Abstract

Background

Since the 2009 healthcare reform, the Chinese government has been committed to establishing a universal healthcare system. This study aims to investigate the complex reasons behind rural residents鈥� decision to forgo participation in the medical insurance system by examining causal relationships and interactions.

Methods

This study employs content analysis, conducting in-depth interviews with 42 stakeholders, including government administration departments, tax departments, medical insurance departments, village committees, and residents who have withdrawn from the health insurance system.

Results

The study finds that the primary reasons rural residents withdraw from the medical insurance system are fourfold: heavy economic burdens, unfair design of the medical insurance system, failure of conventional mobilization strategies, and the internet鈥檚 impact on residents鈥� cognitive biases.

Conclusion

The decision of rural residents in China to withdraw from the medical insurance system is influenced not only by economic factors but also by the system鈥檚 design and various aspects of rural governance. Moving forward, the Chinese government should optimize the medical insurance system鈥檚 design, implement more flexible mobilization and persuasion strategies, and prioritize the identification and regulation of misleading information.

Introduction

Universal health coverage is a priority on the global development agenda and one of the Sustainable Development Goals (SDGs) pursued by countries worldwide. As a crucial measure to promote universal health coverage, healthcare insurance systems are vital to the health sector鈥檚 development globally [1]. China鈥檚 healthcare insurance system aims to establish equitable basic medical coverage for all, and this goal has been pursued through a lengthy period of exploration [2].

In the early years of the People鈥檚 Republic of China, the country established a healthcare insurance system in the 1950s, which included urban labor insurance, public medical insurance, and rural cooperative medical insurance. Farmers primarily participated in the rural cooperative medical insurance, formally institutionalized in the 鈥淩egulations on Rural Cooperative Medical Care鈥� issued by the Ministry of Health in December 1979. Later, in January 2003, the introduction of the new rural cooperative medical insurance aimed to address the changing health needs of rural populations. In 2016, based on the dual urban-rural Hukou system [3], China merged the New Rural Cooperative Medical Scheme with the Urban Residents鈥� Basic Medical Insurance, forming a unified urban-rural medical insurance (URRMI) system (Fig.听1). This system covers all urban and rural residents not included in the Employee-based Medical Insurance system. The employee medical insurance system achieves mandatory coverage through legal compulsion and employer contributions, while basic medical insurance for residents follows a voluntary principle [4].

In recent years, the Chinese government has elevated the collection of urban and rural residents鈥� medical insurance contributions to a national strategy. Expanding the coverage of medical insurance for urban and rural residents has become a crucial component of the social security system, significantly enhancing the mutual assistance and risk-resistance capacity of medical insurance funds, and supporting the health and development of the population [5]. In practice, local governments have explicitly stated their commitment to the political responsibility of 鈥渦niversal insurance coverage鈥� [6, 7]. They meticulously identify and ensure that no household or individual is left out, thereby accelerating insurance coverage expansion and improving service efficiency and quality [8]. Additionally, the government鈥檚 substantial increase in basic medical insurance funding has stimulated public participation in medical insurance [2, 9]. These efforts have rapidly boosted insurance coverage [10]. By the end of 2023, 960听million people in China were covered by urban and rural residents鈥� basic medical insurance, stabilizing at over 95% [7, 11].The establishment of China鈥檚 Urban and Rural Residents Basic Medical Insurance system has significantly improved public health and effectively safeguarded the health rights of its citizens [12].

Fig. 1

Development of China鈥檚 Healthcare Insurance System

However, the system鈥檚 operation continues to face considerable challenges.As of now, nearly 960听million people in China are enrolled in the urban-rural medical insurance system, with approximately 80% of them being rural residents and 20% urban residents. However, around 5% of the population, or nearly 50听million people, remain uninsured [13].Additionally, satisfaction with the URRMI system is low among Chinese residents, leading many to gradually opt out of the insurance system [14, 15]. According to data released by the National Healthcare Security Administration of China, the number of participants in the urban and rural resident health insurance scheme has gradually declined since 2019. Specifically, participants decreased by 0.3%, 0.8%, 0.8%, and 2.5% in 2019, 2020, 2021, and 2022, respectively. In 2022 alone, the number of participants dropped by 25.17听million compared to the previous year [16, 17]. This trend raises critical questions about the sustainability of the URRMI system and its role in achieving universal health coverage [11].

