Medical insurance integration and rural-urban benefit disparities, 2006-2021: evidence from quasi-natural experiments in China.

Abstract

To assess the impact of China's medical insurance integration policy on urban-rural disparities in medical insurance benefit levels, explore its heterogeneous effects in regions with different economic development levels and provide empirical evidence for promoting health equity. Retrospective panel data analysis using a quasi-natural experiment. Causal inference was conducted using propensity score matching-staggered difference in differences (PSM-staggered DID) method with time-varying policy variables. Provincial-level analysis covering 31 provinces in China, using administrative data from 2006 to 2021. 31 Chinese provinces with complete annual data on medical insurance and economic indicators from 2006 to 2021, yielding 496 province-year observations. Gradual implementation of the policy of integration of medical insurance (2006-2021), with start-up dates varying from province to province. The primary outcomes are natural logarithm of per capita medical insurance benefits for all residents, urban residents and rural residents. No secondary outcomes were predefined. Overall, the policy had a weak positive impact on the per capita benefits of rural residents. Subgroup analyses showed no immediate effect in provinces with a gross domestic product (GDP) per capita of more than 100 000 yuan, but an increase in benefits for rural residents 1 year after implementation; an immediate increase in rural benefits in provinces with a GDP per capita of 60 000-100 000 yuan; and a reduction in overall and rural benefits at the beginning in provinces with a GDP per capita of <60 000 yuan, followed by a restoration of rural benefits after 2 years. Mechanistically, the policy increased medical insurance coverage rates, but higher coverage was associated with short-term reductions in per capita benefits. Region-specific strategies need to be developed to provide lessons for developing countries pursuing universal health coverage.