Title: Expansion of Chinese Social Health Insurance: who gets what, when and how?
Abstract: AbstractThis article asks 'who gets what, when and how' from China's recent social welfare expansion. Little research to date examines the overall landscape of China's social health insurance, which has changed dramatically since 2003, and the distributive consequences and implications thereof. Drawing on public survey data and fieldwork for empirical support, this article finds that China's recent social health insurance expansion does significantly expand people's access to social health insurance. However, the expansion, which entails health insurance fragmentation and increasing benefit disparities, not only reinforces existing social cleavages such as the rural–urban divide, but it also generates new divisions within urbanites and workforce. Moreover, multiple social cleavages that cross-cut class differences have been institutionalized into China's social health insurance system. This reflects authoritarian regimes' 'divide and rule' tactic in social welfare provision. Notes 1. Gøsta Esping-Andersen, The Three Worlds of Welfare Capitalism (Cambridge: Polity Press, 1990), p. 23. 2. Guy Carrin and Chris James, 'Social health insurance: key factors affecting the transition towards universal coverage', International Social Security Review 58(1), (2005), pp. 45–64. 3. Liu Jun-Qiang, 'Dynamics of social health insurance development: examining the determinants of Chinese basic health insurance coverage with panel data', Social Science & Medicine 73, (2011), pp. 550–558. Jay Pan and Gordon G. Liu, 'The determinants of Chinese provincial government health expenditures: evidence from 2002–2006 data', Health Economics 21, (2012), pp. 757–777. 4. Isabela Mares and Matthew E. Carnes, 'Social policy in developing countries', The Annual Review of Political Science 12, (2009), pp. 93–113. 5. Examples can be found in Scott Gehlbach and Philip Keefer, 'Investment without democracy: ruling-party institutionalization and credible commitment in autocracies', Social Science Research Network, Working Paper (2008). See also Beatriz Magaloni, Voting for Autocracy: Hegemonic Party Survival and Its Demise in Mexico (Cambridge: Cambridge University Press, 2006); B. Magaloni, A. Diaz-Cayaros and F. Esteves, 'Clientelism and portfolio diversification: a model of electoral investment with applications to Mexico', in S. Wilkinson and H. Kitschelt, eds, Patrons, Clients and Policies: Patterns of Democratic Accountability and Political Competition (Cambridge: Cambridge University Press, 2007), pp. 182–205. 6. Mares and Carnes, 'Social policy in developing countries'. 7. See, among others, Juan Du, 'Economic reform and health insurance in China', Social Science & Medicine 69, (2009), pp. 387–395; Edward X. Gu, 'Market transition and the transformation of the health care system in urban China', Policy Studies 22(3–4), (2001), pp. 197–215; Edward Gu and Tianjin Zhang, 'Health care regime change in urban China: unmanaged marketization and reluctant privatization', Pacific Affairs 79(1), (2006), pp. 49–71; Jen-Der Lue, 'The great economic transformation: social dilemmas of Chinese capitalism', Comparative Sociology 11, (2012), pp. 274–289; Jay Pan and Gordon G. Liu, 'The determinants of Chinese provincial government health expenditures'; Adam Wagstaff, Winnie Yip, Magus Lindelow and William C. Hsiao, 'China's health system and its reform: a review of recent studies', Health Economics 18, (2009), pp. 7–23. 8. Lei Xiaoyan and Lin Wanchuan, 'The new cooperative medical scheme in rural China: does more coverage mean more service and better health?', Health Economics 18, (2009), pp. 25–46; Lin Wanchuan, Gordon G. Liu and Chen Gang, 'The urban resident basic medical insurance: a landmark reform towards universal coverage in China', Health Economics 18, (2009), pp. 83–96; Gordon Liu et al., 'Equity in health care access: assessing the urban health insurance reform in China', Social Science & Medicine 55, (2002), pp. 1779–1794; Liu, 'Dynamics of social health insurance development'. 9. It is debatable whether China's social health insurance coverage, after expansion in 2003, is universal. On paper, every Chinese citizen is entitled to social health insurance of a certain kind, and the enrollment rate for China's social health insurance is over 80%. However, the distribution of health insurance benefits, as this article shows, is not universalistic. This article uses the term 'universal' to describe China's social health insurance after expansion based on its de jure universal coverage; it corresponds to the term quanmin 全民 used in the Chinese government's documents.10. Gu, 'Market transition and the transformation of the health care system in urban China'.11. The World Bank, Old Age Security: Pension Reform in China (Washington, DC: The World Bank, 1997).12. Edward X. Gu, 'Dismantling the Chinese mini-welfare state? Marketization and the politics of institutional transformation, 1979–1999', Communist and Post-Communist Studies 34, (2001), pp. 91–111.13.Ibid.14. Ma Hong, Handbook of Reforms in China, 1978–1991 [Zhongguo Gaige Quanshu, 1978–1991] (Dalian: Dalian chubanshe, 1992).15. Jane Duckett, 'State, collectivism and worker privilege: a study of urban health insurance reform', The China Quarterly 177, (March 2004), pp. 155–173.16.Ibid.17. Gu and Zhang, 'Health care regime change in urban China'.18. Wagstaff et al., 'China's health system and its reform'.19. Ministry of Finance of the People's Republic of China, Report on the Implementation of National Essential Medicines Policies (Beijing: Ministry of Health, 2011).20. For the issue of lack of social rights and its impact in China, see Zhaohui Hong, 'The poverty of social rights and dilemmas of urban poverty in China', Journal of Contemporary China 14(45), (2005), pp. 721–739.21. Some scholars argue that economic openness, especially after 2001, when China was