Public Health Insurance Schemes Research Articles

All-cause excess mortality among end-stage renal disease (ESRD) patients during the COVID-19 pandemic in Thailand: a cross-sectional study from a national-level claims database

ObjectivesCOVID-19 infection increased nephrology-related risks and mortality rate among end-stage renal disease (ESRD) patients. The pandemic also disrupted essential healthcare services. We aim to explore all-cause excess mortality among ESRD...

PP18 Unlocking The Potential Of Medical Device Reimbursement In India For Better Health Outcomes

IntroductionThe Indian healthcare landscape has witnessed several promising changes including the introduction of a comprehensive medical technology inclusion process, Diagnosis-related group (DRG)-pilot and value-based incentives for hospital services under the national public health insurance scheme. Realizing the need for a more patient-centric stance towards improving healthcare outcomes as the way forward, we propose incremental changes including greater participation of public and private care-providers in topic prioritization and the appraisal committee. We also propose a unique evidence-driven approach using reimbursement as a lever for rewarding quality and innovation in medical technologies.MethodsWe developed two discussion guides to capture the ideas around deeper involvement of care-providers and patient societies, and introduction of value-based reimbursement for incentivizing high-quality implantable medical devices in India. The guides were prepared using secondary research and key informant interviews. Over 25 key stakeholders representing payers, regulatory agencies, government authorities, clinical experts, and industry players selected through quota sampling participated in a roundtable meeting. Based on the meeting outcomes, key recommendations for leveraging medical device reimbursement for better health outcomes were developed.ResultsThis qualitative research was carried out with participation of key stakeholders across the medical device reimbursement process. The group proposed recommendations for bringing care-providers closer to the process through a structured and inclusive nomination approach involving therapy users and patient groups at various stages of evaluation. Complementing the existing value-based incentives framework for hospital services, we proposed a similar two-step pathway for incentivizing quality of implantable medical devices. The proposal includes the introduction of certification-based and outcome-based incentives built on a scientific and holistic evaluation criterion.ConclusionsThrough this process, we created a pragmatic and concrete call for a stronger voice from care-providers and patient groups in the evaluation process. Consecutively, the proposed innovative framework introducing value-based incentives for implantable medical devices will be instrumental in enabling access to quality health care to poor patients. These strategies follow the principles of value-based care and will go a long way in achieving better health outcomes for the population. The scientific initiative has been made possible with the support of St. Jude Medical India Pvt Ltd. (now Abbott).

Expanding access to high-cost medicines under the Universal Health Coverage scheme in Thailand: review of current practices and recommendations

BackgroundThere has been an increasing demand to reimburse high-cost medicines, through public health insurance schemes in Thailand.MethodsA mixed method approach was employed. First, a rapid review of select high-income countries was conducted, followed by expert consultations and an in-depth review of three countries: Australia, England and Republic of Korea to understand reimbursement mechanisms of high-cost medicines. In Thailand, current pathways for reimbursing high-cost medicines reviewed, the potential opportunity cost estimated, and stakeholder consultations were conducted to identify context specific considerations.ResultsHigh-income countries reviewed have implemented a variety of pathways and mechanisms for reimbursing high-cost medicines under specific eligibility criteria, listing processes, varying cost-effectiveness thresholds and special funding arrangements. In Thailand, high-cost medicines that do not offer good value-for-money are excluded from the reimbursement process. A framework for reimbursing high-cost medicines that are not cost-effective at the current willingness-to-pay threshold was proposed for Thailand. Under this framework, specific criteria are proposed to determine their eligibility for reimbursement such life-saving nature, treatment of conditions with no alternative treatment options, and affordability.ConclusionHigh-cost medicines may become eligible for reimbursement through alternative mechanisms based on specific criteria which depend on each context. The application of HTA methods and processes is important in guiding these decisions to support sustainable access to affordable healthcare in pursuit of Universal Health Coverage (UHC).

The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review.

Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals. We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively. Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members. We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.

