Failing the Same Group in Different Ways: Comparing China's and the U.S.'s Health Insurance Protections for Chronically Ill Older Adults

Among the challenges of aging populations faced by both China and the United States, older adults with chronic health issues stand out for their demand for medical treatment and long-term care, constituting a "double risk". This paper draws on extant theoretical concepts, such as catastrophic health expenditure, out-of-pocket caps, risk pooling, and means-testing, as well as empirical research on health insurance for older adults. It first compares institutional designs of the two countries: China's Long-Term Care Insurance reform on top of its integrated government-led basic insurance system and Critical Illness Insurance, along with fragmented systems of Medicare, Medicaid, and private coverage in the United States, to analyzes how each country's institutional designs protects this vulnerable group from the double risk. It then conducts case studies within each country, including China's city-level LTCI models (Qingdao and Nantong), China's insurance-eligibility disparities (UEBMI versus URRBMI), and the United States' state-level variation in Medicaid expansion outcomes and PACE program implementation. Comparisons show that their national policies also play out unevenly at the local level. The paper finds that neither system has successfully resolved the double risk, and points out directions for their future medical insurance reforms: China establishes a wide but uneven floor of coverage, while the United States is capable of a standard of protection which remains not always accessible.