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Background

In an effort to provide greater financial protection from the risk of large medical expenditures, China has gradually added catastrophic medical insurance (CMI) to the various basic insurance schemes. Tongxiang, a rural county in Zhejiang province, China, has had CMI since 2000 for their employee insurance scheme, and since 2014 for their resident insurance scheme.

Methods

Compiling and analyzing patient-level panel data over five years, we use a difference-in-difference approach to study the effect of the 2014 introduction of CMI for resident insurance beneficiaries in Tongxiang. In our study design, resident insurance beneficiaries are the treatment group, while employee insurance beneficiaries are the control group.

Findings

We find that the availability of CMI significantly increases medical expenditures among resident insurance beneficiaries, including for both inpatient and outpatient spending. Despite the greater financial protection, out-of-pocket expenditures increased, in part because patients accessed treatment more often at higher-level hospitals.

Interpretation

Better financial coverage for catastrophic medical expenditures led to greater access and expenditures, not only for inpatient admissions—the category that most often leads to catastrophic expenditures—but for outpatient visits as well. These patterns of expenditure change with CMI may reflect both enhanced access to a patient's preferred site of care as well as the influence of incentives encouraging more care under fee-for-service payment.

This study is part of Karen Eggleston's research project Addressing Health Disparities in China

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This blog post was first published by the Australian Strategic Policy Institute's The Strategist analysis and commentary site.


The Quad is stronger than ever. The informal ‘minilateral’ grouping of Australia, India, Japan and the United States has in the past year held its first stand-alone ministerial meeting and its first leaders’ summit, and launched an ambitious project to deliver Covid-19 vaccines. This ‘golden age’ of the Quad is a product of newfound Indian enthusiasm for the grouping, in turn, spurred by the military crisis in Ladakh, where India faces ongoing Chinese troop incursions across the two countries’ disputed border.

But the Quad is not bulletproof. Some experts have suggested that the economic and diplomatic effects of the devastating second wave of the pandemic in India will preoccupy the Indian government, sapping the Quad of capacity for any new initiatives. Others counter that India remains committed to competition with China—which is what really matters for the Quad—although its partners always expected ‘two steps forward, one step back’ from India.


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Related: On the Conversation Six podcast, Tarapore discusses the policy paper on which this blog post is based with Jawaharlal Nehru University Professor of International Politics Rajesh Rajagopalan. Listen:


The pandemic may well prove to be a hiccup in the Quad’s evolution, but a potentially much larger disruption may come from the ongoing Ladakh crisis itself. As I argue in a new ASPI Strategic Insights paper, the crisis has greatly increased the risk of a border war between India and China, which would present a defining test of the Quad. A possible war could either strengthen or enervate the Quad—depending on how India and its partners, including Australia, act now to shape the strategic environment.

Risk is a function of likelihood and consequence. The likelihood of war on the India–China border is still low—both countries would prefer to avoid it—but has risen since the crisis began. Both countries have greatly expanded their military deployments on the border and backed them with new permanent infrastructure to resupply and reinforce them. China has proved its revisionist intent with large and costly military incursions, although its specific objectives and plans remain unknown. And the interaction of both countries’ military strategies and doctrines would, on the threshold of conflict, promote escalation.

The consequences of a possible conflict would be dire for both belligerents and for the region. China — assuming it is the provocateur of conflict—would likely face some political rebuke from states that consider themselves its competitors, but it will work strenuously to reduce those costs, and would likely have priced them in to its calculations of whether to fight. India will suffer high tactical costs on the border, and may also suffer wider harm if China uses coercive cyberattacks against strategic or dual-use targets.

In a costly war, the repercussions may spill over to damage India’s recently developing strategic partnerships, especially with the United States and Australia. Despite generally favorable views of the US, the Indian strategic elite still harbors some latent suspicions. This was highlighted in two episodes in April 2021, when the US Navy conducted a freedom of navigation patrol through the Indian exclusive economic zone, and when the US was slow in delivering Covid-19 vaccine raw materials and other relief. Both instances quickly receded from the Indian public imagination—thanks to quick correctives from Washington—but they did reveal that, under some conditions, Indian perceptions of its new partnerships can be quickly colored by distrust.

