Abstract
Objective
In this study, the impact of medical insurance and old-age security on the use of medical services by the older population with disabilities is analyzed. A reference for decision makers is provided to improve medical and old-age security policies and enhance the use of medical services by the older population.
Methods
Data were drawn from 3,737 older people with disabilities aged 65 years or above from the 2018 China Longitudinal Healthy Longevity Survey. A two-part model based on social ecological theory was used for both analysis and group prediction.
Results
In terms of the use of outpatient medical services, old-age pension significantly increased the probability of outpatient visits for this population group (P < 0.05). Urban employee/resident medical insurance, the new rural cooperative medical insurance, and retirement pension significantly affected medical expenses. In terms of the use of inpatient medical services, the new rural cooperative medical insurance and retirement pension significantly influenced the choice of inpatient medical services; retirement pension increased inpatient medical expenditure (p < 0.01). The expected average probability of hospitalization, unconditional expected cost, and conditional expected cost for the older population with disabilities were 49.5%, RMB 6629.31, and RMB 3281.51, respectively. Both conditional and unconditional expected costs were significantly higher for older people with disabilities with the following attributes: male, married, no less than three chronic conditions, and unassisted daily care; costs were lower for older people with disabilities who are female, not married, had less than three chronic conditions, and had a spouse, child, or other caregiver.
Conclusion
Medical insurance and old-age security can significantly promote the utilization of medical services by the older population with disabilities. It is therefore recommended to focus on strengthening the support and health management of these people who are unattended to improve the effective use of health services and better meet their needs.
Keywords: Older population with disabilities, Medical insurance, Old-age security, Medical service utilization
Strengths and limitations of this study
This is the first study to examine the impact of medical insurance and old-age security on health service utilization among the older population with disabilities based on a two-part model.
Old-age security is used as dependent variable rather than as control variable.
This study focuses on a specific group: older people with disabilities.
This study addresses the issue of health service utilization among older people with disabilities, which has received little attention by existing studies.
In this study, health service utilization uses self-reported measures, which are more prone to potential errors than objective measures.
The data for this study originated from the 2018 China Elderly Health Influencing Factors Tracking Survey, a national survey that was suspended during the COVID-19 pandemic, and provides individual-level of data, which has limitations in terms of data acquisition.
Introduction
With the continuous intensification of the worldwide trend of population aging [1], a larger share of the older population increasingly faces challenges caused by disability. According to the disability report of the World Health Organization, one billion people—15% of the global population—experience some form of disability. The prevalence of disability increases with age and the age of the population is constantly increasing [2]. The significant increase in the number of older people with disabilities because of population aging has become an important issue worldwide. Older people with disabilities should receive more attention because of their higher need for healthcare services [3, 4]. It has been shown that ageing and disability reduce older people’s opportunities to participate in social activities, including access to health care [5]. According to the World report on disability [6], a fifth of all disabled people worldwide face challenges such as lack of accessibility, discrimination, and inadequate health care. Studies from the USA and Malaysia confirmed that the current needs of older people with disabilities are not being met; this imbalance between supply and demand for older people with disabilities needs to be brought to the attention of scholars globally [7–10].
