Ability to pay and catastrophic health expenditure of urban and rural deceased households over the past decade (2009–2018)

Introduction: Examining the equity of health care and financial burden in the household of the deceased in urban and rural areas is crucial for understanding the risks to both national and individual household finances. However, there is a lack of research on Catastrophic Health Expenditure (CHE) in the households of the deceased, specifically in urban and rural contexts. This study aims to identify the ability to pay and equity of CHE between the households of the deceased in urban and rural areas.
Methods: This study analyzed data from the Korea Health Panel for 10 years (2009–2018) and targeted 869 deceased individuals and their households. Annual household income and living costs were adjusted based on equivalent household size, and the difference between these values represented the household's ability to pay. Out-of-pocket (OOP) expenditure included copayments and uninsured healthcare expenses for emergency room visits, inpatient care, outpatient treatments, and prescription medications. CHE was defined as OOP expenditure reaching or exceeding 40% of the household's ability to pay. ANCOVA was performed to control for confounding variables, and the equity of CHE prevalence between urban and rural area was assessed using Chi-square analysis.
Results: The rural household of the deceased had smaller members (2.7 vs. 2.4, p=0.03), higher rate of presence of spouse (63.8% vs. 70.7%, p=0.04), and higher economic activity rate (12.7% vs. 20.5%, p=0.002) than urban ones, respectively. There were 3.7 comorbidities in both urban and rural areas, and there was no difference in the experience of using over-the-counter medicines for more than 3 months, emergency room, hospitalization, and outpatient treatment. In addition, annual household OOP expenditure was US$3,020.2 and US$ 2,812.2 respectively in urban and rural areas, showing no statistical difference (p=0.341). This can be evaluated as a positive effect of various policies and practices aiming to alleviate urban&ndash:rural health equity. However, the financial characteristics of the household of the deceased in the year of death differs decisively between urban and rural areas. The annual income (US$15,673.8 vs. US $12,794.8, p=<0.002), and the annual ability to pay of rural households were lower than urban ones (US$14,734.1 vs. US$12,069.3, p=0.03), respectively. As a result, the prevalence of CHE was higher in rural areas than in urban (68.3% vs 77.6%, p=0.003).
Conclusion: The findings of this study highlight the higher risk of CHE in rural areas due to the lower income level and ability to pay of the household of the deceased. It is evident that addressing the issue of CHE requires broader social development and policy efforts rather than individual-level interventions focused solely on improving health access and controlling healthcare costs. The findings of this study contribute to the growing evidence that income plays a crucial role in rural health outcomes.
Keywords: the deceased, ability to pay, catastrophic health expenditure, CHE, urban area, rural area, household income, out-of-pocket expenditure, comorbidities