Social Protection Under Authoritarianism : Health Politics and Policy in China

Why would an authoritarian regime expand social welfare provision in the absence of democratization? Yet China, the world's largest and most powerful authoritarian state, has expanded its social health insurance system at an unprecedented rate, increasing enrollment from 20 percent of its population in 2000 to 95 percent in 2012. Significantly, people who were uninsured, such as peasants and the urban poor, are now covered, but their insurance is less comprehensive than that of China's elite. With the wellbeing of 1.4 billion people and the stability of the regime at stake, social health insurance is now a major political issue for Chinese leadership and ordinary citizens. In Social Protection under Authoritarianism , Xian Huang analyzes the transformation of China's social health insurance in the first decade of the 2000s, addressing its expansion and how it is distributed. Drawing from government documents, filed interviews, survey data, and government statistics, she reveals that Chinese leaders have a strategy of "stratified expansion," perpetuating a particularly privileged program for the elites while developing an essentially modest health provision for the masses. She contends that this strategy effectively balances between elites and masses to maximize the regime's prospects of stability. In China's multilevel governance, both centralized and decentralized structures are involved in the distribution of social health insurance. When local leaders implement the stratified expansion of social health insurance, they respond to varied local conditions. As a result, China's health insurance policies differ dramatically across subnational regions as well as socioeconomic groups. Providing an in-depth look into China's health insurance system, this book sheds light not only on Chinese politics, but also on how social benefits function in authoritarian regimes and decentralized multilevel governance settings. "Why would authoritarian leaders expand social welfare provision in the absence of democratization? What are the distributive features and implications of social welfare expansion in an authoritarian country? How do authoritarian leaders design and enforce social welfare expansion in a decentralized multilevel governance setting? This book identifies the trade-off authoritarian leaders face in social welfare provision: effectively balancing between elites and masses in order to maximize the regime's survival prospects. Using government documents, filed interviews, survey data, and government statistics about Chinese social health insurance, this book reveals that the Chinese authoritarian leaders attempt to manage the distributive trade-off by a "stratified expansion" strategy, establishing an expansive yet stratified social health insurance system to perpetuate a particularly privileged program for the elites while developing an essentially modest health provision for the masses. In China's decentralized multilevel governance setting, the stratified expansion of social health insurance is implemented by local leaders who confront various fiscal and social constraints in vastly different local circumstances. As a result, there is great regional variation in the expansion of social health insurance, in addition to the benefit stratification across social strata. The dynamics of central-local interaction in enforcing the stratified expansion of social health insurance stands at the core of the politics of health reform in China during the first decade of the 2000s. This book demonstrates that the strategic balance between elites and masses in benefit distribution is delicate in authoritarian and decentralized multilevel governance settings"-- Provided by publisher Why would authoritarian leaders expand social welfare provision in the absence of democratization? How do authoritarian leaders design and enforce social welfare expansion in a decentralized multilevel governance setting? This book identifies the trade-off authoritarian leaders face in social welfare provision: effectively balancing coverage and benefits between elites and masses in order to maximize the regime's survival prospects. Using government documents, field interviews, survey data, and government statistics about Chinese social health insurance, this book reveals that Chinese authoritarian leaders attempt to manage the distributive trade-off by a "stratified expansion" strategy, establishing an expansive yet stratified social health insurance system to perpetuate a particularly privileged program for the elites while building an essentially modest health provision for the masses "In Social Protection under Authoritarianism, Xian Huang analyzes the transformation of China's social health insurance in the first decade of the 2000s, addressing its expansion and how it is distributed. Drawing from government documents, filed interviews, survey data, and government statistics, she reveals that Chinese leaders have a strategy of "stratified expansion," perpetuating a particularly privileged program for the elites while developing anessentially modest health provision for the masses. She contends that this strategy effectively balances between elites and masses in order to maximize the regime's prospects of stability" (ed.) Dedication Contents Acknowledgments List of Abbreviations 1. Introduction 2. A Theory of Stratified Expansion of Social Welfare 3. Overview of China’s Social Health Insurance 4. The Center’s Distributive Strategy and Fund Allocation 5. Local Motivation and Distributive Choices 6. Understanding Subnational Variation in Chinese Social Health Insurance 7. Who Gets What, When, and How from Chinese Social Health Insurance Expansion? 8. Conclusion Appendix A: Data Sources Appendix B: List of Interviewees Cited in Chapters Notes References Index