A China–India border war may create exactly those conditions. There is a chance that conflict may result in a redoubled Indian commitment to the Quad, if New Delhi judges that it has no option but to seek more external assistance. Conversely, unless a conflict is managed well by India and its partners, it is more likely to result in Indian disaffection with the Quad. India deepened Quad cooperation during the Ladakh crisis partly as a deterrent signal to China, and partly because the Quad is still full of promise. However, after a conflict—when China hasn’t been deterred and has probably imposed significant costs on India—the Quad’s utility would have been tested, and probably not ameliorated India’s wartime disadvantage.

The task before Quad governments is to be sensitized to this risk and implement mitigation strategies before a possible conflict, to buttress the coalition in advance. As I outline in the ASPI paper, they could do this at three levels. First, they could offer operational support—such as intelligence or resupply of key equipment, as the US already has done in the Ladakh crisis—although Quad partners’ role here would be limited. Second, they could provide support in other theatres or domains—with a naval show of force, for example, although cyber operations would probably be more meaningful in deterring conflict or dampening its costs. Third, they could provide political and diplomatic support — signaling to Beijing that a conflict would harm its regional political standing.

For Quad members, the main goal would be to deter conflict in the first place, and, failing that, to preserve the long-term strategic partnership with India for the sake of maintaining as powerful and energetic a coalition as possible to counterbalance China in the long term.

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The Ladakh crisis between China and India seems to have settled into a stalemate, but its trajectory could again turn suddenly. If it flares into a limited conventional war, one of its incidental victims could be the Quad.

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A quote from Arzan Tarapore's policy brief on the implications of the China-India border tension for the Quad and a cover of the paper in the Australian Strategic Policy Institute

The Ladakh crisis between China and India seems to have settled into a stalemate, marked by somewhat reduced tactical tensions and continuing fruitless talks on disengagement—but its trajectory could again turn suddenly, even flaring into a limited conventional war. Despite a limited disengagement, both sides continue to make military preparations near the Line of Actual Control (LAC) to increase their readiness for potential conflict. While China proved its revisionist intent with its 2020 incursions, its specific goals and plans remain opaque. The broader political context is marked by distrust and hostility, and bilateral relations are at their lowest ebb in decades. War remains unlikely—both sides can ill-afford the distraction from higher national priorities and have demonstrated a recent keenness to step back from the brink. But, with growing capabilities and unclear intent, and with military operations no longer impaired by winter, the Ladakh crisis may still escalate to conflict.

The crisis has been full of surprises. Despite observing major military maneuvers in China, India didn’t anticipate the multiple incursions across the LAC in May 2020. For weeks thereafter, the Indian Army leadership insisted the incursions were nothing out of the ordinary. After both sides agreed to an early disengagement plan, the crisis took a shocking turn with a deadly skirmish in June — the first loss of life on the LAC in 45 years. India also mustered its own surprises, deploying troops to occupy tactically valuable heights in late August, to gain some bargaining leverage. And the crisis also abated with a surprise, with the sudden announcement of disengagement from heavily militarised stand-off sites around Pangong Tso Lake in February 2021.

Future surprises may yet occur. This paper argues that the risk of China–India conflict is significant because, even if its likelihood is low, its consequences may be considerable. A limited conventional war would be likely to impose significant costs on India, but, depending on the reactions of its partners, it may also reinforce latent Indian suspicions over the utility and reliability of its strategic partnerships. In that way, even a localized limited war on the LAC may have far-reaching implications, if it incidentally drives a wedge between India and its partners in the Quad. Mitigating that risk will require sound policy settings and astute diplomatic and public messaging from Canberra, Washington, Tokyo, and other like-minded capitals.

The remainder of this paper is in three parts: first, why a border war is plausible; second, what costs it would impose on India and how it might stir distrust of India’s Quad partners; and, finally, a framework to mitigate those risks.

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Arzan Tarapore
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"As the ruling Communist Party celebrates its 100th anniversary this week, China’s leaders face formidable economic challenges, from falling birth rates and income inequality to rural-urban opportunity gaps." Scott Rozelle shares his insights.

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Claire Cousineau  is a writer and former researcher at the Stanford Center on China’s Economy and Institutions, she is currently pursuing her MBA at Duke University.

Since studying and working in Beijing and Kunming, Claire is passionate about fostering a deeper public understanding of China’s role on the global stage and creating cross-cultural relationships. Claire is the co-author of the book, The Highest Exam: How the Gaokao Shapes China, along with Hongbin Li and Ruixue Jia, published by Harvard University Press in 2025. 

