Reducing unmet healthcare needs is very important for alleviating inequality in health services and achieving universal health coverage [14]. Although many studies have explored healthcare utilization and underutilization, little research has examined the association between universal health insurance coverage and unmet healthcare needs. In this study, we analyzed the prevalence of, main reasons for, and trends in unmet healthcare needs over the period of the introduction of universal health insurance coverage in China, and estimated the effects of universal health insurance coverage and other socioeconomic factors on unmet healthcare needs.
On the whole, 8.99%, 1.37%, 53.37%, and 13.16% of the respondents in Jiangsu Province reported non-use of outpatient services, inpatient services, physical examinations, and early discharge from hospital, respectively. The prevalence of non-use of physical examinations was much higher than other kinds of healthcare services, which may be due to physical examinations not being included in China’s health insurance system and people lacking awareness of preventive healthcare. Hence, policy efforts should focus on further expanding the service package of health insurance and adopting strategies to improve the effective utilization of preventive healthcare [7].
The prevalence of unmet healthcare needs in rural areas was found to be generally higher than that in urban areas, which is in line with previous surveys [14, 21, 22, 24]. The main reason for outpatient underutilization overall and in urban areas was “Illness is not serious”, while in rural areas it was “No effective treatment”, a discrepancy that may be caused by high-quality medical resources tending to be allocated to urban areas in China [32]. Therefore, narrowing the gap in allocation of health resources between urban and rural areas should be an effective way to alleviate unmet outpatient needs. The prevalence of non-use of inpatient services and physical examinations was higher among people in rural areas than in urban areas, and financial problems were always the main obstacle to rural residents using inpatient services. This finding reflects the huge economic discrepancy between urban and rural areas in China.
Aside from the non-use of inpatient services, the trends in unmet healthcare needs in urban and rural areas were similar, showing a decline from 2008 to 2018, across the period of implementation of universal health insurance coverage in China. The rate of non-use of inpatient services remained relatively lower and was flat from 2008 to 2018, revealing that, in addition to economic factors, the severity of a person’s disease may mainly determine their choice of inpatient services. Therefore, the rate of non-use of inpatient services remained low and stable. It should be noted that the outpatient underutilization rate showed a dramatic rise from 2008 to 2013, followed by a significant decline from 2013 to 2018. In the early stage of the New Medical Reform Plan in 2009, China’s health insurance coverage rate increased rapidly, but the reimbursement ratio remained low, meaning unmet outpatient service needs continued to increase. The rate of unmet outpatient service needs may have started to decline after 2013 as a result of improvement in the reimbursement level of the health insurance system.
Health insurance had a significant impact on the reduction of health service underutilization, except for in the case of physical examinations services. With regard to the annual effect, the probability of non-use of outpatient services and physical examinations significantly declined both in 2013 and 2018, and the likelihood of non-use of inpatient services and early discharge from hospital also significantly reduced in 2018. This finding indicates that unmet healthcare needs were alleviated with the development of the economy and deepening medical reform in China. People having health insurance in 2013 and 2018 demonstrated a significantly lower likelihood of non-use of outpatient services and early discharge from hospital, and the odds ratios decreased over time. This finding reflects a continuously positive role of universal health insurance coverage on reducing unmet healthcare needs. However, the effect on non-use of inpatient services was relatively weak.
In addition, the effect of health insurance and its universal coverage on reducing unmet healthcare needs was estimated to be greater in rural than in urban areas. Therefore, universal health insurance coverage played a greater role in promoting effective health utilization in rural areas [33]. Since the prevalence of unmet healthcare needs in rural areas was higher than that in urban areas, policies should focus on further improving the health insurance system for rural residents, for example by achieving full coverage, gradually increasing the reimbursement level and expanding the service package of health insurance, to alleviate the inequality in healthcare utilization between urban and rural areas.
Universal health insurance coverage only significantly affected non-use of inpatient services caused by financial difficulties. This is mainly due to the fact that health insurance is an important economic guarantee for inpatients. The effect of health insurance on reducing the non-use of inpatient services caused by financial difficulties was significant in 2018, indicating that the reform and adjustment of health insurance in recent years, such as the policy of critical illnesses payment and extending the national medicine catalog of medical insurance, may ease the economic burden on patients and promote the utilization of hospitalization.
Other demographic or socioeconomic factors associated with unmet healthcare needs included age, educational level, income level, area of residence, self-reported health status, depression, and chronic diseases. Specifically, older people were significantly less likely to report underutilization of physical examinations [34, 35]. The prevalence of chronic diseases and resultant disabilities was higher among the elderly, and this may lead to a greater need for physical examinations [36]. However, the association between the other three kinds of unmet healthcare needs and age was found to be the opposite, which is in contrast to other reports [7, 8, 37, 38]. Higher education was associated with lower prevalence of non-use of healthcare services, which is in line with work by Li et al. [39]. Therefore, the government could promote residents’ health awareness by improving education, and this may boost the effective utilization of healthcare. The unemployed or retired were more likely to face barriers in obtaining needed health services [6, 7, 14, 39]. Compared with urban residents, rural residents who were unemployed, retired, or who had lower income demonstrated a higher likelihood of having unmet healthcare needs, especially inpatient services. Therefore, strategies such as increasing financial support, widening employment channels in rural areas, and adjusting the urban and rural income distribution system should be implemented to promote healthcare utilization among these people.
Consistent with existing reports [36, 37, 40–43], the overall likelihood of non-use of outpatient and inpatient services was significantly higher among those with lower self-reported health status, who were depressed, or who had chronic diseases. This may be explained by the fact that people who are depressed or have chronic diseases are generally accompanied by long-term or lifelong treatment and medication, which will certainly result in them having more unmet healthcare needs than healthy individuals, especially if there is a lack of patient compliance [7]. However, having chronic diseases was significantly associated with lower underutilization of physical examinations, indicating that chronic patients may have a stronger awareness of disease prevention [7, 11].
Some limitations of our study must be acknowledged. First, unmet healthcare needs in this paper only refer to people who perceived a need for healthcare but did not seek treatment; those who did not perceive a need for healthcare were not included. Therefore, the prevalence of unmet healthcare needs might have been underestimated to some extent. Also, we did not consider the moral hazard which might overestimate the likelihood of unmet healthcare needs to some extent. Furthermore, the data in our study was from the Jiangsu Province data in the NHSS, which may not be nationally representative.