lacked important contextual measures such as the actual availability of healthcare services, barriers to access (e.g., transportation, distance, terrain), and the quality of healthcare that is provided [1, 59, 60]. Therefore, more research is needed to further investigate these factors and others to better understand the association between access to healthcare and health outcomes in urban and rural settings in developing countries such as China.

Inadequate access to healthcare is significantly associated with higher rates of disability, cognitive impairment, and all-cause mortality among older adults in China. The associations between access to healthcare and health outcomes were generally stronger among older adults in rural areas than in urban areas. Our findings underscore the importance of providing adequate access to healthcare for older adults—particularly for those living in rural areas in developing countries. In the context of near-universal healthcare coverage in China, the results identify opportunities to further improve access in rural areas to improve health outcomes in disadvantaged older adults.