Rural health insurance - rising to the challenge

33235 Rural Health in China: Briefing Notes Series Rural Health Insurance--Rising to the Challenge government's new rural health insurance Background to the Briefing Note program is rolled out, and suggests that the solutions to many of these problems lie in the How can health insurance coverage in China be experiences of the past--both in the rural and expanded and deepened? How can health urban schemes. insurers keep costs down and ensure high quality care for their members? What role should government have in health insurance in The legacy of economic liberalization-- China? These were some of the questions falling and shallower coverage addressed by two critical reviews of the Chinese-language and English-language literatures on rural and urban health insurance in Under China's pre-reform planned economy, China and abroad.* almost all citizens were covered by some form of health insurance. Agricultural workers were The reviews come at a key moment. Against a covered by the old commune-based CMS, state- background of an almost total collapse of the owned enterprise (SOE) workers were covered old rural cooperative medical scheme (CMS) by the Labor Insurance Scheme (LIS), and civil and declining coverage in urban areas, the servants and other government workers were government has started piloting a new CMS in covered by the Government Insurance Scheme over 300 counties and is looking to extend (GIS). There were some gaps in coverage (not coverage of the newly reformed urban scheme. all urban schemes covered dependents, for Both programs face challenges relating to example), but the gaps were relatively small breadth and depth of coverage, cost control, (during the 1970s the CMS covered an quality assurance, and so on. estimated 90% of the rural population). China's near-universal coverage is thought to have been This Briefing Note focuses for the most part on one reason for its spectacular success in the rural health insurance challenge. It traces the improving health outcomes during the 1970s.1 changes in the 1990s in coverage, explores the problems that are likely to be encountered as the China's transition from a planned to a market economy from 1980 onwards brought dramatic reductions in health insurance coverage. The * This briefing note was prepared as part of the World Bank's (WB) ongoing study on China's rural health sector. decollectivization of agriculture resulted in an The study--referred to as the China Rural Health AAA almost total collapse of the CMS. By 1993 less (Analytical and Advisory Activities)--is being undertaken than 10% of the rural population had health in collaboration with the Ministry of Health (MOH) and insurance (Figure 1). The mid-late 1990s saw other government agencies, as well as with selected several attempts to resuscitate the CMS. international partners. The reviews upon which this briefing note is based were prepared by two teams, Despite these initiatives, CMS coverage comprising Professors Wen Chen of Fudan University, nationally remained stubbornly low. By 2003 Gordon Liu of Peking University, Brian Nolan of the 80% of China's rural population--some 640 Economic and Social Research Institute (Ireland), Mao million people--lacked health insurance (Figure Zhengzhong Of China West Medical University, and Liu Yuanli of Harvard University. The team benefited from the 1). Half of the rural respondents in the 2003 comments of Wang Hufeng of the Ministry of Labor and NHS who said they had insurance said they Social Security and Han Jun of the State Council were covered by either private (i.e. commercial) Development Research Center, who were the discussants insurance or `other' insurance. for these critical reviews at the AAA workshop in July 2004. The briefing note was prepared by the World Bank AAA team. The findings, interpretations, and conclusions These included the RAND Sichuan CMS experiment in expressed herein are those of the authors, and do not mid-1990s2, the WHO 14 county study in the early 1990s3, necessarily reflect the views of the World Bank or those of the UNICEF 10- county study in 1997-2000, the World its Executive Directors or the governments they represent. Bank Health VIII project in the late 1990s, and the Harvard For further information on the China Rural Health AAA 2-county study in 20034. and related activities, contact L. Richard Meyers Examples of schemes in these categories would include (lmeyers@worldbank.org). schemes intended to provide broad coverage, as well as Briefing Note No.6 1 May 2005  1995-98. Central government launched a formal Figure 1: Health insurance coverage in China pilot experiment of new community-based insurance has been falling models in the cities of Zhenjiang and