IntroductionIn 2009, China officially launched the New Health Care Reform (NHCR). One important purpose of the reform was to reduce financial burden of health care through health insurance expansion and health care provider regulations. This study aimed to provide evidence on the effect of the NHCR reform on catastrophic health expenditure (CHE) by comparing the occurrence and inequality of CHE among households with chronic diseases patients before and after the reform.MethodsThis study used the subset of data from the 2008 and 2013 National Health Services Survey conducted in Shaanxi Province. Our sample included households with chronic diseases patients and excluded observations with key variables missing. The final sample size was 1942 households in 2008 and 7704 households in 2013. We defined CHE occurrence following the definition of the World Health Organization (WHO). The income-related inequality in CHE was measured by the concentration index. A multi-level logistic regression model was used in the study to explore the influence of the NHCR on CHE occurrence, controlling for important covariates.ResultsFrom 2008 to 2013, the occurrence rate of CHE in rural areas declined from 29.15% to 23.62%. However, the CHE rate in urban areas increased from 19.18% to 24.95%. The interaction term between year and rural/urban location was statistically significant, confirming that the influence of the NHCR on the CHE occurrence rates were heterogeneous between rural and urban areas. As for the CHE inequality, the concentration index in rural areas decreased from -0.4572 to -0.5499 with a p-value less than 0.05. This implied that the CHE occurrence inequality was increased after the implementation of the NHCR.ConclusionOur study suggested that the implementation of the NHCR might not have been effective in reducing the CHE occurrence for households with chronic disease patients. Although the occurrence of CHE of rural households had decreased, the occurrence of CHE in urban areas was higher than before. In addition, the income inequality of CHE occurrence was greater in 2013 compared to that in 2008 in rural areas. Although the reform resulted in higher insurance coverage and higher government expenditure in health care, the financial burden of health care on households did not necessarily improve. Further efforts on developing the current health insurance system and optimizing the hierarchical health care system are required to improve the protection against CHE.

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T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 374;2 nejm. The authors reply: In reply to ShimabukuroVornhagen and colleagues: the mechanism of action underlying the efficacy of CTL019 in the case of multiple myeloma we reported remains uncertain. In our discussion, we acknowledged the possibility that elimination of non-neoplastic B cells by CTL019 might be at least partially responsible for its therapeutic activity, and we cited prior studies showing the tumor-promoting ca- In our study, we used data from the natality files of the Centers for Disease Control and Prevention 3 and the Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality to consider the effect of the ACA on payment sources for childbirth among young adults (details of the methods are provided in the Supplementary Appendix, available with the full 3 The payment sources were private insurance (Panels A and B), Medicaid (Panels C and D), self-payment (Panels E and F), and other payment (Panels G and H). Each circle in the scatter plot represents the percentage of births paid for by the particular payment type in that month for that age group. The category of "other payment" included the Indian Health Service, the TRICARE military health system (formerly known as the Civilian Health and Medical Program of the Uniformed Services), other government insurance at the federal, state, and local levels, and all other insurance. The time period was January 2009 through December 2012, except for the period from March 2010 through December 2010 (the "staggered implementation" period). We used regression modeling of the individual-level data with the payment type as the outcome in order to calculate the monthly seasonal adjustments as coefficients on monthly dummy variables. We then subtracted the seasonal adjustments from averages calculated at the age and month levels.The New England Journal of Medicine Downloaded from nejm.org on May 9, 2018. For personal use only. No other uses without permission.

The prevalence of FGIDs and overlap syndrome in Xi'an, China was lower than that reported in other countries. There was a strong correlation between specific lifestyle habits and psychosocial characteristics and the presence of FGIDs.