The global community has been concerned with the rising prevalence of migrants and population aging. Migrants form a growing proportion of the population in many countries. The economic, social, and cultural differences that exist in the gap between the urban area and rural area inspire rural-to-urban migrants to transfer from agriculture to industry (1). In low- and middle-income countries (LMICs), rural surplus labor’s migration to cities has been fuelled by the rapid progress of urbanization (2). Rapid aging is expected to put new pressure on the migrant issue. Although older migrants (OMs) have worse health status and higher health needs, due to low socioeconomic status and existing policies which create barriers to accessing public welfare benefits, older rural-to-urban migrants are particularly vulnerable to healthcare access and at an increased risk of insufficient receipt of health services (3).

As time goes by, rural-to-urban migrant Chinese workers, a crucial portion of labor, are facing the stage of aging and have transited to a special labor group in the last 2 decades, namely, older migrant workers (OMWs). In China, the coverage and benefits of health insurance programs are not varied by the subgroups of OMs but vary across rural and urban areas (4). Due to low socioeconomic status and poor working conditions, OMWs may be at a higher risk of unmet health needs (5). Urban health financing schemes provide higher reimbursement rates than the rural health insurance scheme (6). Health and the availability of health services are highly variable between rural-to-urban migrants and urban employees (7). Although the health services coverage within health financing models was extended in the 2019 medical reform (8), the gap between rural and urban health insurance schemes still exists: the co-payment for Urban Employee Insurance (UEI) beneficiaries (24.4%) was still lower than the Urban-Rural Resident Medical Insurance (URRMI) which covers rural and urban residents without formal employment (40.3%) (9). A large number of rural-to-urban migrants usually register in their place of origin rather than their current place of residence, who are covered by URRMI or the rural health insurance scheme and excluded from UEI (10); this may be even worse for OMWs. Chinese OMWs often experience significant access barriers to healthcare as their insurance program usually only reimburses health visits that take place in their hometown (11).

The National Health Commission in China (12) stated that OMWs, OMs for looking after offspring, and OMs for receiving care from family constituted the main three subgroups of OM. Researchers have used the China Migrant Dynamic Monitoring Survey to investigate the association between these three reasons for migration and healthcare use with this dataset (13), but they did not go far into the details of the differences among these three subgroups and the pathways of associated factors on healthcare use. Simultaneously, compare with other OMs, OMWs have the dual characteristics of the older population and migrant workers (14), which means they are more inherently disadvantaged and at higher risk of social inequities (13). Therefore, they may face greater challenges in access to health services. These barriers to accessing health services could adversely affect the wellbeing and health outcomes of OMWs (15, 16). In addition, although multiple studies have documented migrant workers’ barriers to accessing public services, there is scant research examining the inequalities in access to healthcare between OMWs and other OMs (17–19). Moreover, prior studies had not specified the paths of how the SHI registration place is associated with health services use across different OMs.

Therefore, this study aims to examine the differences in health services use among OMWs and other OMs (for looking after offspring and for receiving care from family) and explore the associated factors and paths of using health services use among subgroup OMs. Given that there has been an increase in migrants both within countries and internationally, targeted measures will shed light on the global community and inform policymakers who face similar challenges. Empirical strategies based on the differences among subgroups will contribute to identifying the vulnerable population and improving the accessibility of care delivery. The analyses of associated factors and paths offer insights to understand the relationship between health services use and the SHI registration place. Based on the above discussion, this study aims to answer two research questions as followed:

1) Are there differences in health services use between OMWs and other OMs?

Table 1 shows the weighed sample statistics of the three subgroup OMs. The rate of visiting doctors in OMWs (42.22%) was lower than that in OMs for looking after children (53.58%) and OMs for receiving care from family (53.17%). OMWs had a higher proportion of receiving formal education, longer migration duration, being male, married, and healthy than the other two subgroups, whereas OMWs had lower monthly household expenditure per capita.

Table 2 shows the results of binary logistic models to identify the factors associated with visiting doctors. Having SHI registered in the current place of residence is associated with increased odds of visiting doctors among OMWs and OMs for receiving care from family. In addition, greater monthly household expenditure per capita is related to an increased probability of doctor visits, whereas longer migration duration is associated with a decreased occurrence of this seeking health services behavior among OMWs. OMs who migrated to receive care from family and were unable to take care of themselves were less likely to visit doctors when they were sick than their healthy counterparts.

Table 3 reports the model fit of the path analysis models. All fit indices met the criteria, indicating acceptable model fitness between the hypothetic model and the data. Figure 1 shows the base case path analysis models for the three subgroups. Above all, a significant association of having SHI in the current place of residence with less household expenditure per capita was discovered in all three subgroup OMs. SHI in the current place of residence is significantly associated with increases in the occurrence of doctor visits among OMs for looking after children and OMs for receiving care from family, whereas this association is not observed in OMs for better employment. We also found a significant association between worse self-rated health and greater household expenditure per capita and an association between longer migration duration and having SHI in the current place of residence in all the subgroups. It is noted that worse self-assessed health was associated with a lower probability of visiting doctors among OMWs and OMs for receiving care from family. Additionally, regarding OMs for receiving care from family, household expenditure per capita demonstrated a positive association with visiting doctors.

