Why China Is Too Scared to Spend

When the Mao-era system was dismantled, barefoot doctors disappeared and Chinese medicine became city- and hospital-based. Hospitals were permitted to charge for tests and drug prescriptions, and the more costly the procedure, the higher the revenue for both hospitals and doctors. The result has been "overprescription and overutilization of services," says Dr. Sarah Barber, who heads the World Health Organization's Health Policy and Systems team in Beijing.

With only a patchy network of primary-care clinics left, patients these days struggle to find the right doctor or diagnosis since they can rarely afford to visit many hospitals.

Hospitals charge fees way beyond the reach of ordinary Chinese. The problem is illustrated by the case of Liu Jiangtao, a 25-year-old party member who fell sick with leukemia in mid-2007. Liu currently lies in Beijing's No. 307 military hospital, where he's been trying to persuade TV and radio stations to help him raise the $58,000 he needs for a bone-marrow transplant. That sum is the equivalent of 40,000 times the annual income of his parents, who grow wheat and flax on the salty margins of the Yellow River. Liu was originally hospitalized in Shandong's Dongying City, but after eight months of ineffectual chemotherapy, his parents in May asked relatives for money to move him to Beijing. "Now most of my relatives don't want to communicate with us," says Liu. Meanwhile, delay in treatment has eroded his chances of survival.

Liu's plight points to another basic problem: the lack of adequate health insurance in China, a supreme irony for a country that's still officially communist (indeed, many capitalist countries in the West provide more comprehensive care for free). Liu has insurance, but it's China's most basic program, the Rural Cooperative Medical Scheme (RCMS). The RCMS was rolled out in the last four years. It costs participants as little as $3 a year and has been extended to 90 percent of China's farmers in record time. But the system is badly flawed. For one thing, it's a pay-first, claim-later setup, which doesn't do much good to patients like Liu who can't come up with huge fees in the first place. For another, most claimants get back only 20 to 30 percent of their costs. Many of China's poorest, sickest or least-educated citizens find the RCMS baffling and can't manage to jump through its procedural hoops.

Employer-based schemes have similar problems. Benefits aren't portable geographically so they don't help China's massive migrant population, and workers who lose their jobs can't take their contributions with them. Among city dwellers, health insurance coverage levels dropped from 45 percent of the long-term, settled population in 1998 to 39 percent in 2003. To tackle this, the government consolidated numerous employment-based deals into a single package better suited to job mobility. It then plugged a key gap for migrants with a new safety-net scheme that covers both urban and rural poor. Yet the overall health-insurance system remains so badly designed that simply adding money, as the government is doing, will solve little. Extra insurance funds simply tend to be soaked up by profit-hungry hospitals.

Still, the government is trying. Total government health spending increased from $143 billion in 2006 to an estimated $219 billion in 2007, according to Hu, the economist. And Hu and Barber say that the government is rolling out multiple new pilot schemes, experimenting with fixing drug prices, drawing up a national recommended drug-purchase list and passing price-label laws to prevent rip-offs. Village medics (of whom China has far too few) are to get guaranteed basic salaries in five poor provinces to stop them from relying on prescribing. Perhaps the most promising experiment is taking place in Chongqing, where rural and urban insurance pools are being combined to create portable, individual insurance, something China's lacked until now.