Health disparities among illegal immigrants and homeless people in the USA: a struggle within

Undocumented immigrants in the United States face significant barriers in accessing healthcare services, which contribute to health disparities. This population is often affected by homelessness due to limited access to affordable housing, limited employment opportunities, language barriers, fear of deportation, and lack of social support. Homelessness and the fear of deportation can lead to stress, anxiety, and physical illness among undocumented immigrants, highlighting the need for healthcare services tailored to their unique needs. Access to healthcare is further hindered by a lack of health insurance coverage, financial constraints, language and cultural barriers, and the ineligibility for public health insurance schemes. Undocumented immigrants who are homeless encounter additional challenges, including difficulties in accessing resources, navigating the healthcare system, and facing societal discrimination. This article focuses on the barriers faced by undocumented migrants in the United States regarding healthcare access and proposes feasible solutions to promote health equity and advance universal health coverage in the country. The absence of health coverage for undocumented migrants undermines the concept of universal healthcare in the USA, as it excludes a significant portion of the population from accessing essential healthcare services. Hence, there is a need for comprehensive immigration reform and policies that ensure impartial access to healthcare. Practical solutions include establishing culturally competent care, implementing mobile clinics or street medicine programs, fostering collaborative relationships with nonprofit organizations, advocating for policies safeguarding the rights of undocumented immigrants, and enhancing data collection techniques.

Public Health Systems and Health Insurance Schemes (A Study of the Nigerian Public Health System and its Health Insurance Scheme

Public Health Systems and Health Insurance Schemes (A Study of the Nigerian Public Health System and its Health Insurance Scheme

Healthcare Costs and Utilization for Patients With Systemic Lupus Erythematosus in China: A National Claims Database Study

ObjectivesThis study aimed to describe the healthcare resource utilization (HCRU) and healthcare costs associated with systemic lupus erythematosus (SLE) management in China from the patient’s and the payer’s perspective. MethodsHCRU and medical costs (2017 US dollar [USD]) between January 1 and December 31, 2017, were extracted from the national medical insurance claims database, China Health Insurance Research Association (consisting of claims from all public health insurance schemes in China), for adults with ≥ 1 SLE-related claim. The main analysis group comprised all adults with an SLE diagnosis and claim during 2017 (overall group); the annual subgroup (SLE diagnosis and claim in January 2017) informed annual HCRU and costs. ResultsThe overall group consisted of 3645 adults with ≥ 1 SLE-related claim. Outpatient visits constituted 86.9% of healthcare visits. SLE-related healthcare outpatient costs were USD 433 per outpatient, and inpatient costs were USD 2072 per inpatient. Medication costs accounted for 75.0% (USD 42/56) of total costs for outpatient visits and 44.3% (USD 456/1030) for inpatient hospitalizations. Notably, 35.4% of patients had a severe SLE flare; mean SLE-related cost per severe flare was USD 1616. HCRU and costs were similar in the annual subgroup. Female sex, SLE flares, tertiary hospitals, renal involvement, and utilization of anti-infective drugs were associated with higher SLE-related patient costs. ConclusionsSLE in China is associated with considerable HCRU and medical costs, especially for patients experiencing severe SLE flares. Preventing organ involvement, infections, flares, and associated hospitalizations may reduce the burden on patients and healthcare providers in China.

Contracting the private health sector in Thailand's Universal Health Coverage.

Private sector plays an import role in health service provision, therefore the engagement of private health facilities is important for ensuring access to health services. In Thailand, two of the three public health insurance schemes, Universal Coverage Scheme and Social Health Insurance, contract with private health facilities to fill gaps of public providers for the provision of health services under Universal Health Coverage. The National Health Security Office (NHSO) and Social Security Office (SSO), which manage the schemes respectively, have designed their own contractual agreements for private facilities. We aim to understand the current situation of contracting private health facilities within UHC of the two purchasing agencies. This qualitative descriptive case study was conducted through document review and in-depth interviews with key informants to understand how they contract private primary care facilities, service types, duration of contract, standard and quality requirement and renewal and termination of contracts. Private providers make a small contribution to the service provision in Thailand as a whole but they are important actors in Bangkok. The current approaches used by two purchasers are not adequate in engaging private sector to fill the gap of public provision in urban cities. One important reason is that large private hospitals do not find public contracts financially attractive. NHSO classifies contracts into 3 categories: main contracting units, primary care units, and referral units; while SSO only contracts main contracting units. Both allows subcontracting by the main contractors. Contractual agreements are effective in ensuring mandatory infrastructure and quality standards. Both purchasers have established technical capacities to enforce quality monitoring and financial compliance although there remains room for improvement especially on identifying fraud and taking legal actions. Contracting private healthcare facilities can fill the gap of public healthcare facilities, especially in urban settings. Purchasers need to balance the right level of incentives and accountability measures to ensure access to quality of care. In contracting private-for-profit providers, strong regulatory enforcement and auditing capacities are necessary. Further studies may explore various aspects contracting outcomes including access, equity, quality and efficiency impacts.

