International Journal of Behavioral Medicine

, Volume 23, Issue 6, pp 655–663 | Cite as

Care Utilization with China’s New Rural Cooperative Medical Scheme: Updated Evidence from the China Health and Retirement Longitudinal Study 2011–2012

  • Donglan ZhangEmail author
  • Lu Shi
  • Fang Tian
  • Lingling Zhang



China’s New Rural Cooperative Medical Scheme (NRCMS), a healthcare financing system for rural residents in China, underwent significant enhancement since 2008. Studies based on pre-2008 NRCMS data showed an increase in inpatient care utilization after NRCMS coverage. However evidence was mixed for the relationship between outpatient care use and NRCMS coverage.


We assessed whether enrollment in the enhanced NRCMS was associated with less delaying or foregoing medical care, as a reduction in foregoing needed care signals about removing liquidity constraint among the enrollees.


Using a national sample of rural residents (N = 12,740) from the 2011–2012 wave of China Health and Retirement Longitudinal Study, we examined the association between NRCMS coverage and the likelihood of delaying or foregoing medical care (outpatient and inpatient) by survey-weighted regression models controlling for demographics, education, geographic regions, household expenditures, pre-existing chronic diseases, and access to local healthcare facilities. Zero-inflated negative binomial model was used to estimate the association between NRCMS coverage and number of medical visits.


NRCMS coverage was significantly associated with lower odds of delaying or foregoing inpatient care (OR: 0.42, 95 % CI: 0.22–0.81). A negative but insignificant association was found between NRCMS coverage and delaying/foregoing outpatient care when ill. Among those who needed health care, the expected number of outpatient visits for NRCMS enrollees was 1.35 (95 % CI: 1.03–1.77) times of those uninsured, and the expected number of inpatient visits for NRCMS enrollees was 1.83 (95 % CI: 1.16–2.88) times of those uninsured.


This study shows that the enhanced NRCMS coverage was associated with less delaying or foregoing inpatient care deemed as necessary by health professionals, which is likely to result from improved financial reimbursement of the NRCMS.


