The proportion of households associated with CHE and IME in elderly patients with CVD were 19.9% and 7.6%, respectively. These rates were higher than those of developed countries,but were lower than those of low-income countries.29,30 The incidences of CHE participating in medical insurance were 3.6% higher than those of uninsured households (16.3%). In addition, families with cardiovascular disease have a much higher risk of IME than families without cardiovascular disease (7.0%) and the overall population (7.2%).It can be seen that cardiovascular disease patients’ risk tolerance for health care payments is actually lower than the average in China. At the same time, our study also found that cardiovascular families with chronic patients, inpatients, and disabled members, are at a higher risk of falling into poverty because of the cost of health care, and they are becoming a stubborn group with a high burden of CVD disease under the medical insurance system.
As a kind of vulnerable group, patients with cardiovascular disease are mainly characterized as a high-risk group integrating physiological, social, and health factors. We need to identify risk factors for patients with CVD and identify vulnerable groups and then better play the economic protection role of the medical insurance system. As mentioned earlier, despite these governmental efforts, many disadvantaged groups are not considered target populations for benefit enhancement. Through comprehensive analysis, we found that the disadvantaged elderly population with mental health has the following characteristics:
Older groups with physical vulnerability are more prone to CHE.
In the first place, age growth, loss of healthy capital, and decline in physiology are inevitable for the elderly. However, elderly people are at a disadvantage in accessing resources and fail to enjoy social welfare policies fairly.31,32 For example, the incidence of CHE in elderly people over 75 years old in the NCMS was 33.33%, second only to the merger of three chronic diseases (33.88%).The WHO reported that 23% of the world's disease burden is on older people, and chronic non-communicable diseases have a major impact on this burden.33 Furthermore, the morbidity and concurrency of elderly patients with CVD may eventually lead to premature death and disability, while long-term health care costs, drug costs, and rehabilitation costs greatly increase the risk of CHE.34 Our results show that the hospitalization rate (23.5%), rate of visits (24.5%), and incidence of CHE (31.8%) of patients with more than three chronic diseases are far higher than those without chronic diseases (13.3%, 17.7%, 14.7%, respectively), and the treatment-effect model shows that the combination with other chronic diseases increases the risk of 4.68 percentage points of CHE. Past evidence has demonstrated that the likelihood of using health care (e.g, hospitalization) increases in the presence of chronic or multiple conditions.35 It can be seen that with the increase of the number of chronic diseases, the addition of other chronic diseases will prolong the hospitalization time on the basis of the original single disease, which will cause CVD patients to superimpose the cost of other diseases when they bear the economic pressure from their cardiovascular disease burden. Studies have found that one-third of adults have multiple chronic diseases, equivalent to 3/4 of the elderly in developed countries.36 Therefore, suffering from a variety of chronic diseases has become a major health problem for the elderly in the future, greatly increasing the risk of CHE.
The medical insurance system only guarantees the basic health utilization threshold for elderly patients with CVD and lacks policy inclination for high-utilization populations.
The existing medical insurance system reduces the threshold of health service utilization for vulnerable groups. such as those with cardiovascular diseases, but only achieves the first goal of medical insurance—that is, to ensure that all people have access to high-quality care. Our results show that the incidence of CHE for high-demand people with inpatients and disabled patients is much higher than that of the normal population. In our paper, families with disabled patients had higher prevalence (21.7%) and outpatient rates (21.8%) than those without disabilities (13.4% and 19.6%, respectively). However, the hospitalization reimbursement ratio was only 40.6%, far below the overall level (44.5%), and OOP accounted for 35.6% of total household health expenses, which is much higher than that of OECD countries.37 A study in South Korea showed that families with disabilities face higher CHE than those without people with disabilities, and annual living expenses for OOP medical expenses are roughly 1.2 to 1.4 times greater.38 This may be due to physical or mental disability in disabled patients leading to job loss or reduced earnings, while higher medical care needs due to disability increase the burden of high medical costs.39 Even relatively small expenditures are catastrophic for poor families, and excessive out-of-pocket health care spending can lead to poverty.40
The medical insurance system has poorly accurate identification of vulnerable characteristics, which in turn affects the economic protection ability of the medical insurance system for patients with cardiovascular diseases.