The problem of the ageing population is particularly serious in China [11, 12], and has been projected to worsen still. Research has shown that in 2010, there were more than 15 million older people with disabilities in China; moreover, it has been predicted that by 2050, the number of China’s older people with disabilities who need long-term care will reach 25–45 million [13]. Research based on the China Comprehensive Geriatric Assessment Study showed that the incapacitation rate of Chinese older people is 7% and further increases with age [14]. This rapid demographic change will impose enormous pressure on China’s healthcare resources [15]. The scarce supply of healthcare resources in China has resulted in the inability of the healthcare system to meet the demand for healthcare by an ageing population [16]. The demand for community services for older people with disabilities in Beijing has been estimated, indicating that 64% of these people need door-to-door medical services, and more than 85% need chronic disease management [17]. With the implementation of the family doctor system in China, community health institutions have become a key part of the chronic disease management for older people. However, because of the weak capacity and understaffing of primary healthcare organizations, as well as the lack of health literacy and poor medication adherence among older people, the healthcare services provided by family doctors and primary healthcare institutions cannot meet the needs of older people with disabilities [18–20]. At the same time, despite the sizeable medical needs of older people with disabilities, the utilization of medical services is still insufficient. Scholars from both China and the international academic community have confirmed that older adults with disabilities are exposed to more risk factors compared to older adults without disabilities; however, the utilization of medical services is still low [21, 22]. An analysis of the use of medical services according to demographic characteristics showed that in China, less than 5% of older people with disabilities use medical services [23].
Medical insurance and old-age security—important parts of social security—significantly impact the utilization of medical services, especially of vulnerable groups such as older people with disabilities. Research demonstrated that having health insurance promotes the use of both outpatient and inpatient health services among older people [24]. Scholars outside of China have also confirmed that public and private insurance prompts more older people with disabilities to use medical services, especially those with lower incomes [25].
A portion of existing studies has focused on the long-term care of older people with disabilities [26, 27]; a study on the relationship between spousal care and health in Mexico showed that older people with disabilities have better physical health if they have caregivers [28]. The impact of diseases on the utilization of medical services has also been examined [29, 30]. For example, health care utilization in first-episode schizophrenia has been analyzed [31]. Another research stream focused on the impact of Medicare or other social security measures on health care expenditures [24, 32]. The impact of having health insurance on healthcare utilization has been examined among the Spanish population [33]. However, few studies, both in China and internationally, have focused on the impact of social security (such as health insurance and old-age security) on health care utilization among older people with disabilities.
Considering that the health and economic status of older people with disabilities face vulnerabilities, the impact of medical insurance and old-age security on the utilization of medical services in this population group needs to be further clarified. Therefore, this study takes older people with disabilities over 65 years old as the research object. Data of the China Elderly Health Influencing Factors Tracking Survey (CLHLS) were used to analyze the impact of medical care and old-age security on their utilization of medical services. These data were also used to effectively predict the probability of medical care and medical costs for older people with disabilities. The results provide decision-making references for improving medical and old-age security policies as well as the utilization of medical services for older people with disabilities.
Methods
Data
The data were derived from the 2018 CLHLS. During the period from 1998 to 2018, a total of eight follow-up surveys were conducted in about half of the counties and cities randomly selected from 23 provinces, municipalities, and autonomous regions across China. A total of 113,000 older people were surveyed by means of home visits.
In this paper, older people with disabilities over 65 years old were selected as the main research object. The disabilities of older people were assessed using the Activities of Daily Living (ADL) scale [34], which includes six basic human functions: eating, dressing, bathing, using the toilet, indoor transfer, and continence; people who are constrained in one or more of these aspects, cannot care for themselves completely, and rely on help from others are defined as people with a disability [35–38].
The 2018 CLHLS data included 15,874 respondents over the age of 65, and 4,196 seniors who were identified as living with disability. After further exclusion of cases with missing answers related to insurance coverage and medical expenses, 3,737 valid samples were obtained.
Measurements
Explained variable
The explained variable was the utilization of medical services for older people with disabilities, including outpatient and inpatient services. In the questionnaire, the utilization of outpatient services was examined by the question: “How much did you spend on outpatient costs last year?” The utilization of inpatient services was examined by the question: “How much did you spend on inpatient costs last year?”
Explanatory variables
In this study, explanatory variables were medical insurance and old-age security for older people with disabilities, according to the option setting of the question “Do you have following social security and commercialized insurances at present?” Medical insurance and old-age security included the urban employee/resident medical insurance, the new rural cooperative medical insurance, retirement pension, and pension.