This phenomenon is prevalent across many countries and has attracted considerable attention in the academic community. Existing research suggests that a key determinant of whether residents withdraw from the health insurance system is the extent to which the system鈥檚 provisions align with the needs and expectations of rural residents [18, 19]. On the demand side, the most critical factor is an individual鈥檚 objective health status [16, 20]. Additionally, an individual鈥檚 subjective perception of health risks significantly affects their willingness to pay for health insurance system [21]. Awareness of health insurance policies also plays a crucial role [22, 23].Beyond these objective factors, residents鈥檈xperiences during medical treatment are significant. Encounters with unfair treatment or poor service attitudes from healthcare providers increase the likelihood of withdrawal from the health insurance system [24, 25]. On the supply side, factors such as high funding levels for health insurance system [26, 27], inflexible payment methods [28], and inadequate medical service capabilities directly lead to rural residents鈥� withdrawal from health insurance system [29,30,31,32].Furthermore, cultural misalignment between the health insurance system and the local context is another critical factor. If the system design fails to consider the region鈥檚 unique cultural background, residents may refuse to participate [33, 34]. The principle of voluntariness in health insurance enrollment has also been criticized as a major contributor to adverse selection [35, 36], exacerbating the risk to medical insurance funds and threatening system sustainability [37]. Incorporating populations currently excluded from universal health coverage is thus both urgent and necessary. Research shows that under similar conditions, households that have previously participated are more likely to continue their enrollment, indicating a stronger willingness to engage with the insurance scheme [38, 39]. Nonetheless, a significant number of rural residents continue to withdraw from the health insurance system. This counterintuitive reality underscores the importance of investigating the reasons behind rural residents鈥� withdrawal from health insurance, making it a topic of substantial practical significance.

Although existing studies have examined factors influencing health insurance withdrawal, they often fail to account for the unique socio-economic and cultural contexts of rural areas, which play a critical role in shaping decision-making processes. This oversight limits the understanding of the dynamic and complex mechanisms underlying withdrawal behavior. Moreover, current research predominantly emphasizes top-down national health insurance systems, neglecting the grassroots-level implementation that is crucial for achieving universal health coverage [40].This study addresses these research gaps by investigating the reasons why rural residents withdraw from the Urban and Rural Resident Medical Insurance (URRMI) system, aiming to provide valuable insights for both theoretical research and practical policymaking. Using qualitative research methods, the study focuses on the interaction mechanisms between institutional design, individual behavior, and social structures in rural China. By examining withdrawal behavior in depth, this research offers critical perspectives for optimizing the sustainable development of the URRMI system and advancing China鈥檚 progress toward universal health coverage.

Research design

Methods

Regarding the 鈥渞easons for rural residents鈥� withdrawal from the medical insurance system,鈥� the evidence available in academic research is limited. Consequently, this study is better suited to employing qualitative research, which serves an exploratory purpose. Qualitative research offers flexibility in research design, enabling an in-depth investigation of the causes and mechanisms underlying complex phenomena. It provides contextualized insights into behaviors, perceptions, and practices, uncovering subtle nuances that quantitative research may overlook. Moreover, it plays a crucial role in theory construction or supplementing existing theories.Content analysis is a key research method that excels in revealing underexplored topics, investigating the underlying causes of complex social phenomena, and constructing cutting-edge theories. It can be applied in both qualitative and quantitative research, depending on the specific research design and the nature of the data [41]. In qualitative research, content analysis primarily involves a detailed examination of textual or verbal materials. By systematically organizing and analyzing sources such as interview transcripts, it identifies key themes, patterns, and underlying social meanings, thereby contributing to the understanding and interpretation of social phenomena [42].In this study, content analysis is used to examine interview data from rural residents regarding their withdrawal from the medical insurance system. The aim is to uncover the deep-rooted factors that influence residents鈥� decisions.

The sample size for content analysis is primarily determined by whether the content data has reached saturation [43]. Studying specific issues requires representative research samples to ensure the reliability and extensibility of the conclusions, thereby enhancing the research鈥檚 value and theoretical significance. This study selected Y County in S Province, China, as the research subject for the following reasons: First, the choice of research subject is guided by considerations of representativeness and relevance. Y County in S Province is located in the central region of China, with its geographical location, economic development, and population structure all aligning with the median level of the country.These features reflect the shared attributes of a particular category of research subjects and social phenomena. The knowledge derived from these characteristics can provide valuable insights into the research questions. More importantly, the aim of this study is to explore the experiences and perspectives of rural residents as a specific group, rather than to make broad statistical inferences. The selection of participants was based on specific criteria designed to ensure the collection of qualitative data that facilitates in-depth analysis. In this study, the representativeness of the research subject refers to the generalizability of its characteristics rather than the subject itself. The research logic focuses more on key features, relationships between elements, and explanatory factors, rather than on studying subjects or experiences that are identical in terms of actions and events. The goal is to move beyond a narrow focus on a single research subject and instead concentrate on the key theoretical attributes underlying the subject [44].Additionally, the study draws on multiple perspectives, actors, and data sources to analyze the research problem, cross-validating findings to enhance the accuracy, persuasiveness, and explanatory power of the conclusions.Second, the selection of Y County also considered the sufficiency of the sample and the availability of data. Approximately 53,000 residents, or 77.9% of the county鈥檚 population, live in rural areas, making it essential for most residents to participate in the rural health insurance system. This demographic characteristic provides a sufficient sample size for investigating the factors influencing residents鈥� participation in the system. To ensure a broad range of perspectives, the study purposefully selected 22 rural residents from various villages and townships in Y County, aiming to collect diverse insights into the complex reasons behind residents鈥� withdrawal from the basic medical insurance system.

