Restricted accessResearch articleFirst published online 2026-4
Social Health Insurance Programs and Preventive Care Utilization Among Chinese Older Adults: Results From the Chinese Longitudinal Healthy Longevity Survey
China has aimed to establish a universal health care system through a comprehensive health reform since 2009. However, knowledge about the association between basic social insurances and preventive care utilization (PCU) among Chinese older adults, especially as primary coverage, remains limited. This study investigates these associations using data from the 2018 Chinese Longitudinal Healthy Longevity Survey. We analyzed 9,952 older adults with major medical coverage from urban employee/resident insurance (UE/URBMI), cooperative medical programs (New Rural Cooperative Medical System; NCMS), or self-payment (SP). Propensity score matching (PSM) enhanced comparability between UE/URBMI or NCMS and a control group with SP coverage. Subsequent logistic regression examined associations between major medical expense coverage and PCU for older adults with NCMS + SP (n = 6,580) and UE/URBMI + SP (n = 5,248) groups, respectively. NCMS participants had higher odds of reporting PCU compared to SP users (odds ratio: 1.57, 95% CI: 1.40–1.75, P < .001). Conversely, no significant association was observed in the UE/URBMI + SP group (odds ratio: 1.08, 95% CI: 0.93–1.24, P > .05). This study highlights diverse associations between health insurance types and PCU among older adults. Empirical results suggest sustained government-led health insurance reform may need to continue progressing to strengthen financial incentives for PCU within the social insurance framework.
ImaiCToizumiMHallLLambertSHaltonKMerolliniK. A systematic review and meta-analysis of the direct epidemiological and economic effects of seasonal influenza vaccination on healthcare workers. PLoS One. 2018;13(6):e0198685. doi:https://doi.org/10.1371/JOURNAL.PONE.0198685
2.
FuchsSCAlencastroPRIkedaMLR, et al.Risk of coronary heart disease among HIV-infected patients: A multicenter study in Brazil. Scientific World J.2013;2013. doi:https://doi.org/10.1155/2013/163418
3.
HaleNLSmithMHardinJBrock-MartinA. Rural populations and early periodic screening, diagnosis, and treatment services: Challenges and opportunities for local public health departments. Am J Public Health. 2015;105(S2):S330–S336. doi:https://doi.org/10.2105/AJPH.2014.302449
4.
TomazelliJGSilvaGAE. Breast cancer screening in Brazil: An assessment of supply and use of Brazilian National Health System health care network for the period 2010-2012. Epidemiol Serv Saude. 2017;26(4):713–724. doi:https://doi.org/10.5123/S1679-49742017000400004
5.
National Bureau of Statistics of China. National Bureau of Statistics of China. Statistical Bulletin of the People’s Republic of China on National Economic and Social Development in 2022. 2022. https://www.stats.gov.cn/sj/zxfb/202302/t20230228_1919011.html.
6.
PrinceMJWuFGuoY, et al.The burden of disease in older people and implications for health policy and practice. Lancet.2015;385(9967):549–562. doi:https://doi.org/10.1016/S0140-6736(14)61347-7
7.
MusichSKlemesAKubicaMAWangSHawkinsK. Personalized preventive care reduces healthcare expenditures among Medicare Advantage beneficiaries. Am J Manag Care. 2014;20(8):613–620.
8.
LeeYHChangYCLiuCT. Preventative care utilization and associated health-related measurements among older adults following the 2009 health reform in China. Int J Health Plann Manage. 2019;34(2):e1135–e1148. doi:https://doi.org/10.1002/HPM.2749
9.
ZhouLJuPLiY, et al.Preventive health behaviors among the middle-aged and elderly in China: Does social capital matter?Prev Med Rep. 2023;35:102329. doi:https://doi.org/10.1016/J.PMEDR.2023.102329
10.
ZhangZYinATBianY. Willingness to receive periodic health examination based on the health belief model among the elderly in rural China: A cross-sectional study. Patient Prefer Adherence. 2021;15:1347–1358. doi:https://doi.org/10.2147/PPA.S312806
11.
