Catastrophic Health Expenditures and Mental Health in Older Chinese People: The Role of Social Health Insurance

Abstract Catastrophic health expenditure (CHE) has considerable effects on household living standards, but little is known regarding the impacts of CHE on people’s mental health. Using China as an example, this study examines the association between CHE and mental health and investigates whether and to what extent social health insurance (SHI) can lessen the impacts of CHE on mental health among older people aged over 60 in China. The data come from three waves of the China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, and 2015, N = 13,166). We built fixed-effects quantile regression models to analyse the data. We found that incurring CHE has significantly detrimental effects on older people’s mental health, whereas the SHI demonstrates a protective effect. The observed protective effects of SHI are the strongest among those with relatively mild mental health problems, i.e., people whose CES-D scores are below the 50th percentile. Our findings provide empirical evidence that encourages the integration of psychologically informed approaches in health services. We also urge governments in low- and middle-income countries to consider more generous health financing mechanisms for those with higher healthcare needs.

the relationship between education, a marker of cognitive reserve, and income in relation to mild cognitive impairment (MCI) and dementia in England and Japan. We ascertained MCI using a validated algorithm based on one standard deviation below the mean on two standardised cognitive tests. Multinomial logistic regression models were used to study the associations between socioeconomic markers and MCI/ dementia. The prevalence of MCI was almost twice as high among English adults compared to Japanese. Results suggest that nations are similar in overall socioeconomic inequalities of MCI/dementia, but this might differ across socioeconomic markers. Considerable variability in the health inequalities could be attributed to the country-specific socio-culturalpolitical factors, which remains to be further explored.

SOCIOECONOMIC DETERMINANTS OF COGNITIVE AGING: A CROSS-COUNTRY COMPARISON BETWEEN ENGLAND AND CHINA
Dorina Cadar, 1 Yaohui Zhao, 2 Li Yan, 2 Laura Brocklebank, 1 and Andrew Steptoe, 1 1. University College London,London,England,United Kingdom,2. Peking University,Guangzhou,Guangdong,China (People's Republic) Lower educational attainment is associated with a higher risk of dementia and a steeper cognitive decline in older adults. However, less clear is how other socioeconomic markers contribute to cognitive ageing and if these socioeconomic influences on cognitive ageing differ between England and China. We examined the relationship of education, household wealth, and urbanicity with cognitive performance and rate of change over 7-8 years follow up in the English Longitudinal Study of Ageing and Chinese Health and Retirement Longitudinal Study, national representative samples of England and China. We found that the rate of cognitive change appears to be socioeconomically patterned, primarily by education and area-based characteristics (urban vs rural), with a stronger impact of inequalities seen in rural China. Public health strategies for preventing cognitive decline and dementia should target socioeconomic gaps to reduce health disparities and protect those particularly disadvantaged in England and China.

CATASTROPHIC HEALTH EXPENDITURES AND MENTAL HEALTH IN OLDER CHINESE PEOPLE: THE ROLE OF SOCIAL HEALTH INSURANCE
Wei Yang, 1 and Bo Hu, 2 1. King's College London,London,England,United Kingdom,2

. London School of Economics and Political Science, London, England, United Kingdom
Catastrophic health expenditure (CHE) has considerable effects on household living standards, but little is known regarding the impacts of CHE on people's mental health. Using China as an example, this study examines the association between CHE and mental health and investigates whether and to what extent social health insurance (SHI) can lessen the impacts of CHE on mental health among older people aged over 60 in China. The data come from three waves of the China Health and Retirement Longitudinal Study (CHARLS 2011(CHARLS , 2013(CHARLS , and 2015. We built fixed-effects quantile regression models to analyse the data. We found that incurring CHE has significantly detrimental effects on older people's mental health, whereas the SHI demonstrates a protective effect. The observed protective effects of SHI are the strongest among those with relatively mild mental health problems, i.e., people whose CES-D scores are below the 50th percentile. Our findings provide empirical evidence that encourages the integration of psychologically informed approaches in health services. We also urge governments in low-and middle-income countries to consider more generous health financing mechanisms for those with higher healthcare needs. Despite growing attention to the association between living arrangements and health outcomes, less is known about how emotional well-being and life satisfaction vary by living arrangements. Using data from the 2014 and 2016 Leave Behind Questionnaires from the Health and Retirement Survey (N=13,275), we estimated generalized linear regression models comparing emotional well-being (a ratio of positive to negative emotion) and life satisfaction (the satisfaction with life scale, SWLS) by living alone versus living with others, controlling for socioeconomic and other health-related characteristics. Overall, individuals who lived alone had lower emotional well-being (β=-0.11; p<0.01), and SWLS score (β=-0.42; p<0.001), compared to those living with others. The direction of these relationships stratified by the cognitive status was the same. Policies and programs designed to support the growing population of older adults living alone should focus on improvement in these positive outcomes to enhance the quality of life.

