A primary goal of the New Rural Cooperative Medical Insurance (NRCMI) is to provide financial protection against health care costs and alleviate the financial burdens of rural residents in China. This article examines whether NRCMI participation impacted the incidence of catastrophic health expenditure (CHE) among middle-aged and older adults (45 years old and above). The analysis utilized data from the 2007 China Household Income Project survey in rural areas and an instrumental variable estimation method in Anhui and Sichuan provinces, which exhibited heterogeneity in the NRCMI implementation schedule. The results show that NRCMI participation was not associated with changes in the CHE incidence among families. The finding is consistent with the prior literature using quasi-experimental study designs. This study provides empirical evidence for policymakers, highlighting that the impact of NRCMI participation on financial protections is limited despite its extensive population coverage. The limited effects are probably due to the low reimbursement rate and increased utilization of expensive health care services.
HimmelsteinDUThorneDWarrenEWoolhandlerS. Medical bankruptcy in the United States, 2007: Results of a national study. Am J Med. Aug 2009;122(8):741–746. doi:https://doi.org/10.1016/j.amjmed.2009.04.012
2.
VuongQH. Be rich or don’t be sick: Estimating Vietnamese patients’ risk of falling into destitution. SpringerPlus. 2015;4(1):1–31. doi:https://doi.org/10.1186/s40064-015-1279-x
3.
XuKEvansDBKawabataKZeramdiniRKlavusJMurrayCJ. Household catastrophic health expenditure: A multicountry analysis. Lancet.2003;362(9378):111–117. doi:https://doi.org/10.1016/s0140-6736(03)13861-5
4.
YangTChuJZhouC, et al.Catastrophic health expenditure: A comparative analysis of empty-nest and non-empty-nest households with seniors in shandong, China. BMJ Open. 2016;6(7):e010992. doi:https://doi.org/10.1136/bmjopen-2015-010992
5.
MauchVWoodsNKirubiBKiprutoHSitieneiJKlinkenbergE. Assessing access barriers to tuberculosis care with the tool to Estimate Patients’ Costs: Pilot results from two districts in Kenya. BMC Public Health. 2011;11(1):43.
6.
SauerbornRAdamsAHienM. Household strategies to cope with the economic costs of illness. Soc Sci Med.1996;43(3):291–301.
7.
KrukMEGoldmannEGaleaS. Borrowing and selling to pay for health care in low-and middle-income countries. Health Aff.2009;28(4):1056–1066.
8.
DaivadanamM. Pathways to catastrophic health expenditure for acute coronary syndrome in Kerala: ‘Good health at low cost’?BMC Public Health. 2012;12(1):306.
9.
SunYGregersenHYuanW. Chinese health care system and clinical epidemiology. Clin Epidemiol.2017;16(9):167–178. doi:https://doi.org/10.2147/CLEP.S106258
BabiarzKSMillerGYiHZhangLRozelleS. China’s new cooperative medical scheme improved finances of township health centers but not the number of patients served. Health Aff.2012;31(5):1065–1074. doi:https://doi.org/10.1377/hlthaff.2010.1311
13.
LiMWangC. The association between the new rural cooperative medical system and health care seeking behavior among middle-aged and older Chinese. J Aging Soc Policy.2017;29(2):168–181. doi:https://doi.org/10.1080/08959420.2016.1220225
14.
MaSZangWGanL. The effect of the New Rural Cooperative Medical System on rural hosuehold food consumption [Xinxing Nongcun Hezuo Yiliao Baoxian Dui Nongcun Jumin Shiwu Xiaofei de Yingxiang Fenxi]. China Econ Q. 2010;10(1):249–270.
15.
YuBMengQCollinsC, et al.How does the New Cooperative Medical Scheme influence health service utilization? A study in two provinces in rural China. BMC Health Serv Res.2010;10(1):116.
16.
ChengLLiuHZhangYShenKZengY. The impact of health insurance on health outcomes and spending of the elderly: Evidence from China's New Cooperative Medical Scheme. Health Econ. Jun 2015;24(6):672–691. doi:https://doi.org/10.1002/hec.3053
17.
HuoLChenY. The new rural cooperative medical insurance system : Do farmers get happiness? [Xinnonghe: Nongmin Huode Xingfugan le ma?]. J Shanghai Univ Fin Econ. 2017;19(2):38–49.
18.
LiangXGuoHJinCPengXZhangX. The effect of new cooperative medical scheme on health outcomes and alleviating catastrophic health expenditure in China: A systematic review. PLoS One. 2012;7(8):e40850.
19.
LeiXLinW. The new cooperative medical scheme in rural China: Does more coverage mean more service and better health?Health Econ.2009;18(S2):S25–S46.
20.
XuYLiYWuY. A research on the NCMS’ index measuring the effect of preventing the ailing peasants from being impoverished. Fin Econ. 2011;(10):108–116.
21.
ChenYXuXWangR, et al. The study of the effect of the new-type rural cooperative medical system alleviating the poverty due to illness. Chin Health Econ. 2005;24(8):26–28.
22.
SunXSleighACCarmichaelGAJacksonS. Health payment-induced poverty under China’s New Cooperative Medical Scheme in rural Shandong. Health Policy Plan.2010;25(5):419–426.
23.
CheungDPadieuY. Heterogeneity of the effects of health insurance on household savings: Evidence from rural China. World Dev.2015;66:84–103. doi:https://doi.org/10.1016/j.worlddev.2014.08.004
24.