Jiujiang. This pilot model introduced some fundamental changes in 80 the existing GIS and LIS. The most significant 70 Other changes included the socialization of financing, jointly contributed by employers and employees, to % 60 form a citywide insurance pool across all work units. gear Private/commercial 50 The pooled funds were then distributed into ovececnaru individual Medical Savings Accounts (MSA) and a 40 CMS Social Pooling Account (SPA). In the end of 1996, 30 GIS, LIS, BMI the experiment reform was extended to 57 other cities. nsi20 10 1998-2003. In December 1998 a nationwide effort was called for by the State Council to reform the 0 existing GIS and LIS in the remaining cities 1993 1998 2003 1993 1998 2003 following the Zhenjiang and Jiujiang pilots. By the Urban Rural end of 2003, the vast majority of large cities had implemented the new Basic Medical Insurance (BMI) Source: National Health Survey5,* insurance program, covering over 109 million urban employees. Coverage in China's cities has also declined, though less dramatically than in rural areas. As 2000-present. In parallel to the above reforms, the China transitioned to a market economy, the government started to reform the hospital and SOE--the backbone of the LIS--came under pharmacy markets in an effort to lower costs or at increasing pressure. LIS coverage fell, as did least reduce inflation in the health sector. GIS coverage. By 1998 nearly half the urban population lacked insurance coverage. A variety It is not just the number of people covered by of reforms have been introduced, including the health insurance that has been falling. The depth setting up in 1998 of a new single urban scheme of coverage has also been declining (Figure 2). known as Basic Medical Insurance (BMI), into By 1997, insured patients were paying more which LIS and GIS are gradually being than one third of their inpatient costs out of their subsumed (Box 1). Despite these reforms, own pockets.9 The falling depth of coverage coverage by GIS/LIS/BMI continued to fall reflected in part the introduction of formal cost between 1998 and 2003. Had it not been for the containment measures (see below) but also the growth of private and `other' insurance schemes, fact that in the transition to the market economy, coverage would have fallen below 40% in 2003. many SOEs found it increasingly difficult to honor their LIS commitments. The government Box 1: Urban health insurance reform increasingly withdrew from its role of payer of last resort.10 In Zhenjiang, for example, it was Urban health insurance reform in China can be estimated that more than half of the SOEs were broken down into four phases.6-8 unable to fully reimburse the medical bills for their employees. The new schemes that have 1988-94. Small-scale and preliminary reforms were emerged also appear to be less generous than the introduced in a few cities, focusing primarily on the old ones (Figure 2). application of demand-side cost-sharing mechanisms under the existing GIS and LIS. those targeted to specific groups, such as school children, where the risks covered are very limited. Little has been written about such schemes, even in the national media, and it is striking that they provide some form of coverage for as many as 10% of China's rural population. *Figures for urban 2003 are from Ling Xu's presentation at Dec. 2004 MOH seminar on the 2003 NHS survey. Figures for rural 2003 are from Main Findings from the 3rd NHS Survey, www.moh.gov.cn, accessed on April 21st, 2005. Briefing Note No.6 2 May 2005  Figure 2: Inpatient care reimbursement rates In the pilots so far, enrolment is reported to be for the insured have been falling around 70%. 90 80 As the government rolls out the NCMS, it will %etra 70 encounter many challenges. As it does so, the 60 government could usefully learn from relevant nt 50 experiences in China--the various attempts of me serubmire40 the 1990s to resuscitate CMS and the reforms of 30 China's urban health insurance scheme--as well 20 as experiences abroad. 10 0 1987 1991 1993 1997 Is the new CMS affordable? GIS/LIS Dependent Collective Special / other Can each of the parties realistically be expected Overall to be able to afford their contribution of 10 RMB or more per person? Some have expressed Source: China Health and Nutrition Survey*9 doubts. Rising to the rural health insurance It would seem reasonable to expect central challenge--the government's new CMS government to be able to afford its 10 RMB per resident of the central and western provinces. Central government spending on health is While extending health insurance cover to relatively small, as is total government spending China's 155 million uninsured urban residents is on health by international standards. China's also an