LONELINESS, STRESS, AND DEPRESSIVE SYMPTOMS AMONG OLDER IMMIGRANTS: A MODERATING ROLE OF FAMILIAL RELATIONSHIPS Heejung Jang, University of Michigan, Ann Arbor, Michigan, United States
Objectives: Immigration is a stressful life event, and immigrants commonly experience loneliness, a risk factor for depression. However, little is known about how and whether older immigrants' perceived stress exposure/appraisals mediate the association between loneliness and depressive symptoms. Further, this study explores whether familial relationships moderate the indirect or direct effects of the mediation models. Method: This study uses the 2012 Health and Retirement Study from a sample of 719 immigrants age 57 and older. A series of moderated mediation analyses were conducted across the total number of stress exposure and eight stress appraisal domains. Results: The findings indicate that the total number of stress exposure and five domains of stress appraisals (health problems in self, physical/ emotional problems in spouse/child, financial strain, housing problems, and close relationships in others) mediate the association between loneliness and depressive symptoms. In addition, the perceived negative strain from family moderated the mediating effect of health problems and housing problems in the relationship between loneliness and depressive symptoms. Discussion: This study suggests that negative relationships with family may increase upsetting in stress appraisals on health and housing problems, which turn in increased depressive symptoms for lonely older immigrants. Practitioners need to assess older immigrants' stressors and family relationships to understand their loneliness and depressive symptoms.

SOCIAL ISOLATION AS A RISK FACTOR FOR CIGARETTE SMOKING IN OLDER ADULTS
Gilbert Gimm, 1 Mary Lou Pomeroy, 2 and Thomas Cudjoe, 3 1. George Mason University, Vienna,Virginia,United States,2. George Mason University,George Mason University,Virginia,United States,3. Johns Hopkins University School of Medicine,Baltimore,Maryland,United States Objective: This study examined the prevalence of social isolation and cigarette smoking in a national sample of community-dwelling older adults, and assessed the role of social isolation on the risk of cigarette smoking. Methods: Using data from 8,044 participants (age 65+ years) across two waves of the National Health and Aging Trends Study (NHATS), we analyzed the prevalence of social isolation in older adults and as a risk factor for cigarette smoking. Social isolation was measured across 4 relationship domains (Cudjoe, 2018) on a scale of 0 to 4, using objective measures of social interactions. Descriptive and logistic regression analyses were conducted to assess how social isolation is associated with smoking. Results: Preliminary results showed that 18.2% of older adults were socially isolated (3.5% severely isolated) and 7.1% of participants reported current smoking. We found that both social isolation (OR = 2.5, p<.001) and severe isolation (OR = 5.9, p<.001) increased the odds of smoking. Also, older adults with depression (OR = 1.6, p<.01) and dual-eligible beneficiaries (Medicare and Medicaid) with TRICARE coverage (OR = 4.6, p<.05) had greater odds of smoking. However, we did not find evidence that the odds of smoking varied significantly by the number of chronic conditions. Conclusion: Social isolation is associated with an increased risk of cigarette smoking among older adults. Smoking may be an important behavior in the pathway between social isolation and its association with morbidity and mortality.

THERE IS NO COMMUNITY HERE: LIVING ALONE, PLACE, AND OLDER PEOPLES' RISK OF SOCIAL ISOLATION Rachel Weldrick, Simon Fraser University, Vancouver, British Columbia, Canada
Existing research has identified significant risk factors for experiencing social isolation in later life including chronic health conditions, mobility impairments, and living alone among others. Although many older people who live alone maintain active social lives, living alone remains a top predictor of social isolation. Less is known about other types of risk factors, such as place-based risks and social exclusion.