Corruption and informal sector households' participation in health insurance in Sierra Leone.

Lack of credibility and trust in fund managers has been highlighted as one of the key reasons why people do not join health insurance schemes in low- and middle-income countries, especially in Africa. This work investigates the impact of corruption on households' willingness to participate and pay for health insurance in Sierra Leone. A discrete choice experiment (DCE) method was used to elicit households' willingness to participate in a health insurance scheme with different attributes. The data were collected from 1458 representative households working in the informal sector of the Northern and Western regions. We explore the relationship between household characteristics and experienced (respectively, perceived) corruption with binary and ordered logit models. We use a Mixed Logit model to estimate the association between corruption and participation in a Health Insurance Scheme (HIS) and households' willingness to pay for a HIS. We find that corruption decreases participation in a public HIS and the willingness to pay for it. Our results highlight the perverse spillover effects of corruption. Not only does corruption hinder the effectiveness of healthcare systems and, thus, worsen health outcomes. It also undermines the willingness to pay for them, jeopardizing the sustainability of healthcare systems in the countries that need them most.

Can beneficiary information improve hospital accountability? Experimental evidence from a public health insurance scheme in India

We study the role of hospital compliance in the effectiveness of government health insurance in India. Using patient surveys, we document that participating hospitals charge unauthorized fees to poor patients eligible to receive free care. Average out-of-pocket payments (OOPP) for chronic kidney care patients are $43 per month, or 25% annual GDP per capita, and are high at both public and private hospitals. Awareness of program benefits is low despite patients having used insurance for several months. We conduct a randomized experiment to test whether phone-based information about program benefits can enable insurance beneficiaries to hold hospitals accountable and lower OOPP. The intervention effectively increases program awareness by 0.17 standard deviations but has no effect on OOPP overall. However, effects differ dramatically by hospital sector: patients at private hospital see no change in OOPP despite increased bargaining and search; monthly OOPP among patients visiting public hospitals, who are poorer and lower caste, drop by $12 (35%), because they are able to negotiate to get more of their benefits at the hospital instead of paying for them off-site. The findings suggest that patient-driven accountability can meaningfully improve public service delivery, even in the context of specialized tertiary care, but may not substitute for top-down monitoring of private agents.

Effect of Healthcare Financing on Performance of Sub County Hospitals in Trans Nzoia County, Kenya

The main purpose of the study was to examine the effect of Healthcare Financing on Performance of Sub County Hospitals in Trans Nzoia County, Kenya. The study focused on the following specific objectives: To assess the effect of public health insurance scheme on Performance of Sub-County Hospitals in Trans Nzoia County, Kenya., and to examine the effect of devolved health services financing on Performance of Sub-County Hospitals in Trans Nzoia County, Kenya. The study was anchored on the Systems Theory by Kataz and Khan, and governance theory. The study targeted the 164 healthcare providers and patients of sub-county hospitals in Trans Nzoia County using census method since the target population was small and reachable. A descriptive research design was adopted with the questionnaire used as a data collection instrument which include both qualitative and quantitative data. The SPSS v26 software was used in establishing the effect of the independent variables on the dependent variable through the employment of ANOVA, regression and correlation analysis techniques in data analysis. The study findings indicated a statistically significant effect between the variables that led to the prediction of the dependent variable. The F-ratio (F=10.578) which was greater than the significance level of .05 depicted an overall regression model that was used to measure the dependent variable by the predictor variables. The results of the study will be expected to contribute towards the existing findings as well as forming a basis for future scholarly work in the field of healthcare financing on performance of the health facilities. This research will be important to the county governments, and in particular management of sub-county hospitals and in improving the scholarly literature reservoir. Keywords: [Health Care Financing, Financing Challenges, Universal Healthcare, Performance]

