China’s medical insurance system has reached near-universal coverage, yet disparities in access and quality persist. This study investigates how social structural factors shape coverage and quality in the Chinese context. Using 2021 China General Social Survey data (n = 8148), binary logistic regression was applied to basic and commercial insurance participation, and multiple linear regression assessed a composite quality indicator. Predictors included education, income, gender, household registration (hukou), and age. Basic insurance coverage was 94.3%, with education (OR = 1.180, p = 0.003) and income (OR = 1.281, p < 0.001) as positive predictors; gender and hukou were nonsignificant. Commercial insurance coverage was 14.0% and positively associated with education (OR = 1.357), income (OR = 1.276), and urban hukou (OR = 1.180), but negatively with female gender (OR = 0.800) and age (OR = 0.979; all p < 0.01). For quality, education (B = 0.042) and income (B = 0.040) had the strongest positive effects, while gender (B = ？0.032) and age (B = ？0.002) were negative; urban hukou had a small positive effect (B = 0.014). Socioeconomic status—especially education and income—consistently predicts higher coverage and quality. Urban-rural differences are minimal for basic coverage but remain for commercial insurance and quality. Policies should target low-SES groups, women, and older adults through premium subsidies, product customization, and awareness campaigns to advance equity in China’s health insurance system.
References
[1]
Chen, C., & Liu, M. (2023). Achievements and Challenges of the Healthcare System in China. Cureus, 15, e39030. https://doi.org/10.7759/cureus.39030
[2]
Cho, H. E., Wang, L., Chen, J., Liu, M., Kuo, C., & Chung, K. C. (2019). Investigating the Causal Effect of Socioeconomic Status on Quality of Care under a Universal Health Insurance System—A Marginal Structural Model Approach. BMC Health Services Research, 19, Article No. 987. https://doi.org/10.1186/s12913-019-4793-7
[3]
Fan, C. C. (2008). Migration, Hukou, and the City. In T. Saich, & S. Yusuf (Eds.), China Urbanizes: Consequences, Strategies, and Policies (pp. 65-89). World Bank.
[4]
Guo, J., Wu, Y., Deng, X., Liu, Z., Chen, L., & Huang, Y. (2021). Association between Social Determinants of Health and Direct Economic Burden on Middle-Aged and Elderly Individuals Living with Diabetes in China. PLOS ONE, 16, e0250200. https://doi.org/10.1371/journal.pone.0250200
[5]
Hoffman, S., Ward, K., Black, A., Kirby, D., Wood, D. S., & Marsiglia, F. F. (2024). The Influence of Access to Care on the Health Literacy of Families in Mexico. Health Promotion International, 39, daae191. https://doi.org/10.1093/heapro/daae191
[6]
Holt-Lunstad, J. (2022). Social Connection as a Public Health Issue: The Evidence and a Systemic Framework for Prioritizing the “Social” in Social Determinants of Health. Annual Review of Public Health, 43, 193-213. https://doi.org/10.1146/annurev-publhealth-052020-110732
[7]
Hung, J. (2022). Hukou System Influencing the Structural, Institutional Inequalities in China: The Multifaceted Disadvantages Rural Hukou Holders Face. Social Sciences, 11, Article 194. https://doi.org/10.3390/socsci11050194
[8]
Jakovljevic, M., Chang, H., Pan, J., Guo, C., Hui, J., Hu, H. et al. (2023). Successes and Challenges of China’s Health Care Reform: A Four-Decade Perspective Spanning 1985-2023. Cost Effectiveness and Resource Allocation, 21, Article No. 59. https://doi.org/10.1186/s12962-023-00461-9
[9]
Jin, Y., Hou, Z., & Zhang, D. (2016). Determinants of Health Insurance Coverage among People Aged 45 and over in China: Who Buys Public, Private and Multiple Insurance. PLOS ONE, 11, e0161774. https://doi.org/10.1371/journal.pone.0161774
[10]
Lee, D., Wang, J., Shi, L., Wu, C., & Sun, G. (2022). Health Insurance Coverage and Access to Care in China. BMC Health Services Research, 22, Article No. 140. https://doi.org/10.1186/s12913-022-07498-1
[11]
Li, Y., Lu, C., & Liu, Y. (2020). Medical Insurance Information Systems in China: Mixed Methods Study. JMIR Medical Informatics, 8, e18780. https://doi.org/10.2196/18780
[12]
Liu, C., Liu, Z. M., Nicholas, S., & Wang, J. (2021). Trends and Determinants of Catastrophic Health Expenditure in China 2010-2018: A National Panel Data Analysis. BMC Health Services Research, 21, 526. https://doi.org/10.1186/s12913-021-06533-x
[13]
Liu, X., Yang, F., Cheng, W., Wu, Y., Cheng, J., Sun, W. et al. (2020). Mixed Methods Research on Satisfaction with Basic Medical Insurance for Urban and Rural Residents in China. BMC Public Health, 20, Article No. 1201. https://doi.org/10.1186/s12889-020-09277-1
[14]
Munyambu, L. (2024). Systematic Review of Social Determinants of Health. Journal of Medicine, Nursing and Public Health, 4, 30-37.