Ethics approval

The study protocol was approved by the ethics review committee in China based on the assessment of the study鈥檚 design and process, by the principles of the Declaration of Helsinki (Approval Number: 021-gskyb-02-372424198012222511). Informed written consent was obtained from all participants prior to their interviews for the study.The study participants were thoroughly informed about the purpose of the study, the analysis methods, the interview procedure, and the recording process. Data collection commenced after obtaining written consent from the participants. The collected data were used exclusively for research purposes. The consent forms were securely stored in a locked cabinet, and the transcribed data were kept on the researcher鈥檚 password-protected computer.

Data collection

This study focused on rural residents who had previously participated in the health insurance system but have since withdrawn. In addition, stakeholders involved in the rural medical insurance payment process were included as participants. These stakeholders comprised personnel from medical insurance departments, township officials (Table听1), and rural residents (Table听2), totaling 42 individuals. The participant distribution broadly aligns with the research questions addressed in this study.

Table 1 Basic information and coding of government officials

Table 2 Basic information and coding of residents

To better accommodate individual differences among participants and ensure the diversity and validity of the data, the interviews were primarily conducted using a semi-structured format. The average interview duration was no less than 30听min, with the longest individual interview lasting up to one hour. The interview guide and questions were designed to align with the research objectives, informed by an extensive literature review (Supplementary 1). Additionally, for research purposes, the researchers attended internal meetings of government departments responsible for mobilizing medical insurance collection and organized four small seminars. These materials served as supplementary resources and were used to verify theoretical saturation in the study. When data analysis no longer yielded new categories, three additional residents were interviewed to confirm whether data saturation had been reached [45]. The coding outcomes revealed no new categories, confirming that the study had achieved theoretical saturation.

Data analysis

Data collection and analysis are conducted concurrently to ensure that the data aligns with the analytical framework, thereby enhancing data integrity and strengthening the credibility of the research findings.Recorded interviews are transcribed to create interview transcripts, following strict principles of objectivity and confidentiality during the transcription process, without any subjective alterations to the interview content, thus ensuring data authenticity. The interview transcripts undergo initial, unbiased coding, with repeated comparisons made during the primary coding process to identify commonalities and differences within the interview data. The coding process was iterative, with ongoing adjustments made based on further data exploration and category identification. Through continuous comparison and organization, deeper connections between categories were revealed, leading to the reorganization of the data and the formation of themes. Ultimately, this process resulted in the identification of nine categories and four themes. Throughout, the original interview responses are consistently reviewed and compared with the evolving categories and themes to ensure that the interpretations accurately reflect the intent of the research subjects [46].

Research validity and reliability

Credibility in qualitative research refers to the rigor of the study design, the trustworthiness of the researchers, the reliability of the research outcomes, and the applicability of the research methods [47].To ensure credibility in this study, several measures were implemented. Firstly, the study design was carefully developed by the research team and subjected to multiple rounds of open discussion within the team. Additionally, we employed multiple data sources to ensure a comprehensive perspective, including not only interviews and observations with participants but also participation in government department meetings, thus mitigating potential biases from relying on a single data source or viewpoint.Secondly, to ensure the credibility of the researchers, all team members underwent rigorous training prior to conducting interviews. During the interviews, they were instructed to maintain neutrality and objectivity to avoid influencing participants鈥� responses. Moreover, two experienced experts, well-versed in the theoretical framework used, were tasked with independently coding the interview data. In cases of disagreement, other experts in the field were consulted to assist in resolving discrepancies, thereby enhancing the robustness of the research process [48].Thirdly, the credibility of the research outcomes was ensured. During the data collection and analysis phases, we employed strategies of repeated checks and cross-validation. The emerging categories, themes, and their interrelationships were consistently verified, and the research reached theoretical saturation [49]. Lastly, the research questions addressed in this study have not yet developed into fully mature topics, making them suitable for exploratory qualitative research. Additionally, content analysis, which allows for valuable insights into social phenomena through smaller samples, aligns well with the research questions. Based on this approach, in-depth interviews were conducted to ensure the richness of the data, further confirming the appropriateness of the research methods [50].

Results

Based on interviews with the research subjects, the study identified four themes related to the research question, with each theme comprising several distinct categories (Fig. 2).