Long-term effectiveness of a disease management program to prevent diabetic nephropathy: a propensity score matching analysis using administrative data in Japan

BackgroundExisting reviews indicated that disease management for patients with diabetes may be effective in achieving better health outcomes with less resource utilization in the short term. However, the long-term results were inconsistent because of the heterogeneous nature of the study designs. In the present study, we evaluated the 5-year follow-up results of a local disease management program focused on diabetic nephropathy prevention under the universal public health insurance scheme in Japan.MethodsPatients diagnosed with type 2 diabetes who had stage 3 or 4 diabetic kidney disease and were aged between 20 and 75 years were invited to join a disease management program to support self-management and receive a recommended treatment protocol between 2011 and 2013. Follow-up data were collected from an electronic claims database for the public insurance scheme. Considering the non-random selection process, we prepared two control groups matched by estimated propensity scores to compare the incidence of diabetes-related complications, death, and resource utilization.ResultsThe treatment group was more likely to receive clinical management in accordance with the guideline-recommended medication. After propensity score matching, the treatment group had lower incidence of diabetic nephropathy and emergency care use than the control group selected from a beneficiary pool mainly under primary care. Comparisons between the treatment group and the control group with more selected clinical conditions did not show differences in the incidence rate and resource utilization.ConclusionsThe present results demonstrated limited effectiveness of the program for reducing complication incidence and resource utilization during the 5-year follow-up. Further research on the long-term effectiveness of co-management by primary care physicians, subspecialists in endocrinology and nephrology, and nurse educators is required for effective management of diabetes-related nephropathy.

Public health insurance and maternal health care utilization in India: evidence from the 2005–2012 mothers’ cohort data

BackgroundThe introduction of Janani Suraksha Yojana (JSY) in India, a conditional cash transfer program which incentivized women to deliver at institutions, resulted in a significant increase in institutional births. Another major health policy reform, which could have affected maternal and child health care (MCH) utilization, was the public health insurance scheme (RSBY) launched in 2008. However, there is a noticeable lack of studies that examine how RSBY had impacted on MCH utilization in India. We used data from a cohort of mothers whose delivery had been captured in both the 2005 and 2011/12 rounds of the Indian Human Development Survey (IHDS) to study the impact of health insurance (in particular, the public insurance scheme versus private insurance) on MCH access. We also investigated whether maternal empowerment was a significant correlate that affects MCH utilization.MethodsWe used the multilevel mixed-effects ordered logistic regression model to account for the clustered nature of our data. We derived indexes for women’s empowerment using Principal component analysis (PCA) technique applied to various indicators of women’s autonomy and socio-economic status.ResultsOur results indicated that the odds of mothers’ MCH utilization levels vary by district, community and mother over time. The effect of the public insurance scheme (RSBY) on MCH utilization was not as strong as privately available insurance. However, health insurance was only significant in models that did not control for household and mother level predictors. Our findings indicated that maternal empowerment indicators – in particular, maternal ability to go out of the house and complete chores and economic empowerment—were associated with higher utilization of MCH services. Among control variables, maternal age and education were significant correlates that increase MCH service utilization over time. Household wealth quintile was another significant factor with mothers belonging to upper quintiles more likely to access and utilize MCH services.ConclusionsChange in women’s and societal attitude towards maternal care may have played a significant role in increasing MCH utilization over the study period. There might be a need to increase the coverage of the public insurance scheme given the finding that it was less effective in increasing MCH utilization. Importantly, policies that aim to improve health services for women need to take maternal autonomy and empowerment into consideration.

Thailand UHC in Action: Universal Access to Comprehensive COVID-19 Services by Thai and Non-Thai Population