China's medical insurance policy aims to solve the problem of “people falling into poverty due to illnesses” and to ensure that most people are not reduced to poverty because of health-related issues. However, our results indicate that the risk of CHE for CVD patients participating in medical insurance schemes has increased by 28.9%, which had the highest incidence of CHE for NCMS. It can be seen that the medical insurance system has the disadvantages of insufficient protection of policies in reducing the economic burden of residents’ medical care and maintaining residents’ health rights and health. China’s health sector reform has achieved unprecedented progress, but protecting vulnerable groups from health care-related impoverishment remains a challenge. Specifically, we need to reconsider benefit packages and redesign social health care insurance programs in order to further protect the elderly population with cardiovascular disease.
Inequality between types of health insurance systems: binary urban and rural structure divided by place of residence.The household registration system in China directly affects the ability to obtain various medical benefits.41 In our paper, the hospitalized reimbursement ratio of MIUE with cardiovascular disease patients was 69.8%, while that of the NCMS was only 39.7%, accounting for only half of the MIUE. Urban residents are expected to have a greater awareness about their health and better access to health insurance (especially private health insurance) and hence are more likely to obtain health insurance. The health needs of people in rural areas are not able to be converted into effective medical needs in time due to lower income levels, high medical prices, and inadequate medical care, thus bearing the risk of greater CHE. A Chinese study shows that NCMS cannot prevent CHE from happening in poor families but only reduces the incidence of CHE in wealthy families.42 This differentiated design of health care benefits can sometimes lead to social inequalities, often with the same disease, at different costs, and patients with higher socioeconomic status usually enjoy better health insurance and higher service utilization. In rural areas, this should further increase the reimbursement ratio of outpatient and inpatient expenditures to the elderly with cardiovascular diseases who receive treatment at every kind of hospital.43
Inequality of different income groups under the same medical insurance system.Our research indicated that the incidence of CHE in sub-poor households with CVD (22.5%) was higher than 5% of households with the highest income. Its OOP accounts for 22.1% of CTP, and the economic burden of disease was higher than that of high-income families by nearly 10%. A similar phenomenon occurred in India. According to the data, India's medical expenditure accounts for only 0.9% of the GDP, which is lower than the 2.8% of the GDP of less developed countries. However, with only government spending, among the five economic subgroups, the poorest households with less income receive only 10% of medical care, while 20% of the wealthiest households receive up to 33% of social subsidies, three times as much as the poorest households.44 The heavy burden of disease can lead to a difficult family life in low-income groups, which thus fall into the evil cycle of “poor illness due to illness and illness due to poverty.” Therefore, the internal system design of medical insurance should strengthen the economic support and protection for poor families and achieve certain policy inclinations.
The inconsistencies between multiple health care systems lead to blind spots in the economic risk protection of individuals and families.
China has established multiple medical security systems, including basic medical insurance, major illness insurance, commercial medical insurance, social medical assistance, and charity assistance. However, the complexity of cardiovascular disease and the difference in the income of the population mean that various systems have not woven a standard, unified safety net to prevent impoverishment by medical expense, which is mainly reflected in the following two points.
Firstly, the particularity of cardiovascular disease can lead to the loss of labor, the indirect cost of nursing expenses, and transportation expenses, and long-term drug maintenance will also increase the economic burden of patients. These neglected indirect costs and drug costs have become blind spots in the economic protection of basic health care systems. In our study, elderly cardiovascular patients still have to pay more than half (55.5%) of their medical expenses after reimbursement by basic medical insurance schemes. Moreover, there is no effective mechanism to connect basic insurance schemes, major disease schemes, and medical assistance insurance systems, resulting in this group of patients falling into poverty after paying for the high medical expense.
Secondly, our result also shows that sub-poor households have the highest incidence of CHE at 22.5%, and the OOP accounts for 22.1% of CTP, much higher than the poorest households. The medical security system has implemented certain health expense reduction policies for these “extremely poor families” without economic sources or micro-income, including lowering the deductible line, increasing the proportion of reimbursement, and improving or eliminating top-up measures. The high-risk marginalized population with an economic income slightly higher than that of the poorest households, which is prone to CHE, has not reached the standard of assistance for supplementary medical assistance and has failed to be covered by a multilevel medical security system.
It can be seen that exploring the integration of multilevel medical insurance systems, promoting the complementary functions and overlapping effects of multilevel medical insurance systems, and jointly solving the poverty problems caused by cardiovascular patients have become the target task of the current prevention and treatment process of chronic diseases.