As the Wuhan virus spreads, Chinese health care is under the microscope. On Jan. 22, the government declared that it would cover the costs of treatment for victims of the coronavirus. But that might not be enough by itself. In China, some 95 percent of the population has health care coverage, but the system looks more like a business than a platform to save lives. Unlike in democratic socialist or most communist states, where health care is free for all citizens, in China the health care system is mostly private and always pricey. That underlying reality is behind much of the failings of the system.
During Mao Zedong’s communist era, health care, although defined only through basic services, was freely provided to everybody. That was the moment when “barefoot doctors” appeared. Even though they lacked medical studies, by undergoing apprenticeships and by practicing basic medicine, they aided farmers’ health, increasing life expectancy, contributing to the eradication of diseases such as smallpox and polio by promoting vaccination, and reducing the incidence of schistosomiasis—a disease caused by a worm living in swamps and rivers.
But once Deng Xiaoping came to power, China started its journey on the capitalist road, or, as China branded it, socialism with Chinese characteristics. This enabled an economic miracle in which hundreds of millions of people escaped poverty. Unfortunately, while profits boomed, access to health care suffered. Paradoxically, this didn’t stop the average health of Chinese getting better—reflected, among other things, in ever increasing height. Getting richer will do that, especially in a country that lacked food security until the 1980s, as will improved sanitation. But getting sick in China is still a nightmarish experience.
I first encountered the Chinese health care system during my first visit to China in 2016. Because of jet lag, I had problems sleeping, and I was looking for a doctor to give me a prescription for sleeping pills. Since my Chinese colleagues were aware of the impossible waiting times at Chinese doctors’ doors, they recommended that I go to a private Japanese clinic. While it was more available, it was also too expensive to go to for a simple prescription—which would cost around $350.
Modern China has a saying: kanbing nan, kanbing gui— difficult to see a doctor, expensive to see a doctor. Getting an appointment can take anywhere between minutes and months, depending on the doctor’s skills, the illness, and the patient or their family’s connections. The better the doctor, the longer the waiting period. That’s why a new black market job appeared in China, that of the “yellow cows,” the scalpers who make a business by reselling appointment tickets, sometimes even 10 times more expensive. The government has tried to fight that by ensuring that appointments can be made only through a mobile phone app. Bribes are also common, creating another out-of-pocket expense for Chinese patients.
In 2015, the head of a Chinese hospital was investigated for receiving almost $18 million in bribes, including properties. Money is the name of the game, not only for individuals but also for institutions. Most hospitals in China are private or mostly self-funded. They work like businesses, not nonprofits. A friend of mine told me about the Russian roulette doctors played with her. After being hospitalized because she was feeling unwell, she ended each day being told of a new scary diagnosis like cancer or another terminal illness, thus each day bringing new screenings and tests. This friend ended up with a $15,000 bill (a huge amount for China) and without a clear diagnosis.
Even in a capitalist country, this would be a shock. In a socialist country, it’s beyond belief. We don’t even have to compare China with the United States or Europe—all we need to do is take a look across the Taiwan Strait. For example, in a typical case in Taiwan, which introduced single-payer health care in 1995, one foreigner paid just $80 for a few days of hospitalization. In China, for suturing a wound and for a few blood tests, I paid $250 (half of the salary of a typical Chinese factory worker).
There are three types of health insurance in China: Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, and the government insurance offered in rural areas, the New Cooperative Medical Scheme. Many Chinese also have private insurance. But this very rarely covers everything. This is because, in China, almost one-third of health care expenses are paid out of pocket. Chinese patients pay almost 30 percent of health care expenses, the government funds only 30 percent, and insurance covers the remaining 40 percent.
The out-of-pocket cost, incredibly, surpasses the sum in the United States: According to 2015 data from the Organization for Economic Cooperation and Development, it amounted to 32 percent of health care spending, almost three times as much as in the United States, where it represented only 11 percent. I learned this the hard way: going to the emergency room of a top Beijing hospital after an accident. The insurance company refunded me only the cost for the surgical procedure—which it said was the only emergency procedure, ignoring the adjacent medical investigations, which I had to pay for out of pocket.
The poorer you are, the less chance there is you’ll receive free medical care. Poor people from rural areas use health care insurance provided by the government, which has a limited coverage, so they must pay severely from their own pockets. 2015 data showed that 44 percent of poor families in China are impoverished by illness debts. So, if you are poor in China, you will become even poorer because of hospital bills. On top of that comes the hukou system of residence permits, which makes access to better services even more difficult, as James Palmer and Rui Zhong explain, because it’s difficult to use your insurance away from the place you are registered in.
Even if they had the money to pay for medical services, farmers wouldn’t have access to good medical care because there is a scarcity of hospitals and doctors in rural areas. China has only an average of 4.2 hospital beds for 1,000 people, compared with Japan and South Korea, which have 13.1 and 12 beds per 1,000 people. The total number of general practitioners in China reached 300,000 in 2019, meaning that one general practitioner covers almost 4,700 people in China, while in developed nations the ratio is 1 to 1,500-2,000. And they are also getting older—due to the lack of personnel and a low average starting salary. Preventing a disease is always better than curing it, and this applies to government expenses, too.
In China, the health care system is not focused on the patient but led by a capitalist Darwinism—those who have the money survive, while those who don’t suffer or die. Rural patients regularly die or suffer serious problems due to a lack of money. But there is also some good news. The government has introduced an initiative called Healthy China 2030, whose goals include reducing out-of-pocket cost from almost 30 percent to 25 percent by 2030. Yet that marginal improvement isn’t enough in a rapidly aging country.
China needs an Elizabeth Warren or Bernie Sanders—somebody willing to stand up for radical health care reform. As a communist country, free health care access should be a priority. At the moment, the U.K., Nordic countries such as Norway, Sweden, and Finland, and even many other Western states (including my country, Romania) do better at socialist health care than a supposedly communist state.
Xi Jinping has made frequent ideological fodder of Marxist ideas. But the basic ideas of communism—fair and equal provision for all—seem sadly lacking, even as a self-proclaimed communist party still dominates politics. If the People’s Republic actually wants to live up to its name, it needs to take better care of its people.
