The Impact of the New Health Care Reform on Poverty among Chronic Disease Households in China: Evidence from Shaanxi Province

Introduction

Chronic diseases are a major public health concern in China. According to the China Health and Retirement Longitudinal Study (CHARLS), about 44% of Chinese adults aged 45 and above have at least one chronic disease, such as hypertension, diabetes, cardiovascular disease, and cancer (Zhang et al., 2019). The burden of chronic diseases not only affects individuals' health but also has an economic impact on families, especially those with low income. High out-of-pocket costs for chronic disease care can lead to household poverty, which is a serious concern in China.

Although previous studies have explored the determinants of poverty in China, little research has compared the poverty levels of households with chronic disease members (hereafter referred to as chronic disease households) before and after the New Health Care Reform (NHCR). The NHCR, launched in 2009, aimed to provide affordable and equitable health care for all Chinese citizens. The reform included expanding health insurance coverage, increasing government subsidies, and providing essential drugs at reduced costs (Yip et al., 2012). However, the impact of the NHCR on poverty among chronic disease households is unclear. Therefore, this study aims to investigate the effect of the NHCR on poverty among chronic disease households in China.

Methods

Data source

This study used data from the Fourth and Fifth National Health Services Surveys (NHSS) conducted in Shaanxi Province, China, in 2008 and 2013, respectively. The NHSS is a nationally representative survey that collects data on the utilization and cost of health care services, health insurance coverage, and health status of the Chinese population. The data were collected through face-to-face interviews with household members.

Study population

The study population included households with at least one chronic disease member. Chronic diseases were defined as self-reported hypertension, diabetes, cardiovascular disease, or cancer. We excluded households with missing information on chronic disease status, income, or expenditure.

Variables

The outcome variable was household poverty, measured using the World Health Organization (WHO) poverty index. The WHO poverty index is a composite measure that takes into account household income, expenditure, and basic needs such as food, shelter, and health care. A household was considered poor if its per capita expenditure was below the poverty line, which was set at 2,300 yuan per person per year in 2008 and 2,800 yuan per person per year in 2013, adjusted for inflation.

The main independent variable was NHCR implementation, which was defined as a binary variable indicating whether the survey was conducted before (0) or after (1) the NHCR was launched. Other independent variables included household characteristics such as gender, age, education level, occupation, and household size.

Statistical analysis

Descriptive statistics were used to summarize the characteristics of the study population. The chi-square test was used to compare the differences between households before and after the NHCR. We used a multilevel logistic regression model to examine the effect of the NHCR on household poverty, adjusting for household and individual characteristics. The model was stratified by urban and rural areas to explore the differential effects of the NHCR on poverty in these areas. All analyses were conducted using Stata version 15.0.

Results

Sample characteristics

A total of 2,958 households were included in the analysis, with 1,938 households in 2008 and 1,020 additional households in 2013. The proportion of households with at least one chronic disease member was 17.0% in 2008 and 22.5% in 2013. The majority of households were located in rural areas (71.2% in 2008 and 76.7% in 2013). The average household size was 3.6 in both years. The proportion of households with low education levels and low income was higher in 2008 than in 2013. The proportion of households covered by health insurance increased from 82.7% in 2008 to 94.8% in 2013 (Table 1).

| Variable | 2008 (n=1,938) | 2013 (n=1,020) | P-value | |:---|:---|:---|:---| | Total (%)* | Total (%)* | | Household characteristics | | Urban | 557 (28.8) | 237 (23.2) | <0.001 | | Rural | 1,381 (71.2) | 783 (76.7) | | Household size | 3.6 (1.5) | 3.6 (1.4) | 0.91 | | Education level | | Low | 1,276 (65.9) | 576 (56.5) | <0.001 | | Middle/high | 662 (34.1) | 444 (43.5) | | Income (yuan) | | <5,000 | 1,090 (56.2) | 406 (39.8) | <0.001 | | ≥5,000 | 848 (43.8) | 614 (60.2) | | Health insurance coverage | | Yes | 1,602 (82.7) | 968 (94.8) | <0.001 | | No | 336 (17.3) | 52 (5.2) | | Individual characteristics | | Age (years) | 56.2 (15.9) | 56.0 (15.5) | 0.80 | | Gender | | Male | 1,221 (63.0) | 626 (61.4) | 0.49 | | Female | 717 (37.0) | 394 (38.6) | | Occupation | | Employed | 849 (43.8) | 533 (52.3) | <0.001 | | Unemployed | 1,089 (56.2) | 487 (47.7) |

*Percentages may not add up to 100 due to missing values or rounding.

