Objective  To examine hospitalization and outpatient visit medical expenditure, health insurance utilization and their associated factors among middle-aged and elderly residents in Shanxi province.

  Methods  We conducted a cross-sectional questionnaire survey among 1 100 residents aged 45 years and older selected using multistage random sampling in two municipalities of Shanxi province in July 2016.

  Results  Of the participants, 852 (87.65%) and 620 (63.78%) reported hospitalization and outpatient visit during past 12 months. For the participants reporting hospitalization and outpatient visit, 73 (8.57%) and 365 (58.87%) were not involved in the utilization of health insurance; not participating in health insurance was the main reason (39.7%) for the participants without health insurance utilization for hospitalization and medication items not covered by the health insurance was the major reason (47.4%) for the participants without health insurance utilization for outpatient medication. The participants utilizing health insurance reported higher expenditures for both the hospitalization and outpatient visit in comparison to the participants without health insurance utilization. Age, education, type of census register, and type of the hospital selected by the participants were influencing factors for health insurance utilization; while, occupation, type of the hospital selected by the participants, whether suffering from chronic diseases, mean personal income, times of hospitalization, education, and marital status were impact factors of medical expenditure among the participants.

  Conclusion  Social and demographic characteristics could affect health insurance utilization and medical expenditure among middle-aged and elderly residents in Shanxi province. The results suggest that related governmental agencies should enhance the integration of health care system and improve the efficiency of health insurance.