important task, a larger and--in the central government has also seen increases in its government's eyes--more urgent challenge is tax revenues, and is committed to spending that of extending cover to China's 640 million some of them on rural health in general and on rural uninsured. It is this that is the main focus the NCMS in particular. of the remainder of the Briefing Note. Whether local governments can afford their 10 Rising to this challenge, China's government RMB is less clear. The bulk of health spending recently developed plans for a New Coperative in China is financed by local governments who Medical Scheme (NCMS). The scheme is are highly dependent on their own revenues. As currently being piloted in over 300 of China's a result, government spending per capita varies more than 2000 counties, and will be rolled out considerably across provinces--and even more to the rest of the country by 2010. so across counties. The more of the 10 RMB that counties have to finance rather than The NCMS differs from the old CMS in several cities/prefectures and provinces, the more important respects. Contributions from regressive the local government element of the households--starting at 10 RMB per person, NCMS cost will be. For poor counties, even 4 and to be paid on a voluntary basis--will be RMB per person could represent a fairly large supplemented by a subsidy of 10 RMB or more fraction of their existing health spending. And from local government and a 10 RMB matching the NCMS initiative comes at a bad time for subsidy from central government in the case of local government officials. China is in the households living in the poorer central and process of abolishing several agricultural taxes, western provinces. The NCMS will operate at which is reducing the tax revenues of townships the county level rather than at the village or and counties. To some degree this is being township level as was the case in the old CMS. offset by a shifting of expenditure responsibilities to higher levels and by the provision of compensating transfers, but these will go only part of the way to restoring *The figures refer to actual reimbursement rates, not rates township and county government revenues. This promised by the schemes. The CHNS is not statistically representative of the Chinese population but does cover a all assumes the 10-RMB contribution will be broad spectrum of China's provinces. The `other' category additional money--it may be that some local is used in the CHNS as a catch-all for categories other than those listed explicitly in the questionnaire. Briefing Note No.6 3 May 2005 005  governments see the NCMS as an opportunity to care until the problem becomes so severe that shift from supply-side to demand-side subsidies. the care they need is serious enough for them to receive some assistance from the CMS. This The household contribution of 10 RMB or more happens in other countries, and there is no seems affordable at least for the average reason to think it wouldn't happen in China too. household, given that it represents just 0.4% of It may be better, therefore, to have a benefit the rural per capita income. It will, it is true, be package that covers both high-cost and low-cost a much larger fraction for poor households. events, and outpatient and inpatient care. The However, this could be tackled by having the coinsurance rates ought to be higher for Ministry of Civil Affairs' Medical Assistance outpatient than inpatient care. (MA) scheme help the poorest households with their NCMS contributions and perhaps their Should public health services such as copayments too.* immunization be covered by NCMS? There are those who say yes, on the grounds that they are The benefit package of the NCMS and under-funded and including them in the NCMS benefit package could help strengthen their its effect on enrolment provision. But there are also those who argue no, on the grounds that doing so would lead to The key issue from the perspective of additional claims of an already tight NCMS households is not whether they are able to pay budget. Internationally, insurers have a mixed 10 RMB but rather whether they are willing to record on public health activities, not least pay it. Is NCMS a good buy for Chinese because they tend to focus on their members and households? People's willingness to participate overlook the benefits of public health activities in the new CMS is likely to depend on a number that accrue to non-members. The emerging of factors. But one key one is how the benefits practice seems to be to take public health offered compare to the 10-RMB contribution. programs and the financing of them outside the health insurance sector. One important number to keep in mind is that 30 RMB per capita represents less than 