Who Gets What, When, and How from Chinese Social Health Insurance Expansion?

Chapter 7 examines the stratification of Chinese social health insurance in the first decade of the 2000s. Based on analyses of administration data and national social survey data, it examines the variations in social welfare benefits across social strata, addressing who got what, when, and how as a result of China’s social health insurance expansion between the years of 2003 and 2011. It shows that social health insurance expansion did significantly broaden Chinese citizens’ access to basic health care. However, the expansion not only reinforced existing social divisions but also generated new ones within both urban and rural groups. Chinese social health insurance is highly stratified along three cleavage lines among recipients: (1) urban versus rural; (2) labor market insiders versus outsiders; and (3) public versus private sectors. These multiple social cleavages are interwoven to fragment society and privilege elite groups over others without fracturing society along a single and deep class line.

Understanding Subnational Variation in Chinese Social Health Insurance

Chapter 6 investigates the coverage and generosity of Chinese social health insurance in the first decade of the 2000s, with a focus on the regional (i.e., cross-provincial) variation using a cross-sectional time-series research design. First, a cluster analysis provides supportive evidence for the existence of four models of social health insurance expansion in China. The clustering of Chinese provinces in social health insurance expansion also corresponds to the differences among local political economies. Second, the chapter makes detailed inter-regional comparisons and intra-regional studies to reconstruct the mechanism linking a local political economy to the local distributive patterns of health insurance benefits—that is, local socioeconomic conditions shape local leaders’ policy preferences and choices for allocating social health insurance benefits in their jurisdictions. Finally, a regression analysis demonstrates significant correlations between local social risks and social health insurance coverage, and between local fiscal resources and social health insurance generosity.

The Center’s Distributive Strategy and Fund Allocation

Chapter 4 focuses on Chinese central leaders (the Center) and their distributive strategy and behaviors in providing social welfare. The deliberations and calculations reflected in the central leaders’ speeches between 1998 and 2011 show that the stratified expansion of social welfare was the Center’s most preferred model for social welfare provision in this period. Various internal speeches and communication revealed the hidden concern and measures taken to maintain the elites’ welfare privileges and benefits during the welfare expansion. Careful reading of the primary materials also suggests that the Center’s fiscal transfers to local governments were an important means for maintaining the welfare privileges of elite groups (e.g., civil servants, public-sector and SOE formal employees). This chapter later analyzes the central-to-local fiscal transfers from 1999 to 2010 and finds that the larger the elite groups in a province, the greater were the fiscal transfers the province received from the central government.

Conclusion

Chapter 8 summarizes the main findings and contributions of this book. After a speculative note on the prospect of health reform in China after 2012 when the new leader, Xi Jinping, took power, this chapter discusses the implications of this study for both Chinese social welfare development and its authoritarianism. Finally, it concludes with a deliberation of the conditions for applying the argument about stratified expansion of social welfare provision beyond China.

Local Motivation and Distributive Choices

Chapter 5 focuses on local leaders’ distributive motivations and policy choices in social welfare provision. The combination of political centralization and fiscal decentralization compels Chinese local leaders to specify major policies in local circumstances while balancing the Center’s mandates and directives with local resources and constraints. Drawing from qualitative evidence collected during fieldwork in China between 2009 and 2012, this chapter not only demonstrates the regional variation in local policy responses to the Center’s directive of stratified expansion of social health insurance but also provides examples of local calculations and policy choices in implementing the health insurance expansion. The reasons for the regional differences in local policy choices for social health insurance expansion are not only the disparities of local socioeconomic conditions and resources but also the contradiction embedded in the Chinese authoritarian regime’s distributive strategy: expanding basic benefits to the masses while maintaining the welfare privilege for the elites.

Overview of China’s Social Health Insurance

Chapter 3 draws from secondary materials and literature to review the history and evolution of social health insurance in contemporary China (since 1949), providing the historical background and the economic context of China’s social health insurance expansion in the 2000s. It shows that throughout the history of contemporary China, social welfare was never considered a basic social right for citizens. Despite dramatic changes in the coverage and generosity of social health insurance across different developmental periods, the stratification of Chinese social health insurance is persistent and was reinforced during the social health insurance expansion between 1999 and 2011. Moreover, the economic transition and the diversification of regional economies in China constitute the economic context, in which the Chinese central and local leaders’ motivations for and differential responses to social health insurance expansion take shape.

A Theory of Stratified Expansion of Social Welfare

Chapter 2 presents a supply-side theory that explains the political logic and distributive characteristics of social welfare provision in the Chinese authoritarian setting. The theory takes into account the logic of authoritarian regime survival, multilevel governance and local political economies, and specifies the main political actors and their interests and strategies in Chinese social welfare provision. It argues that authoritarian leaders, whose basic interest lies in regime survival and stability, use stratifying and expansive social welfare policies to privilege elites and placate the masses. To explain the stratified social welfare expansion in the Chinese authoritarian yet decentralized setting, it is necessary to disaggregate the authoritarian state and to examine divergences in policy preferences among different levels of the authoritarian state and the factors that shape the dynamics of interaction between them, ultimately with an eye toward the impact of these divergences and interactions on policy implementation and outcomes.

Introduction

Chapter 1 introduces this study about Chinese social welfare development. It presents the puzzling features of Chinese social health insurance in the first decade of the 2000s: expansion and stratification. Then it explains Chinese social health insurance as seen from the political interests of authoritarian leaders in benefit distribution; that is, authoritarian leaders must strike a balance in benefit distribution between elites and masses in order to maintain regime survival and stability. After discussing the alternative explanations of social welfare expansion and variation, this chapter introduces the main argument and research design of the book and provides a preview of the book chapters.