Thailand achieved Universal Health Coverage (UHC) in 2002 through three main public health insurance schemes; the tax-financed Civil Servant Medical Benefit Scheme (CSMBS) covers public sector employees and dependants (7.1% of total population), payroll-tax financed Social Health Insurance (SHI) Scheme covers private sector employees (17.2%), and the tax-financed Universal Coverage Scheme (UCS) covers the remaining majority (75.7%) [1,2]. Registered migrant workers are covered by the SHI while voluntary premium-contribution migrant health insurance, managed by Ministry of Public Health (MOPH), covers undocumented migrants and their dependants. Hence, many unregistered migrant workers and their family members are not covered by any financial risk protection systems; services are paid for out-of-pocket [3]. Extensive geographical coverage of district health systems facilitates adequate and equitable access [4] with low levels of unmet needs [5]. The comprehensive benefit package [2] and free-at-point of services result in low and continually decreasing prevalence of catastrophic health spending [6] (6.7% in 1994 to 2.2% in 2017 [7]) and incidence of impoverishment (1.4% in 1996 to 0.4% in 2015 (using international poverty line of US$ 3.1 per capita per day)) [8]. This perspective analyses how Thailand has responded to the COVID-19 pandemic through the UHC lens, covering all Thai and non-Thai populations, including migrant workers, with a comprehensive set of COVID-19-related services for everyone--a key contributing factor to pandemic containment.

1722P Prevalence and predictors of breast reconstruction following mastectomy in breast cancer patients treated in a public center in Mexico

Breast reconstruction (BR) has psychosocial and sexual well-being benefits in breast cancer (BC) patients that undergo mastectomy. However, this practice remains infrequent in many low- and middle-income countries as it is not usually covered by public health insurance schemes. This study aims to determine the prevalence and main predictors of BR among BC patients treated in a public center in Mexico.

Access to precision medicine in Thailand: a comparative study

PurposeThis study explored health insurance coverage of genetic testing and potential factors associated with precision medicine (PM) reimbursement in Thailand.Design/methodology/approachThe study employed a targeted review method. Thirteen PMs were selected to represent four PM categories: targeted cancer therapy candidate, prediction of adverse drug reactions (ADRs), dose adjustment and cancer risk prediction. Content analysis was performed to compare access to PMs among three health insurance schemes in Thailand. The primary outcome of the study was evaluating PM test reimbursement status. Secondary outcomes included clinical practice guidelines, PMs statement in FDA-approved leaflet and economic evaluation.FindingsCivil Servant Medical Benefits Scheme (CSMBS) provided more generous access to PM than Universal Coverage Scheme (UCS) and Social Security Scheme (SSS). Evidence of economic evaluations likely impacted the reimbursement decisions of SSS and UCS, while the information provided in FDA-approved leaflets seemed to impact the reimbursement decisions of CSMBS. Three health insurance schemes provided adequate access to PM tests for some cancer-targeted therapies, while gaps existed for access to PM tests for serious ADRs prevention, dose adjustment and cancer risk prediction.Originality/valueThis was the first study to explore the situation of access to PMs in Thailand. The evidence alerts public health insurance schemes to reconsider access to PMs. Development of health technology assessment guidelines for PM test reimbursement decisions should be prioritized.

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil...

The Impact of HIV Spending on Health Outcomes in Thailand

Background: The Sustainable Development Goals commitment to Ending HIV/AIDS by 2030 requires sustained adequate investment. This study sought to examine the association between HIV/AIDS spending and outcomes in Thailand between 2008 and 2019. Methods: A quantitative secondary data analysis with time-series was conducted using a retrospective dataset of HIV spending and some selected outcomes including the number of people living with HIV (PLHIV), incidence and prevalence of HIV/AIDS, the prevention of mother-to-child transmission (PMTCT) and AIDS-related deaths. Data were obtained from a diverse set of sources. Descriptive statistics and univariate regression model were used to analyze HIV expenditure and outcomes. Results: HIV spending per PLHIV rose by two folds from $347 in 2008 to more than $600 in 2019, mostly financed by domestic sources. This increase of domestic resources per PLHIV was significantly associated with better HIV-related outcomes especially in the reduction of PLHIV and AIDS-related deaths through increased number of people receiving antiretroviral therapy (ART). However, the spending per PLHIV varied across the three public health insurance schemes. Comparison of HIV expenditure and health outcomes across upper-middle-income countries shows Thailand is not highly ranked in terms of spending efficiency despite having made good progress. Conclusion: Domestic financing for HIV programs is indispensable for achieving the goal of ending AIDS. Despite significant improvement in HIV-related outcomes, challenges remain in achieving the 90-90-90 goal. The redesigning of payment methods should be considered to increase the efficiency of HIV financing. Other factors related to strengthening the health system should not be overlooked.

