Achieving Equitable Social Health Insurance Benefits in China: How Does Domestic Migration Pose a Challenge?

doi:10.21203/rs.3.rs-370136/v1

Background: Universal coverage through social health insurance is promoted by many researchers and policymakers to improve health equity within a country or region. In China, the mass internal migration since 1980s has posed challenges for the social health insurance to ensure equitable benefits for migrant population. This study evaluated the benefit distribution of social health insurance among internal migrants in China.

Methods: Using the 2014 China National Internal Migrants Dynamic Monitoring Survey, , by applying a two-part model, we conducted a benefit analysis of social health insurance among a representative sample of migrants in China.

Results: The study found that the broader the geographic scope of migration, the lower the probability of receiving reimbursements from the social health insurance and the reimbursement ratio; but among those who received reimbursements, the broader the geographic scope of migration, the larger amounts they were reimbursed for health care use. We attributed this unequal benefit distribution to the current insurance design that replies on localized administration and patients paying services up-front and requesting reimbursement later.

Conclusion: To improve the equity in social insurance benefits between migrants and non-migrants and among migrants, policies that promote the insurance portability across regions and immediate reimbursement are warranted, while at the same time efforts should be done to control inflation of health care expenditures and to prevent inverse government subsidies from the regions that have more out-migration to regions that have in-migration.

Health Economics & Outcomes Research

health insurance

health service

migrant

equity

China

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Table 1 Characteristic of the study sample, n (%)

Variables	Total sample (N=1165)	NCMS subsample (N=777)	URBMI&UEBMI subsample (N=388)
Total expenditure per inpatient stay (Yuan) *	10366.05(±17549.73)	10197.45(±18374.85)	10704.99(±15778.28)
Probability of receiving reimbursement	778(66.78)	470(60.49)	308(79.38)
Reimbursement amount received (Yuan) *	5506.16(±9761.79)	5128.44(±10838.10)	6049.14(±7952.00)
Reimbursement ratio received (%) *	46.77(±19.91)	39.41(±17.86)	57.35(±17.87)
Social health insurance programs ^a
NCMS	777(66.70)	-	-
URBMI	120(10.30)	-	120(30.93)
UEBMI	268(23.00)	-	268(69.07)
Age (Years) *	37.65(±9.75)	37.79(±9.80)	37.37(±9.65)
Female	532(45.67)	361(46.46)	171(44.07)
Married	1040(89.27)	705(90.73)	335(86.34)
Education attainment
Primary school and below	279(23.95)	218(28.06)	61(15.72)
Junior high school	554(47.55)	416(53.54)	138(35.57)
Senior high school	212(18.20)	118(15.19)	94(24.23)
College and above	120(10.30)	25(3.22)	95(24.48)
Monthly household income per capita (Yuan) *	2256.43(±2092.85)	1999.55(±1687.47)	2770.86(±2658.26)
Having any job	927(79.57)	610(78.51)	317(81.70)
Rural Hukou	1023(87.81)	777(100.00)	267(68.81)
Living in urban area	808(69.36)	502(64.61)	306(78.87)
Geographic scope of migration
Across counties within a city	296(25.41)	216(27.80)	80(20.62)
Across cities within a province	335(28.76)	214(27.54)	121(31.19)
Across provinces	534(45.84)	347(44.66)	187(48.20)
Reasons of migration
Seeking jobs	981(84.21)	642(82.63)	339(87.37)
Family members following migrants	146(12.53)	115(14.80)	31(7.99)
Other reasons	38(3.26)	20(2.57)	18(4.64)
Migration duration (Years)
0~1	147(12.62)	117(15.06)	30(7.73)
1~5	484(41.55)	305(39.25)	179(46.13)
5~10	272(23.35)	181(23.29)	91(23.45)
10 and above	262(22.49)	174(22.39)	88(22.68)
Facility level of hospitalization
Primary care facility	131(11.24)	90(11.58)	41(10.57)
Secondary hospital	400(34.33)	282(36.29)	118(30.41)
Tertiary hospital	538(46.18)	340(43.76)	198(51.03)
Private hospital	96(8.24)	65(8.37)	31(7.99)

Note: * mean (± Standard Deviation).

a. NCMS: New Rural Cooperative Medical Scheme; URBMI: Urban Resident Basic Medical Insurance; UEBMI: Urban Employee Basic Medical Insurance.

