Inequality of opportunity in healthcare expenditures: evidence from China

Yuyang Zhang,Peter C Coyte

doi:10.1186/s12913-020-05252-z

Abstract

BackgroundThe theory of equality of opportunity attributes total inequality to effort levels and circumstance factors. Inequality attributable to circumstance is defined as inequality of opportunity (IOp), namely inequity. Many studies have been pursued in this area but few concerning health care, especially in China. Despite Chinese health system reforms, healthcare inequity remains. This study explores the extent and sources of IOp in outpatient and inpatient expenditures in China.MethodsWe used three waves (2011, 2013 and 2015) of data from the China Health and Retirement Longitudinal Study that offer a nationally representative sample of Chinese residents aged 45 and older. Based on a pooled regression model, we estimated the contribution of circumstance factors to the inequality in outpatient and inpatient expenditures by defining a counterfactual distribution. The “circumstance-free effort” was introduced to deal with the correlation between circumstance and effort.ResultsWe report a decline in inequity from 2011 to 2015, and the IOp ratio to total inequality in outpatient and inpatient expenditures decreased 9.4% (from 28.6 to 25.9%) and 3.3% (from 49.1 to 47.5%), respectively. Social background, medical supply-side factors, including the type of basic medical insurance, region and community medical resources were important sources of IOp in outpatient and inpatient expenditures.ConclusionsThese findings provide information on which to base policies designed to reduce inequity in healthcare expenditures. It is necessary to transfer more subsidies to the New Co-operative Medical System, and to address the uneven regional distribution of medical resources. Additionally, increasing access to quality primary community clinics may be a pro-poor policy to alleviate inequity in the use of outpatient care. Compared to outpatient services, policies protecting vulnerable populations need to pay more attention to the financing and design of inpatient services.

Highlights

The theory of equality of opportunity attributes total inequality to effort levels and circumstance factors
The improvement shown in healthcare equity over our study period was consistent with the findings of Zhou et al [22] and Zhou et al [43]. Together these results suggest that health reforms in China have been successful in yielding improvements in health inequity, inequality of opportunity, in our study, still accounted for a large share of total inequality (27.3% for outpatient care and 47.7% for inpatient care)
As our study focused on inequality due to circumstance, it did not matter whether supplementary insurance was a proxy for preference or need, as it did not affect our inequality of opportunity (IOp) measure

Summary

Introduction

The theory of equality of opportunity attributes total inequality to effort levels and circumstance factors. Zhang and Coyte BMC Health Services Research (2020) 20:379 caused by need is usually considered to be fair (effort), while many studies have focused on healthcare inequality attributable to socioeconomic status (i.e. SES), with such inequality deemed unfair (circumstance). These studies [19, 20] analyzed a “partial” inequity only associated with the SES factor, while the IOp framework could include any other relevant factors, such as medical supply [17]. Compared with comprehensive coverage under the UEBMI, the other two insurance plans’ have focused coverage to inpatient care and catastrophic illness insurance for outpatient services; some basic outpatient services are not insured [21]

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