Control variables
The social-ecological systems theory, which was proposed by the American psychologist Urie Bronfenbrenner in 1979, was applied to classify variables. This theory examines the interaction of the social environment on individual behavior based on integrating system perspective, social perspective, and ecological perspective [39]. This study divided variables into individual characteristics, family environment, and social environment based on social-ecological systems theory [40]. Individual characteristics include gender, age, marital status, education level, self-assessed economic status, self-assessed health status, number of restrictions experienced in daily life, and number of chronic diseases. The family environment included financial support from children, the number of surviving children, and the type of caregivers. The factor of the social environment mainly referred to the policy environment related to health and old-age security among explanatory variables.
Model design
In the survey sample for this study, 18% and 47% of older people with disabilities had no expenditure on outpatient and inpatient health services in the past year, respectively. Because of the existence of a large number of zero observations in the explained variable, the sample data are semi-continuous and right skewed; these data do not conform to the assumption of normal distribution of random errors. Lei et al. pointed out that it cannot be described by a simple parametric distribution [41]. Lu and Jie proposed to use a two-part model to analyze such data [42], and Duan et al. emphasized that the estimation of a two-part model has no statistically significant effect on the results [43].
In this study, a two-part model method was therefore used to divide the specific process of parameter estimation into the following two parts: in the first part, the probability that older people incur medical service costs was predicted by establishing a Probit regression model; in the second part, a log-linear model was used to analyze the impact of older people’s medical service costs factor.
The first part of the medical service expenditure probability model treated the explanatory variable as a binomial distribution. This part was used to express the influences of both the explanatory variable and the control variable on the possibility of medical service expenditure for older people with disabilities. The indicator variable Z was used to indicate whether older people had medical expenditure, and Y was used to indicate medical expenses. The value range was (0, <+∞). The following Probit regression model was used:
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The second part reflects the model of medical service expenditure. The log-linear model was used to estimate and analyze the influencing factors of medical expenditure for older people with disabilities. The log-transformed linear model is shown as follows:
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Combining the above two parts of the model, the estimated value of the expenditure on inpatient medical and health services for older people with disabilities was obtained. Its function can be expressed as:
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All data analysis procedures were conducted in Stata 15.0.
Patient and public involvement
The Patient and Public Involvement Statement does not apply to this study. Because the data used in this study were obtained from the CLHLS database, the hypotheses, research questions, and outcome measures were designed without patient involvement. Moreover, the results of the study will not be disseminated to study participants or any other individuals or communities.
Results
Sample characteristics
Of the 3,737 older people with disabilities surveyed, the majority were female (67.3%) and most were not married at the time of the survey (82.9%); 67.5% had no formal schooling; 67.2% of older people considered themselves to be in an average financial situation and 29.1% considered themselves to be in good health; more than 50% older people had no less than three restrictions of ADL and 46.9% suffered from one or two chronic diseases; 68.0% of the older people received financial support from their children, and more than 70% of the older population had at least three children; a high proportion (84.1%) of older people with disabilities received care from their spouse or children.
In terms of medical care and old-age security, among the older people with disabilities surveyed in this study, the numbers of people with urban employee/resident medical insurance, old-age pensions, and retirement pensions were relatively low, accounting for only 24.6%, 27.2%, and 23.8%, respectively. The number of people with new rural cooperative medical insurance accounted for 56.1% (Table 1).
Table 1.
