Introduction Migrants are a vulnerable population and could experience various challenges and barriers to accessing health insurance. Health insurance coverage protects migrants from financial loss related to illness and death. We assessed social health insurance (SHI) coverage and its financial protection effect among rural-to-urban internal migrants (IMs) in China.
Methods Data from the ‘2014 National Internal Migrant Dynamic Monitoring Survey’ were used. We categorised 170 904 rural-to-urban IMs according to their SHI status, namely uninsured by SHI, insured by the rural SHI scheme (new rural cooperative medical scheme (NCMS)) or the urban SHI schemes (urban employee-based basic medical insurance (UEBMI)/urban resident-based basic medical insurance (URBMI)), and doubly insured (enrolled in both rural and urban schemes). Financial protection was defined as ‘the percentage of out-of-pocket (OOP) payments for the latest inpatient service during the past 12 months in the total household expenditure’.
Results The uninsured rate of SHI and the NCMS, UEBMI/ URBMI and double insurance coverage in rural-to-urban IMs was 17.3% (95% CI 16.9% to 17.7%), 66.6% (66.0% to 67.1%), 22.6% (22.2% to 23.0%) and 5.5% (5.3% to 5.7%), respectively. On average, financial protection indicator among uninsured, only NCMS insured, only URBMI/UEBMI insured and doubly insured participants was 13.3%, 9.2%, 6.2% and 5.8%, respectively (p=0.004). After controlling for confounding factors and adjusting the protection effect of private health insurance, compared with no SHI, the UEBMI/URBMI, the NCMS and double insurance could reduce the average percentage share of OOP payments by 33.9% (95% CI 25.5% to 41.4%), 14.1% (6.6% to 20.9%) and 26.8% (11.0% to 39.7%), respectively.
Conclusion Although rural-to-urban IMs face barriers to accessing SHI schemes, our findings confirm the positive financial protection effect of SHI. Improving availability and portability of health insurance would promote financial protection for IMs, and further facilitate achieving universal health coverage in China and other countries that face migration-related obstacles to achieve universal coverage.
By the end of 2015, the estimated population of rural-to-urban internal migrants (IMs) in China had reached 277.5million, accounting for one-fifth of China’s population.1 2 Like many other countries across the world, achieving universal health coverage (UHC) is one of China’s health priorities to ensure all people receive needed quality healthcare without financial hardship. Social health insurance (SHI) has been the primary focus of efforts to promote access to healthcare and to provide financial protection against impoverishing healthcare cost in China and other low-income and middle-income countries.3 4 SHI has made remarkable progress in China since the late 1990s. Similar to many countries that currently have SHI systems,5 China started the reform of national SHI schemes by first introducing an SHI scheme for workers in 1998, which is the urban employee-based basic medical insurance (UEBMI). In 2003, the new rural cooperative medical scheme (NCMS), a form of community-based health insurance, was established and offered cover to rural residents. Later, in 2007, the urban resident-based basic medical insurance (URBMI) scheme for unemployed urban residents was piloted and then scaled up across China. The NCMS and URBMI are mainly subsidised by the local government, while the financing of the UEBMI comes mainly from joint urban employers and employees’ premiums.6 The detailed financing and benefits of the three SHI schemes are summarised in table 1. 6–8 By the end of 2015, the Chinese government had successfully provided the three SHI schemes to more than 95% of the population.
In China, rural-to-urban IMs face a dilemma regarding access to SHI, which was mainly created by the registered permanent residence (hukou in Chinese) system. Rural and urban residents are categorised separately according to their hukou, 10 11 and the government financing of the NCMS and the URBMI only targets rural and urban residents, respectively.10 That is without an urban hukou status, the rural-to-urban IM population is largely excluded from accessing the URBMI available only to urban residents, and their eligibility for the UEBMI varies across the country depending on local UEBMI policies. For example, in the China Health and Retirement Longitudinal Study, retired rural-to-urban IMs were more likely to be uninsured (relative risk ratio=1.39, 95% CI 1.24 to 1.57) compared with their local counterparts.12 Another study conducted in the South China’s megacity of Shenzhen found 43.1% of IMs and 12.2% of local residents were uninsured, respectively, and IMs were five times as likely as their urban peers to be uninsured.13 On the other hand, although IMs are eligible for the NCMS, the scheme runs at the county level and encourages enrollees to use designated hospitals within the county. For migrants who use health services outside the NCMS counties, the coinsurance for health services could rise markedly, and they need to pay for health services out-ofpocket (OOP) and afterwards get reimbursed.14 High OOP payments could discourage IMs from seeking care and may lead to impoverishment or even destitution for people with a need for treatment.
While there is a growing literature assessing SHI schemes among urban or/and rural residents, such as coverage, financial protection and equality of insurance schemes,15–18 only a few studies have been carried out among IMs. Most of the studies among IMs in China have focused on the impact of SHI status on health service utilisation.19–21 Yet little is known about SHI coverage and its financial protection effects among this vulnerable population. Previous studies showed insurance coverage was not significantly associated with OOP payments among IMs.22 23 While the level of OOP payment is indicative of financial protection, it fails to measure the extent to which the cost of medical services accounts for a household’s living budget, and limits the comparison across regions and time. Therefore, WHO suggests using indicators drawn from both medical costs and household expenditure data to monitor financial protection.3 Thus, using data from the 2014 ‘National Internal Migrant Dynamic Monitoring Survey (NIMDMS)’, our study aimed to extend our knowledge of coverage and financial protection in SHI schemes among rural-to-urban IMs in China. We hypothesised that (1) rural-to-urban IMs would have lower health insurance coverage than the national average and would vary by regions, and (2) the financial protection would be stronger among SHI insured rural-to-urban IMs than their uninsured counterparts and the relative degree of protection would vary by schemes.
The current study used data from the NIMDMS, collected in May 2014. The NIMDMS is a nationwide cross-sectional study aimed to be representative of IMs in mainland China,and is funded and organised by the National Health and Family Planning Commission of China (NPFPC) yearly since 2009, with the fieldwork undertaken by local Health and Family Planning Commissions.24 We chose the 2014 NIMDMS data because the NIMDMS changed survey topics every year, and variables related to SHI coverage and financial protection were only included in the 2014 questionnaire. The 2014 NIMDMS data (http:// hdl.handle.net/11620/10725) are publicly available to authorised researchers who have been permitted by the NPFPC, and we received the permission.
Study participants and sampling
The 2014 NIMDMS included IMs aged 15–59 years old who had lived in the study sites for at least 1month prior to the survey. IMs are defined as individuals who do not have hukou in the study sites, excluding people migrating for study/training purposes, tourism and medical care.24 IMs with urban hukou were excluded for the analysis in this study.
The 2014 NIMDMS planned to investigate 201 000 IMs in all provinces in mainland China. The survey was based on a stratified three-stage sampling design (figure 1).