Financial protection and healthcare utilization for low-income populations under China's multi-tiered health financing system: a cross-sectional study in an Eastern city.

backgroundChina's Multi-tiered Health Financing System (MTHFS) integrates basic medical insurance, critical illness coverage, and the Medical Assistance System (MAS) to advance Universal Health Coverage (UHC). While the MAS targets low-income populations, the degree of financial protection and equity in healthcare access it affords remains incompletely understood. This cross-sectional study aims to describe patterns of healthcare utilization and analyze the incidence and determinants of catastrophic health expenditure (CHE) among low-income groups under the MTHFS.

methodsA cross-sectional analysis was conducted using 2021-2022 administrative claims data from a representative city in Eastern China. Disparities between low-income (MAS recipient) and non-low-income groups in healthcare utilization (hospital tier, cross-regional care) and financial outcomes (reimbursement rates, CHE incidence) were assessed using Chi-square tests. Multivariate logistic regression was employed to identify determinants of CHE, adjusting for demographics, chronic disease status, service utilization, and expenditure levels.

resultsKey findings were: (1) Utilization Disparities: The proportion of low-income individuals seeking inpatient care at tertiary hospitals (23.25% in 2021 and 21.42% in 2022) or across provinces (4.59% in 2021 and 4.00% in 2022) was significantly lower than that of the non-low income populations (p < 0.001). (2) Financial Protection: Under the MTHFS, low-income populations had high reimbursement rates (80.02% in 2021 and 82.53% in 2022), indicating a substantial reduction in the medical cost burden. However, despite these high reimbursement rates, 30.05% and 39.44% of low-income individuals still experienced CHE in 2021 and 2022, respectively. When the analysis was restricted to costs covered by the benefit package, these proportions fell to 17.37% and 21.45%, respectively. (3) Risk Factors: Chronic conditions (OR = 5.91 [4.64, 7.53]), tertiary hospital use (OR = 5.83 [4.35, 7.82]), and inpatient services (OR = 13.84 [10.71, 17.88]) significantly increased CHE risk.

conclusionsThe findings suggest that within the studied context, the MTHFS, particularly the MAS, is associated with a reduction in the proportion of out-of-pocket payments for covered services among low-income populations. Despite progress, the limited benefit package of URRMI and reimbursement caps under MAS still leave vulnerable groups at risk of CHE.To mitigate CHE, policy measures should include expanding the benefit package to cover cost-effective innovations (e.g. newly launched anticancer drugs) and implementing income-linked out-of-pocket payment caps for low-income groups.