Social ecological characteristics of older people with disabilities
| Variable type (corresponding to the dimension of social ecological systems theory) | Variable | N | Percentage (%) | |
|---|---|---|---|---|
| Explanatory variables (Social environment) | Urban employee/resident medical insurance | Yes | 920 | 24.6 |
| No | 2817 | 74.4 | ||
| New Rural Cooperative Medical Insurance | Yes | 2097 | 56.1 | |
| No | 1640 | 43.9 | ||
| Old-age pensions | Yes | 1017 | 27.2 | |
| No | 2720 | 72.8 | ||
| Retirement pension | Yes | 889 | 23.8 | |
| No | 2848 | 76.2 | ||
| Control variables (Individual characteristics) | Gender | Male | 1222 | 32.7 |
| Female | 2515 | 67.3 | ||
| Marital status | Married | 635 | 17.1 | |
| Unmarried | 3072 | 82.9 | ||
| Education | Educated | 2255 | 67.5 | |
| Uneducated | 1086 | 32.5 | ||
| Self-reported economic status | Rich | 693 | 18.7 | |
| Generally | 2494 | 67.2 | ||
| poor | 492 | 13.3 | ||
| Not answered | 34 | 0.9 | ||
| Self-reported health status | Good | 1081 | 29.1 | |
| Generally | 1065 | 28.7 | ||
| poor | 668 | 18.0 | ||
| Not answered | 899 | 24.2 | ||
| Activities of Daily Living | 1–2 | 1796 | 48.1 | |
| ≥ 3 | 1941 | 51.9 | ||
| Chronic disease | 0 | 1085 | 29.0 | |
| 1–2 | 1754 | 46.9 | ||
| ≥ 3 | 898 | 24.1 | ||
| (Family environment) | Financial support from children | Yes | 2543 | 68.0 |
| No | 1194 | 32.0 | ||
| Surviving children | 0 | 170 | 4.5 | |
| 1–2 | 912 | 24.4 | ||
| ≥ 3 | 2655 | 71.1 | ||
| Type of caregiver | Spouse or child | 2922 | 84.1 | |
| Other people | 510 | 13.7 | ||
| Unattended | 43 | 1.2 |
In terms of medical service utilization, 81.3% of the 3,737 older people with disabilities in this survey utilized outpatient medical services in the past year, at an average annual outpatient cost of RMB 4,251.01; 51.8% of older people with disabilities utilized inpatient medical services in the past year, at an average annual inpatient cost of RMB 6,630.75.
Utilization of outpatient health services
According to the results of the two-part model analysis of outpatient medical expenditure (Table 2), urban employee/resident medical insurance had no significant effect on the probability of outpatient visits; however, these types of insurance resulted in a significant reduction in outpatient medical cost expenditures (p < 0.05). New Rural Cooperative Medical Insurance was significantly and negatively associated with medical expenses. There was a significant reduction in outpatient medical expenses was achieved compared to those without New Rural Cooperative Medical Insurance (p < 0.01), no significant effect was found regarding the choice of outpatient medical services. Old-age pension significantly increased the probability of choosing outpatient medical services for older people with disabilities (p < 0.05), and retirement pension were positively associated with medical expenditure (p < 0.01).
Table 2.
Two-part model analysis of the impact of medical insurance and old-age security on outpatient medical expenses
| Probability of outpatient visits | Outpatient medical expenditure | ||||||
|---|---|---|---|---|---|---|---|
| Coef | SE | P | Coef | SE | P | ||
| Explanatory variables | Urban employee/resident medical insurance | 0.121 | 0.073 | 0.099 | -0.364 | 0.183 | 0.047 |
| New Rural Cooperative Medical Insurance | 0.047 | 0.064 | 0.462 | -0.483 | 0.167 | 0.004 | |
| Old-age pension | 0.125 | 0.552 | 0.023 | -0.068 | 0.136 | 0.615 | |
| Retirement pension | 0.117 | 0.684 | 0.087 | 0.509 | 0.173 | 0.003 | |
| Control variables | Gender | 0.001 | 0.056 | 0.997 | -0.052 | 0.141 | 0.713 |
| Marital status | -0.056 | 0.025 | 0.027 | -0.139 | 0.057 | 0.017 | |
| Education | 0.002 | 0.003 | 0.489 | 0.018 | 0.010 | 0.058 | |
| Self-reported economic status | 0.025 | 0.045 | 0.570 | -0.134 | 0.110 | 0.224 | |
| Self-reported health status | -0.062 | 0.039 | 0.110 | 0.034 | 0.096 | 0.720 | |
| Activities of Daily Living | 0.002 | 0.013 | 0.908 | 0.017 | 0.033 | 0.617 | |
