No health insurance and multiple insurance among internal migrants in China: a national cross-sectional study

Background

China's system of social health insurance is fragmented into three separated insurance plans and is not transferrable across regions, which can leave some migrants without insurance or with multiple insurance. This study aimed to investigate the health insurance status among internal migrants, and its relationship with migration characteristics.

Methods

We used data from a national cross-sectional database from the 2014 and 2015 Migrant Dynamics Monitoring Survey in China for respondents aged 15 years or older. We applied multinomial logistic regressions to estimate the association between migration characteristics and health insurance status, adjusting for sociodemographic characteristics. Insurance status included being uninsured, having one insurance plan, and having multiple insurance.

Findings

The 2014 sample included 200?937 respondents and the 2015 sample included 201?294 respondents. In 2014, 163?906 (81·6%) migrants were covered by one insurance plan, and 7098 (3·5%) had multiple insurance, while 29?933 (14·9%) were uninsured. In 2015, the uninsured rate and the multiple insurance rate decreased to 7·3% (n=14 783) and 2·9% (n=5780), respectively. Using the 2014 sample, cross-city migration within a province significantly increased the probability of being uninsured by 53% (relative risk ratio 1·53, 95% CI 1·46–1·61) and having multiple insurance by 35% (95% CI 1·22–1·46) compared with intra-city migration, whereas cross-province migration increased the probability of being uninsured by 105% (95% CI 1·93–2·13) and having multiple insurances by 14% (95% CI 1·03–1·23). Living in the destination city for 5 years or longer significantly increased the likelihood of being uninsured by 4% (95% CI 1·01–1·08) and having multiple insurance by 30% (95% CI 1·21–1·37), compared to those staying for less than 1 year. The same patterns held in the 2015 sample except that no statistically significant relationship was detected between years lived in the destination city and having multiple insurance.

Interpretation

Cross-province migration and living in the destination city for longer times were positively associated with no insurance and multiple insurance, causing inequality and inefficiency in the insurance system. Policies that integrate the three insurance plans across the country should be urgently promoted to achieve universal coverage.

Funding

National Nature Science Foundation of China (grant no 71403007 and 71503059).