Asia Health Policy Program Director Karen Eggleston and colleagues examine China’s progress in enhancing financial protection under its social health insurance to achieve universal health coverage.

In 2009, China launched comprehensive health system reforms to address challenges such as increasing rates of non-communicable diseases and population aging, problems with health financing and healthcare delivery, and overall growing health expectations of its people. Promoting universal health coverage by building a social health insurance system was a central pillar of the reforms.

After a decade of system reforms, has the Chinese government made good on its commitment to bolster universal health coverage? In a new article published in a BMJ collection, a team of four co-authors including Karen Eggleston, APARC’s deputy director and director of the Asia Health Policy Program, evaluates China’s progress towards enhancing financial protection of social health insurance and identifies the main gaps that need to be filled to achieve universal health coverage. Their article is part of a special BMJ collection with Peking University that marks the tenth anniversary of China’s health system reforms by analyzing their accomplishments and challenges ahead.

The 2009 reforms aimed to cover the entire Chinese population with one of three (since 2012 one of two) basic social health schemes. To provide added financial protection to patients with critical illnesses, catastrophic medical insurance was initially launched in 2012 and implemented nationally in 2015. Eggleston and her co-authors determine that the expansion of health insurance has had several major successes. First, it improved access to and use of healthcare. In 2011, China achieved near-universal health insurance coverage, with more than 95% of the Chinese population covered by health insurance. Moreover, the annual inpatient hospital admission rate increased from 3.6% in 2003 to 17.6% in 2017, and admission rates for outpatient services were much higher than the global average.

Second, the expansion of health insurance coverage reduced the share of out-of-pocket heath expenses in total health expenditure, thus raising the level of financial protection. Third, catastrophic medical insurance was also effective in supplementing the basic social health insurance schemes and provided extra financial protection to a range of vulnerable groups. By 2017, more than a billion people in China were covered by such insurance.

However, much remains to be done. Out-of-pocket health expenditures remain fairly high and are one of the main reasons for catastrophic health expenses and low financial protection in China, which disproportionately affect deprived populations. Catastrophic medical insurance currently does not target underprivileged people, while medical aid is relatively small in scale and covers only a minority of patients with catastrophic health expenses.

Eggleston and her colleagues conclude that the Chinese government should focus on underprivileged populations within the current insurance system and enhance their financial protection as an important element of targeted poverty alleviation. Such targeting, the researchers emphasize, requires a clear and integrated policy encompassing the basic social health insurance schemes, catastrophic medical insurance, medical aid, and improved healthcare efficiency.

Forty years after the establishment of diplomatic relations between the United States and China, the two superpowers are competing and contesting every arena, from trade to AI research and from space exploration to maritime rights. Instead of what Americans referred to as engagement and Chinese called reform and opening, many experts and analysts now characterize the relations between the two countries as dangerously brittle. Some see a new kind of Cold War in the making. Such assertions, however, argues Shorenstein APARC Fellow Thomas Fingar, “both ignore history and impute a level of fragility that has not existed for many years.”

Fingar reflects on the U.S.-China bilateral relationship in a new article, “Forty years of formal—but not yet normal—relations,” published in the China International Strategy Review. He claims that the relationship is resilient and not destined for conflict, albeit it is beset by a host of aspirational, perceptual, and structural differences.

A political scientist and China specialist who served over two decades in senior government positions, Fingar urges readers to remember that assertions of fragility of the U.S.-China relationship undervalue the strength, scope, and significance of interdependence, shared interests, and constituencies in both countries. These, he says, have a substantial stake in the maintenance of at least minimally cooperative relations.

U.S.-China relations are indeed highly asymmetrical: Chinese citizens and organizations have far greater access to the United States than Americans do to China, notes Fingar. He also recognizes that the troubles that have soured the relationship are more intricate and often more sensitive than those of the past. Decades ago, most of the issues that arose were handled at the governmental level. But now “the number and variety of players with stakes in the relationship and disputes with counterpart actors are much greater.” Furthermore, explains Fingar, the U.S. business community is expressing a stronger voice for government action to change Chinese behavior and is not as consistent an advocate of stability in U.S. policy toward China as it used to be. “This is an extremely important development,” he says, “because it reverses a key dynamic in the U.S.-China relationship.”

Ultimately, however, the two countries and our institutions and people are linked by myriad ties that bring mutual benefits as well as the constraints of interdependence. “I remain confident that we will continue to be able to manage the relationship,” concludes Fingar. He expresses disappointment, though, that normalization of U.S.-China relations remains a work in progress and cautions that merely managing the relationship to prevent it from deteriorating is an unsatisfactory goal that should be unacceptable to both sides. Not only does such a low bar limit what each counterpart can achieve, but it also inhibits the kind of cooperation required to address transnational challenges like climate change, infectious disease, and proliferation of dangerous technologies.

Karl Eikenberry, director of the U.S.-Asia Security Initiative, spoke with "Bloomberg Markets: Asia" about the ongoing trade disputes between the U.S. and China. Video of his interview—conducted on the sidelines of the Morgan Stanley China Summit in Beijing—is posted below.

“But as I read what the communist party, what President Xi says, I don't see the same fervor to the ideological dimension of what China is doing around the world...[compared to what] the Soviets were doing.”

It was during the 2019 Oksenberg Conference that FSI Director Michael McFaul made the preceding assessment. Titled On the Brink: A New Cold War with China, the conference sought to explore the causes underlying today’s intensified conflict between the United States and China. McFaul was joined on stage by APARC's Oksenberg-Rohlen Fellow David M. Lampton and China Program Director Jean Oi. Their panel followed an earlier fireside chat featuring keynote speaker Dr. Condoleezza Rice.

Rice, the 66th U.S. Secretary of State, opened the program with a wide-ranging conversation with Oi regarding our rapidly deteriorating trade relations with China. Among other topics, Secretary Rice drew contrasts between our current tensions with China and the Soviet-era Cold War; the potential sources of China’s increasing nationalism; and what the appropriate U.S. policy responses could be.

Condoleezza Rice (right) listens on as Jean Oi addresses the audience

Dr. Jean Oi (left) and Dr. Condoleezza Rice

Audio recordings and transcripts of the formal remarks by McFaul and Lampton are available below.

The annual Oksenberg Conference honors the legacy of Professor Michel Oksenberg. A renowned China scholar and senior fellow at Shorenstein APARC, Professor Oksenberg served as a key member of President Jimmy Carter’s National Security Council, guiding the United States towards normalized relations with China and consistently urging that the U.S. engage with Asia in a more considered manner.