| Chronic disease | 0.207 | 0.019 | 0.000 | 0.123 | 0.035 | 0.001 | |
| Financial support from children | 0.251 | 0.052 | 0.000 | -0.030 | 0.138 | 0.826 | |
| Surviving children | -0.023 | 0.035 | 0.518 | 0.203 | 0.093 | 0.030 | |
| Type of caregiver | -0.001 | 0.009 | 0.957 | 0.058 | 0.021 | 0.007 | |
Note: SE stands for standard error
Among control variables, marital status significantly impacted the choice of outpatient health care services and health care expenditure among older people with disabilities. Married older people with disabilities were more likely to use inpatient health care services and incurred higher health care expenditure than divorced, widowed, and never married older people with disabilities. The number of chronic conditions was significantly and positively associated with outpatient health care choice and health care expenditure. Financial support from children significantly increased health care utilization, and the number of surviving children as well as the type of caregiver significantly increased outpatient health care expenditure.
Utilization of inpatient health services
The results of the two-part model of inpatient care expenditure (Table 3) showed that of the medical insurance and old-age security variables, both New Rural Cooperative Medical Insurance and pensions significantly affected the choice of inpatient care. New Rural Cooperative Medical Insurance was significantly negatively associated with the choice of inpatient care, while pensions were significantly positively associated; pensions also significantly increased inpatient care expenditure.
Table 3.
Two-part model analysis of the impact of medical insurance and old-age security on inpatient medical expenses
| Probability of inpatient visits | Inpatient medical expenditure | ||||||
|---|---|---|---|---|---|---|---|
| Coef | SE | P | Coef | SE | P | ||
| Explanatory variables | Urban employee/resident medical insurance | -0.002 | 0.063 | 0.965 | 0.219 | 0.137 | 0.109 |
| New Rural Cooperative Medical Insurance | -0.136 | 0.056 | 0.016 | -0.187 | 0.133 | 0.159 | |
| Old-age pension | 0.052 | 0.047 | 0.270 | 0.162 | 0.109 | 0.137 | |
| Retirement pension | 0.242 | 0.059 | 0.000 | 0.340 | 0.128 | 0.008 | |
| Control variables | Gender | -0.042 | 0.047 | 0.375 | -0.023 | 0.113 | 0.840 |
| Marital status | -0.107 | 0.020 | 0.000 | -0.128 | 0.045 | 0.005 | |
| Education | 0.005 | 0.003 | 0.046 | 0.008 | 0.006 | 0.141 | |
| Self-reported economic status | 0.033 | 0.038 | 0.038 | -0.158 | 0.091 | 0.083 | |
| Self-reported health status | 0.115 | 0.033 | 0.000 | 0.034 | 0.074 | 0.644 | |
| Activities of Daily Living | 0.026 | 0.011 | 0.022 | 0.060 | 0.027 | 0.024 | |
| Chronic disease | 0.111 | 0.013 | 0.000 | 0.135 | 0.029 | 0.000 | |
| Financial support from children | 0.080 | 0.045 | 0.080 | 0.009 | 0.111 | 0.933 | |
| Surviving children | -0.015 | 0.039 | 0.625 | 0.296 | 0.017 | 0.000 | |
| Type of caregiver | 0.024 | 0.007 | 0.001 | 0.053 | 0.017 | 0.002 | |
Note: SE stands for standard error
Among control variables, older people with disabilities who were married were more likely to use inpatient health services and spend more on health care than those who were divorced, widowed, or never married. Education, self-rated economic status, self-rated health status, number of limitations of ADL, number of chronic conditions, and type of caregiver significantly increased the probability of utilizing inpatient health services. Older people with disabilities with fair or poor self-rated economic status and health status were more likely to choose inpatient health services. The number of limitations of ADL, the number of chronic conditions, financial support from children, and type of caregiver were significantly positively associated with inpatient care expenditure. Older people with disabilities who received care from their spouse or children were less likely to choose inpatient care and incurred less inpatient costs (Table 3).
