Over the past two decades, China has pursued an ambitious plan to establish an accessible and affordable health system that meets the needs of its population. As part of this journey, China’s leadership implemented comprehensive health system reforms and achieved near-universal health insurance coverage at a relatively low per capita income level. Key to this process was the integration of rural and urban resident health insurance programs, which has proven to yield positive outcomes in health care utilization, physical health, and related equity issues. Thus far, however, the integration’s potential psychological effects have been understudied.

New research, published in the journal Health & Social Care in the Community, addresses this gap in the literature. The researchers – Stanford health economist Karen Eggleston, the director of APARC’s Asia Health Policy Program (AHPP); Peking University’s Gordon Liu; and Renmin University of China’s Yue-Hui Yu and Qin Zhou, the latter a former visiting scholar with AHPP – find that the urban-rural health insurance integration has been beneficial for improving mental health among China’s rural adults.

Their study underscores the potential of policy-driven health system reforms to address longstanding disparities, promote mental well-being in vulnerable communities, and enhance quality of life among aging populations. This is the researchers’ final installment in a series of studies on China’s urban-rural health insurance integration.

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Tracking Mental Health Over Eight Years

For decades, China had a fragmented health insurance system, which led to disparities between different populations and hindered the implementation of the Healthy China 2030 blueprint, a bold national strategy to make public health a precondition for all future economic and social development. Responding to this challenge, in 2016, China announced plans to unify its rural and urban health insurance programs. The unified health insurance system, called Urban and Rural Residents’ Basic Medical Insurance (URRBMI), offered equal health service packages and insurance benefits to rural and urban residents. Studies have shown that the integrated system improved healthcare access for nearly 800 million rural residents and helped reduce coverage gaps and inequality. Yet evidence about the integration’s potential psychological impacts has been limited.

Eggleston and her co-authors hypothesized that this reform might also benefit rural adults’ psychological well-being. To test this hypothesis, the researchers conducted a comprehensive analysis using data from the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative survey that tracks health, economic, and social variables among Chinese adults aged 45 and older. The study focused specifically on rural residents, examining changes in mental health, particularly depressive symptoms, before and after the insurance integration. Data from four waves of CHARLS, spanning from 2011 to 2018, allowed the team to analyze trends over a substantial period.

The researchers used an event study combined with a time-varying difference-in-differences (DID) approach, capturing the effect of the health insurance integration on depressive symptoms and comparing changes over time between those affected by the reform and a control group not yet impacted (since local governments introduced the integration reforms in different years, samples in the control group had constantly entered the treatment group during the survey period). This method helps isolate the effect of the policy from other confounding factors, providing a clearer picture of causality. The researchers further examined the heterogeneity of the integration effect across subgroups by gender, age, health status, and family economic status. They also analyzed possible mechanisms through which the reform produced psychological effects

Key Findings: A Significant Drop in Depression

The researchers find that the health insurance integration was associated with a measurable reduction in depressive symptoms among rural seniors. Specifically:

• CES-D scores – a standard measure of depression severity (using a version of the Centre for Epidemiological Studies Depression Scale) – decreased by an average of 0.441 points among those covered by the reform.
• The likelihood of experiencing depression dropped by approximately 3.5% in the post-reform period.
• The decline in depression scores following the integration was continuous, suggesting cumulative effects of the reform. Notably, some psychological benefits appeared up to two years before the reform took effect, likely due to public awareness and positive expectations generated by advance announcements from local authorities.

The results were statistically significant, indicating that the health insurance integration reform has significantly improved the mental health of rural adults and reduced their risk of becoming depressed.

The findings also indicate that a key driver that produced continuous positive psychological effects was the integration’s reduction of health care costs for rural residents, particularly for hospital care. By lowering financial barriers to treatment, the integration improved access to healthcare and made its use more equitable. This, in turn, boosted rural adults’ satisfaction with their health and overall sense of well-being. The improvement may have set off a positive cycle, encouraging more social engagement and physical activity, which helped further ease symptoms of depression.

While the reform reduced depressive symptoms for both male and female older adults, the findings revealed differences across subgroups. It appears the reform did not significantly reduce depressive symptoms for those aged 40-49 and over 70, individuals in poor health, or those in the lowest economic bracket. The researchers attribute this to ongoing financial barriers and limited insurance financing, which may blunt the perceived benefits for high-need groups.

Policy Implications: A Path Toward Health Equity

The study’s co-authors highlight several policy implications for China:

• Expand and standardize coverage: Build on the success of the URRBMI by moving from local-level integration to broader provincial or national coverage, and encourage enrollment among vulnerable populations through subsidies.
• Improve equity for high-need groups: Design more targeted insurance policies for older adults, those with chronic illnesses or disabilities, and low-income groups, especially by covering outpatient treatments for high-cost conditions.
• Increase funding for the URRBMI: Despite progress, reimbursement rates remain low, highlighting the need for greater investment in the program.
• Strengthen rural health infrastructure: Insurance reforms must be paired with improvements in rural healthcare facilities and services to ensure quality care is both accessible and effective.

China’s experience offers valuable lessons for countries aiming to achieve universal health coverage and those grappling with health disparities and aging populations. The positive association between insurance integration and mental health among rural adults in China underscores the importance of comprehensive, inclusive policies addressing financial and social determinants of health.

The study’s findings highlight the need to ensure that the most vulnerable populations benefit equally from health reforms. They also serve as a compelling reminder that thoughtfully designed and implemented reforms can improve physical health and increase mental resilience and social cohesion.