20% of With less than 20% of average spending per capita annual health spending in rural areas. covered by NCMS, many households may feel So, NCMS is going to leave a lot of expenses the scheme does too little to reduce exposure to uncovered. It is important that the actuaries medical-expense risk. In that case, support for developing the NCMS benefit package do their the NCMS may dwindle, and people will either arithmetic carefully. If they promise too much, not join or start to disenrol. If, as is likely, it is the NCMS will quickly go bankrupt. the `better' risks (the young and healthy) who leave first, the NCMS will start making a loss, One option is to provide generous coverage (i.e. and contributions may need to be raised. This have low coinsurance rates) on low-frequency may prompt a further exodus by good risks, and high-cost medical events--the sort that lead to a downward spiral will start, with the scheme `catastrophic' medical expenses. One risk with eventually collapsing--a problem known as this is that since very few people experience adverse selection. such expenses, most members will receive little direct financial assistance from the CMS. Of The experience from other countries indicates course, they receive indirect assistance since the that adverse selection can quickly undermine CMS has reduced if not eliminated their and ultimately precipitate the collapse of a exposure to the risk of catastrophic medical purely voluntary scheme. This does not depend costs. But they may not see it that way. on how sound the benefit package is from an Potentially this attitude could be changed actuarial standpoint, or on the fraction of through education and social marketing. average spending covered by the scheme. It simply reflects the fact that in any population, But there is a further problem with a scheme there will be good risks and bad risks, and if the that focuses exclusively on catastrophic costs, scheme is voluntary, the better risks will prefer namely that people may delay seeking medical to self-insure. It is for this reason that health insurance in industrialized countries is almost *The links between health safety nets and the NCMS are always compulsory. to be discussed in a future Briefing Note on health safety nets. Briefing Note No.6 4 May 2005  members are likely to be more heterogeneous in Trustworthy and competent terms of their health conditions and management--key ingredients of geographical locations than BMI members. NCMS success NCMS involves a more complex fund- collection process than the BMI, where contributions are collected through a payroll tax. It is not just a question of getting the NCMS NCMS also has to deal with a more diverse set benefit package right. There is another of providers. important lesson from the previous attempts to resuscitate CMS, especially in the UNICEF 10- One question for NCMS management to answer county study, namely that people need to trust is: Which providers will be certified to deliver the organizers of a CMS scheme if they are to care at the NCMS's expense? This process is participate in it. critical for holding down NCMS costs as well as ensuring NCMS members receive quality care. Trust is partly about eliminating corruption. But it is also critical to ensuring access. Will Many CMS schemes that have failed have done village doctors be certified even though they are so because of corruption. Involving private? Will only public township hospitals be beneficiaries in overseeing the CMS may help certified? Restricting the list to public providers reduce corruption. This is one of the ideas may have has some merit but has the underlying an experiment sponsored by Harvard disadvantage that people may find they cannot University in Kaiyang county (Guizhou) and use their usual provider with their NCMS Zhenan county (Shaanxi), where villagers serve coverage. This may mean households have to on the CMS board of directors.4 travel further to see a provider than before. It may also mean that NCMS results in households Some argue that the lack of trust in the simply substituting public visits for private resuscitated CMS schemes was sometimes due visits, rather than increasing the overall number to management team members having a dual of visits. function as manager of an insurance fund and manager of a health facility. This led CMS Central government could play a useful role in members to wonder whether the CMS was helping develop trustworthy and competent acting in the interests of providers or CMS management in the NCMS, providing technical members. The fact that NCMS is to be located assistance, and ensuring that there is learning at county level and separate from the provider from and cooperation with relevant parts of network should substantially militate against government, such as BMI, tax bureaux, and so this. NCMS seems set to play the role of on. `purchaser' for its members, negotiating service delivery arrangements--cost, quality, timing Moral hazard and NCMS costs and location of treatment, etc.