Fig. 2

The Multidimensional Causes of Rural Residents鈥� Withdrawal from the Basic Health Insurance System in China

Economic burden

Persistent rise in payment standards

Since the introduction of the resident medical insurance system in China in 2003, the minimum payment standards for insured individuals have steadily increased, rising from an initial 10 CNY per person to 380 CNY per person by 2024. However, rural residents in China generally have low and unstable incomes. In 2024, the per capita disposable income of rural residents was only 23,119 CNY, the escalating medical insurance payment standards impose a significant financial burden on rural families.鈥淎t the beginning, the annual payment was very low, but in just a few years, it has increased to over 300 CNY.鈥� (Interview Data: CM12) Furthermore, adult children in a family are responsible for covering the medical insurance costs of all family members, including elderly parents and underage children. Consequently, within a short period, a family must allocate a lump sum to cover the medical insurance expenses of all household members. Younger members of the family are compelled to 鈥渟acrifice鈥� themselves, saving money to pay the insurance premiums for family members at higher risk of illness. 鈥淚鈥檓 not paying for myself alone. I have my parents, my wife, and two children. There are six of us in the family, and we have to pay over 2000 CNY in one go. It鈥檚 indeed a significant expense. This year, our family couldn鈥檛 afford it, so I paid for my parents. They are elderly, and we, the younger ones, didn鈥檛 pay.鈥� (Interview Data: CM08) Currently, residents in urban and rural China pay medical insurance premiums annually from September to December. Many rural residents propose extending the payment period or altering the payment methods, suggesting, 鈥淐an we pay in installments? This way, our economic pressure would be lighter, and we could pay when we have the money.鈥� (Interview Data: CM11).

The inability to significantly alleviate the economic burden of illness

Farmers enroll in medical insurance to mitigate the financial burden of diagnosis and treatment when they fall ill. However, current reimbursement policies are limited in coverage and offer low reimbursement rates, resulting in negative healthcare experiences for many farmers. 鈥淢y wife went to the hospital last time and spent over 1000 CNY. When we tried to claim reimbursement with the payment receipt, the staff said it wasn鈥檛 covered. We don鈥檛 know what is covered. If they say it鈥檚 not covered, then it鈥檚 not. If we pay and still can鈥檛 get reimbursement, what鈥檚 the point of paying?鈥� (Interview Data: CM20) Additionally, the removal of 鈥渋ndividual accounts鈥� in the urban and rural resident medical insurance system means that rural residents can no longer use their medical insurance cards to purchase medication at pharmacies. This exacerbates the financial burden on rural residents who previously relied on nearby pharmacies for medication. 鈥淥ur biggest need each year is to buy medicine from the pharmacy. In the past, we had 鈥榠ndividual accounts.鈥� I paid fees every year, even if I didn鈥檛 go to the hospital, at least I bought some medicine. Now it鈥檚 canceled. If we don鈥檛 get hospitalized, we have to pay for medication ourselves, whether it鈥檚 a major or minor illness, the burden is getting heavier and heavier.鈥� (Interview Data: CM16) Due to the inability to use medical insurance cards at pharmacies, some rural residents now seek treatment at hospitals for conditions that could be managed at home, solely to access the benefits. However, some farmers argue that, even with insurance, the cost of medical treatment and medication is higher than purchasing medication directly from a pharmacy out-of-pocket. 鈥淭he same medicine costs me 3 CNY at a street corner pharmacy, but at the hospital, the doctor prescribes the same medicine for 10 CNY. After reimbursement, I still have to pay 5 CNY out of pocket. Isn鈥檛 that cheating our money?鈥� (Interview Data: CM01) The effectiveness of medical insurance in alleviating the economic burden of illness for farmers has been questioned by rural residents, who often struggle to directly benefit from reimbursements when they require medical care.

The inequity in health insurance system design

Inequitable funding standards

The funding for China鈥檚 medical insurance covers only the medical services provided within the current year, regardless of whether residents have utilized medical treatment during that period. However, in the subsequent year, they are required to repay according to the new payment standards. 鈥淎s a young person like me, if I haven鈥檛 been sick for a year and haven鈥檛 visited the hospital, can you return some of the money I paid, or let me pay less next year? This could also motivate me to actively manage my health. It鈥檚 unacceptable to me that I pay the money, and then after a year, it鈥檚 reset to zero, and the next year I鈥檓 asked for it again. My money doesn鈥檛 come out of thin air, and I can鈥檛 psychologically accept it.鈥� (Interview Data: CM17) For many residents, remaining healthy often feels like a waste of money, fostering a sense of unfairness. 鈥淚鈥檝e been paying fees for over ten years, and I鈥檝e never used it. Can I pay less if I pay again? It鈥檚 too unfair. Why should I pay if I haven鈥檛 spent any medical insurance money?鈥� (Interview Data: CM02) As a result, young people choose to withdraw from the medical insurance payment system, leaving behind primarily elderly individuals who face a higher risk of illness. This sense of unfairness not only exists between healthy and unhealthy populations but also between urban and rural residents. 鈥淭he payment standards are the same, but urban residents have much better economic conditions. High-quality medical resources and hospitals are mostly located in cities. Urban residents are also closer to high-quality hospitals. It鈥檚 completely unreasonable for us to pay the same amount as them.鈥� (Interview Data: CM09) Additionally, the current medical insurance policies are linked to rural subsistence allowance policies and poverty alleviation policies. If selected as a subsistence allowance recipient, individuals can pay less or even exempt from paying medical insurance fees, further exacerbating the disparity between the general population and special groups. 鈥淢y parents and younger brother all suffer from mental health conditions and are unable to care for themselves. Last year, my mother lost her sight, but despite multiple applications, we were not approved for assistance. Meanwhile, many individuals in the village who are in better circumstances than us have been selected as recipients of subsistence allowances and benefit from medical insurance subsidies. Why are we not eligible for the same support? As a result, I am considering discontinuing my medical insurance payments.鈥� (Interview Data: CM14).

