{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T19:31:28Z","timestamp":1791401488858,"version":"4.3.3"},"reference-count":50,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2020,6,15]],"date-time":"2020-06-15T00:00:00Z","timestamp":1592179200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["71573089"],"award-info":[{"award-number":["71573089"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Social Science Foundation of China","award":["12 & ZD212"],"award-info":[{"award-number":["12 & ZD212"]}]},{"name":"China Scholarship Council Foundation","award":["201906140040"],"award-info":[{"award-number":["201906140040"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>This study aimed to examine the association between health insurance, city of residence, and outpatient visits among older adults living alone in China. A sample of 3173 individuals was derived from \u201cSurvey on Older Adults Aged 70 and Above Living Alone in Urban China\u201d in five different cities. Logistic regression models indicated that older adults living alone who had urban employee basic medical insurance, urban resident basic medical insurance, and public medical insurance were more likely to have outpatient visits than those without any health insurance. After controlling the number of chronic diseases, only those with public medical insurance were more likely to have outpatient visits than uninsured older adults. Additionally, older adults who resided in Shanghai and Guangzhou were more likely to have outpatient visits than those in Chengdu, whereas older adults who were in Dalian and Hohhot were less likely to have outpatient visits. To improve the equity of outpatient visits among older adults living alone in China, policy efforts should be made to reduce fragmentation of different health insurance plans, expand the health insurance coverage for older adults, provide programs that consider the needs of this special group of older adults, and reduce the inequality in health resources and health insurance policies across cities.<\/jats:p>","DOI":"10.3390\/ijerph17124256","type":"journal-article","created":{"date-parts":[[2020,6,15]],"date-time":"2020-06-15T12:16:57Z","timestamp":1592223417000},"page":"4256","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Outpatient Visits among Older Adults Living Alone in China: Does Health Insurance and City of Residence Matter?"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8469-3136","authenticated-orcid":false,"given":"Jianyun","family":"Wang","sequence":"first","affiliation":[{"name":"School of Public Administration, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China"},{"name":"Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yaolin","family":"Pei","sequence":"additional","affiliation":[{"name":"Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renyao","family":"Zhong","sequence":"additional","affiliation":[{"name":"School of Public Administration, East China Normal University, 3663 North Zhongshan Road, Shanghai 200062, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6891-244X","authenticated-orcid":false,"given":"Bei","family":"Wu","sequence":"additional","affiliation":[{"name":"Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, USA"},{"name":"NYU Aging Incubator, New York University, 433 First Avenue, New York, NY 10010, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1186\/1471-2458-13-313","article-title":"Health-related quality of life and long-term care needs among elderly individuals living alone: A cross-sectional study in rural areas of Shaanxi Province, China","volume":"13","author":"Liu","year":"2013","journal-title":"BMC Public Health"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s40711-015-0011-0","article-title":"Household changes in contemporary China: An analysis based on the four recent censuses","volume":"2","author":"Hu","year":"2015","journal-title":"J. Chin. Sociol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1080\/01634372.2011.650319","article-title":"Long-term care in China: Issues and prospects","volume":"55","author":"Wong","year":"2012","journal-title":"J. Gerontol. Soc. Work"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1111\/j.1442-2018.2005.00220.x","article-title":"Social support as a predictor of health status among older adults living alone in Japan","volume":"7","author":"Saito","year":"2005","journal-title":"Nurs. Health Sci."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"617","DOI":"10.1111\/j.1532-5415.2004.52172.x","article-title":"Living alone and outpatient care use by older veterans","volume":"52","author":"Guzman","year":"2004","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1177\/0164027511429808","article-title":"Chronic illness self-management while living alone in later life: A systematic integrative review","volume":"34","author":"Haslbeck","year":"2012","journal-title":"Res. Aging"},{"key":"ref_7","first-page":"271","article-title":"Health risk appraisal in older people: Are older people living alone an \u2018at-risk\u2019 group?","volume":"57","author":"Kharicha","year":"2007","journal-title":"Br. J. Gen. Pract."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1016\/j.socscimed.2007.10.016","article-title":"Factors affecting physician visits in Chinese and Chinese immigrant samples","volume":"66","author":"Miltiades","year":"2008","journal-title":"Soc. Sci. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"864","DOI":"10.1093\/geront\/43.6.864","article-title":"Health-seeking behaviors of elderly Chinese Americans: Shifts in expectations","volume":"43","author":"Pang","year":"2003","journal-title":"Gerontologist"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1111\/hsc.12051","article-title":"Loneliness and social support of older people in China: A systematic literature review","volume":"22","author":"Chen","year":"2014","journal-title":"Health Soc. Care Community"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1024","DOI":"10.1080\/13607863.2010.508772","article-title":"Social vulnerability, mental health and correlates of frailty in older outpatients living alone in the community in Italy","volume":"14","author":"Bilotta","year":"2010","journal-title":"Aging Ment. Health"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1593","DOI":"10.1007\/s11136-013-0587-2","article-title":"Quality of life and related factors: A questionnaire survey of older people living alone in Mainland China","volume":"23","author":"Chen","year":"2014","journal-title":"Qual. Life Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"783","DOI":"10.2105\/AJPH.94.5.783","article-title":"Delays and unmet need for health care among adult primary care patients in a restructured urban public health system","volume":"94","author":"Diamant","year":"2004","journal-title":"Am. J. Public Health"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1186\/s12939-017-0706-8","article-title":"Socioeconomic inequalities of outpatient and inpatient service utilization in China: Personal and regional perspectives","volume":"16","author":"Zhu","year":"2017","journal-title":"Int. J. Equity Health"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.socscimed.2013.02.037","article-title":"The impacts of health insurance on health care utilization among the older people in China","volume":"85","author":"Li","year":"2013","journal-title":"Soc. Sci. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1644","DOI":"10.1016\/j.jpubeco.2007.10.005","article-title":"What did Medicare do? The initial impact of Medicare on mortality and out of pocket medical spending","volume":"92","author":"Finkelstein","year":"2008","journal-title":"J. Public Econ."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1186\/s12877-017-0538-9","article-title":"Urban-rural differences in the association between access to healthcare and health outcomes among older adults in China","volume":"17","author":"Zhang","year":"2017","journal-title":"Bmc Geriatr."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1001\/jamainternmed.2019.6764","article-title":"Looking Back to Improve Access to Health Care Moving Forward","volume":"180","author":"Ayanian","year":"2020","journal-title":"JAMA Internal Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1186\/s12913-019-4480-8","article-title":"Can integration reduce inequity in healthcare utilization? Evidence and hurdles in China","volume":"19","author":"Zhao","year":"2019","journal-title":"BMC Health Serv. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s11205-015-1221-1","article-title":"Assessing income-related health inequality and horizontal inequity in China","volume":"132","author":"Zhou","year":"2017","journal-title":"Soc. Indic. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1007\/s11684-012-0179-5","article-title":"Integration of current identity-based district-varied health insurance schemes in China: Implications and challenges","volume":"6","author":"Wang","year":"2012","journal-title":"Front. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2584","DOI":"10.1016\/S0140-6736(17)33109-4","article-title":"The primary health-care system in China","volume":"390","author":"Li","year":"2017","journal-title":"Lancet"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2764","DOI":"10.1377\/hlthaff.2012.0535","article-title":"China\u2019s rapidly aging population creates policy challenges in shaping a viable long-term care system","volume":"31","author":"Feng","year":"2012","journal-title":"Health Aff."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"155","DOI":"10.2147\/RMHP.S233949","article-title":"Health Insurance and Long-Term Care Services for the Disabled Elderly in China: Based on CHARLS Data","volume":"13","author":"Chen","year":"2020","journal-title":"Risk Manag. Healthc. Policy"},{"key":"ref_25","first-page":"1247","article-title":"Potential effect of medical insurance on Medicare: Evidence from China","volume":"45","author":"Wu","year":"2016","journal-title":"Iran. J. Public Health"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1452","DOI":"10.1377\/hlthaff.2016.1658","article-title":"Health insurance in China: After declining in the 1990s, coverage rates rebounded to near-universal levels by 2011","volume":"36","author":"Li","year":"2017","journal-title":"Health Aff."},{"key":"ref_27","first-page":"38","article-title":"An Empirical Analysis on the Operational Issues of the Basic Medical Insurance System for Urban Residents: A Survey of Urban Residents in Pilot Cities in Fujian Province","volume":"11","author":"Su","year":"2010","journal-title":"J. Southwest Jiaotong Univ. (Soc. Sci.)"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1016\/j.phrp.2015.11.007","article-title":"Factors associated with health services utilization between the years 2010 and 2012 in Korea: Using Andersen\u2019s behavioral model","volume":"7","author":"Kim","year":"2016","journal-title":"Osong Public Health Res. Perspect."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1","DOI":"10.2307\/2137284","article-title":"Revisiting the behavioral model and access to medical care: Does it matter?","volume":"36","author":"Andersen","year":"1995","journal-title":"J. Health Soc. Behav."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1214","DOI":"10.1016\/j.jhealeco.2013.10.002","article-title":"Rising inequalities in income and health in China: Who is left behind?","volume":"32","author":"Baeten","year":"2013","journal-title":"J. Health Econ."