{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T12:19:53Z","timestamp":1773836393052,"version":"3.50.1"},"reference-count":45,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2020,6,26]],"date-time":"2020-06-26T00:00:00Z","timestamp":1593129600000},"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":["71373146"],"award-info":[{"award-number":["71373146"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["71702131"],"award-info":[{"award-number":["71702131"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: Medical debt is a persistent global issue and a crucial and effective indicator of long-term family medical financial burden. This paper fills a research gap on the incidence and causes of medical debt in Chinese low- and middle-income households. Method: Data were obtained from the 2015 China Household Finance Survey, with medical debt measured as borrowings from families, friends and third parties. Tobit regression models were used to analyze the data. The concentration index was employed to measure the extent of socioeconomic inequality in medical debt incidence. Results: We found that 2.42% of middle-income families had medical debt, averaging US$6278.25, or 0.56 times average household yearly income and 3.92% of low-income families had medical debts averaging US$5419.88, which was equivalent to 2.49 times average household yearly income. The concentration index for low and middle-income families\u2019 medical debt was significantly pro-poor. Medical debt impoverished about 10% of all non-poverty households and pushed poverty households deeper into poverty. While catastrophic health expenditure (CHE) was the single most important factor in medical debt, age, education, and health status of householder, hospitalization and types of medical insurance were also significant factors determining medical debt. Conclusions: Using a narrow definition of medical debt, the incidence of medical debt in Chinese low- and middle-income households was relatively low. But, once medical debt happened, it imposed a long-term financial burden on medical indebted families, tipping many low and middle-income households into poverty and imposing on households several years of debt repayments. Further studies need to use broader definitions of medical debt to better assess the long-term financial impact of medical debt on Chinese families. Policy makers need to modify China\u2019s basic medical insurance schemes to manage out-of-pocket, medical debt and CHE and to take account of pre-existing medical debt.<\/jats:p>","DOI":"10.3390\/ijerph17124597","type":"journal-article","created":{"date-parts":[[2020,6,29]],"date-time":"2020-06-29T05:28:56Z","timestamp":1593408536000},"page":"4597","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6590-4455","authenticated-orcid":false,"given":"Jiajing","family":"Li","sequence":"first","affiliation":[{"name":"Center for Health Economics Experiment and Public Policy, School of Public Health, Cheeloo College of Medicine, Shandong University, No. 44 Wenhua West Road, Lixia District, Jinan 250012, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chen","family":"Jiao","sequence":"additional","affiliation":[{"name":"Center for Health Economics Experiment and Public Policy, School of Public Health, Cheeloo College of Medicine, Shandong University, No. 44 Wenhua West Road, Lixia District, Jinan 250012, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6770-7105","authenticated-orcid":false,"given":"Stephen","family":"Nicholas","sequence":"additional","affiliation":[{"name":"School of Economics and School of Management, Tianjin Normal University, No. 339 Binshui West Avenue, Tianjin 300387, China"},{"name":"Guangdong Institute for International Strategies, Guangdong University of Foreign Studies, 2 Baiyun North Avenue, Guangzhou, Guangdong 510420, China"},{"name":"Top Education Institute, 1 Central Avenue, Australian Technology Park, Eveleigh, Sydney, NSW 2015, Australia"},{"name":"Newcastle Business School, University of Newcastle, University Drive, Newcastle, NSW 2308, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8769-7928","authenticated-orcid":false,"given":"Jian","family":"Wang","sequence":"additional","affiliation":[{"name":"Dong Fureng Institute of Economics and Social Development, Wuhan University, No. 54 Dongsi Lishi Hutong, Dongcheng District, Beijing 100010, China"},{"name":"Center for Health Economics and Management, Economics and Management School, Wuhan University, Luojia Hill, Wuhan 430072, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gong","family":"Chen","sequence":"additional","affiliation":[{"name":"Institute of Population Research, Peking University, No. 5 Yiheyuan Road, Haidian District, Beijing 100871, China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jinghua","family":"Chang","sequence":"additional","affiliation":[{"name":"Institute of Population Research, Peking University, No. 5 Yiheyuan Road, Haidian District, Beijing 100871, China"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2020,6,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1437","DOI":"10.2105\/AJPH.2010.300080","article-title":"Health insurance status, medical debt, and their impact on access to care in Arizona","volume":"101","author":"Herman","year":"2011","journal-title":"Am. J. Public Health"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"7","DOI":"10.2190\/HS.44.1.b","article-title":"Health Issues and Health Care Expenses in Canadian Bankruptcies and Insolvencies","volume":"44","author":"Himmelstein","year":"2014","journal-title":"Int. J. Health Serv."