Inequities in treatment benefits

The inequities in treatment benefits primarily manifest between urban and rural areas. Rural residents perceive rural medical institutions to have lower service capabilities, resulting in many illnesses unable to be treated at nearby medical facilities. Consequently, they seek treatment at higher-level medical institutions, where the reimbursement rates are lower. This presents a phenomenon where individuals in the same city experience different treatment benefits, thus leading to lower accessibility to quality medical services for rural residents. 鈥淚n nearby grassroots medical institutions, the reimbursement rate is higher, but they cannot provide effective treatment. Therefore, one can only resort to larger hospitals. However, seeking treatment at these hospitals incurs higher expenses and lower reimbursements. Ultimately, the money we pay for medical care benefits wealthier individuals.鈥� (Interview Data: CM05) Additionally, medical insurance reimbursement policies are unfavorable for individuals who migrate from rural areas for employment. Disparities in medical insurance policies across different cities hinder young people from fully benefiting from their insurance contributions.鈥淢y household registration is in province S, but I work in another city. If I fall ill, I naturally seek medical treatment in the city where I work. However, this constitutes cross-city medical treatment, resulting in minimal reimbursement because the treatment location does not match the insured location. It feels like the insurance is of little use.鈥� (Interview Data: CM13) The unfairness in medical reimbursement benefits exacerbates the relative deprivation felt by rural residents, directly translating into resistance to medical insurance contributions. Many medical insurance personnel corroborate the existence of this inequality, stating, 鈥淔rom the perspective of medical insurance reimbursement, if rural residents do not first visit designated medical institutions, but instead directly go to large hospitals, their reimbursement rates will decrease. Nowadays, rural residents also desire better medical services. Since medical resources in rural areas are inadequate, we understand their behavior of seeking medical treatment outside the region.鈥� (Interview Data: ZF05).

Failure of conventional mobilization strategies

The mismatch between publicity content and residents鈥� needs

A significant proportion of rural residents have limited awareness of medical insurance reimbursement policies and are slow to comprehend updates to these policies. As a result, they often hold outdated views, with some still interpreting the policies through the lens of individual account-based medical insurance systems. 鈥淚n the past, after paying for medical insurance, I could still use the card to purchase medicine at the pharmacy. However, for the past two years, I suddenly couldn鈥檛 anymore. Yet, I see some people still can, I don鈥檛 know why.鈥� (Interview Data: CM11) During the collection period for medical insurance, government agencies such as the tax bureau and the medical insurance bureau dispatch personnel to rural villages to conduct on-site policy promotion activities, engaging with residents face-to-face for policy interpretation. 鈥淒uring the collection period, we go door-to-door to promote this year鈥檚 medical insurance policies, payment standards, and benefits.鈥� (Interview Data: ZF03) Government personnel seek to raise payment rates by encouraging rural residents to contribute. However, from the perspective of the residents, these efforts often fail to address their most pressing concerns, offering limited support. 鈥淭he content of the promotions is about the payment deadline and payment standards, which we already know. The leaflets distributed in the village contain this information. What we want to know is where and how much we can be reimbursed when seeking treatment, what expenses are covered, what are not, and how to claim reimbursement. They haven鈥檛 provided us with this information.鈥� (Interview Data: CM21) Furthermore, these promotional activities mainly occur during the three-month collection period, with no face-to-face promotions during the rest of the year. Consequently, updates to medical insurance policies often go unnoticed by rural residents, creating a gap between the information provided and the actual reimbursement practices. 鈥淭hey told us we could claim reimbursement when we paid, but in reality, we couldn鈥檛. The policy changes too quickly, and now we have no idea what the rules are.鈥� (Interview Data: CM18) It can be argued that the current stage of medical insurance policy promotion has not addressed the issue of information asymmetry.

