Rural-urban differences in health outcomes, healthcare use, and expenditures among older adults under universal health insurance in China

Rural-urban inequalities in health status and access to care are a significant issue in China, especially among older adults. However, the rural-urban differences in health outcomes, healthcare use, and expenditures among insured elders following China’s comprehensive healthcare reforms in 2009 remain unclear. Using the Chinese Longitudinal Healthy Longevity Surveys data containing a sample of 2,624 urban and 6,297 rural residents aged 65 and older, we performed multivariable regression analyses to determine rural-urban differences in physical and psychological functions, self-reported access to care, and healthcare expenditures, after adjusting for individual socio-demographic characteristics and health conditions. Nonparametric tests were used to evaluate the changes in rural-urban differences between 2011 and 2014. Compared to rural residents, urban residents were more dependent on activities of daily living (ADLs) and instrumental ADLs. Urban residents reported better adequate access to care, higher adjusted total expenditures for inpatient, outpatient, and total care, and higher adjusted out-of-pocket spending for outpatient and total care. However, rural residents had higher adjusted self-payment ratios for total care. Rural-urban differences in health outcomes, adequate access to care, and self-payment ratio significantly narrowed, but rural-urban differences in healthcare expenditures significantly increased from 2011 to 2014. Our findings revealed that although health and healthcare access improved for both rural and urban older adults in China between 2011 and 2014, rural-urban differences showed mixed trends. These findings provide empirical support for China’s implementation of integrated rural and urban public health insurance systems, and further suggest that inequalities in healthcare resource distribution and economic development between rural and urban areas should be addressed to further reduce the rural-urban differences.

Yes -all data are fully available without restriction   Inequitable access to health services is an enduring concern of health care planners and (CLHLS),one study (24)found that the associations between access to healthcare and health The independent variable of interest in this study was the rural/urban residency status.

174
The CLHLS provides urban/rural residency at the time of survey (rather than "hukou" status,  status on a scale from 0 to 2 (assistance needed always, assistance needed sometimes, and no 189 assistance needed, respectively). Thus, the total score ranges from 0 to 10 for the ADL measure  alcohol drinking behavior, exercise, sleep quality, and regular physical examination. We also 218 included regional dummies (east, middle, and west) to adjust for possible geographic variations. Education, occupation, whether respondents went to bed hungry or had sufficient 247 medical service in childhood had relatively high missing rates, ranging from 4.4% to 20.6%.

248
We defined missing values as a separate group in main analyses (described above). In the 249 sensitivity analyses, we excluded the individuals with any missing values, and the results 250 remained very similar and thus are not reported. All regressions reported robust standard error.

251
To help ease the interpretation of model results, we computed margins of adjusted 252 outcomes for urban (i.e., Urban-adjusted in Table 2 and Table 3) and rural (i.e., Rural-adjusted 253 in Table 2 and Table 3 After adjusting for covariates, rural-urban differences in these health measures above 271 were still significant ( Table 2 and Appendix Tables A1, A2 P<0.0001). We also found urban residents to face lower self-payment ratio (adjusted 282 difference=-13.7%; P<0.0001) than their rural counterparts.

283
In analyses stratified by year, we found slightly improved ADL and IADL functions, 284 psychological well-being, adequate access to care, healthcare expenditures (higher) and self-285 payment ratio (lower) for both rural and urban residents from 2011 to 2014 (Table 3, Appendix   286   Tables A7, A8  Our results also suggested that the gaps in health outcomes, adequate access to care and 292 self-payment ratio between rural and urban residents narrowed, but differences in healthcare

372
In line with earlier studies, (7,9,70) our study showed that urban residents had   Examination. Urban-adjusted and rural-adjusted columns report margins of adjusted outcomes. Adjusted differences are marginal differences calculated based on the coefficients of the Urban variable. The adjusted difference of adequate access to care* is odds ratio. Regressions on ADL, IADL, and psychological wellbeing, adjusted for age, sex, marital status, number of living children, annual income per capita, education, living with people, arm length, drinking at present, smoking at present, regular exercise at present, sufficient financial support, went to bed hungry in childhood, able to access to healthcare in childhood, quality of sleeping, occupation, regular physical examination, and regional and year dummies. Regression on adequate access to care, adjusted for age, sex, marital status, number of living children, annual income per capita, education, living with people, arm length, drinking at present, smoking at present, regular exercise at present, sufficient financial support, went to bed hungry in childhood, able to access to healthcare in childhood, quality of sleeping, occupation, regular physical examination, number of diagnosed chronic diseases, self-reported health status, severe diseases, ADL, IADL, MMSE, psychological well-being, and regional and year dummies. Regressions on total medical expenditure, total inpatient expenditure, total outpatient expenditure, total out of pocket expenditure, total inpatient out of pocket expenditure, total outpatient out of pocket expenditure and self-payment ratio, adjusted for age, sex, marital status, number of living children, annual income per capita, education, living with people, number of diagnosed chronic diseases, self-reported health status, occupation, severe diseases, ADL, IADL, MMSE, psychological well-being, and regional and year dummies. More detailed results are reported in the appendix. ADL=activities of daily living. IADL=instrumental activities of daily living. MMSE=Mini-mental State Examination. Urban-adjusted and rural-adjusted columns report margins of adjusted outcomes. Adjusted differences are marginal differences calculated based on the coefficients of the Urban variable. The adjusted difference of adequate access to care* are odds ratios. Regressions on ADL, IADL, and psychological well-being, adjusted for age, sex, marital status, number of living children, annual income per capita, education, living with people, arm length, drinking at present, smoking at present, regular exercise at present, sufficient financial support, went to bed hungry in childhood, able to access to healthcare in childhood, quality of sleeping, occupation, regular physical examination, and regional dummies. Regression on adequate access to care, adjusted for age, sex, marital status, number of living children, annual income per capita, education, living with people, arm length, drinking at present, smoking at present, regular exercise at present, sufficient financial support, went to bed hungry in childhood, able to access to healthcare in childhood, quality of sleeping, occupation, regular physical examination, number of diagnosed chronic diseases, self-reported health status, severe diseases, ADL, IADL, MMSE, psychological well-being, and regional dummies. Regressions on total medical expenditure, total inpatient expenditure, total outpatient expenditure, total out of pocket expenditure, total inpatient out of pocket expenditure, total outpatient out of pocket expenditure and self-payment ratio, adjusted for age, sex, marital status, number of living children, annual income per capita, education, living with people, number of diagnosed chronic diseases, self-reported health status, occupation, severe diseases, ADL, IADL, MMSE, psychological well-being, and regional dummies. More detailed results are reported in the appendix.