Authors
Xingxing Ren, Yu Hao, Sucheng Mu, Chaoyuan Jin
Published in
BMC public health. Jul 15, 2026. Epub Jul 15, 2026.
Abstract
China has achieved broad health insurance coverage, but financial protection may still differ across schemes. We assessed whether insurance scheme was associated with out-of-pocket medical burden among Chinese adults.
We analyzed repeated cross-sectional adult person-wave data from the China Family Panel Studies for 2016, 2018, 2020, and 2022. Adults were classified as employee/public insured, resident insured, uninsured, or covered by other or multiple schemes. The primary outcome was log-transformed annual out-of-pocket expenditure after reimbursement. Among medical spenders, the second financial-protection outcome was an out-of-pocket ratio of at least 50% of total medical expenditure. Weighted regression models adjusted for age, sex, education, relative income rank, employment, urban residence, chronic disease, and survey year. Exact-scheme and sensitivity analyses tested robustness.
The study included 120,063 adult observations; 107,116 had a known insurance scheme, 49,111 entered the primary out-of-pocket model, and 8,034 medical spenders entered the high-ratio model. In the weighted analytic sample, resident insurance accounted for 69.9% of observations, employee/public insurance for 18.0%, and no insurance for 8.7%. Compared with employee/public insurance, resident insurance was associated with higher log out-of-pocket expenditure (beta 0.275, 95% CI 0.188 to 0.362, p < 0.001), as was no insurance (beta 0.313, 95% CI 0.177 to 0.449, p < 0.001). Among medical spenders, resident insurance and no insurance were associated with higher probability of an out-of-pocket ratio of at least 50% (risk difference 0.174, 95% CI 0.127 to 0.221, p < 0.001; and 0.177, 95% CI 0.098 to 0.256, p < 0.001, respectively). Exact-scheme, province fixed-effect, clustered-standard-error, income-rank, year-stratified, and alternative-threshold analyses were directionally consistent.
In CFPS 2016-2022, resident insurance and no insurance were associated with higher out-of-pocket medical burden than employee/public insurance. Causal interpretation should remain cautious because plan-level benefit design, health-care utilization intensity, and household capacity to pay were not fully observed.
PMID:
42458413
Bibliographic data and abstract were imported from PubMed on 16 Jul 2026.
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