Guanping Liu, Zhongliang Zhou, Yangling Ren, Xiaohui Zhai, Yan Zhuang, Zhichao Wang, Ruifeng Cui
{"title":"通过多层次健康保险加强财务保护：来自中国667055个低收入家庭的证据。","authors":"Guanping Liu, Zhongliang Zhou, Yangling Ren, Xiaohui Zhai, Yan Zhuang, Zhichao Wang, Ruifeng Cui","doi":"10.1136/bmjgh-2025-019440","DOIUrl":null,"url":null,"abstract":"<p><strong>Introduction: </strong>Low-income households face disproportionate out-of-pocket hardship when accessing healthcare, undermining equity and universal health coverage. To address these challenges, China implemented a three-tiered health coverage system-basic medical insurance, catastrophic medical insurance and medical assistance-but its comprehensive impact on the financial protection remains underexplored.</p><p><strong>Methods: </strong>We analysed Shaanxi Province's Medical Assistance database (2013-2016) to evaluate the impact of China's multitiered health coverage system on financial protection by: (1) estimating the incidence of catastrophic health expenditure (out-of-pocket payments> 25% of annual income) and medical impoverishment (postpayment income <US$1.90/day) before and after reimbursement-lower incidence indicating better protection and (2) assessing income-related inequality and inequity using concentration indices and horizontal inequity indices (ranging -1 to 1, where zero indicates equality/equity, negative values indicate pro-poor and positive values pro-rich distributions). All estimates accounted for household-level clustering.</p><p><strong>Results: </strong>A total of 667 055 households were included. After reimbursement, the incidence of catastrophic health expenditure fell from 58.59% (95% CI: 58.47 to 58.70) to 17.89% (95% CI: 17.79 to 17.97) and medical impoverishment from 41.43% (95% CI: 41.30 to 41.54) to 13.47% (95% CI: 13.38 to 13.55), driven mainly by basic medical insurance and medical assistance. Rural households received larger absolute declines yet remained higher than urban counterparts. Financial protection inequity worsened: the Horizontal Inequity Index for catastrophic health expenditure shifted from -0.0890 (95% CI: -0.0902 to -0.0879) to -0.1717 (95% CI: -0.1746 to -0.1689) and for medical impoverishment from -0.2653 (95% CI: -0.2669 to -0.2640) to -0.5251 (95% CI: -0.5280 to -0.5222), a pattern observed in both urban and rural areas.</p><p><strong>Conclusion: </strong>Our findings underscore the need for a three‑tiered health coverage system-including targeted, equitable reimbursement-to advance universal health coverage. Emerging tools such as big data analytics and artificial intelligence offer new ways to monitor and optimise equity; it is timely to extend equity considerations beyond funding mobilisation to reimbursement.</p>","PeriodicalId":9137,"journal":{"name":"BMJ Global Health","volume":"10 9","pages":""},"PeriodicalIF":6.1000,"publicationDate":"2025-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12519334/pdf/","citationCount":"0","resultStr":"{\"title\":\"Strengthening financial protection through multitiered health coverage: evidence from 667 055 low-income households in China.\",\"authors\":\"Guanping Liu, Zhongliang Zhou, Yangling Ren, Xiaohui Zhai, Yan Zhuang, Zhichao Wang, Ruifeng Cui\",\"doi\":\"10.1136/bmjgh-2025-019440\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Introduction: </strong>Low-income households face disproportionate out-of-pocket hardship when accessing healthcare, undermining equity and universal health coverage. To address these challenges, China implemented a three-tiered health coverage system-basic medical insurance, catastrophic medical insurance and medical assistance-but its comprehensive impact on the financial protection remains underexplored.</p><p><strong>Methods: </strong>We analysed Shaanxi Province's Medical Assistance database (2013-2016) to evaluate the impact of China's multitiered health coverage system on financial protection by: (1) estimating the incidence of catastrophic health expenditure (out-of-pocket payments> 25% of annual income) and medical impoverishment (postpayment income <US$1.90/day) before and after reimbursement-lower incidence indicating better protection and (2) assessing income-related inequality and inequity using concentration indices and horizontal inequity indices (ranging -1 to 1, where zero indicates equality/equity, negative values indicate pro-poor and positive values pro-rich distributions). All estimates accounted for household-level clustering.