Does introducing outpatient pooling scheme reduce socioeconomic inequality in healthcare utilization? Evidence from a longitudinal study in China, 2011–2020

Abstract

Background In China, persistent health care inequalities coexist with universal health coverage due to limited financial protection for outpatient care. To address this issue, the Chinese Urban Employee Basic Medical Insurance implemented an outpatient pooling scheme, aiming to alleviate cost-sharing burdens for outpatients. This study assesses the impact of this policy on socioeconomic disparities in outpatient care utilization. Methods Data from five waves of the China Health and Retirement Longitudinal Study (2011–2020) were utilized. Outcome variables included the possibility of outpatient visits, visits to hospitals and primary care facilities, as well as outpatient expenditures and out-of-pocket (OOP) payments. Propensity score matching formed a matched sample, and the concentration index (CI) for outcomes was calculated for policy-implementing and non-implementing groups. Decomposition of the CI and its changes were performed to identify the outpatient pooling's contribution to inequalities in outpatient care. Results The CI value for the likelihood of outpatient visits decreased from 0.1142 in 2011 to 0.0972 in 2020, with outpatient pooling contributing positively (4.14%) to this reduction. However, inequalities across different facility types increased over time. The CI for visits to hospitals changed from 0.0069 to 0.0431, and the CI for visits to primary care facilities changed from 0.0064 to -0.1091. The implementation of the policy counteracted these growing inequalities. Despite persistent pro-rich inequalities in outpatient expenditures and OOP payments, their CI values exhibited a substantial decline, and outpatient pooling played a pivotal role in steering the trend towards improving equity. Conclusion The introduction of the outpatient pooling scheme significantly contributes to diminishing pro-rich inequalities in outpatient care. However, socioeconomic disparities in the utilization of primary care and advanced services continue to widen despite the counteractive effects of policy implementation. Future interventions should adopt a comprehensive approach, extending beyond mere insurance benefits coverage, to address and rectify these persisting inequalities.