Table 2 Benefit distribution of social health insurance by geographic scope of migration

Variables	Across counties within a city	Across cities within a province	Across provinces	P
Total expenditure per inpatient stay (Yuan)	10326.81 (14079.35)	14458.96 (27139.10)	12771.68 (20428.78)	0.354
Probability of receiving reimbursement (%)	81.76 (38.69)	69.85 (45.96)	56.55 (49.62)	<0.001
Reimbursement amount received (Yuan)	4402.12 (6541.01)	6706.32 (13681.56)	5495.89 (8105.80)	0.056
Reimbursement ratio received (%)	44.75 (18.17)	47.76 (20.51)	47.72 (20.79)	0.195

Note: Standard Deviations are reported in parentheses.

Table 3 Association between insurance programs, migration scope, other factors and benefit of social health insurance

Variables	Probit Model		Generalized Linear Model
	Probability of getting reimbursement		Reimbursement amount		Reimbursement ratio
	Coefficient	S.E.	Coefficient	S.E.	Coefficient	S.E.
Social health insurance (referred to NCMS)
URBMI	0.021	0.049	0.222	0.136	0.147^***	0.031
UEBMI	0.375^***	0.044	0.428^***	0.094	0.201^***	0.023
Age (years)	0.010	0.012	0.026	0.030	0.006	0.006
Age² (years)	0.000	0.000	0.000	0.000	0.000	0.000
Female	0.024	0.031	-0.004	0.078	0.018	0.016
Married	0.063	0.051	-0.037	0.146	0.010	0.032
Education attainment (referred to primary school and below)
Junior high school	0.039	0.038	0.108	0.099	0.014	0.020
Senior high school	0.081	0.050	0.014	0.125	0.027	0.026
College and above	-0.038	0.068	-0.015	0.173	0.032	0.039
Monthly household income per capita (referred to 1st quintile)
2nd quintile	0.062	0.048	0.328^***	0.124	-0.029	0.026
3rd quintile	-0.033	0.051	0.014	0.139	-0.041	0.028
4th quintile	0.047	0.049	0.179	0.124	-0.031	0.026
5th quintile	0.029	0.053	0.336^**	0.137	-0.023	0.030
Having any job	-0.070^*	0.042	-0.247^**	0.109	0.010	0.022
Rural hukou	0.088	0.053	-0.106	0.126	0.000	0.031
Living in urban area	0.063^**	0.032	-0.012	0.088	0.004	0.017
Geographic scope of migration (referred to migration across counties within a city)
Across cities within a province	-0.147^***	0.041	0.334^***	0.093	-0.019	0.019
Across provinces	-0.260^***	0.038	0.272^***	0.093	-0.032^*	0.019
Reasons of migration (referred to Seeking jobs)
Family members following migrants	-0.007	0.050	0.553^***	0.137	0.047^*	0.027
other reasons	-0.025	0.087	-0.224	0.207	0.024	0.048
Migration duration (referred to 0~)
1~	-0.014	0.045	0.078	0.125	-0.032	0.026
5~	0.017	0.051	0.162	0.135	-0.022	0.028
10~	-0.011	0.052	0.085	0.140	-0.040	0.029
Facility level of hospitalization (referred to primary care facility)
Secondary hospital	-0.031	0.048	0.603^***	0.139	-0.046	0.032
Tertiary hospital	0.083^*	0.048	1.065^***	0.135	-0.083^***	0.031
Private hospital	-0.156^**	0.063	0.092	0.188	-0.027	0.043
Observations	1165		663		663

Note: ***, ** and * denote statistical significance at 1, 5 and 10% level, respectively.

S.E.: Standard Error. NCMS: New Rural Cooperative Medical Scheme; URBMI: Urban Resident Basic Medical Insurance; UEBMI: Urban Employee Basic Medical Insurance.

Table 4 Association between migration scope and benefit by social health insurance programs

Variables	Probit Model		Generalized Linear Model
	Probability of getting reimbursement		Reimbursement amount		Reimbursement ratio
	Coefficient	S.E.	Coefficient	S.E.	Coefficient	S.E.
NCMS subsample
Geographic scope of migration (referred to migration across counties within a city)
Across cities within a province	-0.139^***	0.052	0.410^***	0.120	-0.044^*	0.023
Across provinces	-0.333^***	0.048	0.282^**	0.118	-0.055^**	0.024
URBMI & UEBMI subsample
Geographic scope of migration (referred to migration across counties within a city)
Across cities within a province	-0.135^**	0.061	0.339^**	0.154	0.073^**	0.033
Across provinces	-0.118^*	0.061	0.285^*	0.152	0.039	0.033

Note: All models included confounding factors in Table 3. ***, ** and * denote statistical significance at 1, 5 and 10% level, respectively.

S.E.: Standard Error. NCMS: New Rural Cooperative Medical Scheme; URBMI: Urban Resident Basic Medical Insurance; UEBMI: Urban Employee Basic Medical Insurance.

Achieving Equitable Social Health Insurance Benefits in China: How Does Domestic Migration Pose a Challenge?

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