</p><p><strong>Results: </strong>A total of 667 055 households were included. After reimbursement, the incidence of catastrophic health expenditure fell from 58.59% (95% CI: 58.47 to 58.70) to 17.89% (95% CI: 17.79 to 17.97) and medical impoverishment from 41.43% (95% CI: 41.30 to 41.54) to 13.47% (95% CI: 13.38 to 13.55), driven mainly by basic medical insurance and medical assistance. Rural households received larger absolute declines yet remained higher than urban counterparts. Financial protection inequity worsened: the Horizontal Inequity Index for catastrophic health expenditure shifted from -0.0890 (95% CI: -0.0902 to -0.0879) to -0.1717 (95% CI: -0.1746 to -0.1689) and for medical impoverishment from -0.2653 (95% CI: -0.2669 to -0.2640) to -0.5251 (95% CI: -0.5280 to -0.5222), a pattern observed in both urban and rural areas.</p><p><strong>Conclusion: </strong>Our findings underscore the need for a three‑tiered health coverage system-including targeted, equitable reimbursement-to advance universal health coverage. Emerging tools such as big data analytics and artificial intelligence offer new ways to monitor and optimise equity; it is timely to extend equity considerations beyond funding mobilisation to reimbursement.</p>\",\"PeriodicalId\":9137,\"journal\":{\"name\":\"BMJ Global Health\",\"volume\":\"10 9\",\"pages\":\"\"},\"PeriodicalIF\":6.1000,\"publicationDate\":\"2025-09-10\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12519334/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"BMJ Global Health\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1136/bmjgh-2025-019440\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"BMJ Global Health","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1136/bmjgh-2025-019440","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH","Score":null,"Total":0}
Strengthening financial protection through multitiered health coverage: evidence from 667 055 low-income households in China.
Introduction: Low-income households face disproportionate out-of-pocket hardship when accessing healthcare, undermining equity and universal health coverage. To address these challenges, China implemented a three-tiered health coverage system-basic medical insurance, catastrophic medical insurance and medical assistance-but its comprehensive impact on the financial protection remains underexplored.
Methods: We analysed Shaanxi Province's Medical Assistance database (2013-2016) to evaluate the impact of China's multitiered health coverage system on financial protection by: (1) estimating the incidence of catastrophic health expenditure (out-of-pocket payments> 25% of annual income) and medical impoverishment (postpayment income
Results: A total of 667 055 households were included. After reimbursement, the incidence of catastrophic health expenditure fell from 58.59% (95% CI: 58.47 to 58.70) to 17.89% (95% CI: 17.79 to 17.97) and medical impoverishment from 41.43% (95% CI: 41.30 to 41.54) to 13.47% (95% CI: 13.38 to 13.55), driven mainly by basic medical insurance and medical assistance. Rural households received larger absolute declines yet remained higher than urban counterparts. Financial protection inequity worsened: the Horizontal Inequity Index for catastrophic health expenditure shifted from -0.0890 (95% CI: -0.0902 to -0.0879) to -0.1717 (95% CI: -0.1746 to -0.1689) and for medical impoverishment from -0.2653 (95% CI: -0.2669 to -0.2640) to -0.5251 (95% CI: -0.5280 to -0.5222), a pattern observed in both urban and rural areas.
Conclusion: Our findings underscore the need for a three‑tiered health coverage system-including targeted, equitable reimbursement-to advance universal health coverage. Emerging tools such as big data analytics and artificial intelligence offer new ways to monitor and optimise equity; it is timely to extend equity considerations beyond funding mobilisation to reimbursement.
期刊介绍：
BMJ Global Health is an online Open Access journal from BMJ that focuses on publishing high-quality peer-reviewed content pertinent to individuals engaged in global health, including policy makers, funders, researchers, clinicians, and frontline healthcare workers. The journal encompasses all facets of global health, with a special emphasis on submissions addressing underfunded areas such as non-communicable diseases (NCDs). It welcomes research across all study phases and designs, from study protocols to phase I trials to meta-analyses, including small or specialized studies. The journal also encourages opinionated discussions on controversial topics.
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