China’s cross-provincial settlement policy and the mental health of the elderly and adult population

China’s cross-provincial settlement policy and the mental health of the elderly and adult population | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article China’s cross-provincial settlement policy and the mental health of the elderly and adult population Chun-Chieh Hu, Xiaoming Nie, Siyu Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9654903/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This paper examines the mental health effects of China’s 2017 cross-provincial hospitalization settlement policy, which improved the portability of public health insurance for internal migrants. Using five waves (2011–2020) of nationally representative panel data from the China Health and Retirement Longitudinal Study (CHARLS), we estimate its causal impact on depressive symptoms among middle-aged and older adults whose insurance was registered outside their place of residence. A province-level policy intensity index, based on hospital participation rates, is combined with a triple-difference strategy exploiting variation across time, regions, and hukou-linked insurance access. The policy reduced CESD depression scores among non-local hukou holders by about 1.3 points, with stronger effects for low-income, rural, and female subgroups. Event study results support the parallel trends assumption, and placebo tests confirm robustness. We introduce the concept of hukou lock—a form of welfare-induced geographic immobility where access to inpatient reimbursement is tied to one’s hukou rather than residence. This lock-in mechanism, analogous to “job lock” in employer-based systems, distorts residential choices, constrains healthcare access, and heightens care-related anxiety. The 2017 reform’s dismantling of hukou lock provides a quasi-natural experiment to assess its psychosocial consequences. Our findings highlight the mental health benefits of portable and inclusive insurance systems, offering policy lessons for aging societies with decentralized welfare structures. Health Economics & Outcomes Research Mental health CHARLS Cross-provincial settlement policy Full Text Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9654903","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":636934899,"identity":"efc8e0a2-78ac-4a3a-9c3e-2bb47b7bfe63","order_by":0,"name":"Chun-Chieh Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYDACCTB5gAfIYGNgqACxYVIHsOtA03KGBC0MYC2MbURo4Z/dY/aAoeaODL90A9tj3nmH5fmO9x6T+LiHQY7vRgJ2S+6cMTdgOPaMR3LOAXZj3m2HDWeeOZcmOeMZg7EkDi0GEjlm0n8bDvMY3EhgkwZqSTC4kWNszHOAIXEDHi0SjEAt9mAtc4Ba7r8xNv5zgKGeoBYDCZCWBpAtPIaPgV4HMnD45UZamQTDscM8EjcS2yTnHEsH+iXH8GHPAQkg4wH2EJuRvE2CoeawPZBxTOJNjTUwxM4YHPhxwAbIwG4LEmBsQLGekPJRMApGwSgYBXgAAAvBX2boLG/wAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0009-7337-885X","institution":"University of Colorado Denver","correspondingAuthor":true,"prefix":"","firstName":"Chun-Chieh","middleName":"","lastName":"Hu","suffix":""},{"id":636935668,"identity":"54a70683-dc64-4b63-ad78-7d013f59f02f","order_by":1,"name":"Xiaoming Nie","email":"","orcid":"","institution":"Yale University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Xiaoming","middleName":"","lastName":"Nie","suffix":""},{"id":636935669,"identity":"9ebf95fc-acc2-4dcc-954c-08cb134ab283","order_by":2,"name":"Siyu Wang","email":"","orcid":"","institution":"Zhejiang University International Business School","correspondingAuthor":false,"prefix":"","firstName":"Siyu","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-05-08 13:46:05","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9654903/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9654903/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108985061,"identity":"42203d94-c7e2-4b4c-9ef0-e163ccad4163","added_by":"auto","created_at":"2026-05-11 12:43:27","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":497206,"visible":true,"origin":"","legend":"","description":"","filename":"ChinaHukoulockFinal0508.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9654903/v1_covered_56540000-8dfa-442d-b6d2-1bc284db5518.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eChina’s cross-provincial settlement policy and the mental health of the elderly and adult population\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental health, CHARLS, Cross-provincial settlement policy","lastPublishedDoi":"10.21203/rs.3.rs-9654903/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9654903/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis paper examines the mental health effects of China\u0026rsquo;s 2017 cross-provincial hospitalization settlement policy, which improved the portability of public health insurance for internal migrants. Using five waves (2011\u0026ndash;2020) of nationally representative panel data from the China Health and Retirement Longitudinal Study (CHARLS), we estimate its causal impact on depressive symptoms among middle-aged and older adults whose insurance was registered outside their place of residence. A province-level policy intensity index, based on hospital participation rates, is combined with a triple-difference strategy exploiting variation across time, regions, and hukou-linked insurance access. The policy reduced CESD depression scores among non-local hukou holders by about 1.3 points, with stronger effects for low-income, rural, and female subgroups. Event study results support the parallel trends assumption, and placebo tests confirm robustness. We introduce the concept of hukou lock\u0026mdash;a form of welfare-induced geographic immobility where access to inpatient reimbursement is tied to one\u0026rsquo;s hukou rather than residence. This lock-in mechanism, analogous to \u0026ldquo;job lock\u0026rdquo; in employer-based systems, distorts residential choices, constrains healthcare access, and heightens care-related anxiety. The 2017 reform\u0026rsquo;s dismantling of hukou lock provides a quasi-natural experiment to assess its psychosocial consequences. Our findings highlight the mental health benefits of portable and inclusive insurance systems, offering policy lessons for aging societies with decentralized welfare structures.\u003c/p\u003e","manuscriptTitle":"China’s cross-provincial settlement policy and the mental health of the elderly and adult population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 11:55:37","doi":"10.21203/rs.3.rs-9654903/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"433e12bb-0517-42ff-b1d1-729e594ad85b","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67795273,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2026-05-11T11:55:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 11:55:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9654903","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9654903","identity":"rs-9654903","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}