Refugees and Sustainable Health Development in Iran

Refugees' access to quality healthcare services might be compromised, which can in turn hinder universal health coverage (UHC), and achieving Sustainable Development Goal (SDG), ultimately. Objective: This article aims to illustrate the status of refugees' access to healthcare and main initiatives to improve their health status in Iran. This is a mixed-method study with two consecutive phases: qualitative and quantitative. In the qualitative phase, through a review of documents and semi-structured interviews with 40 purposively-selected healthcare providers, the right of refugees to access healthcare services in the Iranian health system was examined. In the quantitative phase, data on refugees' insurance coverage and their utilization from community-based rehabilitation (CBR) projects were collected and analyzed. There are international and upstream policies, laws and practical projects that support refugees' health in Iran. Refugees and immigrants have free access to most healthcare services provided in the PHC network in Iran. They can also access curative and rehabilitation services, the costs of which depend on their health insurance status. In 2015, the government allowed the inclusion of all registered refugees in the Universal Public Health Insurance (UPHI) scheme. Moreover, the mean number of disabled refugees using CBR services was 786 (±389.7). The mean number of refugees covered by the UPHI scheme was 112,000 (±30404.9). The United Nations' SDGs ask to strive for peace and reducing inequity. Along its pathway towards UHC, despite limited resources received from the international society, the government of Iran has taken some fundamental steps to serve refugees similar to citizens of Iran. Although the initiative looks promising, more is still required to bring NGOs on board and fulfill the vision of leaving no one behind.

The influence of integration of health-insurance schemes on catastrophic health expenditure in China: a cohort study

BackgroundFragmented health-insurance schemes led to inefficiency and inequality in financial protection for universal health-care coverage. The Chinese government proceeded to consolidate the urban and rural health-insurance schemes with a unified fund collection, pooling, and payment system in 2016. Our study aims to establish the effects of the integration policy on incidence and distribution of catastrophic health expenditure (CHE) in China. MethodsWe obtained nationally representative cohort data for analysis from five China Family Panel Studies from 2010 to 2018, which included 17 858 households from 23 provinces. Families were selected using a probability proportional to size sampling technique with implicit stratification from 25 provinces in mainland China. In this natural experimental design, the five provinces with integrated health-insurance schemes before 2016 were considered to be the treatment group, and the other 18 provinces were considered to be the control group. We used a differences-in-differences method to capture the effects of integration policy on CHE incidence, measured by whether the out-of-pocket health expenditure exceeded 25% of the total household non-food expenditure, controlling for both household characteristics and geographical fixed effects. Further, we used the concentration index to investigate changes in the distribution of CHE. FindingsThe incidence of CHE for total population decreased from 17·4% (95% CI 16·7–18·0, SE 0·0034) in 2010 to 13·0% (12·4–13·6, 0·0031) in 2018. The incidence of CHE in urban areas decreased from 14·1% (13·3–15·0, 0·0045) in 2010 to 9·6% (8·8–10·3, 0·0038) in 2018, whereas it declined from 20·3% (19·3–21·3, 0·0050) to 16·6% (15·7–17·6, 0·0049) in rural areas. The incidence of CHE in treatment groups reduced from 15·2% (14·0–16·5, 0·0063) in 2010 to 10·1% (9·0–11·2, 0·0057) in 2018, whereas it decreased from 18·1% (17·3–18·9, 0·0040) in 2010 to 14·0% (13·2–14·7, 0·0036) in 2018 in control groups. In addition, consolidation of health-insurance schemes decreased the incidence of CHE by 1·7% (0·68–2·73, p<0·0001) in the treatment group, compared with the control group. The concentration index for CHE was –0·26 (treatment vs control group, p<0·0001) in the total population in 2018, –0·24 (treatment vs control group, p<0·0001) in the unconsolidated provinces, and –0·34 (treatment vs control group, p<0·0001) in consolidated provinces. InterpretationThe integration of different public health-insurance schemes in China might have increased the financial protection of residents covered by these schemes. However, urban–rural disparity in health insurance and unequal distribution of CHE among poor households have not altered. This study suggests that bulk purchasing and payment reform can be implemented to contain health-care costs and to refrain out-of-pocket payments, particularly for rural and population with low incomes. FundingNHC Key Laboratory of Health Economics and Policy Research, Shandong University (grant NHC-HEPR2019017).