China Rural care Health insurance, health disparities Liquidity effect 


Compliance with Ethical Standards



Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article is a secondary data analysis. It does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    MOH. Ministry of Health of the People’s Republic of China. New Cooperative Medical Scheme in 2011. 2012;1–6. Accessed May 2015.
  2. 2.
    Xu K, Saksena P, Fu XZH, Lei H, Chen N, Carrin G. Health care financing in rural China: new rural cooperative medical scheme. Geneva: World Health Organization Publ.; 2009. Scholar
  3. 3.
    Mao Z. The development status and challenges of New Cooperative Medical Scheme. 新型农村合作医疗的发展状况与挑战. Health Econ Study. 2009;261:10–1.Google Scholar
  4. 4.
    Ying M, Du Z. The effects of medical insurance on durables consumption in rural China. China Agric Econ Rev. 2012;4:176–87. doi: 10.1108/17561371211224764.CrossRefGoogle Scholar
  5. 5.
    Zheng Z. The influence of new rural cooperative medical scheme on domestic consumption in Rural China—an empirical analysis. 新型农村合作医疗保险与拉动农村内需——一个来自于中国农村微观数据的实证分析. CCISSR Conference Paper. 2010.Google Scholar
  6. 6.
    Chinanews. Annual income for Chinese farmers in 2012. 2013. Accessed 5 Apr 2016.
  7. 7.
    Xie Y, Zhou X. Income inequality in today’s China. Proc Natl Acad Sci. 2014;111(19):6928–33.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Ying Y. Differential funding: a necessary requirement of the New Rural Cooperative Medical Scheme’s development差别化筹资: 新农合制度发展的必然要求. China Health. 2012;4:36–7.Google Scholar
  9. 9.
    Wu L, Shen S. An evaluation of New Rural Cooperative Medical Scheme我国新型农村合作医疗制度运行状况评估. J Southwest Univ (Social Sciences Edition). 2011. Accessed June 2015.
  10. 10.
    MOH. Ministry of Health of the People’s Republic of China. New rural cooperative medical scheme development report (2002–2012). 2013. Accessed May 2015.
  11. 11.
    Shi L, Zhang D. China’s New Rural Cooperative Medical Scheme and underutilization of medical care among adults over 45: evidence from CHARLS pilot data. J Rural Health. 2013;29:s51–61.CrossRefPubMedGoogle Scholar
  12. 12.
    Smith Jea. Health outcomes and socio-economic status among the elderly in China: Q2 evidence from the CHARLS Pilot. Working Paper. 2010.Google Scholar
  13. 13.
    Yip W, Hsiao W. Non-evidence-based policy: how effective is China’s new cooperative medical scheme in reducing medical impoverishment? Soc Sci Med. 2009;68:1–33.CrossRefGoogle Scholar
  14. 14.
    Nyman JA. The value of health insurance: the access motive. J Health Econ. 1999;18(2):141–52.CrossRefPubMedGoogle Scholar
  15. 15.
    Decker S, Doshi J, Knaup A, Polsky D. Health service use among the previously uninsured: is subsidized health insurance enough? Health Econ. 2012;21:1155–68. doi: 10.1002/hec.1780.CrossRefPubMedGoogle Scholar
  16. 16.
    Lei X, Lin W. The new cooperative medical scheme in rural China: does more coverage mean more service and better health? Health Econ. 2009;18(S2):1–36.Google Scholar
  17. 17.
    Ma Y, Zhang L, Chen Q. China’s new cooperative medical scheme for rural residents: popularity of broad coverage poses challenges for costs. Health Aff (Project Hope). 2012;31:1058–64. doi: 10.1377/hlthaff.2009.0808.CrossRefGoogle Scholar
  18. 18.
    Long Q, Klemetti R, Wang Y, Tao F, Yan H, Hemminki E. High Caesarean section rate in rural China: is it related to health insurance (New Co-operative Medical Scheme)? Soc Sci Med (1982). 2012;75:733–7. doi: 10.1016/j.socscimed.2012.03.054.CrossRefGoogle Scholar
  19. 19.
    Sun X, Jackson S, Carmichael G, Sleigh AC. Prescribing behaviour of village doctors under China’s New Cooperative Medical Scheme. Soc Sci Med (1982). 2009;68:1775–9. doi: 10.1016/j.socscimed.2009.02.043.CrossRefGoogle Scholar
  20. 20.
    Smith JP, Majmundar M (Eds.). Aging in Asia: Findings from New and Emerging Data Initiatives. Washington, DC: National Academies Press; 2012.Google Scholar
  21. 21.
    CCER. China Health and Retirement Longitudinal Survey (CHARLS). Peking University; 2011. Accessed Dec 2013.
  22. 22.
    Strauss J, Park A, Smith JP. Health outcomes and socio-economic status among the elderly in Gansu and Zhejiang Provinces, China: evidence from the CHARLS pilot. J Popul Ageing. 2010;1:111–42. doi: 10.1007/s12062-011-9033-9.Health.CrossRefGoogle Scholar
  23. 23.
    Feng X, Pang M, Beard J. Health system strengthening and hypertension awareness, treatment and control: data from the China Health and Retirement Longitudinal Study. Bull World Health Organ. 2014;92:29–41. doi: 10.2471/BLT.13.124495.CrossRefPubMedGoogle Scholar
  24. 24.
    Li H. The SWOT analysis and the countermeasures for overall manning in outpatient clinics in New Rural Cooperative Medical Service. Modem Hosp Manage. 2010;3:28–30.Google Scholar
  25. 25.
    Li X, Zhang W. The impacts of health insurance on health care utilization among the older people in China. Soc Sci Med. 2013;85:59–65.Google Scholar
  26. 26.
    Wen J. Report on the Work of the Government 2012. March 5th, 2012 at the fifth Plenary Session of the National Congress. 政府工作报告——2012年3月5日在第十一届全国人民代表大会第五次会议上. 2012.Google Scholar
  27. 27.
    Meng Q, Xu K. Progress and challenges of the rural cooperative medical scheme in China. Bull World Health Organ. 2014;92:447–51.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Qin L, Pan S. Adverse selection in China’s New Rural Cooperative Medical Scheme. China Agric Econ Rev. 2012;4:69–83.CrossRefGoogle Scholar
  29. 29.
    Buchmueller TC, Grumbach K, Kronick R, Kahn JG. The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature. Med Care Res Rev: MCRR. 2005;62:3–30. doi: 10.1177/1077558704271718.CrossRefPubMedGoogle Scholar
  30. 30.
    Ying M, Wenbin F, Fengye W. Analysis on the game theory view of the moral hazard in the urban workers’ basic medical insurance [J]. Chin Med Ethics. 2006;4:028.Google Scholar
  31. 31.
    Babiarz K, Miller G, Yi H, Zhang L, Rozelle S. New evidence on the impact of China’s New Rural Cooperative Medical Scheme and its implications for rural primary healthcare: multivariate difference-in-difference. BMJ. 2010;341:c5617.CrossRefPubMedGoogle Scholar
  32. 32.
    Barber L, Yao L. Health insurance systems in China: a briefing note. World Health Report. 2010. Accessed May 2015.
  33. 33.
    Yip W, Eggleston K. Provider payment reform in China: the case of hospital reimbursement in Hainan province. Health Econ. 2001;339:325–39.Google Scholar
  34. 34.
    Yip WC-M, Hsiao W, Meng Q, Chen W, Sun X. Realignment of incentives for health-care providers in China. Lancet. 2010;375:1120–30. doi: 10.1016/S0140-6736(10)60063-3.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2016

Authors and Affiliations

  • Donglan Zhang
    • 1
    Email author
  • Lu Shi
    • 2
  • Fang Tian
    • 3
  • Lingling Zhang
    • 2
  1. 1.Department of Health Policy and Management, College of Public HealthUniversity of GeorgiaAthensUSA
  2. 2.Department of Public Health SciencesClemson UniversityClemsonUSA
  3. 3.Research Institute of Health Development StrategiesFudan UniversityShanghaiChina

Personalised recommendations