--on behalf of its members. In the rush to extend coverage to China's large This calls for a strong NCMS management-- rural uninsured population, one further one that is not simply trustworthy but also important lesson needs to be kept firmly in capable of discharging the functions of an mind. It is a lesson that comes from China's insurer-purchaser agency. This will require own experience with urban health insurance in building up a professional staff, albeit one that the 1980s and 1990s. And it is one that comes is overseen by local representatives. through loud and clear from other countries, especially the United States. The lesson is that The task of developing competent management health insurance is associated with a problem in NCMS is a challenging one, as comparisons known as moral hazard. with BMI indicate. BMI typically covers about 10,000 members at the county level, albeit with This curious term refers to the fact that with a more generous benefit package. Each county someone else picking up the bill for treatment, might have as many as 15 full-time staff. patients and providers alike have an incentive to NCMS, by contrast, is expected to cover an increase the amount of care delivered--extra average of 250,000 members per county, and is tests, more expensive medicines, a switch to also more complex in many respects. Its Briefing Note No.6 5 May 2005005  surgery even though it is not medically at different times. Furthermore, different cities necessary, and so on. tried different approaches to demand-side cost sharing. Two approaches developed in the 1995- China's experience with urban health insurance 98 pilots are often contrasted--the pathway illustrates this nicely. LIS and GIS members model and the compartmental model (Box 2). paid very little out of their own pockets, and Both make use of a Medical Savings Account providers were paid on a fee-for-service basis. (MSA) and a Social Pooling Account (SPA), There was, in short, no or little demand-side or with the employee and employer contributing to supply-side cost sharing. Unsurprisingly, moral the former, and only the employer to the latter. hazard ensued, exacerbated by the continuous However, the contribution rates vary across introduction of ever-more-costly medical schemes as does the use to which each of the technology. In the city of Zhenjiang between accounts is put.6,12,13 The supply-side cost- 1992 and 1995 total medical insurance expenses sharing approaches also differ between the two increased at an annual rate of 33%.11 models. Most of the past and many of the current CMS Box 2: The pathway and schemes operated or operate like the old GIS compartmental models of cost sharing and LIS in that they passively reimburse members' medical bills. If this were to be the The pathway model--Zhenjiang and Jiujiang model of the NCMS, health care costs in China would be likely to rise quite dramatically. When any costs are incurred under this three-tier NCMS needs therefore to think carefully about reimbursement system, payments are first made out introducing measures to contain costs. What of the MSAs funds. After the MSA funds are could these be? exhausted, the patient pays an out-of-pocket deductible as the second tier, up to 8-10% of the individual's annual salary (deductibles for retired Cost containment--lessons from the members are half). After the member has reached his urban reforms deductible, the third tier payment begins to pay by drawing funds from the SPA. As indicated earlier in this Note, urban health Before 1997, medical providers in Zhenjiang were insurance in China has recently been through paid primarily retrospectively at the patient or many important reforms. These appear to have service level using various fee schedules that varied had considerable impacts on costs. with the level and type of provider. In 1997, the retrospective reimbursement approach was changed to a global budget approach. Prospective payment In Zhenjiang, for example, a series of reforms was used to pay for all medical services out of funds were introduced from the mid-1990s onwards. in the SPA. Initially, these involved demand-side cost- sharing only--patients being required to pay The Compartmental model--Hainan more of the cost out of their own pocket--and costs carried on rising at similar rates. So, in In this approach the MSA and SPA are service- 1997 supply-side cost sharing was introduced-- specific, with the former primarily paying for providers were required to take on more outpatient