Erosion of traditional persuasion mechanisms

The primary social environment in rural areas is confined to small villages, where close 鈥渟ocial bonds鈥� unite individuals, creating a 鈥渇amiliarity-based society鈥� shaped by geographical factors. Rural residents are often reluctant to sever these social ties. In previous instances of health insurance levies, village leaders played a crucial role, using their local connections to engage in widespread 鈥減ersuasion鈥� campaigns to encourage rural participation. Despite many residents鈥� limited understanding of health insurance policies, trust in village leaders and the importance of maintaining interpersonal relationships led to compliance with their mobilization efforts for insurance contributions. However, in recent years, rapid urbanization in China has challenged this traditional rural social structure and operational framework, as material interests increasingly take precedence over personal ties.鈥淣辞飞补诲补测蝉, every household has internet access; they can look things up online. Over the past few years when I visited to urge them to pay, they might not necessarily give me face.鈥� (Interview Data: CW01) Geographical connections in rural areas no longer wield the same influence over villagers鈥� payment decisions. 鈥淚n the past, they (village cadres) came to press me for payment. I felt obligated due to our village connections, but when they came every year, I realized they were using our relationship to meet their own performance targets.鈥� (Interview Data: CM03) Such mobilization tactics are increasingly ineffective with the younger generation, who are no longer bound by geographical ties, finding traditional persuasion and lobbying efforts unconvincing. 鈥淢y parents still respond actively to the village cadres鈥� calls. Why should I listen to them? I seek tangible benefits, not just relationship maintenance.鈥� (Interview Data: CM07)More alarmingly, intervention through traditional mobilization tactics exacerbates the younger generation鈥檚 aversion. 鈥淭hey (village cadres) keep calling me to pay and even visit my home to press me, which is really annoying. They don鈥檛 give prior notice before coming, regardless of what you鈥檙e doing, disrupting my normal life.鈥� (Interview Data: CM06).

Excessive implementation of supervisory measures

During the medical insurance collection period, higher-level authorities require subordinate collection departments to report daily collection data to ensure policy implementation and task completion.鈥淭he higher-level authorities need to monitor collection progress in real time and keep urging us. Under pressure, we have no choice but to repeatedly push them to comply.鈥�(Interview Data: ZF02)In addition to government agencies, schools have long played a supervisory role in the medical insurance collection process. Leveraging their unique influence, schools have significantly increased the insurance enrollment rate among children and adolescents. 鈥淢y child attends school in the town, and during enrollment, we have to verify whether the child is insured. Additionally, teachers regularly remind us to pay for our child鈥檚 insurance through class meetings and class group chats.鈥� (Interview Data: CM04) However, this supervisory approach is not a sustainable solution and has, to some extent, led to adverse consequences. 鈥淣ot being insured means you can鈥檛 enroll in school. Education and insurance are now 鈥榯ied鈥� together, creating 鈥榠mplicit鈥� pressure. Initially, we could have communicated and paid, but now we choose not to.鈥� (Interview Data: CM22) This mobilization strategy is not the direct cause of rural residents withdrawing from the health insurance system. However, unreasonable supervisory measures have prompted some initially hesitant individuals to opt out of the payment process. Additionally, these measures have gradually strained the relationship between rural residents and government officials. Interestingly, government personnel continue to assert that these actions do not constitute coercion, as participation in the health insurance system remains based on the principle of voluntariness.鈥淣辞飞, medical insurance follows the principle of voluntariness. If they really don鈥檛 want to, they don鈥檛 have to pay. But if we don鈥檛 urge them, hardly anyone voluntarily pays. We don鈥檛 want to resort to measures that prevent children from attending school; we just 鈥榬emind鈥� them, but we鈥檙e obligated by our superiors to collect this money.鈥� (Interview Data: ZF01).

The internet鈥檚 impact on residents鈥� cognitive biases

Internet reduces subjective identification with welfare

In recent years, the widespread availability of the Internet has significantly expanded, offering rural residents new opportunities to access information about various healthcare insurance plans. No longer limited by time or geographic constraints, rural residents can now use the Internet to search for, browse, and obtain healthcare information and resources.鈥淲ith the convenience of the internet, we can now access information such as diagnostic results, doctors鈥� prescriptions, and details about medical insurance reimbursement processes and rates online. This allows us to evaluate their compliance independently, rather than simply accepting the claims made by local authorities.鈥� (Interview Data: CM19)Prior to the Internet鈥檚 penetration in rural areas, rural residents primarily perceived medical insurance benefits through comparison with other villagers. However, in recent years, the Internet鈥檚 ubiquity has provided rural residents with more reference points. 鈥淚 saw comments from others in a video鈥檚 comment section, people in situations similar to mine, and their reimbursement rates are much higher than mine.鈥� (Interview Data: CM15) Rural residents realize that other populations are enjoying high-quality medical resources that they have never had access to, leading to a subjective sense of unfairness among rural residents. This diminishes rural residents鈥� relative sense of achievement and gradually reduces their identification with medical insurance benefits. 鈥淭hey (rural residents) don鈥檛 consider anything, nor do they care where others come from or how much others have contributed. As long as they see differences on the internet, they become dissatisfied, feeling that they have not enjoyed the benefits, suffered losses, and blindly pursue high benefits.鈥� (Interview Data: ZF04).

