Trends and Variation in User Fees across Provinces in China: a Population-based Longitudinal Data Analysis from 2011-2015

ObjectivesUnderstanding the variation in user fees is essential for the design of targeted health financing strategies and monitoring progress towards universal health coverage. This study examines user fees in terms of: (1) temporal trends in cost sharing and out-of-pocket payment (OOPs); (2) factors associated with cost sharing and OOPs; and (3) the relationships between province-level economic development and cost sharing and OOPs in China. Setting28 provinces of China ParticipantsA total of 10316 elderly aged [≥]45 years were included in the analysis. ResultsOverall, there were no substantial changes in cost sharing, but the OOPs continued to rise among the middle-aged and older Chinese. Cost sharing was substantially higher for outpatient than inpatient care (84.0% vs 69.2% in 2011; 80.8% vs 62.2% in 2015), and the majority paid more than 80% of the total cost for prescription drugs when visiting outpatient or inpatient care. Provinces with higher GDP per capita tend to have lower cost sharing and a higher OOPs than their counterparts, but the relationship for OOPs became insignificant after adjusting for individual factors. Respondents with health insurance and older age were associated with lower cost sharing. The respondents with higher socioeconomic status and a higher number of chronic conditions incurred higher OOPs for outpatient and inpatient utilisation. ConclusionCost sharing and OOPs remain very high despite near-universal insurance coverage. Health financing reforms should prioritise improving health services coverage and reducing cost sharing to improve financial protection and reduce health inequalities. Although such improvement will likely have the greatest benefits for financial protection for populations from less developed regions, developed provinces with a higher OOPs will benefit as well. STRENGTHS AND LIMITATIONS OF THIS STUDYO_LIThis is the first longitudinal study to measure the trend of and variation in patient cost sharing and OOPs in China. C_LIO_LIUser fees was self-reported by the respondents, which may be subject to recall bias. C_LIO_LIUser fees in this study only reflected the general cost burden from formal healthcare services, therefore, user fees from informal care services were not captured. C_LI KEY FINDINGO_LIThere were no substantial changes in patient cost sharing for outpatient and inpatient services, but the amount of out-of-pocket payment (OOPs) continued to rise during 2011-2015, especially for outpatient services from 371 Yuan in 2011 to 1031 Yuan in 2015. C_LIO_LIDespite universal health insurance coverage, patient cost sharing was still high among the middle-aged and older Chinese: 84.0% for outpatient care and 69.2% for inpatient care in 2011; and 80.8% vs 62.2% in 2015. The majority of patients paid more than 80% of the total cost for prescription drugs when visiting outpatient or inpatient care. C_LIO_LISeveral patient-level characteristics affected cost-sharing and OOPs, including insurance status, age, education, household economic status and number of chronic conditions. Cost sharing was lower for those with insurance compared to those without insurance. C_LIO_LIProvinces with higher GDP per capita had lower cost sharing than provinces with lower GDP per capita, but no significant difference was found in the amount of OOPs after controlling for individual-level factors. C_LI