Xiaoyan Lei

The New Cooperative Medical Scheme in rural China: does more coverage mean more service and better health?

This paper explores the impact of the New Cooperative Medical Scheme (NCMS), a newly adopted public health insurance program in rural China. Using a longitudinal sample drawn from the China Health and Nutrition Survey (CHNS), we employed multiple estimation strategies (individual fixed-effect models, instrumental variable estimation, and difference-in-differences estimation with propensity score matching) to correct the potential selection bias. We find that participating in the NCMS significantly decreases the use of traditional Chinese folk doctors and increases the utilization of preventive care, particularly general physical examinations. However, we do not find that the NCMS decreases out-of-pocket expenditure nor do we find that it increases utilization of formal medical service or improves health status, as measured by self-reported health status and by sickness or injury in the past four weeks. Our study indicates that despite the wide expansion of coverage, the impact of the NCMS is still limited.

Depressive symptoms and SES among the mid-aged and elderly in China: Evidence from the China Health and Retirement Longitudinal Study national baseline

We examine the prevalence of depressive symptoms among the mid-aged and elderly in China and examine relationships between depression and current SES factors such as gender, age, education and income (per capita expenditures). In addition, we explore associations of depressive symptoms with measures of early childhood health, recent family deaths and current chronic health conditions. We use data from the China Health and Retirement Longitudinal Study (CHARLS) national baseline, fielded in 2011/12, which contains the ten question version of the Center for Epidemiologic Studies-Depression scale (CES-D) for 17,343 respondents aged 45 and older. We fill a major gap by using the CHARLS data to explore the general patterns of depression and risk factors among the Chinese elderly nationwide, which has never been possible before. We find that depressive symptoms are significantly associated with own education and per capita expenditure, and the associations are robust to the inclusion of highly disaggregated community fixed effects and to the addition of several other risk factors. Factors such as good general health during childhood are negatively associated with later depression. There exist strong gender differences, with females having higher depression scores. Being a recent widow or widower is associated with more depressive symptoms, as is having a series of chronic health problems, notably having moderate or severe pain, disability or problems with measures of physical functioning. Adding the chronic health problems to the specification greatly reduces the SES associations with depressive symptoms, suggesting that part of the pathways behind these associations are through these chronic health factors.

Gender Differences in Cognition Among Older Adults in China

In this paper, the authors model gender differences in cognitive ability in China using a new sample of middle-aged and older Chinese respondents. Modeled after the American Health and Retirement Survey (HRS), the CHARLS Pilot survey respondents are 45 years and older in two quite distinct provinces — Zhejiang a high growth industrialized province on the East Coast, and Gansu, a largely agricultural and poor Province in the West. Their measures of cognition in CHARLS relies on two measures that proxy for different dimensions of adult cognition — episodic memory and intact mental status. They relate both these childhood health measures to adult health and SES outcomes during the adult years. They find large cognitive differences to the detriment of women that were mitigated by large gender differences in education among these generations of Chinese people. These gender differences in cognition are especially concentrated within poorer communities in China with gender difference being more sensitive to community level attributes than to family level attributes, with economic resources. In traditional poor Chinese communities, there are strong economic incentives to favor boys at the expense of girls not only in their education outcomes, but in their nutrition and eventually their adult height. These gender cognitive differences have been steadily decreasing across birth cohorts as the economy of China grew rapidly. Among younger cohorts of young adults in China, there is no longer any gender disparity in cognitive ability.

Incentive Problems in China’s New Rural Pension Program

China’s new rural pension program (NRPP), a fully funded defined contribution plan among the rural residents with heavy government subsidy toward contributions, has expanded rapidly since its introduction in 2009, and is expected to achieve universal coverage by the end of 2012. Empirical evidence, however, shows that although those close to pension eligibility age are enthusiastic, take-up rate is low among younger people, and participants tend to choose plans with the least contribution requirements, threatening the long-term viability of the program. We calculate the net benefits of participation on behalf of rural residents and demonstrate that poor designs are responsible for these problems. A proper rate of return on individual investment is not only essential for encouraging participation and ensuring a higher replacement rate but will also require less government subsidy and relieve fiscal burdens on the government.

Living Arrangements of the Elderly in China: Evidence from CHARLS

Recent increases in Chinese elderly living alone or only with a spouse has raised concerns about elderly support, especially when public support is inadequate. However, using rich information from the China Health and Retirement Longitudinal Study, we find that the increasing trend in living alone is accompanied with a rise in living close to each other. This type of living arrangement solves the conflicts between privacy/independence and family support. This is confirmed in further investigation: children living close by visit their parents more frequently. We also find that children who live far away provide a larger amount of net transfers to their parents, a result consistent with responsibility sharing among siblings. Having more children is associated with living with a child or having a child nearby, while investing more in a childs schooling is associated with greater net transfers to parents.

