Effects of Social Health Insurance Reform on People's Out-of-Pocket Health Expenditure in China: The Mediating Role of Institutional Arrangement

This study examines and explains the relationship between social health insurance (SHI) participation and out-of-pocket expenditures (OOP) as well as the mediating role of institutional arrangement in this relationship in China.;Accordingly, this study embraces a new institutionalist perspective and develops a theoretical framework, which involves two perspectives: of determination and of strategic interaction. For the perspective of determination, we identify three mechanisms of SHI, including the reimbursement, the behavior management and the purchasing. For the perspective of strategic interaction, we adopt a calculus approach to explore the interaction between SHI agencies, healthcare providers, and patients and the role that SHI and other institutions play in shaping the interaction.;This study uses a mixed methods design. The quantitative analysis draws data from a nationally representative dataset and uses structural equation modeling to examine the performance of the three mechanisms of SHI. The qualitative analysis uses semi-structured interview to trace the interaction between stakeholders. We conduct a fieldwork in a Chinese province. We adopt thematic analysis to facilitate data analysis.;The quantitative analysis finds that the reimbursement mechanism offers considerable benefits to insured patients. However, the behavior management and purchasing mechanisms perform poorly. SHI participants would like to go to higher-level hospitals, use more medical items, and have longer hospital stay compared with uninsured patients. As a result, SHI participation has a weak or no significant association with OOP. It indicates that the malfunction of the behavior management and purchasing mechanisms undermines the performance of the reimbursement mechanism.;The qualitative analysis of the behavior management mechanism reveals that SHI agencies use the referral system and tiered copayment and deductibles to guide patients' choices of hospitals. However, the magnitude of these strategies is offset by the inequitable allocation of healthcare resources and the benefits concern of patients. In addition, the reimbursement provided by SHI may stimulate patients to go to high-level hospitals.;Furthermore, the qualitative analysis of the purchasing mechanism reveals that SHI agencies use similar strategies of purchasing to restrain the improper prescription behaviors of doctors and the excessive demands of patients, including payment methods reform, indicator management, and so on. However, these strategies are undermined by the strategic interaction between SHI agencies, doctors and patients, which is shaped by a larger disenabling institutional surrounding. The inequitable allocation of healthcare resources, the poor compensation system of hospitals, the distorted price schedule and the fragmented design of the SHI system induce SHI agencies to be a weak purchaser, propel healthcare providers to be profit-driven, and are responsible for moral hazards of patients.;This study is expected to contribute to theory and policy practice in the following ways. It implies that institutional arrangement play a mediating role in the relationship between welfare institutions and social outcomes; it also suggests that welfare institutions may be shaped and undermined by a larger institutional arrangement through the strategic interaction between actors. Finally, this study proposes a single payer model, profiling the process of establishing a strong and unified SHI purchaser.