Determinants of Health Insurance Coverage among People Aged 45 and over in China: Who Buys Public, Private and Multiple Insurance

BACKGROUND: China is reforming and restructuring its health insurance system to achieve the goal of universal coverage. This study aims to understand the determinants of public, private and multiple insurance coverage among people of retirement-age in China. METHODS: We used data from the China Health and Retirement Longitudinal Survey 2011 and 2013, a nationally representative survey of Chinese people aged 45 and over. Multinomial logit regression was performed to identify the determinants of public, private and multiple health insurance coverage. We also conducted logit regression to examine the association between public insurance coverage and demand for private insurance. RESULTS: In 2013, 94.5% of this population had at least one type of public insurance, and 12.2% purchased private insurance. In general, we found that rural residents were less likely to be uninsured (Relative Risk Ratio (RRR) = 0.40, 95% Confidence Interval (CI): 0.34-0.47) and were less likely to buy private insurance (RRR = 0.22, 95% CI: 0.16-0.31). But rural-to-urban migrants were more likely to be uninsured (RRR = 1.39, 95% CI: 1.24-1.57). Public health insurance coverage may crowd out private insurance market (Odds Ratio = 0.55, 95% CI: 0.48-0.63), particularly among enrollees of Urban Resident Basic Medical Insurance. There exists a huge socioeconomic disparity in both public and private insurance coverage. CONCLUSION: The migrants, the poor and the vulnerable remained in the edge of the system. The growing private insurance market did not provide sufficient financial protection and did not cover the people with the greatest need. To achieve universal coverage and reduce socioeconomic disparity, China should integrate the urban and rural public insurance schemes across regions and remove the barriers for the middle-income and low-income to access private insurance.