In Social Protection under Authoritarianism: Health Politics and Policy in China, Xian Huang explores patterns of welfare under an authoritarian system, examining the rapid growth in health insurance in China in the first decade of the twenty-first century. This valuable book throws light on how authoritarian states use social protection to further economic development and regime stability, finds Mel Cousins, and will form a sound basis for future studies in this important policy area. Social Protection under Authoritarianism: Health Politics and Policy in China. Xian Huang. Oxford University Press. 2020

Cousins, Mel

English

LSE Research Online

Book	Review:	Social	Protection	underAuthoritarianism:	Health	Politics	and	Policy	in	Chinaby	Xian	HuangIn	Social	Protection	under	Authoritarianism:	Health	Politics	and	Policy	in	China,	Xian	Huang	explorespatterns	of	welfare	under	an	authoritarian	system,	examining	the	rapid	growth	in	health	insurance	in	China	in	thefirst	decade	of	the	twenty-first	century.	This	valuable	book	throws	light	on	how	authoritarian	states	use	socialprotection	to	further	economic	development	and	regime	stability,	finds	Mel	Cousins,	and	will	form	a	sound	basis	forfuture	studies	in	this	important	policy	area.	Social	Protection	under	Authoritarianism:	Health	Politics	and	Policy	in	China.	Xian	Huang.	OxfordUniversity	Press.	2020.Find	this	book	(affiliate	link):	Professor	Xian	Huang	highlights	the	important	role	of	social	policy	in	an	authoritariansociety	in	her	compelling	book,	Social	Protection	under	Authoritarianism.	In	particular,she	examines	the	rapid	growth	of	health	insurance	in	China	in	the	Hu-Wen	decade(2003-2012).	In	only	a	few	years,	coverage	increased	from	less	than	one-fifth	of	thepopulation	in	2000	to	90	per	cent	having	some	form	of	health	insurance	by	2011.	Asthe	author	points	out,	much	welfare	theorising	has	been	set	in	the	context	ofdemocratic	societies	and	some	have	assumed	(or	asserted)	that	democracy	is	aprecondition	for	expanded	social	protection.	But,	like	a	growing	number	of	recentbooks	and	theses	on	the	Chinese	welfare	state,	Huang	explores	the	patterns	ofwelfare	in	an	authoritarian	society:	‘who	gets	what,	when	and	how’	(51).Huang	describes	the	introduction	and	expansion	of	health	insurance	in	China.	Sheargues	that	it	was	originally	introduced	largely	to	support	reform	of	state-ownedentreprises	(SoEs)	(and	to	prevent	social	unrest).	However,	it	was	then	expanded(including	to	the	rural	population)	to	improve	risk-pooling	(that	is,	to	bring	in	morefunds)	and	in	response	to	the	medical	needs	of	the	population,	highlighted	by	the	SARS	epidemic	in	2003.	ButHuang	also	shows	that	coverage	was	highly	stratified	with	a	range	of	different	health	insurance	schemes	fordifferent	groups	(public	servants,	urban	workers,	rural	workers).LSE Review of Books: Book Review: Social Protection under Authoritarianism: Health Politics and Policy in China by Xian Huang Page 1 of 3		Date originally posted: 2021-07-01Permalink: https://blogs.lse.ac.uk/lsereviewofbooks/2021/07/01/book-review-social-protection-under-authoritarianism-health-politics-and-policy-in-china-by-xian-huang/Blog homepage: https://blogs.lse.ac.uk/lsereviewofbooks/Image	Credit:	‘Shanghai:	HongKou	Hospital,	April	2008’	by	Paul	Kretek	licensed	under	CC	BY	2.0Huang	argues	that	in	expanding	health	insurance,	China	has	aimed	both	to	retain	the	privileges	of	elite	groups	suchas	public	servants	and	to	reach	out	to	more	marginalised	groups	such	as	rural	migrant	workers	as	part	of	a	generalstrategy	to	maintain	regime	stability.	