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1046\/j.1365-3156.2003.01194.x","article-title":"Out-of-pocket health expenditure and debt in poor households: Evidence from Cambodia","volume":"9","author":"Damme","year":"2004","journal-title":"Trop. Med. Int. Health"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"w89","DOI":"10.1377\/hlthaff.25.w89","article-title":"Bankruptcy Is the Tip of a Medical-Debt Iceberg","volume":"25","author":"Seifert","year":"2006","journal-title":"Health Affair"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"w74","DOI":"10.1377\/hlthaff.25.w74","article-title":"Medical Bankruptcy: Myth Versus Fact","volume":"25","author":"Dranove","year":"2006","journal-title":"Health Affair"},{"key":"ref_6","first-page":"1","article-title":"Seeing red: Americans driven into debt by medical bills. Results from a National Survey","volume":"837","author":"Doty","year":"2005","journal-title":"Issue Brief"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/j.injms.2015.08.005","article-title":"Health insurance coverage and healthcare expenditure pattern in rural Mysore","volume":"6","author":"Siddalingappa","year":"2015","journal-title":"Ind. J. Med. Spec."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"277","DOI":"10.5455\/msm.2014.26.277-286","article-title":"Public Health Aspects of the Family Medicine Concepts in South Eastern Europe","volume":"26","author":"Masic","year":"2014","journal-title":"Mater. Soc. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1177\/0951484816670191","article-title":"Role of health insurance in enabling universal health coverage in India: A critical review","volume":"29","author":"Thomas","year":"2016","journal-title":"Health Serv. Manag. Res."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1002\/(SICI)1099-1751(199601)11:1<69::AID-HPM414>3.0.CO;2-P","article-title":"Access and payment for health care: The poor of Northern Vietnam","volume":"11","author":"Ensor","year":"1996","journal-title":"Int. J. Health Plann. Manag."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1002\/hec.1346","article-title":"Catastrophic medical payment and financial protection in rural China: Evidence from the New Cooperative Medical Scheme in Shandong Province","volume":"18","author":"Sun","year":"2009","journal-title":"Health Econ."},{"key":"ref_12","first-page":"67","article-title":"An Analysis on Household Consumption-Fueled Borrowing in China","volume":"44","year":"2018","journal-title":"J. Finance Econ."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Leng, A., Jing, J., Nicholas, S., and Wang, J. (2019). Catastrophic Health Expenditure of Cancer Patients at the End-of-Life: A Retrospective Observational Study in China. BMC Palliat Care, 18.","DOI":"10.1186\/s12904-019-0426-5"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Gan, L., Yin, Z., Jia, N., Xu, S., Ma, S., and Zheng, L. (2014). Data You Need to Know about China. Research Report of China Household Finance Survey 2012, Springer.","DOI":"10.1007\/978-3-642-38151-5"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Hao, Y., Wu, Q., Zhang, Z., Gao, L., Ning, N., Jiao, M., and Zakus, D. (2010). The impact of different benefit packages of Medical Financial Assistance Scheme on health service utilization of poor population in Rural China. BMC Health Serv. Res., 10.","DOI":"10.1186\/1472-6963-10-170"},{"key":"ref_16","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_17","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1002\/hpm.2424","article-title":"China\u2019s health care system reform: Progress and prospects","volume":"32","author":"Li","year":"2017","journal-title":"Int. J. Health Plan. Manag."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/1475-9276-13-23","article-title":"The effects of China\u2019s urban basic medical insurance schemes on the equity of health service utilisation: Evidence from Shaanxi Province","volume":"13","author":"Zhou","year":"2014","journal-title":"Int. J. Equity Health"},{"key":"ref_19","unstructured":"General Department of Poverty Alleviation Office of the State Council (2019, September 18). Achievements and Experiences of Poverty Alleviation in the 70 Years since the Founding of New China, Available online: http:\/\/www.cpad.gov.cn\/art\/2019\/9\/18\/art_624_103441.html."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s12939-019-0933-2","article-title":"The effect of China\u2019s new cooperative medical scheme on health expenditures among the rural elderly","volume":"18","author":"Zeng","year":"2019","journal-title":"Int. J. Equity Health"},{"key":"ref_21","unstructured":"China Health and Family Planning Statistical Yearbook Committee (2018, September 18). Health Statistics Yearbook of China. Available online: http:\/\/www.yearbookchina.com\/navibooklist-n3018112802-1.html."},{"key":"ref_22","first-page":"88","article-title":"Research on Social Capital and Urban Household Debt Behavior\u2014Based on the Empirical Analysis of 3011 Families in Cities","volume":"2","author":"Hongbo","year":"2017","journal-title":"Finance Econ."},{"key":"ref_23","first-page":"48","article-title":"The Medical Burden of Urban and Rural Poor Families and Strategy Advices for Improving the Medical Assistance\u2014Based on the Survey Data from \u201cthe Social Policy Support System Project of Urban and Rural Poor Family\u201d","volume":"4","author":"Zhiqiang","year":"2018","journal-title":"Soc. Secur. Stud."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1080\/13696998.2019.1581620","article-title":"Does the critical illness insurance reduce patients\u2019 financial burden and benefit the poor more: A comprehensive evaluation in rural area of China","volume":"22","author":"Jiang","year":"2019","journal-title":"J. Med. Econ."