The impact of China’s employee basic medical insurance outpatient pooling scheme on outpatient healthcare utilization among middle-aged adults

Xinjuan Zhou, Xinrui Li, Haiyi Chen and Jing Deng

PLOS ONE, 2026, vol. 21, issue 5, 1-17

Abstract: Background: This study evaluates the association between China’s Employees’ Basic Medical Insurance (EBMI) outpatient pooling policy and outpatient service utilization among middle-aged insured individuals (aged 45–60). By analyzing outpatient service use, visit frequency, and out-of-pocket (OOP) expenditures, the study documents utilization patterns associated with the policy and explores their implications for healthcare-seeking behavior among middle-aged enrollees, providing evidence that may inform future adjustments to outpatient coverage design. Methods: Using cross-sectional data from the 2018 wave of the China Health and Retirement Longitudinal Study (CHARLS), this study employed a logistic regression model to examine the effect of the outpatient pooling policy and different levels of outpatient benefit coverage on the probability of outpatient visits. A zero-inflated negative binomial regression model was used to analyze the impact on the frequency of outpatient visits, and a Tobit model was applied to assess its effect on out-of-pocket outpatient expenditures. Although the analysis relies on 2018 pilot data, the core institutional mechanisms of outpatient pooling were retained in the post-2021 national framework, suggesting that behavioral responses observed in pilot regions may still be informative under the current reform framework. Results: Implementation of the outpatient pooling policy was associated with a 5.0 percentage points higher probability of outpatient visits (p

Date: 2026
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Persistent link: https://EconPapers.repec.org/RePEc:plo:pone00:0350183

DOI: 10.1371/journal.pone.0350183

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