The discrepancy between objective and subjective assessments of catastrophic health expenditure: evidence from China

The pro-rich nature of catastrophic health expenditure (CHE) indicators has garnered criticism, inspiring the exploration of the subjective approach as a complementary method. However, no studies have examined the discrepancy between subjective and objective approaches. Employing data from the Chinese Social Survey (CSS) 2013-2021 waves, we analysed the discrepancy between objective and subjective CHE and its associated socioeconomic factors using logit regression modelling. Overall, self-rating generated higher CHE incidence (28.35% to 33.72%) compared to objective indicators (9.92% to 21.97%). Objective indicators did not support 17.57% to 23.90% of self-rated cases of household CHE, while 2.73% to 8.42% of households classified with CHE by objective indicators did not self-rate with CHE. The normative subsistence spending indicator showed the least consistency with self-rating (70.66% to 74.28%), while the budget share method produced the most consistent estimation (72.73% to 76.10%). Living with elderly and young children [adjusted odds ratios (AOR): 1.069 to 1.169, P < 0.1], lower educational attainment (AOR: 1.106 to 1.225, P < 0.1), lower income (AOR: 1.394 to 2.062, P < 0.01), and lower perceived social class (AOR: 1.537 to 2.801, P < 0.05) were associated with higher odds of self-rated CHE without support from objective indicators. Conversely, low socioeconomic status (AOR: 0.324 to 0.819, P < 0.1) was associated with lower odds of missing CHE cases classified by objective indicators in self-rating. The commonly used objective indicators for assessing CHE may attract doubts about their fairness from socioeconomically disadvantaged people. The CHE subjective approach can be adopted as a complementary measure to monitor financial risk protection.