services and some small inpatient services financial risk, by moving away from full-cost not covered by the scheme, and the latter paying reimbursement towards a system where the mainly for inpatient care and some large outpatient bills. Only those drugs and diseases that are amount paid is fixed in advance. For example, included in official lists are paid by SPA, coupled instead of being paid fee-for-service (FFS), a with a deductible (400 RMB) and decreasing co- provider might be paid a fixed amount for a payment schedules, ranging from 15 percent, 9 given casetype, or a budget based on expected percent, 5 percent, and 0 percent. Outpatient care caseload. When supply-side cost sharing was services are paid by funds in MSAs on a fee-for- introduced in Zhenjiang, the annual rate of service basis according to a pre-determined pricing increase of insurance costs was brought down schedule.14,15 from 33% to 15%, where it has since stayed.11 The SPA has paid providers primarily through a The urban reforms in China involved a mixture global budget. A current-year global budget is determined on the basis of the actual total medical of demand-side and supply-side cost sharing, expenditures in the previous year, adjusted for and different cities tried different combinations changing factors such as price inflation and Briefing Note No.6 6 May 2005 005  increased numbers of beneficiaries. The Medical this, it has been the compartmental model that Insurance Bureau generally withholds 10 percent of has proved most popular--only Shenzhen has the total budget upfront in order to monitor and adopted the pathway model. control provider behavior during the year. At the end of the budget year, the Bureau will then determine how much of the withheld amount is returned to the NCMS and the rural-urban divide provider according to the performance and quality of services delivered.16 As in other countries, the urban and rural areas of China are not hermetically-sealed entities. What have been the effects of the various cost- People increasingly migrate from rural to urban sharing measures? And what lessons are there-- areas, and this is likely to become an important if any--for the new rural CMS? engine of economic growth. Migrants from rural areas to cities may find themselves in a health The Zhenjiang and Hainan reforms appear to insurance no-man's land--ineligible for urban have reduced costs to insurers.17-19 Part of the health insurance because of lack of official reason seems to be that providers' unit costs residency, and likely to be required by their fell. In part this may have been due to the NCMS to return to their village for treatment or introduction of drug formularies and restrictions risk having NCMS pay only part of their on the use of advanced medical technology.17 medical bill if they seek treatment in the city But cost sharing on the supply side seems likely where they are working. If the economic to have played a bigger role. In Hainan hospitals benefits of labor migration are to be fully shifting from FFS to global budgets reduced harnessed, it will be important to ensure that cost per case while hospitals that continued to health insurance becomes more portable--that be paid FFS increased theirs.20 Hospitals in the loss of effective health insurance coverage does first group reduced costs by spending less on not become a reason to prevent people moving. expensive drugs and high technology.21 And in Zhenjian, it was not until supply-side cost As the boundaries between urban and rural areas sharing was introduced in 1997 that spending by becomes increasingly blurred, and as the insurers was successfully brought under government strives to reduce rural-urban control.11 inequalities, there will be a pressure to reduce the stark divisions between the rural and urban On top of the reductions on unit costs, there is health insurance schemes. The gap in terms of also evidence that the reforms led to patients generosity of coverage is stark and unlikely to substituting outpatient care for inpatient care, be explained by cost differences: revenue per with the poor substituting the most.18,22 The beneficiary in the urban scheme is around RMB impacts on health outcomes are not known, 400, while the proposed revenue per beneficiary although it is known that during the period in in the NCMS is (a minimum of) 30 RMB. question there was a reduction in the fraction of people saying they had been told they needed Narrowing the rural-urban health insurance gap hospital care but didn't seek it.18,22 need not necessarily involve a merger of the rural and urban schemes, although in some While insurers saw their costs fall as the result provinces--periurban Shanghai is an example-- of the reforms, out-of-pocket payments by this seems