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.1377\/hlthaff.2018.0349","article-title":"Unlike Medical Spending, Medical Bills in Collections Decrease with Patients\u2019 Age","volume":"37","author":"Batty","year":"2018","journal-title":"Health Affair"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1093\/qje\/qjs020","article-title":"The Oregon Health Insurance Experiment: Evidence from the First Year","volume":"127","author":"Finkelstein","year":"2012","journal-title":"Q. J. Econ."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"i3228","DOI":"10.1136\/bmj.i3228","article-title":"TV comedian writes off $15m in US medical debt","volume":"353","author":"McCarthy","year":"2016","journal-title":"BMJ Brit. Med. J."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.jhealeco.2016.12.003","article-title":"The long-term health impacts of Medicaid and CHIP","volume":"51","author":"Thompson","year":"2017","journal-title":"J. Health Econ."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Richard, P., Walker, R., and Alexandre, P. (2018). The burden of out of pocket costs and medical debt faced by households with chronic health conditions in the United States. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0199598"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1176\/appi.ajp.2008.07081340","article-title":"Empirically Derived Decision Trees for the Treatment of Late-Life Depression","volume":"165","author":"Andreescu","year":"2008","journal-title":"Am. J. Psychiatry"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1370\/afm.573","article-title":"Short-term impacts of coverage loss in a Medicaid population: Early results from a prospective cohort study of the Oregon Health Plan","volume":"4","author":"Carlson","year":"2006","journal-title":"Ann. Fam. Med."},{"key":"ref_32","first-page":"djw2052","article-title":"Financial Hardships Experienced by Cancer Survivors: A Systematic Review","volume":"109","author":"Altice","year":"2017","journal-title":"JNCI J. Natl. Cancer I"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1377\/hlthaff.2015.0830","article-title":"For Working-Age Cancer Survivors, Medical Debt and Bankruptcy Create Financial Hardships","volume":"35","author":"Banegas","year":"2016","journal-title":"Health Affair"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/S0140-6736(03)13861-5","article-title":"Household catastrophic health expenditure: A multicountry analysis","volume":"362","author":"Xu","year":"2003","journal-title":"Lancet"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1846","DOI":"10.1111\/tmi.12611","article-title":"Protecting patients with cardiovascular diseases from catastrophic health expenditure and impoverishment by health finance reform","volume":"20","author":"Sun","year":"2015","journal-title":"Trop. Med. Int. Health"},{"key":"ref_36","unstructured":"Xu, K., Aguilarmahecha, A., Carrin, G., Evans, D., Hanvoravongchai, P., Kawabata, K., Klavus, J., Knaul, F., Murray, C., and Ortiz, J. (2005). Distribution of Health Payments and Catastrophic Expenditures: Methodology, WHO."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1016\/S0304-4076(96)01807-6","article-title":"Socioeconomic inequalities in health: Measurement, computation, and statistical inference","volume":"77","author":"Kakwani","year":"1997","journal-title":"J. Econom."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1002\/hec.953","article-title":"The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality","volume":"14","author":"Wagstaff","year":"2005","journal-title":"Health Econ."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1016\/j.jpain.2015.02.004","article-title":"Disrupted Sleep Is Associated with Altered Pain Processing by Sex and Ethnicity in Knee Osteoarthritis","volume":"16","author":"Petrov","year":"2015","journal-title":"J. Pain"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/0304-4076(84)90074-5","article-title":"Tobit Models: A Survey","volume":"24","author":"Amemiya","year":"1984","journal-title":"J. Econom."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"850","DOI":"10.1097\/ACM.0000000000002045","article-title":"Transitioning to a High-Value Health Care Model: Academic Accountability","volume":"93","author":"Johnson","year":"2018","journal-title":"Acad. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"772","DOI":"10.1111\/j.1525-1497.2004.30099.x","article-title":"Baltimore Community Health Consortium. Medical Debt and Aggressive Debt Restitution Practices","volume":"19","author":"Arbelaez","year":"2004","journal-title":"J. Gen. Intern Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1007\/s10834-016-9491-6","article-title":"The Burden of Medical Debt Faced by Households with Dependent Children in the United States: Implications for the Affordable Care Act of 2010","volume":"37","author":"Richard","year":"2016","journal-title":"J. Fam. Econ. Issue"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1002\/pon.5034","article-title":"Cancer-related financial hardship among head and neck cancer survivors: Risk factors and associations with health-related quality of life","volume":"28","author":"Lu","year":"2019","journal-title":"Psycho Oncol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1097\/SLA.0000000000002254","article-title":"Cured into Destitution: Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States","volume":"267","author":"Scott","year":"2018","journal-title":"Ann. Surg."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/12\/4597\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:43:17Z","timestamp":1760175797000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/12\/4597"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,26]]},"references-count":45,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2020,6]]}},"alternative-id":["ijerph17124597"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17124597","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,6,26]]}}}