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1016\/j.healthplace.2008.12.007","article-title":"Health care access in rural areas: Evidence that hospitalization for ambulatory care-sensitive conditions in the United States may increase with the level of rurality","volume":"15","author":"Laditka","year":"2009","journal-title":"Health Place"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1030","DOI":"10.1002\/hec.1772","article-title":"Affording to wait: Medicare initiation and the use of health care","volume":"21","author":"David","year":"2012","journal-title":"Health Econ."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1016\/j.healthpol.2011.08.008","article-title":"Impact of universal health care coverage on patient demand for health care services in Thailand","volume":"103","author":"Panpiemras","year":"2011","journal-title":"Health Policy"},{"key":"ref_34","unstructured":"(2020, March 10). Ministry of Human Resources and Social Security of the People\u2019s Republic of China, Available online: http:\/\/www.mohrss.gov.cn\/SYrlzyhshbzb\/rdzt\/syshehuibaoxianfa\/bxffaguijijiedu\/201208\/t20120807_28573.html."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1186\/s12939-017-0690-z","article-title":"Health financing and integration of urban and rural residents\u2019 basic medical insurance systems in China","volume":"16","author":"Zhu","year":"2017","journal-title":"Int. J. Equity Health"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"767","DOI":"10.1097\/MLR.0b013e3180618b9a","article-title":"Rural and urban disparity in health services utilization in China","volume":"45","author":"Liu","year":"2007","journal-title":"Med Care"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1177\/107755802237808","article-title":"Access to medical care for low-income persons: How do communities make a difference?","volume":"59","author":"Andersen","year":"2002","journal-title":"Med Care Res. Rev."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.healthpol.2009.08.002","article-title":"Regional inequality in health and its determinants: Evidence from China","volume":"94","author":"Fang","year":"2010","journal-title":"Health Policy"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"S25","DOI":"10.1002\/hec.1501","article-title":"The new cooperative medical scheme in rural China: Does more coverage mean more service and better health?","volume":"18","author":"Lei","year":"2009","journal-title":"Health Econ."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Fan, S., Kanbur, R., and Zhang, X. (2009). Spatial inequality in education and health care in China. Regional Inequality in China: Trends, Explanations and Policy Responses, Routledge.","DOI":"10.4324\/9780203881484"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Lu, N., Spencer, M., Sun, Q., and Lou, V.W. (2020). Family social capital and life satisfaction among older adults living alone in urban China: The moderating role of functional health. Aging Ment. Health, 1\u20138.","DOI":"10.1080\/13607863.2019.1709155"},{"key":"ref_42","unstructured":"(2020, March 10). The 2015 National GDP Rankings of China\u2019 Major Cities. Available online: http:\/\/www.mnw.cn\/news\/china\/1093806.html."},{"key":"ref_43","unstructured":"Chatterjee, S., and Hadi, A.S. (2012). Regression Analysis by Example, John Wiley & Sons. [5th ed.]."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1016\/j.jce.2014.02.003","article-title":"Does health insurance matter? Evidence from China\u2019s urban resident basic medical insurance","volume":"42","author":"Liu","year":"2014","journal-title":"J. Comparat. Econ."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1186\/s12939-019-1068-1","article-title":"Effects of health insurance integration on health care utilization and its equity among the mid-aged and elderly: Evidence from China","volume":"18","author":"Li","year":"2019","journal-title":"Int. J. Equity Health"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1016\/S0140-6736(11)61880-1","article-title":"Early appraisal of China\u2019s huge and complex health-care reforms","volume":"379","author":"Yip","year":"2012","journal-title":"Lancet"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"27","DOI":"10.23937\/2469-5858\/1510027","article-title":"The Relationship between Self-Treatment and Outpatient Visits: Findings from a National Survey in China","volume":"3","author":"Luo","year":"2017","journal-title":"J. Geriatr. Med. Gerontol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1002\/hec.1272","article-title":"Equity in health and health care in a decentralised context: Evidence from Canada","volume":"17","author":"Smith","year":"2008","journal-title":"Health Econ."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Liu, H., and Dai, W. (2020). An Empirical Study on the Benefits Equity of the Medical Security Policy: The China Health and Nutrition Survey (CHNS). Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17041203"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1080\/08959420.2016.1151310","article-title":"Shanghai: Front-runner of community-based eldercare in China","volume":"28","author":"Chen","year":"2016","journal-title":"J. Aging Soc. Policy"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/12\/4256\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:39:04Z","timestamp":1760175544000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/12\/4256"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,15]]},"references-count":50,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2020,6]]}},"alternative-id":["ijerph17124256"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17124256","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,6,15]]}}}