accepted into the WTO, is a powerful driving force behind China's social welfare expansion. See Yongnian Zheng, 'Society must be defended: reform, openness, and social policy in China', Journal of Contemporary China 19(67), (2010), pp. 799–818.22. China Health & Nutrition Panel Survey (CHNS) is an international collaborative, multi-waved panel survey project. It covers nine Chinese provinces that vary substantially in geography, economic development, public resources and health indicators. The first wave of the CHNS data was collected in 1989 and more data were collected (almost every three years) in the following decades. For more information about CHNS, see http://www.cpc.unc.edu/projects/china.23. Social health insurance is the dominant type of health insurance in China. Chinese social health insurance is organized and managed by the government; it is also enforced by the government through economic, administrative and legal means. Other types of health insurance in China include commercial health insurance for individuals and company supplementary health insurance.24. Meng Qingyue and Tang Shenglan, 'Universal coverage of health care in China: challenges and opportunities', in World Health Report 2010 (New York: World Health Organization, 2010).25. The China General Social Survey (CGSS) is an annual or biannual questionnaire survey of China's urban and rural households aiming to systematically monitor the changing relationship between social structure and quality of life in urban and rural China. For more information, see http://www.chinagss.org/.26. A hukou is a record in the system of household registration required by law in China. The household registration system was officially promulgated by the Chinese Communist Party in 1958 to control the movement of people between urban and rural areas. Individuals were broadly categorized as a 'rural' or 'urban' person.27. These categories of employment sectors are state-owned enterprise or SOE, collective-owned enterprise or COE, private enterprise or POE, foreign-owned enterprise or FOE, and other.28. Andrew Gelman and Jennifer Hill, Data Analysis Using Regression and Multilevel/Hierarchical Models (Cambridge: Cambridge University Press, 2006), p. 82. The main idea of the 'divide by four' rule is that one can take logistic regression coefficients and divide them by four to get an upper bound of the predictive difference corresponding to a unit difference in x. This upper bound is a reasonable approximation near the midpoint of the logistic curve, where probabilities are close to 0.5. At this point the slope of the logistic curve or the derivative of the logistic function is maximized.29. The variable 'prog' is multinomial, with '1' being 'commercial or other health insurance scheme'; '2' being GIS or 'government scheme'; '3' being UEBMI or 'urban employee scheme'; '4' being URBMI or 'urban resident scheme'; and '5' being NRCMI or 'rural corporative scheme'. Because the urban resident health insurance, URBMI, was initiated in 2007, there is no case under this category in the 2004 CHNS sample.30. The variable 'urban hukou' is binary, with '1' representing urban hukou and '0' meaning having no urban hukou.31. The variable 'edu' is ordinary, with '0' = no regular education; '1' = primary school; '2' = middle school; '3' = high school; '4' = technical or occupational school; '5' = college; '6' = graduate school and above.32. The variable 'employsta' is categorical, with '1' = employed; '2' = unemployed or student; '3' = housekeeping; '4' = retired; '5' = other.33. The variable 'employown' is categorical with '1' = government or public institute; '2' = state-owned enterprise; '3' = collective-owned enterprise; '4' = private firms; '5' = foreign firm; '6' = other.34. The variable 'employsz' is ordinary with '1' = ' < 20 employees'; '2' = '20–100 employees'; '3' = '>100 employees'.35. '80% of Chinese provinces abolished government free medical care', Xinhua News Agency, available at: http://news.xinhuanet.com/local/2012-12/14/c_114025198.htm (accessed 15 December 2012).36. 'Labor market insiders' refers to employees who have formal and stable employment relations or contracts with employers. On the contrary, 'labor market outsiders' are people who have no formal or stable labor relations or contracts, such as temporary, part-time or student workers.37. For more examples on the fragmented social insurance model promoted by the authoritarian welfare state such as Germany under Bismarck, Austria under von Taaffe and France under Napoleon III, see Esping-Andersen, The Three Worlds of Welfare Capitalism; Hermann Beck, The Origins of the Authoritarian Welfare State in Prussia: Conservatives, Bureaucracy, and the Social Question, 1815–70: Social History, Popular Culture, and Politics in Germany (Ann Arbor, MI: University of Michigan Press, 1997); and Gaston V. Rimlinger, Welfare Policy and Industrialization in Europe, America, and Russia (New York: Wiley, 1971).38. For an in-depth analysis of segmentation of the Chinese employee class, see Zhining Ma, 'Chinese employee class: an analysis using a three-dichotomy segmentation approach', Journal of Contemporary China 19(67), (2010), pp. 935–948.39. 'Further integrating social security system for urbanization' ['Cheng zhen hua jin cheng zhong jia kuai tui jin she hui bao zhang zhi du xie jie yu zeng he'], Xinhua News, available at: http://news.xinhuanet.com/politics/2013-05/15/c_124715276.htm (accessed 31 October 2013); 'Urbanization requires eliminating several institutional obstacles' ['Cheng zhen hua gai ge xu jia kuai po chu xiang guan zhi du zang ai'], Xinhua News, available at: http://news.xinhuanet.com/2013-05/25/c_124763476.htm (accessed 31 October 2013).
Publication Year: 2014
Publication Date: 2014-03-21
Language: en
Type: article
Indexed In: ['crossref']
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Cited By Count: 33
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