Prediction of hospitalization costs for older people with disabilities
Table 4 shows the expected average probability of hospitalization, conditional expected costs, and non-conditional expected costs for older adults with disabilities; these expected values are based on a two-part model approach estimated for different genders, marital status, number of chronic conditions, and types of caregivers. The expected mean probability of hospitalization for older people with disabilities was 49.5%, the conditional expected cost was RMB 6,629.31, and the unconditional expected cost was RMB 3,281.51. The conditional expected cost and unconditional expected cost for older people with disabilities who were male, married, had at least three chronic conditions, and did not receive help with daily care were significantly higher than those who were female, not married, had less than three chronic conditions, and received care from a spouse or child. The cost incurred for caring for an older person with a disability was significantly higher for respondents who were male, married, had no less than three chronic conditions, and had a spouse, child, or other caregiver.
Table 4.
Expected hospitalization costs for older people with disabilities by gender, marital status, education level, and type of caregiver
| Average probability of hospitalization | Conditional expected cost (yuan) | Unconditional expected cost (yuan) | ||
|---|---|---|---|---|
| Gender | Male | 0.533 | 8161.73 | 4350.20 |
| Female | 0.477 | 5884.73 | 2807.02 | |
| Marital status | Married | 0.630 | 10875.44 | 6851.53 |
| Unmarried | 0.467 | 5756.80 | 2688.43 | |
| Number of chronic diseases | 0 | 0.370 | 2346.34 | 868.15 |
| 1–2 | 0.500 | 6815.60 | 3407.80 | |
| ≥ 3 | 0.635 | 11440.29 | 7264.58 | |
| Type of caregiver | Spouse or child | 0.475 | 5912.08 | 2808.24 |
| Other people | 0.602 | 10395.51 | 6258.10 | |
| Unattended | 0.682 | 13088.09 | 8926.08 | |
| Total | 0.495 | 6629.31 | 3281.51 |
Discussion
Health services for the vulnerable population group of older people with disabilities are a common challenge worldwide. Currently, there is a lack of research on the utilization of health services for older people with disabilities and the roles of health care and old age security. Using 2018 CLHLS data, this study empirically analyzed the impact of medical insurance and old-age security on the utilization of outpatient and inpatient medical services for older people with disabilities based on the social-ecological systems theory and a two-part model method. The expected mean hospitalization probability, conditional expected cost, and unconditional expected cost were estimated for older people with disabilities with differences in gender, marital status, number of chronic conditions, and type of caregiver.