FrazierELJilesRBMayberryR. Use of screening mammography and clinical breast examinations among black, hispanic, and white women. Prev Med (Baltim). 1996;25(2):118–125. doi:https://doi.org/10.1006/PMED.1996.0037
RossJSBernheimSMBradleyEHTengHMGalloWT. Use of preventive care by the working poor in the United States. Prev Med (Baltim). 2007;44(3):254–259. doi:https://doi.org/10.1016/J.YPMED.2006.11.006
14.
LiuXLiNLiuC, et al.Urban-rural disparity in utilization of preventive care services in China. Medicine (United States). 2016;95(37):e4783. doi:https://doi.org/10.1097/MD.0000000000004783
WuTTLiuWWZouM, et al.Changes in preventive care utilisation and its influencing factors among Chinese adults before and after the healthcare reform: Cross-sectional evidence from the China Health and Nutrition Survey in 2004–2015. BMJ Open. 2020;10(10):e038763. doi:https://doi.org/10.1136/bmjopen-2020-038763
17.
FaulknerLASchaufflerHH. The effect of health insurance coverage on the appropriate use of recommended clinical preventive services. Am J Prev Med. 1997;13(6):453–458.
18.
NundyM. Challenges to health service system in China: Institutional and financial reforms. In: Public Health Challenges in Contemporary China: An Interdisciplinary Perspective. Springer; 2016:9–23.
19.
LeeYHChiangTShelleyMLiuCT. Chinese residents’ educational disparity and social insurance coverage. Int J Health Care Qual Assur. 2018;31(7):746–756. doi:https://doi.org/10.1108/IJHCQA-06-2017-0098
YuH. Universal health insurance coverage for 1.3 billion people: What accounts for China’s success?Health Policy. 2015;119(9):1145–1152. doi:https://doi.org/10.1016/J.HEALTHPOL.2015.07.008
23.
JiaH. The institutional change of basic medical insurance and the improvement for citizens’ sense of gain. Social Science Journal. 2022;260:39–49.
24.
YinDWongSTChenW, et al.A model to estimate the cost of the National Essential Public Health Services Package in Beijing, China. BMC Health Serv Res. 2015;15(1):222. doi:https://doi.org/10.1186/s12913-015-0902-4
25.
NHC.GOV.CN. Notice on doing a good job of the national basic public health service project in 2018. The State Council The People's Republic of China.
26.
ZhangDPanXLiS, et al.Impact of the national essential public health services policy on hypertension control in China. Am J Hypertens. 2018;31(1):115–123. doi:https://doi.org/10.1093/AJH/HPX139
27.
YangLSunLWenL, et al.Financing strategies to improve essential public health equalization and its effects in China. Int J Equity Health. 2016;15(1):1–12. doi:https://doi.org/10.1186/S12939-016-0482-X/FIGURES/5
XuYZhangTWangD. Changes in inequality in utilization of preventive care services: Evidence on China’s 2009 and 2015 health system reform. Int J Equity Health. 2019;18(1). doi:https://doi.org/10.1186/s12939-019-1078-z
31.
China health statistics yearbook. National health and family planning commission of People’s Republic of China. 2016.
HuangCLiuCJPanXFLiuXLiNX. Correlates of unequal access to preventive care in China: A multilevel analysis of national data from the 2011 China Health and Nutrition Survey. BMC Health Serv Res. 2016;16(1):1–13. doi:https://doi.org/10.1186/S12913-016-1426-2/TABLES/4
35.
ZhouYWushouerHVuillerminDNiBGuanXShiL. Medical insurance and healthcare utilization among the middle-aged and elderly in China: Evidence from the China health and retirement longitudinal study 2011, 2013 and 2015. BMC Health Serv Res. 2020;20(1). doi:https://doi.org/10.1186/s12913-020-05522-w
ShaoSWangMJinGZhaoYLuXDuJ. Analysis of health service utilization of migrants in Beijing using Anderson health service utilization model. BMC Health Serv Res. 2018;18(1):1–11. doi:https://doi.org/10.1186/S12913-018-3271-Y/TABLES/7
38.