Internet triggers institutional biases

Rural residents utilize the internet to search for information related to medical insurance collection and benefits, using it as a basis for their decisions regarding medical insurance participation. However, there is a significant amount of misleading information online, and due to the limited knowledge and experience of rural residents, they are easily influenced by one-sided narratives and information presented by the media. This leads to irrational cognitive biases regarding their health status and the level of medical insurance coverage. Additionally, ongoing increases in payment standards have contributed to persistent doubts about the policy among rural residents. Misleading information online often exploits these sentiments, further exacerbating their cognitive biases.鈥淚 followed an expert online who commented on current medical insurance policies. The expert stated that these policies are not beneficial for rural people like us; the money we pay ends up being used by others, so I decided not to pay the fees.鈥� (Interview Data: CM10) It is uncertain whether these experts possess professional backgrounds in healthcare or policy. However, their use of exaggerated and absolute language tends to attract attention. The information they disseminate is highly likely to mislead rural residents鈥� judgments and may foster distrust in the system.Despite repeated efforts by government officials to promote scientific awareness, the impact has been minimal, as most rural residents continue to trust the information circulating online. 鈥淲e鈥檝e explained to them that these so-called 鈥榚xperts鈥� are often involved in deceptive hype, and whether they are genuine experts is uncertain. However, they (rural residents) stubbornly believe them. They have great trust in online rumors, even doubting our official publicity.鈥� (Interview Data: CW03)This also reflects a major challenge faced by the government in the process of information dissemination: even when the information is truthful and accurate, the audience鈥檚 trust and biases often significantly influence how the information is received. Additionally, the speed and widespread nature of online information dissemination exceed the reach of government communication efforts.

Discussion

Our study reveals that the primary reasons for rural residents鈥� withdrawal from medical insurance include significant economic pressures, perceived unfairness in the design of the medical insurance system, ineffective conventional mobilization methods, and cognitive biases fostered by the internet. The research also highlights that this behavior is not merely an economic obstacle; at its core, it reflects significant challenges within China鈥檚 health insurance system and rural governance structures.

The primary reason for voluntary withdrawal from medical insurance among rural residents in China is the economic burden imposed by insurance premiums.The continuous and rapid increase in medical insurance premium standards has, objectively, increased the economic burden on rural residents. Moreover, the economic volatility caused by the global COVID-19 pandemic has further exacerbated the income instability of rural residents. During this period, their incomes did not experience significant growth. As a result, the increasing medical insurance contribution standards have placed a greater financial burden on low-income rural residents, raising the likelihood of their withdrawal from the medical insurance system.Additionally, China鈥檚 swift urbanization has raised expectations among rural residents for higher-quality healthcare, leading many to bypass local township health centers and county-level medical institutions in favor of larger, urban medical facilities [15].The increasing demand for high-quality medical services, along with the rising costs of healthcare provision, has resulted in a significant overall rise in healthcare expenditures within society [8], ultimately translating into a rapid elevation of individual medical insurance contribution standards. From 2003 to 2023, the annual growth rate of per capita disposable income for rural residents in China was approximately 7.6%, while the annual growth rate of basic medical insurance premiums during the same period was about 19.78%. As a result, the proportion of insurance premiums in rural households鈥� annual income has increased rapidly.If the rate of increase in medical insurance premiums continues to outpace the growth of rural residents鈥� incomes, the number of individuals withdrawing from the medical insurance system may rise further [14]. Hence, policies must strike a balance between ensuring a steady enhancement in healthcare service quality and controlling healthcare service costs [17].

The escalating costs of medical insurance have heightened the motivation for rural residents with varying health conditions to further distance themselves. Rural residents in China perceive participation in medical insurance as an investment. When they have not enjoyed insurance benefits for many years, they may deem premium payments as wasteful, aligning with the 鈥渦nderpurchase demand-side anomaly鈥� proposed by Kunreuther [25]. Conversely, adverse selection gradually increases with the rise in premium standards, leading to a moral hazard phenomenon of 鈥渂ad money driving out good,鈥� significantly elevating operational risks for medical insurance funds. On the other hand, the effectiveness of medical insurance in alleviating the economic burden caused by illness for rural residents is insufficient. This issue arises from the increasing demand for high-quality medical services, which leads residents to bypass primary healthcare facilities and directly seek treatment at higher-level institutions, thereby driving up overall medical expenses. In 2023, China鈥檚 total health expenditure exceeded 9 trillion CNY, with the annual growth rate of medical costs consistently surpassing 10%, far exceeding the growth rates of GDP and disposable income. The abnormal rise in medical costs has resulted in an increase in the reimbursement rate, but the out-of-pocket expenses for residents have not decreased, and in fact, have risen. Additionally, the lack of a dynamic adjustment mechanism for the basic medical insurance catalog means that many drugs, medical supplies, and services are not included in the reimbursement scope, still requiring rural residents to pay out of pocket [10]. Consequently, from the perspective of rural residents, despite their urgent need to reduce medical expenses and seek high-quality medical services, they harbor a logical reluctance to pay for medical insurance.Rural residents believe that the medical insurance system fails to address their needs adequately. The perceived value of medical insurance reimbursement policies for rural residents is low [14, 19].

