ABSTRACT
The institutional changes described in Chapter 2 have been the outcome of political processes and the balance of power between pro-government and pro-market actors in the national arena. They have been the target of constant contestation and political conflict, as this chapter will show using the example of the CMS in the 1980s and 1990s. By the mid-1980s, the central government had decided to establish a public rural social security system until the year 2000, which was to guarantee, among other things, universal access to healthcare. On the one hand, the social problems caused by the fallback on family as the primary guarantee of social security already had become visible by the mid-1980s (Hsiao and Du 1985). On the other, the one-child policy would ultimately render the model of family-based social security unsustainable. As noted in Chapter 2, the overburdening of families’ financial capacity by illness-related burdens and financial shocks increasingly caused temporary or permanent impoverishment in the rural areas. Against this background, the central government decided to explore new options for the rural welfare regime. The problem of illness-induced poverty was to become pivotal in the process of agenda-setting for a rural public health insurance system. The main choice was between state-provided healthcare and a more
market-oriented approach. A market-oriented approach meant the primary responsibility of the PICC for local insurance programs and individual insurance contracts. The MoH and the MoCA were the main ministerial stakeholders of state-provided social security, and they were not ready to leave social security in the rural areas to the PICC alone. The second half of the 1980s was thus characterized by strategic local experimentation with various riskpooling programs in health and pensions. The 1990s saw two initiatives to rebuild the CMS in the rural areas, one enacted in 1991 and the other in 1996/97. Both of the programs failed to attain nationwide coverage at the implementation stage. By 2000, insurance companies were expanding quickly in the rural areas. This chapter will analyze the policy process around the establishment of a
rural social security system between 1985 and 2000, focusing on health
insurance and the CMS. The first part will introduce the main actors in the national arena and the political status quo between the pro-government and pro-market actors during this time. The second part will focus on the competing experiments in the 1980s. The third and fourth part will analyze the first and second initiative to rebuild the CMS in the rural areas. Chapter 4 will continue with the policy process of the NRCMS.