[15]
National Healthcare Security Administration (2024). Statistical Bulletin on the Development of China’s Medical Security System. National Healthcare Security Administration. https://www.nhsa.gov.cn/art/2025/7/14/art_7_17248.html
[16]
National Survey Research Center (2023). The 2021 China General Social Survey (CGSS) Data Are Now Publicly Available. Renmin University of China. http://nsrc.ruc.edu.cn/xwygg/xwdt/146d63ccc86f4f979e4bb749fb84762c.htm
[17]
Tzenios, N. (2019). The Determinants of Access to Healthcare: A Review Of individual, Structural, and Systemic Factors. Journal of Humanities and Applied Science Research, 2, 1-14.
[18]
Wan, G., Peng, Z., Shi, Y., & Coyte, P. C. (2020). What Are the Determinants of the Decision to Purchase Private Health Insurance in China? International Journal of Environmental Research and Public Health, 17, Article 5348. https://doi.org/10.3390/ijerph17155348
[19]
Wang, P., Li, S., Wang, Z., Jiao, M., Zhang, Y., Huang, W. et al. (2023). Perceptions of the Benefits of the Basic Medical Insurance System among the Insured: A Mixed Methods Research of a Northern City in China. Frontiers in Public Health, 11, Article 1043153. https://doi.org/10.3389/fpubh.2023.1043153
[20]
Wang, Q., Zhang, D., & Hou, Z. (2016). Insurance Coverage and Socioeconomic Differences in Patient Choice between Private and Public Health Care Providers in China. Social Science & Medicine, 170, 124-132. https://doi.org/10.1016/j.socscimed.2016.10.016
[21]
Yang, D., Acharya, Y., & Liu, X. (2022). Social Health Insurance Consolidation and Urban-Rural Inequality in Utilization and Financial Risk Protection in China. Social Science & Medicine, 308, Article ID: 115200. https://doi.org/10.1016/j.socscimed.2022.115200
[22]
Yip, W., Fu, H., Chen, A. T., Zhai, T., Jian, W., Xu, R. et al. (2019). 10 Years of Health-Care Reform in China: Progress and Gaps in Universal Health Coverage. The Lancet, 394, 1192-1204. https://doi.org/10.1016/s0140-6736(19)32136-1
[23]
Yu, B., Meng, Q., Collins, C., Tolhurst, R., Tang, S., Yan, F. et al. (2010). How Does the New Cooperative Medical Scheme Influence Health Service Utilization? A Study in Two Provinces in Rural China. BMC Health Services Research, 10, Article No. 116. https://doi.org/10.1186/1472-6963-10-116
[24]
Yu, Q., He, Y., Li, L., Xu, D., Li, Y., Yin, Q. et al. (2025). Study on the Willingness to Enroll in the Urban and Rural Residents Basic Medical Insurance: From the Perspectives of Policy Awareness and Institutional Trust. Frontiers in Public Health, 13, Article 1535558. https://doi.org/10.3389/fpubh.2025.1535558
[25]
Zhang, C., Lei, X., Strauss, J., & Zhao, Y. (2017). Health Insurance and Health Care among the Mid-Aged and Older Chinese: Evidence from the National Baseline Survey of Charls. Health Economics, 26, 431-449. https://doi.org/10.1002/hec.3322
[26]
Zhou, M., Zhao, S., & Zhao, Z. (2021). Gender Differences in Health Insurance Coverage in China. International Journal for Equity in Health, 20, Article No. 52. https://doi.org/10.1186/s12939-021-01383-9
[27]
Zuo, Y., Yang, G., Cheng, H., & Zhang, L. (2025). Why Do Rural Residents in China Withdraw from the Health Insurance System?—A Qualitative Study Based on Y County in S Province, China. BMC Public Health, 25, Article No. 1629. https://doi.org/10.1186/s12889-025-22882-2
