Income Inequality, Critical Illness Insurance, and Depressive Symptoms Among Older Adults in China
Yuehong Zhang, Kexiang Gao, Manxia TianBackground
Critical Illness Insurance (CII) is an important supplementary component of China’s health security system, designed to alleviate the financial burden associated with serious illness. Among older adults, however, the extent to which formal insurance coverage translates into mental health gains may depend on the broader socioeconomic and community context. This study examines whether income inequality attenuates the association between CII policy exposure and depressive symptoms among older adults in China.
Methods
This study used panel data from the China Health and Retirement Longitudinal Study (CHARLS). CII policy exposure was identified according to the timing of policy implementation in respondents’ regions of residence and survey years. Income inequality was measured primarily using the city‐level Gini coefficient calculated from household income per capita within the corresponding city‐year sample. Depressive symptoms were measured using the center for epidemiologic studies depression scale (CES‐D). A staggered difference‐in‐differences framework and panel ordered probit models were employed to estimate the association between CII policy exposure and depressive symptoms and to examine the moderating role of income inequality. Robustness checks and heterogeneity analyses were also conducted.
Results
CII policy exposure was significantly associated with fewer depressive symptoms among older adults. However, the interaction between income inequality and CII was positive and statistically significant, indicating that greater income inequality attenuated the mental health benefits associated with the policy. The main findings remained robust across alternative model specifications and city‐level inequality measures. The heterogeneity results revealed a nonlinear pattern across income groups, with significant moderating associations observed among both low‐ and high‐income older adults but not among the middle‐income group. The moderating association was also more evident among rural residents, participants in the New Rural Cooperative Medical Scheme, and older adults in eastern China.
Conclusion
CII policy exposure is associated with improved mental health among older adults, but the magnitude of this association varies across different income‐distribution and institutional contexts. Greater income inequality may limit the extent to which formal insurance protection is translated into mental health gains. Insurance expansion should therefore be complemented by equity‐oriented benefit design, accessible primary healthcare, and community‐based health and social care support, particularly for older adults who face socioeconomic or service‐access disadvantages.