Evaluating health policies with subnational disparities: a text-mining analysis of the Urban Employee Basic Medical Insurance Scheme in China

Abstract

Subnational disparities in most health systems often defy ‘one-size-fits-all’ approach in policy implementation. When local authorities implement a national policy in a decentralized context, they behave as a strategic policy actor in specifying the central mandates, selecting appropriate tools, and setting key implementation parameters. Local policy discretion leads to diverse policy mixes across regions, thus complicating evidence-based evaluations of policy impacts. When measuring complex policy reforms, mainstream policy evaluation methodologies have tended to adopt simplified policy proxies that often disguise distinct policy choices across localities, leaving the heterogeneous effects of the same generic policy largely unknown. Using the emerging ‘text-as-data’ methodology and drawing from subnational policy documents, this study developed a novel approach to policy measurement through analysing policy big data. We applied this approach to examine the impacts of China’s Urban Employee Basic Medical Insurance (UEBMI) on individuals’ out-of-pocket spending. We found substantial disparities in policy choices across prefectures when categorizing the UEBMI policy framework into benefit-expansion and cost-containment reforms Overall, the UEBMI policies lowered enrollees’ out-of-pocket spending in prefectures that embraced both benefit-expansion and cost-containment reforms In contrast, the policies produced ill effects on out-of-pocket spending of UEBMI enrollees and uninsured workers in prefectures that carried out only benefit-expansion or cost-containment reforms The micro-level impacts of UEBMI enrolment on out-of-pocket spending were conditional on whether prefectural benefit-expansion and cost-containment reforms were undertaken in concert. Only in prefectures that promulgated both types of reforms did UEBMI enrolment reduce out-of-pocket spending. These findings contribute to a comprehensive text-mining measurement approach to locally diverse policy efforts and an integration of macro-level policy analysis and micro-level individual analysis. Contextualizing policy measurements would improve the methodological rigour of health policy evaluations. This paper concludes with implications for health policymakers in China and beyond.

Holistic Evaluation of the National Health Insurance Program in the Local Context of Indonesia

“…A holistic text measurement approach to policy initiatives at the local level with the integration of macro policy analysis and individual analysis at the micro level [6]. Policy evaluation has significant potential to influence the decision-making process in a variety of varied ways.…”

“…In the context of developed and developing countries, this needs to be explored by exploring relevant studies, as has been done by [1]; in Thailand, focusing on the analysis of complex balancing efforts in the use of economic evaluations from the perspective of policy actors to provide direction in decisions related to health care coverage; Studies IAPA conducted by [2]; in Korea discusses the evaluation of the effectiveness of policies in expanding the scope of service benefits; Research conducted by [3] explore the evaluation of public health financing and national health insurance scheme policies in Nigeria; Research conducted by [4] review the impact of publicly financed health insurance on financial protection in the Indian state of Rajasthan; As for the research conducted by [5] investigate the evaluation of public perspectives on national health insurance policy in healthcare provision in Ghana; and [6] in China discussed the evaluation of health policies related to subnational disparities. The research mentioned reflects a broad and in-depth effort in exploring aspects of health policy in different countries.…”

Does the integration of urban and rural health insurance influence the functional limitations of the middle-aged and elderly in rural China?

“…The funds for UEBMI are composed of both pooled funds and personal accounts. Personal payments and 30% of the employer's payment for UEBMI are deposited into personal accounts, used for outpatient expenses, while the remaining payments are directed towards a pooled fund, which is used for inpatient reimbursements ( Liu et al, 2023 ).…”

Direct medical costs of ischemic heart disease in urban Southern China: a 5-year retrospective analysis of an all-payer health claims database in Guangzhou City

“…These two schemes differed considerably in terms of financing, coverage of health services, and reimbursement rates ( 18 ). The UEBMI scheme is financed by contributions from both employers and employees ( 19 ), while the URBMI scheme is financed by individual premiums and government subsidies ( 17 ). UEBMI enrollees have more comprehensive service coverage and higher reimbursement rates than URBMI enrollees ( 16 ).…”