Effects of digital health education on expanding health insurance protection among university students: survey evidence from Shandong, China.

BACKGROUND: Although Chinese universities have rolled out the Basic Medical Insurance for Urban and Rural Residents (BMIUR) on a nearly universal basis, actual enrollment, knowledge of benefits, and real-world claim use remain uneven. Many students, particularly rural and first-generation entrants, commence the academic semester without having activated their accounts or understanding referral rules, leaving large pockets of under-protection.

METHODS: We exploit a campus-level natural experiment at a large public university in Shandong: on September 1, 2024, an institution-wide digital health education program was launched for incoming 2024 freshmen, while earlier cohorts (2021-2023) received no comparable intervention. Using a fuzzy regression discontinuity design (RDD) with enrollment date as the running variable, we estimate the effect of the program on a composite index of health insurance protection combining variables on enrollment status, policy knowledge, claim experience and satisfaction. Survey data of 4,872 students were merged with enrollment data. Robustness checks: several bandwidths, donut-RD, placebo cutoffs, propensity score matching. Heterogeneity is by hukou, only child status, and self-rated health. KHB mediation decomposed cognitive, behavioral and psychological channels (Cronbach's alpha = 0.82; F > 200 in first stage).

RESULTS: At the cutoff, enrollment jumped from 87.3 to 98.5% (β = 0.112, SE = 0.018, p < 0.001), knowledge of policy details rose from 42.1 to 93.6% (β = 0.515, p < 0.001), successful claim rate climbed from 87.2 to 97.7% (β = 0.105, p < 0.001), and composite satisfaction moved from 52.6 to 88.3 on a 0-100 scale (β = 35.7, p < 0.001). The claim denial rate decreased from 17.6 to 10.1%, representing a relative reduction of approximately 43% (risk difference = 7.5 percentage points, p = 0.012). Effects are greatest for rural students, for non-only-children, and for those in poor or fair health. Cognitive and behavioral channels account for most of the mediation (42 and 30% of indirect effects, respectively), and the psychological channel of mediation amounts to 17%. The direct, unmediated residual effect is small and not statistically different from zero.

CONCLUSION: A comparatively benign, digital health education intervention can exert a significant positive effect on health insurance coverage expansion in a cohort of matriculating university students. There is evidence for scaling digital onboarding modules during enrollment, and maintaining support during annual enrollment, and it is cognition and through-the-hand activation, rather than diffusion of information only, that sticks.