to be happening. It could happen households increased. On the positive side, they through a gradual process of moving towards a increased by the same proportion for everyone, more equal sharing of health risks. As in other irrespective of their income.23 The reforms did countries, such as Colombia and The not, however, eliminate inequity: the poor still Netherlands, an equalization fund could be set pay a higher share of their income toward health up where individuals make contributions care than the better off. according to their per capita income, and insurers receive payments from the fund There is broad agreement, then, that the urban according to the risk profile of their members. insurance reforms reduced costs. Some In the longer-term, as the gaps are reduced, it questions remain unanswered, however. For might make sense to bring all Chinese residents example, the available evidence does not into a single universal scheme, as other provide a clear picture of the relative merits of countries--including The Philippines, Thailand the pathway and compartmental models. Despite Briefing Note No.6 7 May 2005  and Vietnam--have done or are in the process 10. Huang M, Sun Y. Current situation, problems and of doing. reform measures of labor insurance system. Zhejiang Social Science 1994(5):64-67. Looking ahead, learning from the past 11. Cai L, Wan C, Wang J. Analysis on Proportion of In- patient Expenses and the Influencing Factors. Journal of Hospital Statistics 1999;6(4):206-209. All told, China faces many challenges as it tries to extend cover to the 800 million uninsured 12. Shen H, Chen X, al. e. Assessing the performance of Chinese, and to deepen the cover of those who integration of medical savings account and social pooling account in Shenzheng. Chinese Health do have it. A brave and historic start has been Service Management 1999;129:123-125. made with the piloting of the NCMS. And many important reforms have been implemented in the 13. Wu R. Try to perfect the system. China Medical urban scheme. But many challenges still Insurance Research 2004;1,2:16-19. remain, as this Note has shown. The good news is that there is considerable scope for learning-- 14. Wang F. Some thoughts about the combination of the medical savings account and social pooling from the urban reforms of the 1990s, from past account. Chinese Health Economics attempts to resuscitate the CMS, and from 1998;17(4):34-36. abroad. 15. Wang H. Controlling for the growth of medical References expenditures using the combined mechanisms of medical savings account and social pooling account. Chinese Health Economics 1999;18(4): 1. Sidel V. New lessons from China: equity and economics 40-42. in rural health care. American Journal of Public Health 1993;83:1665-1666. 16. Luo L. Hainan medical insurance practice and thoughts. China Medical Insurance Association 2. Cretin S, Duan N, Albert P. Williams J, Gu X, Shi Y. Annual Meeting 1998, Beijing. Modeling the effect of insurance on health expenditures in the People's Republic of China. 17. Yip W, Hsiao W. Medical savings accounts: Lessons Health Services Research 1990;25(4):667-685. from China. Health Affairs 1997;16(6):244-251. 3. Carrin G, Ron A, Yang H, et al. The Reform of the 18. Liu G, Cai R, al. e. Urban healthcare reform initiative Rural Cooperative Medical System in the in China: findings from its pilot experiment in People's Republic of China: interim experience Zhenjiang City. International Journal of in 14 pilot counties. Social Science & Medicine Economic Development 1999;1(4):504-525. 1999;48(7):961-972. 19. Zou F. A review of the pilot employee medical 4. Hsiao W, et al. Rural Mutual Medical Care in China. insurance system reform. 2002;13(6):66-72. The Chinese Health Economics 2004;Forthcoming. 20. Yip W, Eggleston K. Provider Payment Reform in China: The Case of Hospital Reimbursement in 5. Gao J, Qian J, Tang S, Eriksson B, Blas E. Health equity Hainan Province. Health Economics in transition from planned to market economy in 2001;10(4):325-339. China. Health Policy and Planning 2002;17(Suppl.1):20-29. 21. Yip W, Eggleston K. Addressing government and market failures with payment incentives: 6. Wang H, Huang G. Assessing the reform models of Hospital reimbursement reform in Hainan, China's urban health insurance system. Chinese China. Social Science & Medicine 2004;58:267- Health Policy 2000:9-11. 277. 7. Ma X, Zhang L, al. e. The current status of urban health 22. Liu G, Cai R, al. e. China's urban health insurance insurance reform in China. Chinese Health experiment in Zhenjiang: cost and utilization Economics 2001;3:50-51. Analyses. In: Hu T, Hsieh C, eds. Economics of Health Care Reform in Pacific Rim. England: 8. Liu Y. 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