ReddySRRoss-DegnanDZaslavskyAMSoumeraiSBWagnerAK. Health care payments in the Asia Pacific: Validation of five survey measures of economic burden. Int J Equity Health.2013;12(1):49.
25.
GongXYuBMengQYanFRachelT. Study on the effect of new rural cooperative medical system on catastrophic health care payment [Xinxing Nongcun Hezuo Yiliao dui Zinanxing Weisheng Zhichu de Yingxiang Yanjiu]. J Chem Inf Model.2019;53(9):1689–1699. doi:https://doi.org/10.1017/CBO9781107415324.004
26.
ZhangLChengXTolhurstRTangSLiuX. How effectively can the New Cooperative Medical Scheme reduce catastrophic health expenditure for the poor and non-poor in rural China?Trop Med Int Health.2010;15(4):468–475.
27.
JiangCMaJZhangXLuoW. Measuring financial protection for health in families with chronic conditions in Rural China. BMC Public Health. 2012;12(1):988.
28.
LiYWuQLiuC, et al.Catastrophic health expenditure and rural household impoverishment in China: What role does the new cooperative health insurance scheme play?Plos One. 2014;9(4):e93253.
29.
SunXJacksonSCarmichaelGSleighAC. Catastrophic medical payment and financial protection in rural China: Evidence from the New Cooperative Medical Scheme in Shandong Province. Health Econ.2009;18(1):103–119.
30.
WagstaffALindelowMJunGLingXJunchengQ. Extending health insurance to the rural population: An impact evaluation of China's new cooperative medical scheme. J Health Econ.2009;28(1):1–19. doi:https://doi.org/10.1016/j.jhealeco.2008.10.007
31.
Health statistical information Center. Xinxing Hezuo Yiliao dui Nongmin Jiating Yiliao Weisheng Zhichu de Yingxiang. Review of the Progress and Effectiveness of New Rural Cooperative Medical Care in China. China Union Medical College Press; 2007:68–74:chap 6.
32.
MakinenMWatersHRauchM, et al.Inequalities in health care use and expenditures: Empirical data from eight developing countries and countries in transition. Bull WHO.2000;78(1):55–65.
33.
MwangiJKulaneA. Chronic diseases among the elderly in a rural Vietnam: Prevalence, associated socio-demographic factors and healthcare expenditures. Int J Equity Health.2015;14(1):134.
34.
VerguetSMemirieSTNorheimOF. Assessing the burden of medical impoverishment by cause: A systematic breakdown by disease in Ethiopia. BMC Med.2016;14(1):164.
35.
SchoenbergNEKimHEdwardsWFlemingST. Burden of common multiple-morbidity constellations on out-of-pocket medical expenditures among older adults. Gerontologist.2007;47(4):423–437.
36.
MoffattSNobleEWhiteM. Addressing the financial consequences of cancer: Qualitative evaluation of a welfare rights advice service. PloS One. 2012;7(8):e42979.
37.
MohantySKLadusinghLKastorAChauhanRKBloomDE. Pattern, growth and determinant of household health spending in India, 1993–2012. J Public Health (Bangkok).2016;24(3):215–229.
38.
AyéMChampagneFContandriopoulosA-P. Economic role of solidarity and social capital in accessing modern health care services in the Ivory Coast. Soc Sci Med.2002;55(11):1929–1946.
World Health Organization. Distribution of health payments and catastrophic expenditures methodology. 2005.
41.
WagstaffAFloresGHsuJ, et al.Progress on catastrophic health spending in 133 countries: A retrospective observational study. Lancet Glob Health.2018;6(2):e169–e179.
42.
WagstaffADoorslaerE. Catastrophe and impoverishment in paying for health care: With applications to Vietnam 1993–1998. Health Econ.2003;12(11):921–933.
43.
XuKEvansDBCarrinG, et al.Protecting households from catastrophic health spending. Health Aff (Millwood). Jul-Aug 2007;26(4):972–983. doi:https://doi.org/10.1377/hlthaff.26.4.972
44.
WagstaffALindelowMJunG, et al.Extending Health Insurance to the Rural Population: An Impact Evaluation of China's New Cooperative Medical Scheme. The World Bank; 2007.
45.
AngristJDPischkeJ-SPischkeJ-S. Mostly Harmless Econometrics: An Empiricists Companion. Cram101 Publishing; 2013.
46.
LeHNguyenH. Intergenerational transmission in health: Causal estimates from fixed effects instrumental variables models for two cohorts of Australian children. 2015.
47.
BrownPHTheoharidesC. Health-seeking behavior and hospital choice in China's New Cooperative Medical System. Health Econ.2009;18(S2):S47–S64.
48.
DongK. Medical insurance system evolution in China. China Econ Rev. 2009;20(4):591–597.
49.
BaumCFSchafferMEStillmanS. IVREG2: Stata module for extended instrumental variables/2SLS, GMM and AC/HAC, LIML and k-class regression. 2010.
50.
TangS. Developing More Equitable and Efficient Health Insurance in China. The Paulson Institute; 2014: 1186.
51.
WagstaffALindelowM. Can insurance increase financial risk? The curious case of health insurance in China. J Health Econ.2008;27(4):990–1005. doi:https://doi.org/10.1016/j.jhealeco.2008.02.002
52.
The State Council Leading Group Office of Poverty Alleviation and Development. Endeavouring to move forward in the fast five years. 2017.
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