The implementation of the outpatient pooling scheme in China has substantially elevated the compensation levels for outpatient expenses. This study aims to assess whether socioeconomically disadvantaged enrollees benefit proportionally compared to their non-disadvantaged counterparts.
A cohort comprising 14,581 Urban and Rural Resident Basic Medical Insurance (URRBMI) enrollees and 830 Urban Employee Basic Medical Insurance (UEBMI) enrollees was derived from the China Health and Retirement Longitudinal Study 2018. Outpatient pooling scheme benefits were evaluated based on two metrics: the probability of obtaining benefits and the magnitude of benefits (reimbursement amounts and ratios). Two-part models were employed to adjust outpatient benefits for healthcare needs. Inequality in benefit distribution was assessed using the concentration curve and concentration index (CI).
Following adjustments for healthcare needs, the CI for the probability of receiving outpatient benefits for URRBMI and UEBMI enrollees were − 0.0760 and − 0.0514, respectively, indicating an evident pro-poor pattern under the outpatient pooling scheme. However, the CIs of reimbursement amounts (0.0708) and ratio (0.0761) for URRBMI recipients were positive, signifying a discernible pro-rich inequality in the degree of benefits. Conversely, socioeconomically disadvantaged UEBMI enrollees received higher reimbursement amounts and ratios.
Despite a higher likelihood of socioeconomically disadvantaged groups receiving outpatient benefits, a pro-rich inequality persists in the degree of benefits under the outpatient pooling scheme in China. Comprehensive strategies, including expanding outpatient financial benefits, adopting distinct reimbursement standards, and enhancing the accessibility of outpatient care, need to be implemented to achieve equity in benefits distribution.