The findings indicate that medical insurance significantly contributes to the utilization of medical services for older people with disabilities; further, the impact of the New Rural Cooperative on the level of outpatient medical service utilization of older people with disabilities was more significant than that of hospitalization. According to the results of the study, the average annual outpatient medical expenses of older people with disabilities and medical insurance decreased by RMB 1,547.37 for urban employee/residents medical insurance and by RMB 2,040.48 for New Rural Cooperative Medical Insurance. This shows that China’s current medical insurance system can play a role in alleviating the burden of promoting the use of medical services to ease medical care [44, 45]. In addition, New Rural Cooperative Medical Insurance significantly reduced the outpatient medical expenses of older people (p < 0.01), and the impact on outpatient care was more significant than that on inpatient care. This differed from the findings of existing studies on the general population. It has been argued that New Rural Cooperative Medical Insurance had no significant effect on outpatient utilization, substantiating that New Rural Cooperative Medical Insurance policies focused on inpatient services [46]. Other scholars argued that New Rural Cooperative Medical Insurance positively and significantly affects both outpatient and inpatient health service utilization; however, a more significant increase in utilization of outpatient services was found in village health clinics, and a more significant increase in utilization of inpatient services was found in county hospitals [47]. The possible reason for this result is the specific nature of older people with disabilities. Their mobility problems, the high burden of inpatient care, and the proximity of village health clinics led to a tendency for older people with disabilities to prefer to use village health clinics rather than inpatient care. Furthermore, the role of New Rural Cooperative Medical Insurance in alleviating the financial burden of medical care for older people with disabilities in rural areas was still limited [48]. Today, New Rural Cooperative Medical Insurance has been integrated with the Urban Resident Medical Insurance, thus forming the Urban and Rural Resident Medical Insurance. Research has shown that urban and rural resident medical insurance has reduced the cost of medical care for older people; it has also increased the utilization of medical services by increasing the number of older people choosing lower-level health care facilities as the proximity of primary institutions to their homes results in more convenient access and also saves time and money [49]. This confirms the above speculation as to the probable cause. However, the cost of inpatient medical services for rural residents remains relatively high [50]. Although health insurance can significantly promote the utilization of healthcare services in older people with disabilities, the results of this study show that the rate of insurance coverage for this group is only about 80% while nearly 20% are not covered by insurance; therefore, the insurance coverage of older people with disabilities should be further increased. To protect the needs of older people with disabilities, the Urban and Rural Resident Medical Insurance should further increase hospitalization compensation, focus on covering medical services for older people in rural areas, and narrow the gap between urban and rural areas [51]. At the same time, health insurance coverage should be expanded to also include in-home care services in the scope of health insurance; this will reduce the financial burden and accessibility of services for older people with disabilities [52].
This study showed that old-age security can significantly contribute to the use of health services for older people with disabilities (p < 0.05); moreover, pensions—an important type of financial income for older people with disabilities—significantly promote the use of inpatient medical services (p < 0.001) and increase the spending on outpatient (p < 0.01) and inpatient (p < 0.01) medical services. Certain scholars have come to the same conclusion in a study of Mexican pension schemes, namely that pensions can significantly increase the level of health care utilization [53]. Possible reasons for this result are that pensions increase the financial income of older people with disabilities and that reduced financial barriers enable the use of more expensive services with higher quality [54]. It was confirmed that pensions can have a significant impact on promoting the use of outpatient and inpatient health care services by improving the economic level of the disabled elderly. One study indicated that the pension is the largest financial source, followed by government subsidies, and 63.5% of rural disabled older people have incomes of less than 500 yuan, some of whom are unable to make ends meet [55]. The lack of financial security for rural disabled older people can easily lead to negative changes in attitudes towards ageing and affect the motivation to use healthcare services [56]. It is suggested that the implementation of a care system and medical assistance system for the disabled older people should be accelerated, and the disabled older people should be financially subsidized and the national welfare policy for the older people should be gradually improved [57]. However, by analyzing and evaluating China’s future pension income and expenditure, the hidden government debt resulting from governmental subsidies required to maintain the pension insurance system has been calculated; the results show that if the current pension insurance system continues to develop at pace, there will be a large shortfall in pensions in the future because of population aging. It is therefore recommended that the sustainability of pension insurance in the context of ageing should be ensured via reforms within the pension insurance system or the transformation of state-owned enterprises and state-owned assets [58].
It is worth mentioning that significant differences exist in the expected health care costs of older people with disabilities with different characteristics; the use of health care services by unattended people with disabilities is of particular concern. The results of this study indicate that older people with disabilities who receive care by a spouse or child are less likely to choose inpatient care and incur lower inpatient costs. This finding was confirmed by predicting the probability and costs of hospitalization for older people with disabilities. The reason may be that the needs of older people without support from a caregiver are less likely to be met than those of older people whose spouse or children provide daily care. The analysis of Liu et al. on the relationship between caregiver type and mortality in older people with disabilities over the age of 80 years confirms that caregiving has a definite impact on the health status of this group in China; moreover, they showed that interventions can significantly reduce the unmet needs of older people with disabilities [38], thereby reducing medical service utilization. Therefore, to effectively meet the demand for inpatient care for older people with disabilities, the focus should be on unaccompanied older people with disabilities.
