The top-level design of social health insurance reforms in China: towards universal coverage, improved benefit design, and smart payment methods

Abstract

Health insurance was prioritized as one of the four key areas for reform in China’s Health Care Reform Plan released in April 2009. The Plan aimed to expand coverage, enhance security, and improve payment methods, but implementation was sluggish. In 2011, the government announced that social health insurance (SHI) schemes had reached a coverage rate of 95%, but official statistics did not match the claim. Universal coverage is still an unfinished mission, while inadequate financing and benefit design remain major challenges. Despite a substantial increase in government funding over the past decade, SHI schemes have so far never accounted for more than 54% of national health care expenditure. Surplus has also become a serious policy issue for SIH funds. Finally, payment methods still require further reform and improvement. Traditional fee-for-service payments prevail in many localities, and new payment methods, such as capitation, global budgets, diagnosis-related groups (DRGs), per diem payments, and mixed payments, are only in the stage of experimentation. The health care delivery system still lacks sufficient governance structure and incentives. Health insurance reform is an important part of welfare-state building, and China still has a long path ahead before it reaches its goals in this respect.