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This article was originally published in The Wire China on June 20, 2021. You can see the full article here.

Q: In your book, Invisible China, you paint a stark portrait of rural China and those left behind in the country’s economic boom, and you offer some dire warnings about the consequences of such a large and potentially growing underclass. Can you tell us how and why they’ve been left behind?

 

A: Well, China has 1.4 billion people, and nearly 70 percent of them are rural. That’s more than 900 million people. That means one out of nine people in the world is from rural China. They’re factory and construction workers. They’re in the informal service sector. They’re the ones who sweep the streets and collect the garbage and deliver the packages to the door and open little stores and sit on the curbside and hawk apples and plums. 

The ironic thing is that even though there are so many of them, in many ways they are invisible to the outside world. They mostly live in villages in central and western China, which is a separate world from the cities that we see on CNN or read about in The New York Times. They have to send their kids to rural schools in their own remote local counties. They get their health care in home counties. 

In fact, in a number of ways it’s very much like the United States. We have 40,000 school districts in the United States. China has 40,000 school districts. All the school districts in the U.S. are funded by local property taxes. So if you’re rich, like Palo Alto [California] or Cambridge [Mass.], you have lots of resources to invest in your schools. About the only people they hire as new teachers at Palo Alto High School have PhDs. But if you’re in Fresno, California, or in the Appalachians or Mississippi, property taxes are really low, so the localities cannot afford to have very good schools. 

The same thing happens in China. Schools are supported by local fiscal resources, which in rural counties are terribly scarce. So you’ve got this system where there’s really two castes: a rural caste and an urban caste. You can move from rural to urban if you get a college degree but that tends to be very hard.

In fact, China has some of the highest rates of inequality in the world. And yet many of these people will say, “I’m much better off than my parents were…” And until now, this has sort of allowed them to buy into the system. There is also a long-held belief that the progress of the past will continue; that they will be better off 10 years from now. This is the China dream. 

But if some of those people at the bottom begin to lose hope that the future will be better — and, if they see the lives of others, meanwhile, continuing to improve — you could start to have the emergence of a polarized society where wages for those in the lower income strata start to top off or even fall, and their employment prospects also fall. People could begin to say, “I don’t know what my life is going to be like 10 years from now.” 

That’s what I try to address in the book; precisely that danger. It’s not a 100 percent certainty that the economy is going to unfold in that way, but if polarization does begin to emerge, hope for a better life would begin to fade for a large segment of society. And if it is going to happen, it is likely to begin to unfold now, since this often happens when a nation tries to go from an upper middle income society to a high income one; the nature of jobs change and the nature of opportunities in high-skilled economies changes.

Read the full Q&A.

 

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In this article by the Wire Scott Rozelle, SCCEI Co-Director and development economist, talks about the middle income trap, educating China's children, and why we should all want China's economy to succeed.

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Webinar recording: https://youtu.be/ShtOUZ67F-s

 

Webinar Description:

From amazing athletic feats to beautiful pageantry, the Olympics command the world’s attention like no other event. Students and families alike are sure to watch at least some of this summer’s games from Tokyo. But how might we, as teachers, use the Olympics to introduce topics from East Asian history? In this webinar, Ethan Segal explores the many meanings of the Olympics for China, Japan, and South Korea, from displaying recovery to promoting democracy. Join us for an interesting, engaging session that will provide useful background content, help you rethink some old assumptions, and highlight some connections for teachers to use in bringing the Olympics into your classroom.

Register at https://bit.ly/3gU7SC5.

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China’s economy has doubled in size every eight years since 1979, making it over 32 times bigger now then it was then and the second largest in the world today.1 Four decades of growth have ushered more than 400 million people in China into the global middle class.2 According to the World Bank, China is currently an upper middle-income country. The country is the only major economy on earth to report growth in 2020 in the wake of the coronavirus pandemic.3 What are the prospects for China to continue its spectacular economic rise and become a high-income country? In this article, we aim to draw attention to an underappreciated factor that we believe may complicate China’s continued economic ascent: hundreds of millions of poorly educated, increasingly underemployed workers hailing from China’s rural hinterland.
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The Washington Quarterly
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Scott Rozelle
Matthew Boswell
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