Amartya Sen once noted that “health is the necessary basis for people to realize other capabilities”. Healthcare service, as the post intervention in diseases, is the last “safety net” to guarantee health, and the equalization of healthcare utilization is an important approach to guarantee health equity [29]. Since the reform and opening up of China, the medical industry and technology have developed rapidly, which also led to an increase in medical expenses. As a result, the inequity in healthcare utilization has also intensified among people of different income groups. Compared to high-income groups, low-income groups have a higher need for healthcare services due to their poor health status [20]. But constrained by income, the healthcare utilization for low-income groups is much less than that of high-income groups.
In China, the inequity in healthcare utilization is more serious in rural areas because there are a large number of low-income groups there [23]. Moreover, for low-income groups, a low level of healthcare utilization can consume most of their wealth, so some of them dare not see a doctor when they are ill. To reduce the inequity in healthcare utilization in rural areas, the Chinese government established the New Cooperative Medical Scheme (NCMS) for rural populations in 2003. By bearing a portion of the medical expenses of the insured, NCMS aims to reduce the economic barriers in healthcare utilization and to improve equity of healthcare services for rural populations regardless of individual socioeconomic factors such as marital status, education and income.
Although the coverage of NCMS has been above 90% since 2008, its services coverage and financial protections are less than those of the Urban Resident Basic Medical Insurance (URBMI) available to the urban populations. According to statistics, “urban residents per capita healthcare expenditure paid by medical insurance is around three times as much as that of the rural residents in 2012”.Footnote 1 The segmentation of the urban-rural medical insurance scheme has become a main factor that caused the urban-rural inequity in healthcare utilization and it is hardly to ensure the healthcare demands of low-income groups in rural areas [24]. This will be harmful to the implementation of rural revitalization strategies and poses a serious threat to social stability in that China is in a critical period of social and economic transformation.
Therefore, the integration of urban-rural medical insurance has gained governmental attention since 2008, and the government established the Urban and Rural Resident Basic Medical Insurance (URRBMI) based on NCMS and URBMI to make residents participate in the same medical insurance regardless of household registration. In 2016, the central government announced that the URRBMI was gradually implemented nationwide in China. Against this backdrop, comparing the inequity in healthcare utilization between URRBMI and NCMS can provide important information for the implementation and development of URRBMI.
Previous studies have revealed that inequity in healthcare utilization exists widely in the world [4, 6, 16]. Apart from inequity between countries, it also exists between regions within one country [1, 3, 21, 25]. The influencing factors of inequity in healthcare utilization are different because of differences in the economy, medical insurance systems and cultures between countries and regions. In previous studies, scholars investigated the relationship between income and the inequity in healthcare utilization, and they found that the inequity is pro-rich in both developed and developing countries, causing an interest transfer between the rich and the poor [4, 6, 17]. Some scholars have also taken other socioeconomic factors into consideration, and they found that factors like medical insurance can also influence the inequity in healthcare utilization [2, 24].
Theoretically, medical insurance can reduce inequity as it provides a financial support in healthcare utilization and covers a large proportion of medical expenses for low-income groups. In China, although medical insurance schemes are a major payment system for healthcare utilization, there are conflicting opinions about the relationship between medical insurance and healthcare utilization inequity. First, some of the studies claim that the implementation of medical insurance narrowed the gap of healthcare utilization [11,12,13]; second, others argue that medical insurance failed to reduce the degree of inequity in healthcare utilization [17, 18, 26,27,28, 31], and some scholars also found that medical insurance has intensified the inequity of healthcare utilization instead of narrowing it [2, 23].
The reason that medical insurance fails to reduce healthcare utilization inequity is that the top-level design of the Chinese medical insurance system pays more attention to economic efficiency during the period of primitive accumulation of capital. Studies have shown that the income gap, the fragmentation management of medical insurance and the difference in medical insurance benefits have become the main factors of healthcare utilization inequity [8, 9, 14, 15, 24]. In China, the urban-rural segmentation of the medical insurance system ensures that the rural population experiences lower medical insurance benefits than the urban population. Meanwhile, the proportion of low-income groups in rural areas is higher than that in urban areas. As a result, NCMS cannot meet the healthcare demands of low-income groups and improve the healthcare utilization inequity completely in rural China.
The aim of URRBMI is to provide the same services coverage and financial protections to both urban and rural residents. We assume that the healthcare utilization inequity in rural areas will be reduced as URRBMI improves the medical insurance benefits of rural populations. Referring to URRBMI, some studies found that the opportunity inequity of healthcare utilization was reduced in URRBMI [13], and it also promoted the healthcare utilization of the insured [7, 14, 19, 30]. Meanwhile, other studies implied that the effect of URRBMI on outpatient and inpatient care utilization is not significant [22] and that the rural regional difference in medical insurance benefits still exists under URRBMI [10, 22].
In summary, the previous studies have analyzed the influence of socioeconomic factors on the inequity of healthcare utilization comprehensively, and most of them employed the Concentration Index (CI) to quantify the degree of inequity. Moreover, they also revealed the profound reasons for the healthcare utilization inequity in rural areas by analyzing the urban-rural segmentation of medical insurance, which provided a reference for this article. However, few of them focus on the healthcare utilization inequity in rural areas under URRBMI. Although Ma Chao et al. measured the opportunity inequity of healthcare utilization between urban and rural areas after the integration of urban-rural medical insurance, their research was only limited to three counties in Jiangsu Province of China and did not analyze the inequity within rural areas [13].
Based on the existing studies, this paper analyzes the relationship between URRBMI and the inequity of healthcare utilization in rural areas by comparing the inequity in healthcare utilization under URRBMI and NCMS. Theoretically, the degree of inequity in URRBMI will be lower than in NCMS in that the services coverage and financial protections of URRBMI are better than those of NCMS, but the assumption needs to be verified by data analysis in the next section. This paper is organized as follows:
First, as the fact that healthcare utilization is mainly affected by health status and socioeconomic factors, we use the chi-square test to make a comparison of differences in healthcare utilization and other influence factors among the individuals who were insured by URRBMI and NCMS.
Second, as the dependent variables in this paper are discrete, and the inequity in healthcare utilization is income-related, the binary logistic regression model is employed in this paper to analyze the differences in healthcare utilization among different income levels under the two medical insurance schemes.
Third, the concentration index (CI) and horizontal inequity index (HI index) are used to quantify the degree of inequity in healthcare utilization under the two groups, the decomposition of the concentration index is used to present the contribution of each independent variable to the concentration index.