However,	the	level	of	reimbursement	for	core	urban	employees	wassignificantly	higher	than	that	available	to	those	newly	covered	such	as	rural	workers.	So	China	has	developed	‘anexpansive	yet	stratified’	welfare	system.	And	these	plans	are	implemented	at	a	local	level	by	leaders	with	significantautonomy	so	the	precise	shape	of	the	local	system	is,	Huang	argues,	driven	by	local	political	economies.Therefore,	as	with	other	policy	areas	such	as	pensions	or	social	assistance,	there	has	been	a	very	high	level	ofregional	policy	variation.	Huang	examines	regional	patterns	of	health	insurance	based	on	generosity	(averagebenefits	received)	and	coverage	(the	percentage	who	receive	benefits),	and	she	identifies	four	distinct	clusters	ofprovision	ranging	from	a	general	and	inclusive	approach	to	a	strict	and	exclusive	one.	She	argues	that	theserepresent	different	local	policy	choices,	reflecting	political	economy	conditions,	in	particular	social	risk	and	fiscalcapacity.Below:	Reviewer’s	table	based	on	analysis	in	Chapter	Six	of	Social	Protection	under	Authoritarianism	by	XianHuang.	Oxford	University	Press.	2020.Cluster Description Outcome Related	factors1.	Dual Coastal	provinces High	coverage,	aboveaverage	benefits High	fiscal	capacity,	high	in-migration2.Privileging(a)	Large	cities	and	(b)	ethnicminority	provincesHigh	coverage,	lowbenefits(a)	High	fiscal	capacity,	high	in-migration;	largeelite	groups(b)	High	minority	population;	high	centralsubsidies,	limited	labour	mobility3.	Statusquo North-east	and	south-westLow	coverage,	lowbenefits Less	developed	economy,	low	labour	mobility4.	Risk-pooling CentralHigh	coverage,	lowbenefits Out-migration,	low	fiscal	capacityLSE Review of Books: Book Review: Social Protection under Authoritarianism: Health Politics and Policy in China by Xian Huang Page 2 of 3		Date originally posted: 2021-07-01Permalink: https://blogs.lse.ac.uk/lsereviewofbooks/2021/07/01/book-review-social-protection-under-authoritarianism-health-politics-and-policy-in-china-by-xian-huang/Blog homepage: https://blogs.lse.ac.uk/lsereviewofbooks/As	set	out	in	the	table	above,	Huang	argues	that	these	patterns	correspond	to	key	differences	in	regionaleconomies	(143),	though	she	accepts	that	this	cannot	fully	explain	the	clusters	and	notes	that	within	each	clusterthere	are	significant	variations	in	economic	level.	This	is	particularly	marked	in	Group	2.	Huang	suggest	that	politicalfactors	such	as	a	desire	to	prioritise	elite	groups	in	Beijing	and	Tianjin	or	ethnic	minorities	in	provinces	such	asXinjiang	or	Qinghai	must	also	be	taken	into	account.Regression	analysis	supports	Huang’s	proposed	links	between	coverage	and	social	risk	(labour	mobility	and	levelsof	dependency),	and	generosity	and	fiscal	capacity.	Unsurprisingly	GDP	per	capita	is	also	positively	related	tocoverage.	But,	in	contrast	to	other	studies	such	as	Ke	Meng	(2019),	Huang	finds	that	provincial	leaders’	level	ofambition	is	not	related	to	expanded	health	insurance,	suggesting	that	trajectories	are	shaped	by	socioeconomicfactors	rather	than	political	ambition.	Huang	argues	that,	because	of	the	stratified	structure	of	health	insurance,	thedramatic	expansion	in	cover	has	reinforced,	rather	than	reduced,	health	inequalities	(Chapter	Seven).The	book	again	highlights	the	problem	of	getting	reliable	and	comparable	data	in	a	Chinese	context.	Even	wherethe	data	is	available,	the	author	shows	how	local	government	manipulates	policies	and	data	to	‘achieve’	centralgovernment	targets:	for	example,	by	excluding	certain	hospitals	or	types	of	service	in	the	calculation	of	thereimbursement	rate	for	health	services	in	order	to	get	the	‘right’	result	(and,	in	one	case,	just	making	upreimbursement	bills	and	receipts).	