The association between basic medical insurance and the management of chronic obstructive pulmonary disease in China: a cross-sectional study based on the national “Happy Breathing” Programme

Background: China has established universal basic medical insurance to reduce financial barriers to improve healthcare access. However, the role of medical insurance in addressing broader population health challenges remains understudied. As China faces a significant challenge in managing the substantial burden of chronic obstructive pulmonary disease (COPD), it is imperatively important to understand how medical insurance is associated with each step of the care for patients with COPD. Methods: We used individual-level patient data from the national Chinese “Happy Breathing” Programme from 2018 to 2023. We applied region fixed effects models with modified Poisson regression to assess the association between being insured and reaching each care cascade step: (i) had ever undergone a pulmonary function test, (ii) had been diagnosed with COPD in the past, (iii) were currently on treatment for COPD, and (iv) had achieved COPD control. Stratified analyses were performed by local reimbursement policy, age group, sex, occupation, and residential location. Results: A total of 8841 COPD patients were included in the analysis, with 98.7% covered by basic medical insurance, including 83.1% under the Urban and Rural Resident Basic Medical Insurance (URRBMI) and 15.6% under the Urban Employee Basic Medical Insurance (UEBMI). Patients with URRBMI and UEBMI were more likely to receive a diagnosis compared with the uninsured, with modest risk ratios of 2.20 (95% CI: 1.01–4.78, p = 0.047) and 2.32 (1.06–5.05, p = 0.035), respectively. UEBMI was negatively associated with the treatment step (RR:0.73 (95% CI: 0.55–0.98), p = 0.034), but this effect became insignificant in regions where the prescribed medications for COPD were covered by insurance (RR:0.93 (95% CI: 0.80–1.08), p = 0.338). We also observed that residential location could modify the association between insurance status and being tested. Conclusions: We found that insurance status was not significantly associated with each step of the COPD care cascade, except for a modest association with a higher proportion diagnosed. Our study underscores the need for optimizing the current medical insurance design, integrating public health interventions and clinical care delivery with insurance coverage, and harmonizing regional policies to enhance the effectiveness and equity of COPD care cascade outcomes.