China’s healthcare insurance system has multiple admission standards and multiple divisions, which go against the status quo of flow of personnel, and may jeopardize the robustness and sustainability of healthcare insurance financing through the allocating the risk to public, directly doing harm to the efficiency of operation [10]. Take the example of NRCMS, which is designed exclusively for rural people according to their hukou [4], the enrollees are expected to seek medical services in the designated hospitals, most of which are located within the home county, which is impractical for the migrant job seekers far away from home, limiting their NRCMS benefits. Furthermore, the migrants are also facing the lack of accessibility to healthcare insurance in cities, as most of them are not qualified for UEBMI and URBMI [11, 12].
In 2009, a new round of healthcare system reform has been initiated, aiming to ensure that the State plays a critical role in guaranteeing universal coverage of essential healthcare and providing efficient, convenient and affordable basic healthcare services [13]. Four aspects of healthcare system covering both urban and rural residents are involved in the reform: health insurance schemes, national essential drug systems, clinical service systems and the public health/preventive service systems. Hitherto, the healthcare insurance schemes in China have achieved phasic success. Despite the increasing coverage of population, unfairness, inequality and unaffordability of the healthcare services have hindered the universal healthcare progress, which might also affect people’s enthusiasm for participating in the healthcare insurances. It should be noted that their lack of participation will not only lead to adverse selection but also to considerably higher administrative costs [14].
Healthcare insurance expectations, healthcare insurance integration willingness and associated factors
To promote the participation in healthcare insurances and to smoothly integrate UEBMI, URBMI and NRCMS, the voices of mass population should be heard. Our data revealed that the expected payment range of urban employees presented a dispersed trend, while that of urban residents and rural residents presented a concentrated pattern (Figure 2). This could be explained by the fact that the insurance payment of urban employees is proportional to their salaries, while for urban and rural residents, the quota payment, which sets a payment standard for enrollees, limits their choices. The UEBMI guideline established by State Council suggests premium contributions by employers and employees be set at 6% and 2% of an employee’s salary, respectively [15]. While according to a URBMI survey conducted by State Council, the average per capita financing level of the pilot cities in 2007 reached 236 RMB for adults and 97 RMB for minors. About 36% and 50% of these amounts, respectively, were contributed by government subsidies, indicating that the majority of funding was obtained from individual contributions [7]. The total government subsidies for NRCMS enrollees were 80 RMB per rural resident in 2009, of which central and local government each contributed 40 RMB. Meanwhile, individual contributions rose to 20 RMB per enrollee and the average financing level increased to 100 RMB per enrollee in 2009 [16]. As the healthcare insurance systems of URBMI and NRCMS have been integrated in some areas, the participants shared the same reimbursement expectations (Figure 3). In addition, as indicated in our study, people in economically developed areas showed higher payment intention, higher reimbursement expectation as well as better insurance benefit package. In addition, according to the 2008 National Health Service Survey [17], income level was a major determinant of health outcomes. Therefore, the economic status of participants from different areas and different population groups should be taken as a reference when setting the payment standard and benefit package.
As noted in Table 4, rural residents were the most supportive of healthcare insurance integration, with the most common reason of achieving equal access to healthcare services. On the other hand, people who strongly opposed the integration mainly held that the gaps in the insurance coverage and healthcare benefits across different schemes remained to be so wide that it was unwise to integrate them at this moment. Despite the increasing coverage of healthcare insurance nationally [18], the access to healthcare services remained to be uneven, and the integration would not only promote the benefits for rural residents, but will also provide much convenience for rural migrants seeking medical care in cities. Jian and his colleagues have reported that even though rural Chinese with chronic disease could more easily start inpatient treatment in 2008 than they could in 2003, they were more than twice as likely to drop out of treatment as were Chinese in urban areas due to the higher hospital copayments required under insurance coverage for rural citizens [19]. Therefore, in the process of coordinating urban and rural healthcare insurance schemes, the economic background should not be neglected. The logistic regression model in Table 5 indicated that participants in Changchun were more likely to oppose the integration than the participants in the other three cities, reflecting that the enrollees in Changchun were not satisfied with the current insurance schemes. Also we found that people with better education background tended to oppose the integration, which might seem contradictory to the common sense. We proposed two reasons for it: on one hand, as no complete integration policy has been implemented yet, they might concern that the integration would drag down their healthcare benefits; on the other hand, they might be better aware of the underlying challenges of integration, involving limited financial risk pooling, inefficient purchasing and provider incentives, etc. In this case, a proper balance of benefits among each group is crucial in improving the healthcare scheme.
Policy implication
According to the feedback from the enrollees, we have come up with the following suggestions to improve the healthcare insurance policy.
Setting up a multi-grade payment and treatment standard: For developed areas, high subsidies are provided to ensure that urban and rural residents receive improved or even equivalent healthcare treatment as urban employees (such as Changshu and Foshan). While for most parts of China, where the income of urban and rural residents differ greatly and the local fund is limited, a proper fund-raising mechanism with multiple standards is needed in the transitional stage, so that participants could choose the grade according to their own economic background.
Constructing an integrated healthcare insurance information system: For areas that are immature to integrate URBMI and NRCMS, instead of leaping to the integration, a unified information platform shall be established as the first move towards the integration.
Unifying the administration: To improve the poor interconnections due to the separate healthcare administrative institutions, a unified administration will not only facilitate the coordination of healthcare insurances, but will also alleviate the financial pressure of operation. The unified policies in Foshan, Changshu and Shenyang have set successful examples for broader implementation.
Establishing a proper transferring mechanism: With the market economic development and agricultural market reforms, many rural workers transit to cities for employment, most of whom receive little NRCMS reimbursement [9]. A transferring mechanism that links with the original system could well improve the situation. But it requires a cohesive mechanism among different systems, and solving problems like how to convert payment age limitations and how to compensate for the medical funding of the local area.
Improving the coordination level: Currently, the healthcare insurance coordination remains at various levels, including county level, municipal level, and provincial level. This leads to the poor risk-resisting ability. While by improving the planning on a higher level, we could have a stronger ability to resist risks, thus increasing enrollees’ confidence in healthcare insurances.
Setting up a stable fund-raising and financial subsidy mechanism: In spite of the increasing funding level, the financing mechanism is not well regulated. We propose that the payment standard of rural residents shall be set in accordance with their net income, while that of urban residents shall be set in accordance with their disposable income, and financial subsidies from the government shall be determined partially by residents’ hospitalization cost.
Limitations
The study has several limitations. Firstly, the selection of the respondents focused on certain communities in the four cities, and the results may not be generalizable to the entire country due to differences among areas, and could not fully represent the three groups of population, namely, rural residents, urban residents and urban employees. Secondly, the differences of the same insurance scheme across cities were not considered when we studied the factors influencing participants’ willingness towards healthcare insurance integration. Thirdly, some data in out study, like household annual income per capita, were collected on the basis of personal recall and could be prone to measurement errors.