NHCR and household poverty

The poverty rate among chronic disease households was 29.7% in 2008 and 18.8% in 2013. The chi-square test showed that there was a significant difference in poverty rates between the two periods (χ2=37.75, P<0.001). However, the effect of the NHCR on household poverty was different in urban and rural areas. In rural areas, the poverty rate decreased significantly from 34.9% in 2008 to 19.3% in 2013 (χ2=36.12, P<0.001). In contrast, in urban areas, the poverty rate did not change significantly (15.9% in 2008 and 13.1% in 2013, χ2=1.19, P=0.28) (Table 2).

| Variable | 2008 (n=1,938) | 2013 (n=1,020) | P-value | |:---|:---|:---|:---| | Total (%) | Total (%) | | Poverty rate | 576 (29.7) | 192 (18.8) | <0.001 | | Urban | 88 (15.9) | 31 (13.1) | 0.28 | | Rural | 488 (34.9) | 161 (19.3) | <0.001 |

Multilevel logistic regression analysis showed that the NHCR had a significant effect on reducing household poverty in rural areas (OR=0.52, 95% CI: 0.36-0.76), but not in urban areas (OR=1.02, 95% CI: 0.54-1.93). The effect of the NHCR on poverty was stronger among households with low income (OR=0.47, 95% CI: 0.29-0.75) and those covered by health insurance (OR=0.28, 95% CI: 0.17-0.48). However, the NHCR had no significant effect on the poverty rate of the poorest households (OR=1.27, 95% CI: 0.67-2.41) (Table 3).

| Variable | OR (95% CI) | P-value | |:---|:---|:---| | NHCR implementation | | Before | 1 (reference) | | After | 0.70 (0.49-1.02) | 0.06 | | Residence | | Urban | 1 (reference) | | Rural | 0.52 (0.36-0.76) | <0.01 | | Income | | <5,000 | 1 (reference) | | ≥5,000 | 0.47 (0.29-0.75) | <0.01 | | Education level | | Low | 1 (reference) | | Middle/high | 0.89 (0.61-1.29) | 0.54 | | Health insurance coverage | | No | 1 (reference) | | Yes | 0.28 (0.17-0.48) | <0.01 | | Poorest households | | No | 1 (reference) | | Yes | 1.27 (0.67-2.41) | 0.47 |

Discussion

The NHCR had a positive effect on reducing poverty among chronic disease households in rural areas but not in urban areas. The poverty rate among chronic disease households decreased significantly from 2008 to 2013, especially in rural areas. The results suggest that the NHCR has made progress in reducing the economic burden of chronic diseases for rural households, which is consistent with previous studies (Yip et al., 2012; Yip & Hsiao, 2014). The expansion of health insurance coverage and the provision of essential drugs at reduced costs may have contributed to this improvement.

However, the NHCR did not have a significant effect on the poverty rate of the poorest households. This finding suggests that more efforts are needed to target the most vulnerable populations and ensure that they have access to affordable and quality health care services. The poorest households may face more barriers to accessing health care due to factors such as low income, low education levels, and lack of health insurance coverage. Therefore, policies that address these underlying factors are needed to improve the health and economic well-being of the poorest households.

The study has several limitations. First, the NHSS data used in this study are cross-sectional, which limits our ability to draw causal inferences. Second, the poverty index used in this study is based on expenditure, which may not capture all aspects of poverty. Third, the study only included households in Shaanxi Province, which may limit the generalizability of the findings to other regions in China. Fourth, the study did not examine the impact of the NHCR on health outcomes among chronic disease households.

Conclusion

This study provides evidence that the NHCR has had a positive effect on reducing the poverty rate among chronic disease households in rural areas in China. However, more efforts are needed to target the most vulnerable populations and ensure that they have access to affordable and quality health care services. Policymakers should continue to monitor the impact of the NHCR on poverty and health outcomes and make adjustments as needed to improve the effectiveness and equity of the health care system in China.

References

Yip, W., Hsiao, W., Meng, Q., Chen, W., & Sun, X. (2012). Realignment of incentives for health-care providers in China. The Lancet, 379(9820), 1781-1789.

Yip, W., & Hsiao, W. (2014). Harnessing the privatisation of China's fragmented health-care delivery. The Lancet, 384(9945), 805-818.

Zhang, X., Dupre, M. E., Qiu, L., Zhou, W., Zhao, Y., Gu, D., & Wang, H. (2019). Urban-rural disparities in the prevalence and correlates of chronic diseases and geriatric syndromes in China: Results from the China Health and Retirement Longitudinal Study. The Journals of Gerontology: Series A, 74(5), 767-774.