Living arrangements of the elderly in China: evidence from the CHARLS national baseline

Declining fertility in China has raised concerns about elderly support, especially when public support is inadequate. Using rich information from the nationally representative China Health and Retirement Longitudinal Study (CHARLS) baseline survey, we describe the patterns of current living arrangements of the Chinese elderly and investigate their determinants and correlation with intergenerational transfers. We find that roughly 41% of Chinese aged 60 and over live with an adult child; living with a male adult child being strongly preferred. However another 34% have an adult child living in the same immediate neighborhood and 14% in the same county; only 5% have an adult child with none of them living in the same county. At the same time, a large fraction of the elderly, 45% in our sample, live alone or with only a spouse. In general, women, those from western provinces, and those from rural areas are more likely to live with or close to their adult children than their corresponding counterparts, but different types of intergenerational transfers play a supplementary role in the unequal distribution of living arrangements. Among non-co-resident children, those living close by visit their parents more frequently and have more communications by other means. In contrast, children who live farther away are more likely to send financial and in-kind transfers and send larger amounts.

Health Insurance and Health Care among the Mid‐Aged and Older Chinese: Evidence from the National Baseline Survey of CHARLS

We document the recent profile of health insurance and health care among mid-aged and older Chinese using data from the China Health and Retirement Longitudinal Study conducted in 2011. Overall health insurance coverage is about 93%. Multivariate regressions show that respondents with lower income as measured by per capita expenditure have a lower chance of being insured, as do the less-educated, older, and divorced/widowed women and rural-registered people. Premiums and reimbursement rates of health insurance vary significantly by schemes. Inpatient reimbursement rates for urban people increase with total cost to a plateau of 60%; rural people receive much less. Demographic characteristics such as age, education, marriage status, per capita expenditure, and self-reported health status are not significantly associated with share of out-of-pocket cost after controlling community effects. For health service use, we find large gaps that vary across health insurance plans, especially for inpatient service. People with access to urban health insurance plans are more likely to use health services. In general, Chinese people have easy access to median low-level medical facilities. It is also not difficult to access general hospitals or specialized hospitals, but there exists better access to healthcare facilities in urban areas. Copyright

Health Insurance and Health Status: Exploring the Causal Effect from a Policy Intervention.

Whether health insurance matters for health has long been a central issue for debate when assessing the full value of health insurance coverage in both developed and developing countries. In 2007, the government-led Urban Resident Basic Medical Insurance (URBMI) program was piloted in China, followed by a nationwide implementation in 2009. Different premium subsidies by government across cities and groups provide a unique opportunity to employ the instrumental variables estimation approach to identify the causal effects of health insurance on health. Using a national panel survey of the URBMI, we find that URBMI beneficiaries experience statistically better health than the uninsured. Furthermore, the insurance health benefit appears to be stronger for groups with disadvantaged education and income than for their counterparts. In addition, the insured receive more and better inpatient care, without paying more for services. Copyright

Patterns and correlates of intergenerational non-time transfers : evidence from CHARLS

Using the China Health and Retirement Longitudinal Study 2008 pilot, this paper analyzes the patterns and correlates of intergenerational transfers between elderly parents and adult children in Zhejiang and Gansu Provinces. The pilot is a unique data source from China that provides information on the direction as well as amount of transfers between parents and each of their children, and clearly distinguishes transfers between parents and children from those among other relatives or friends. The paper shows that transfers flow predominantly from children to elderly parents, with transfers from children playing an important role in elderly support. Taking advantage of the rich information available in this survey, the authors find strong evidence that transfers are significantly affected by the financial capabilities of individual children. Educated and married children have a higher tendency to provide transfers to their parents; and oldest sons are less likely to provide transfers than their younger brothers. With future continued rapid economic growth in China, the income disadvantage of the elderly will persist and upward generational transfers will likely remain the most common form of private transfers. In the absence of some other source of elderly support (such as a public pension or own savings), the dwindling number of children implies that the financial burden associated with supporting the elderly is likely to increase.

Effects of Social Activities on Cognitive Functions: Evidence from CHARLS

Using the China Health and Retirement Longitudinal Study (CHARLS) 2008 pilot, the authors investigate the relationship between cognitive abilities and social activities for people aged 45 or older. They group cognition measures into two dimensions: intact mental status and episodic memory. Social activities are defined as participating in certain common specified activities in China such as playing chess, card games, or Mahjong, interacting with friends, and other social activities. OLS association results show that playing Mahjong, chess or card games and interacting with friends are significantly related with episodic memory, both individually and taken as a whole (any of the 3 activities), but individually they are not related to mental intactness while taken as a whole they are. Because social activities may be endogenous, they further investigate using OLS reduced form models whether having facilities that enables social activities in the community level is related to cognition. They find that having an activity center in the community is significantly related to higher episodic memory but no relation to mental intactness. These results point to a possible causal relationship between social activities and cognitive function, especially in strengthening short-term memory.