Health insurance and chronic disease control: Quasi-experimental evidence from hypertension in rural China

Introduction Hypertension (i.e., high blood pressure) is the epitome of a prevalent risk factor for chronic disease in China (as noted in prior chapters). This condition could be better controlled by successful implementation of the country’s reform effort to expand health insurance. This chapter makes the case for addressing hypertension through improved diagnosis and treatment funded by insurance. We first summarize previous literature studying the impact of insurance coverage in rural China. We then present empirical evidence from two quasi-experimental settings: (1) the rollout of insurance coverage across almost 40 counties in nine provinces and (2) two counties in Shandong Province, one of which adopted an initiative to offer free antihypertensive medications. Given the high and growing prevalence of hypertension in China, diagnosis, treatment, and control might serve as good metrics for assessing whether government-subsidized insurance such as the New Cooperative Medical Scheme (NCMS) can improve the control of chronic non-communicable diseases (NCDs) among China’s rural residents. Why Hypertension? Hypertension is a major risk factor in China that is prevalent, underdiagnosed, and undertreated. The large and growing burden of NCDs in China is fueled by the prevalence of uncontrolled hypertension alongside other prominent risk factors such as (male) smoking, increasingly high-fat and calorie-rich diets, air and water pollution, and physical inactivity (cf. Chapters 3, 4, 6). In 2011–2012, 40 percent of men and 44 percent of women aged 45+ years in China were hypertensive, according to the China Health and Retirement Longitudinal Study (CHARLS). About 40 percent of China’s hypertensives are undiagnosed, and almost half of Chinese hypertensives aged 45+ years (both diagnosed and undiagnosed) are not receiving any treatment for their condition. Among people aged 60+ years, 54 percent have hypertension; 30–40 percent of them remain undiagnosed. Underdiagnosis is also common for diabetes, a serious and incurable chronic disease that is often comorbid with hypertension. The prevalence of diabetes among Chinese aged 45+ years is 16.0 percent for men and 16.1 percent for women; the high rates of undiagnosed patients are alarming (61 percent of men, 53 percent of women) according to the CHARLS data. Nationally across all ages, the age-standardized prevalence of diabetes was 9.7 percent in 2007–2008 (20.4 percent among the elderly).

Duke Scholars

Author M. Kate Bundorf Sanford School of Public Policy