AndersenRMDavidsonPL. Improving access to care in America: Individual and contextual indicators. In: AndersenRMRiceTHKominskiGF eds. Changing the U.S. Health Care System: Key Issues in Health Services, Policy, and Management. Jossey-Bass; 2001:3–30.
39.
ZengY. Toward deeper research and better policy for healthy aging – using the unique data of Chinese longitudinal healthy longevity survey. China Economic J. 2012;5(2-3):131–149. doi:https://doi.org/10.1080/17538963.2013.764677
40.
AlkhawaldehAAl BashtawyMRayanA, et al.Application and use of andersen’s behavioral model as theoretical framework: A systematic literature review from 2012–2021. Iran J Public Health. 2023;52(7):1346–1354. https://creativecommons.org/licenses/by-nc/4.0/
41.
RosenbaumPRRubinDB. Constructing a control group using multivariate matched sampling methods that incorporate the propensity score. Am Stat. 1985;39(1):33. doi:https://doi.org/10.2307/2683903
42.
HoDEImaiKKingGStuartEA. Matching as nonparametric preprocessing for reducing model dependence in parametric causal inference. Polit Anal.2007;15(3):199–236. doi:https://doi.org/10.1093/pan/mpl013
43.
LiaoYGilmourSShibuyaK. Health insurance coverage and hypertension control in China: Results from the China health and nutrition survey. PLoS One. 2016;11(3):e0152091. doi:https://doi.org/10.1371/JOURNAL.PONE.0152091
44.
LeeYHChangYCShelleyM. Is preventive care utilization associated with lower outpatient and inpatient health-care expenses among Chinese older adults? A longitudinal analysis. Int J Health Plann Manage. 2020;35(1):e142–e155. doi:https://doi.org/10.1002/HPM.2945
45.
LeeYHChangYCShelleyMLiuCT. Factors associated with preventive care utilisation among Chinese older adults: Evidence from the 2018 Chinese longitudinal healthy longevity survey. Soc Policy Soc.2024;23(2):314–329. doi:https://doi.org/10.1017/S1474746422000161
46.
DongWGaoJZhouZ, et al.Effects of China’s urban basic health insurance on preventive care service utilization and health behaviors: Evidence from the China Health and Nutrition Survey. PLoS One. 2018;13(12):e0209890. doi:https://doi.org/10.1371/JOURNAL.PONE.0209890
47.
ZengYLiJYuanZFangY. The effect of China’s new cooperative medical scheme on health expenditures among the rural elderly. Int J Equity Health. 2019;18(1). doi:https://doi.org/10.1186/S12939-019-0933-2
48.
XuXGuHYouH, et al.Are People Enrolled in NCMS and CURBMI Susceptible in Catastrophic Health Expenditure? Evidence From China. Inquiry. 2020;57. doi:https://doi.org/10.1177/0046958020919282
49.
ZhangYDongDXuL, et al.Ten-year impacts of China’s rural health scheme: Lessons for universal health coverage. BMJ Glob Health. 2021;6(4):e003714. doi:https://doi.org/10.1136/BMJGH-2020-003714
50.
YangW. China’s new cooperative medical scheme and equity in access to health care: Evidence from a longitudinal household survey. Int J Equity Health. 2013;12(1):1–13. doi:https://doi.org/10.1186/1475-9276-12-20/FIGURES/1
51.
DongWZwiABBaiRShenCGaoJ. Benefit of China’s social health insurance schemes: Trend analysis and associated factors since health reform. Int J Environ Res Public Health. 2021;18(11). doi:https://doi.org/10.3390/IJERPH18115672/S1
52.
RenJDingDWuQ, et al.Financial affordability, health insurance, and use of health care services by the elderly: Findings from the China health and retirement longitudinal study. Asia Pac J Public Health. 2019;31(6):510–521. doi:https://doi.org/10.1177/1010539519877054
53.
ZhuYÖsterleA. China’s policy experimentation on long-term care insurance: Implications for access. Int J Health Plann Manage. 2019;34(4):e1661–e1674. doi:https://doi.org/10.1002/HPM.2879
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