title: New cooperative medical scheme decreased financial burden but expanded the gap of income-related inequity: evidence from three provinces in rural China.
abstract: BACKGROUND
  Subsidizing healthcare costs through insurance schemes is crucial to overcome financial barriers to health care and to avoid high medical expenditures for patients in China. The health insurance could decrease financial risk by less out-of-pocket (OOP) payment, but not promise the protection equity. With the growth of New Cooperative Medical Scheme (NCMS) financing and coverage since 2008, the protection effectiveness and equity of the modified NCMS policies on financial burden should be further evaluated.
  
  
  METHODS
  A cross-sectional household survey was conducted in Zhejiang, Hubei, and Chongqing provinces by multi-stage stratified random sampling in 2011. A total of 1,525 households covered by the NCMS were analyzed. The protection effectiveness and protection equity of NCMS was analyzed by comparing the changes in health care utilization and medical expenditures, and the changes in the prevalence of catastrophic health expenditure (CHE) and its concentration indices (CIs) between pre- and post-NCMS reimbursement, respectively.
  
  
  RESULTS
  The medical financial burden was still remarkably high for the low income rural residents in China due to high OOP payment, even after NCMS reimbursement. In Hubei province, the OOP payment of the poorest quintile was almost same as their households' annual expenditures. Even it was higher than their annual expenditures in Chongqing municipality. Effective reimbursement ratio of both outpatient and inpatient services were far lower than nominal reimbursement ratio originally designed by NCMS plans. After NCMS reimbursement, the prevalence of CHE was considerably high in all three provinces, and the absolute values of CIs were even higher than those before reimbursement, indicating the inequity exaggerated.
  
  
  CONCLUSIONS
  Policymakers should further modify NCMS policy in rural China. The high OOP payment could be decreased by expanding the drug list and check directory for benefit package of NCMS to minimize the gap between nominal reimbursement ratio and effective reimbursement ratio. And the increase in medical expenditures should be controlled by monitoring excess demand from both medical service providers and patients, and changing fee-for-service payment for providers to a prospective payment system. Service accessibility and affordability for vulnerable rural residents should be protected by modifying regressive financing in NCMS, and by providing extra financial aid and reimbursement from government.
authors.affiliation: Department of Health Information, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430030, China.
authors.forename: Jingdong
authors.initials: J
authors.lastname: Ma
authors.affiliation: Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430030, China.
authors.forename: Juan
authors.initials: J
authors.lastname: Xu
authors.affiliation: Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430030, China.|The Key Research Institute of Humanities and Social Science of Hubei Province, Huazhong University of Science and Technology, Hubei, 430030, China.
authors.forename: Zhiguo
authors.initials: Z
authors.lastname: Zhang
authors.affiliation: Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430030, China. jingwang@hust.edu.cn.|The Key Research Institute of Humanities and Social Science of Hubei Province, Huazhong University of Science and Technology, Hubei, 430030, China. jingwang@hust.edu.cn.
authors.forename: Jing
authors.initials: J
authors.lastname: Wang
mesh_terms: D002681:China / Q000453:epidemiology; D003430:Cross-Sectional Studies; D005260:Female; D005380:Financing, Government / Q000379:methods / Q000592:standards; D017048:Health Care Costs / Q000592:standards* / Q000639:trends; D054625:Healthcare Disparities / Q000191:economics* / Q000592:standards / Q000639:trends; D006801:Humans; D008297:Male; D012424:Rural Population / Q000639:trends
keywords: Catastrophic health expenditure; China; Concentration index; Financial burden; Inequity; New Cooperative Medical Scheme