Huang	also	shows	how	some	provinces	require	people	to	insure	in	two	schemesto	boost	coverage	data.In	this	book,	the	operationalisation	of	‘generosity’	as	spending	per	capita	is	perhaps	questionable,	particularly	in	thearea	of	health	where	the	money	goes	not	to	the	claimant	but	to	the	medical	system.	So	a	‘generous’	province	mightbe	an	inefficient	one	with	high	medical	costs	and	poor	services.	The	focus	on	the	province	(a	common	one	inChinese	studies	for	data	reasons)	is	also	probably	oversimplistic.It	may	be	that	such	data	issues	explain	why	Huang’s	categorisation	differs	from	other	studies,	such	as	by	Jing	Lin(2017)	and	Yang	Luo	(2019),	which	focus	on	pensions	and	social	insurance,	or	by	Kerry	Ratigan	(2017),	whichlooks	at	broader	social	policies.	In	fact,	the	picture	of	the	three	large	city	states	(Beijing,	Shanghai	and	Tianjin)	ashaving	high	benefits	but	low	coverage	is	the	opposite	to	what	one	finds	in	looking	at	pensions.	Of	course,	differentsocial	protection	policies	might	conceivably	cluster	in	different	patterns.	But	the	logic	driving	Huang’s	analysis	ofsocial	risk	and	fiscal	capacity	might	be	expected	to	lead	to	similar	patterns	for	health	insurance	and	pensions.A	picture	of	an	omniscient	central	government	manipulating	welfare	to	achieve	support	is	perhaps	too	reductive	(infairness,	the	author	accepts	that	‘social	demands’	are	also	a	relevant	factor	but	does	not	explore	this	issue	indetail).	No	doubt	this	is	what	the	government	tries	to	do	and,	as	Yan	Wang	(2020)	shows,	it	attempts	to	createpublic	discourse	in	line	with	its	objectives.	But	the	government	must	also	respond	to	public	concerns	if	it	is	tomaintain	its	legitimacy,	as	shown	by	its	reluctance	to	address	the	issue	of	the	low	pension	age.This	is	a	very	interesting	study	even	if	it	perhaps	raises	as	many	questions	as	it	can	definitively	answer.	This	is	nocriticism	of	a	work	which	forms	part	of	what	might	be	described	as	the	‘first	wave’	of	analytical	studies	of	theChinese	social	protection	system	and	which	is	forced	to	rely	on	limited	and	perhaps	unreliable	data.	Huang’s	workwill	form	a	sound	basis	for	future	studies	in	this	important	policy	area	and	also	throws	light	on	how	authoritarianstates	more	generally	use	social	protection	to	further	both	economic	development	and	regime	stability	(see	199-202).Note:	This	review	gives	the	views	of	the	author,	and	not	the	position	of	the	LSE	Review	of	Books	blog,	or	of	theLondon	School	of	Economics	and	Political	Science.	The	LSE	RB	blog	may	receive	a	small	commission	if	youchoose	to	make	a	purchase	through	the	above	Amazon	affiliate	link.	This	is	entirely	independent	of	the	coverage	ofthe	book	on	LSE	Review	of	Books.	LSE Review of Books: Book Review: Social Protection under Authoritarianism: Health Politics and Policy in China by Xian Huang Page 3 of 3		Date originally posted: 2021-07-01Permalink: https://blogs.lse.ac.uk/lsereviewofbooks/2021/07/01/book-review-social-protection-under-authoritarianism-health-politics-and-policy-in-china-by-xian-huang/Blog homepage: https://blogs.lse.ac.uk/lsereviewofbooks/

Book review: Social protection under authoritarianism: health politics and policy in China by Xian Huang

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Book review: Social protection under authoritarianism: health politics and policy in China by Xian Huang

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