Evaluation of the enrolment of health insurance after the integration between the New Cooperative Medical Scheme and the Urban Residents Basic Medical Insurance scheme in Hangzhou, China: a longitudinal study

Abstract Background The recent integration between the New Cooperative Medical Scheme (NCMS) and the Urban Residents Basic Medical Insurance (URBMI) into the Urban and Rural Resident Basic Medical Insurance (URRBMI) scheme has reduced the disparity among one billion rural and urban Chinese people. During the transition, URRBMI in some provinces provided two to three different plans with graded contributions and corresponding benefit packages; however, how enrolees make decisions among different plans is still unknown. Our study therefore aimed to provide the first longitudinal analysis on the enrolment of health insurance after the integration of NCMS and URBMI. Methods We did a longitudinal study in Hangzhou, China. NCMS and URBMI in Hangzhou were integrated in 2011, and URRBMI had two packages: contribution for plan A was CNY1200 and plan B was CNY800. Both plans have the same benefits for hospital admission, whereas plan B has better benefits for outpatient visits. A prospective cohort of more than 800 households was established in 2009 and followed up annually for 5 years by the same household health survey. Individuals enrolled in URBMI–NCMS–URRBMI with at least two observations were eligible for analysis. The primary outcome was the association between insurance enrolment decision and the enrolees' health condition in the previous year. Demographic, socioeconomic, self-reported health (measured by the visual analogue scale [VAS] score of 1–100), health need, use of services, household income, and satisfaction on insurance in surveyed year T (2009–12) were inputted as independent variables; and enrolment decision (ie, upgrade or downgrade) in Year T + 1 (2010–13) was inputted as a dependent variable for the multi-level regression model with random effect. Any change from uninsured to URRBMI or from plan B to plan A was defined as an upgrade, whereas a change from URRBMI to uninsured or from plan B to plan A was defined as a downgrade. The protocol was reviewed and approved by the Institutional Review Board of the School of Public Health, Fudan University, and all participants of this study gave written consent. Findings Between June 1, 2009, and Aug 31, 2013, 1576 individuals with 5171 records (3595 pair of observations) were included, of whom 958 (26·6%) upgraded, 568 (15·8%) downgraded, and the rest remained on the same plan during the observation. Age, marriage, and household income significantly influenced the enrolment decision; whereas sex, education, or household size had no influence. Individuals with a VAS score of 0–59 were 37·2% more likely to upgrade their plan (p=0·041) than those with a VAS score of 80–89; individuals with one to three outpatient visits for non-communicable diseases within 3 months before the survey were 80·5% less likely to downgrade their plan than those without use of these services for non-communicable diseases (p=0·029); and individuals with hospital admissions were 58·4% less likely to downgrade than those who remained on the same plan (p=0·017). Condition of self-reported health status (ie, VAS score) and service use in the previous year significantly influenced individuals' insurance enrolment decision, indicating the existence of adverse selection. Interpretation Enrolment flexibility within URRBMI is intended to serve different affordability but is accompanied with adverse selection, which might endanger the sustainability of insurance funds. Family enrolment should be encouraged at this current stage, and compulsory insurance with subsidies for people who live in poverty is recommended to achieve long-term universal health coverage in China. Funding CMB Collaborative Program on Pharmaceutical Policy and Economics and the Fourth Round of Shanghai Three-year Action Plan on Public Health Discipline and Talent Program: Evidence-based Public Health and Health Economics (15GWZK0901)