In the robustness check, this study changed the categorical variable, age, into a continuous variable measured by years. Table 4 compares the test statistics for the specific paths between the main models and robustness checks. The results of the robustness check, reported in the lower panel of Table 4, were in line with the results of the main models in the upper panel.

This study offers four novel contributions to the existing research on older migrants. First, the analysis suggested that OMWs were the particularly vulnerable population in visiting doctors, and SHI, compared with other OMs. The results indicate that OMWs are more disadvantaged in using health services and socioeconomic status. OMWs had the least rate of visiting doctors in times of sickness, the least household expenditure, and the largest proportion of receiving secondary education or below among the three subgroups. Besides, given OMWs are still employed in their current place of residence after retirement to support their family, they are more likely to be from a low socioeconomic background and have unmet health needs. Previous research also evidenced the existence of significant unmet healthcare needs in Chinese rural-to-urban migrant workers (39).

Second, the negative relationship between worse health status and visiting doctors in OMs might be related to their disadvantages in low socioeconomic status. The path analyses demonstrate OMWs and OMs for receiving care from family who had worse health status are less likely to visit doctors, and worse health status was associated with less household expenditure. Disposable income and chronic disease might explain this finding. The CMDMS data indicate that the average monthly household disposable income per capita of OMWs and OMs for receiving care from family was merely CNY 1068 and CNY 1027 per month, while the figure was CNY 1363 among OMs for caring offspring. OMs for looking after children are more likely to live with their adult children who have formal employment and stable income resources. This is consistent with the broad body of literature which shows the role of income in using health services among older adults (40, 41). Simultaneously, the CMDMS data suggest that the prevalence of hypertension or diabetes in OMs for looking after offspring (24.6%) was higher than that of OMWs (12.5%). Due to the longstanding disease course, chronic diseases require regular healthcare and have more rigid demand, which is less influenced by socioeconomic status, and might incur increases in medical expenses. Research also shows that the price elasticity for older patients with high chronic diseases is higher than those without (42).

Third, a significant association between having SHI in the current place of residence and less expenditure was discovered in all three sub-group OMs. Moreover, regarding OMs for looking after offspring and OMs for receiving care from family, the expenditure reduced by the SHI in the current place of residence further increased the probability of visiting doctors. These findings might imply that addressing the inequalities in the reimbursement of health expenses among different types of SHI via unifying all types of health financing schemes into a single-payer program might be considered as a future approach. Due to the fragmented SHI schemes, rural and urban health insurance schemes are separately operated, and a gap exists in healthcare delivery between rural-to-urban migrants and urban residents (43). Although the Chinese government has implemented the Urban-Rural Resident Medical Insurance (URRMI) since 2016 by combing URI and NCMS (28), there are still 130 million Chinese people covered by NCMS in 2018 (6). On the one hand, since SHI is linked with the household registration scheme, a large number of rural-to-urban OMs is still covered by NCMS due to a lack of non-agricultural Hukou in urban area (29). Rural-to-urban OMs with SHI in their current place of residence benefit more from the reimbursement of healthcare expenses, in comparison to those without (4, 44). UEI which targets urban employees is evidence to be more effective in improving access to health services by providing higher financial protection, compared with other types of SHI (4). On the other hand, for those migrants who enrolled in URRMI, they still had a higher co-payment than urban employees enrolling in UEI (6). The high reimbursement of the urban health financing scheme could be a vital factor in the decision for OMs to seek health services (41). With a higher reduction in out-of-pocket health expenses benefiting from urban health financing schemes (45), OMs for receiving care from their family who have SHI in their current place of residence may be more likely to visit doctors during times of illness.

Fourth, OMWs with a longer migrating duration are more likely to have SHI in their current place of residence. This finding is in line with previous research that shows as the duration extends, rural-to-urban migrants are more likely to be eligible for urban health financing schemes (29). In the short run, rural-to-urban OMWs face policy barriers and discrimination in seeking employment and healthcare expenses reimbursement in their current place of residence. As time goes by, rural-to-urban migrants could undergo elaborate procedures in their current place of residence under transfer policies. OMWs might benefit from a long service for local employers (3, 46) to get enrolled in urban health financing schemes and other public welfare.

The following policy implications could be derived from the above analyses. First, policymakers are suggested to further promote the URRMI by combining the NCMS and UEI across rural residents and urban residents. Second, streamlined transfer policies for rural-to-urban migrants covered by NCMS to enroll in URRMI and improved elaborate procedures for OMWs to enroll in UEI are worthwhile. More efforts on community-based education or counseling on the transfer procedure on SHI in the current place of residence are needed. Third, we also suggest policymakers consider unifying all types of health insurance programs into a single-payer program to address the gap between existing URRMI and UEI. Fourth, the Chinese government has announced nationwide direct reimbursement for seeking cross-provincial inpatient expenses, but this reimbursement for outpatient expenses across provinces is still limited in pilot areas after the medical reform in 2019. We suggest the government to future extend the coverage of direct reimbursement for seeking cross-province outpatient services. Fifth, simply improving health services use among OMs via existing SHI is insufficient. We suggest policymakers in LMICs to consider a more generous public welfare scheme. Further programs targeting OMWs needed to be better designed to guarantee wage payment, pension, and other public benefits and improve access to health services. Sixth, to improve the awareness of active health-seeking behaviors during times of illness, social media and family members need to guide OMs to face their health needs and understand the importance of their health to the family.