Are there Tangible Benefits of Cooperative Health Insurance Schemes for Chinese RuralSuburban School

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Are there Tangible Benefits of Cooperative
Health Insurance Schemes for Chinese
Rural-Suburban Schoolchildren? WPHC2009.4.29
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Jane M Zhu Harvard University Medical School,
USA Yiliang Zhu College of Public Health,
University of South Florida, USA Work
supported in part by a Duke University Fellowship
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Background
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Health Insurance 1970s

• Nearly all urban Chinese population had some
  sorts of insurance
• 85 rural residents (farmers) were covered under
  a cooperative health insurance

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Health Insurance through 1990s

• Some twenty years economic reform later by 2003
• Insurance rate fell to 54-55 in urban
  population
• Only 10 of the lowest income quartile had any
  sort of insurance
• 640 million (79) rural residents were without
  insurance

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Current Governments Initiatives and Actions

• Basic Health Insurance System for Registered
  Urban Workers Retirees (BHIS-W)
• Basic Health Insurance System for registered
  urban residents (non-workers), and also
  non-residents migrants in some regions (BHIS-R)
• New Rural Cooperative Medical System for farmers
  and dependents (RCMS)

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Urban Workers BHIS-W

• First piloted in 1998 to replace and unify
  existing insurance schemes
• Does not cover children/dependents
• Pooled funding from local government, employer,
  and individual
• Operating as a CAPPED medical saving account to
  reimburse routine and major medical events

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Rural Residents Dependents RCMS

• First piloted in 2003 implemented in 310
  counties by 2004 to cover entire country by 2010
• Voluntary enrollment by households
• Capped and pro-rata reimbursements for only major
  medical events
• Funding pooled from central, regional, and local
  governments as well as an annual premium
  (1050) per person

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Urban Residents BHIS-R

• New initiative in 2008 to cover non-workers (also
  migrant workers in some municipalities)
• Funding pooled from local government, employer,
  and individual
• Medical saving account for pro-rata reimburse of
  major medical events only
• Substantial variation across regions

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What about Schoolchildren?
A Survey of Elementary Schoolchildren in Ping-gu
District, Beijing
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• A rural county to the NE of Beijing
• 70 agricultural population
• 60 agricultural land

Beijing

• School-based clustered sampling
• Selection of 4 elementary schools from a total
  108
• Random selection of classes of 1st and 4th
  grades
• 490 (80) returned questionnaires

Pinggu
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What Have Learned
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Health Insurance Status

• 54 children had some kind of health insurance
• Insurance rate of children from farmer households
  was comparable to that of non-farmer households
• Rural children mostly covered by low premium,
  cooperative-like schemes (76) vs. that of
  non-farmer households (42)

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Barriers to Health Insurance

• Perceived affordability
• Knowledge and belief about health insurance
• Mediating factors of the two

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Are there Tangible Benefits?

• Barriers are determined in large part by
  tangible benefits
• Tangible benefits determines the growth and
  sustainability of cooperative schemes

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Tangible Benefits - Care Access and Affordability
Cooperative schemes may have improved perceived
accessibility, but not affordability
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Tangible Benefits Care Utilization

• No significant difference in using outpatient
  care
• Reduced frequency of delayed care
• Reduced frequency of forgone care

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Conclusions

• Cooperative Health Insurance Schemes
• Improved perceived accessibility to care
• Did not improve perceived affordability of care
• Did not improve routine care
• But may improved care utilization when symptoms
  were serious (surgery and hospitalization)

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Implications

• Without significant tangible benefits,
  cooperative schemes are difficult to sustain
• Tangible benefits are critical in sustaining
  insurance enrollments and avoiding reverse
  selection
• Tiered insurance options with varying premium may
  provide different levels of benefits to meet
  individual needs