Several scholars have called for the community to organize various forms of social activities on a regular basis, and to actively disseminate health information related to the use of health services; these measures can guide older people with disabilities to make full use of medical services and raise their health awareness, thereby improving their health [59]. In addition, services such as daily care and rehabilitation care can be provided to older people with disabilities through the community; chronic disease screening and disease prevention can be provided through regular medical check-ups; early intervention of diseases can be provided for older people with disabilities to reduce major diseases. With these measures, the burden of medical costs can be reduced and the utilization of medical services can be promoted.
This study has several limitations that inform future research. Firstly, as cross-sectional data were used, the associations could not be interpreted as causal associations of older people with disabilities. Longitudinal research is required to identify casualty. Secondly, CLHLS uses self-reported measures on health service utilization, which are more prone to potential errors than objective measures. To obtain more reliable results, future studies could use hospital registration information and clinical assessments. Thirdly, because of the setting of the CLHLS questionnaire options, this study analyzed urban employee basic medical insurance and urban resident basic medical insurance as one variable; the impacts of these two types of insurance on health services for older people with disabilities were not explored separately. Fourthly, because of the COVID-19 pandemic, the national survey was not completed and therefore, This study still chose the 2018 CLHLS data. However, this study is of research interest and value due to the paucity of current research on older people with disabilities. This study analyses the utilization of healthcare services for the older people with disabilities in China and the influential factors, clarifies the impact of health insurance and old-age security on the utilization of healthcare services for the older people with disabilities, and predicts the expected healthcare costs for different types of older people with disabilities. It is of great significance to promote the use of medical services by the older people with disabilities to meet their needs and improve their health.
Conclusion
In general, the demand for health services for older people with disabilities is high, but the utilization rate is low, and the need is not yet being met. Medical insurance and old-age security can greatly improve the utilization level of medical services. The government should strengthen health insurance and old-age security subsidies, which should be skewed toward special groups such as older people with disabilities; moreover, the gap between urban and rural areas should be narrowed. Further, the old-age security system should be improved to strengthen the support and health management of the older people with disabilities who are financially disadvantaged and unattended. These measures can effectively meet their healthcare service needs.
Acknowledgements
The authors thank the staff and participants of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) team for providing the data.
Author contributions
All authors have contributed to the development of the research ideas. YBZ obtained the dataset. XMT cleaned the dataset, performed the data analysis and drafted the manuscript. WPJ revised, checked and proofread the manuscript. All authors commented on the manuscript.
Funding
This work was supported by the National Natural Science Foundations of China (NO. 71874147) and the Humanities and Social Sciences Programme, Ministry of Education (NO. 23YJAZH010). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.
Data availability
The data that support the findings of this study are available from the China Elderly Health Influencing Factors Tracking Survey (CLHLS) at https://opendata.pku.edu.cn/. These data were used under license for the current study, and are therefore not publicly available. However, reasonable requests should be directed at Yanbing Zeng.
Declarations
Ethics approval and consent to participate
Ethical approval was confirmed by the Medical Ethics Committee of the Capital Medical University and approved to conduct the study. The Chinese Longitudinal Healthy Longevity Survey (CLHLS) is an open dataset. All participants in the survey signed or marked (if illiterate) the informed consent forms. The authors got a permission to access the data from the CLHLS.
Consent for publication
Not applicable.
Competing interests
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the China Elderly Health Influencing Factors Tracking Survey (CLHLS) at https://opendata.pku.edu.cn/. These data were used under license for the current study, and are therefore not publicly available. However, reasonable requests should be directed at Yanbing Zeng.