Association Between Healthcare Accessibility Barriers and Perceived Healthcare Fairness Among Chinese Residents: An Empirical Study Based on CSS 2023 Data

Objective: Barriers to healthcare accessibility and individuals’ perceived fairness of medical services are crucial indicators for evaluating the performance of a health system. An in-depth analysis of the statistical associations among these factors and the role played by different types of medical insurance can provide targeted, evidence-based references for policy formulation in China. Methods: Data were analyzed from 9109 respondents of the 2023 Chinese Social Survey (CSS2023). Descriptive statistics, Spearman correlation analysis, multinomial logistic regression, and path analysis based on structural equation modeling were employed to examine the distribution of barriers and perceived fairness, the correlations among them, the differential impacts of various obstacles on perceived fairness, and the statistical pathways between insurance types and perceived fairness. Results: Economic barriers (reported as severe by 48.16% of respondents) and capacity barriers (reported as severe by 22.48%) were the most prevalent types of obstacles. All five types of barriers exhibited significant negative correlations with perceived healthcare fairness (p < 0.01), with economic barriers (ρ = −0.309) and capacity barriers (ρ = −0.267) demonstrating the strongest associations. Multinomial logistic regression revealed a progressively smaller magnitude of association across the outcome contrasts: for each one-unit increase in the economic-barrier score, the odds ratios for reporting “very unfair,” “somewhat unfair,” and “fair” (compared to “very fair”) were 2.30, 1.77, and 1.23, respectively (all p < 0.001), while the impact of geographical barriers was comparatively limited. Lower levels of perceived fairness were reported by adults aged 31–45 years and 46–60 years, divorced individuals, and the unemployed. Path analysis indicated that Urban Employee Basic Medical Insurance (indirect statistical association = 0.022, 95% CI: 0.002–0.042, p = 0.029) and Urban Resident Basic Medical Insurance (indirect statistical association =0.050, 95% CI: 0.001–0.099, p = 0.044) were significantly associated with higher perceived fairness, and a portion of these associations was statistically consistent with the reduction in accessibility barriers, whereas no statistically significant indirect associations were detected for Government-funded Medical Insurance, NRCMS, or Critical Illness Insurance. Given the small sample sizes for Government-funded Medical Insurance (n = 189) and Critical Illness Insurance (n = 83), these non-significant findings should not be interpreted as evidence of the absence of an association. Conclusions: Economic burdens and substandard medical services are the primary drivers of perceived inequity. Urban employee and resident insurance programs were statistically associated with higher perceived fairness, and a portion of these associations was consistent with the reduction in accessibility barriers, whereas rural and critical illness schemes lack such an indirect association. Policy priorities should focus on alleviating financial burdens, improving healthcare quality, strengthening insurance schemes for vulnerable groups, and addressing the specific needs of adults aged 31–45 years and 46–60 years, divorced, and unemployed populations to advance healthcare fairness in China.