The unfairness in the design of the medical insurance system also constitutes a significant factor for the non-enrollment of medical insurance among rural residents in China. However, China鈥檚 dual urban-rural Hukou system has created disparities in socio-economic development between urban and rural areas [32]. The per capita income of rural residents is significantly lower than that of urban residents. Consequently, the proportion of the same payment base in the disposable income of urban and rural residents differs significantly, imposing a greater burden on rural residents [15]. Based on 2023 data, after grouping urban and rural residents into five income quintiles, it was estimated that the insurance premium of 400 CNY accounts for more than 7.6% of the per capita disposable income in the lowest income group of rural households. In contrast, for the lowest income group in urban areas, this proportion is only 2.2%, highlighting a significant disparity between the two groups.This disparity has resulted in an unfair allocation of medical and health financing between urban and rural residents, leading to adverse selection [27]. Moreover, despite economic and social development, the inequality in the financing of medical insurance for urban and rural residents has not diminished, a conclusion corroborated by several studies [26, 36]. This necessitates, at the policy level, adjustments to the financing mechanism for rural residents based on 鈥渋ncome levels鈥� and 鈥減ayment capacity鈥� [9]. Additionally, it is important to consider extending the payment period and allowing rural residents to pay in installments, while also exploring payment mechanisms that accommodate seasonal income fluctuations from agricultural production. Simultaneously, to reduce the risk of rural households falling back into poverty due to illness, the Chinese medical insurance system is integrated with low-income and poverty alleviation policies. Over time, medical insurance has evolved beyond a mechanism to mitigate the financial risk of illness, becoming a policy designed to protect against broader societal risks [10]. The transfer of partial responsibilities from poverty alleviation and civil affairs departments to medical insurance departments exacerbates the sense of unfairness among different groups and disrupts the normal process of medical insurance collection. Essentially, this arises from the lack of clear positioning of different institutional mandates [4].

The current medical insurance system ensures equal access to healthcare for all insured individuals. However, rural residents do not receive the same medical benefits as urban residents. Due to the uneven distribution and development of medical resources in China, there are significant disparities in healthcare resources and service levels across regions [15]. High-quality medical resources are typically concentrated in major cities, giving urban residents greater access to healthcare services [8]. In contrast, rural residents utilize fewer medical services due to geographical barriers and budget constraints [17]. When local primary healthcare facilities are unable to meet the medical needs of rural residents, they are forced to spend more time and money seeking care at higher-level medical institutions in other regions.However, current Chinese health insurance policies provide limited or no reimbursement for cross-regional medical expenses, leading to reduced net healthcare benefits for rural residents [37].In recent years, large-scale rural-to-urban migration for employment and living has occurred. However, China鈥檚 healthcare reimbursement system is geographically defined, with benefits based on the Hukou location. As a result, the reimbursement scope and benefits vary across different regions, preventing migrant rural populations from accessing local healthcare resources and benefits on an equal footing [16]. The potential cause of these inequalities may lie in China鈥檚 Hukou system. On one hand, the dual Hukou system creates disparities in the economic and social development between urban and rural areas, resulting in unequal distribution of social resources such as healthcare. On the other hand, under the influence of the Hukou system, an individual鈥檚 access to social resources and welfare is closely tied to their place of birth and household registration status, leading to differences in the channels and capabilities for obtaining healthcare resources across different populations [3].Overall, this situation leads to a significantly lower utilization of quality medical resources by rural residents compared to urban residents [26], with government subsidies intended to promote universal healthcare coverage disproportionately benefiting urban residents.The result of this is not only an inequality in physical health between urban and rural residents but also a further widening of the gap in mental health between these groups [32].Therefore, the impact of China鈥檚 Hukou system on social inequality should be fully considered, with an emphasis on expanding the coverage and reimbursement rates of basic medical insurance for rural residents to achieve equitable access to essential healthcare services [40].

The failure of conventional mobilization strategies has increased the propensity of rural residents in China to withdraw from health insurance system, eroding their trust in both the system and the government. China鈥檚 health insurance model, which is based on voluntary participation, allows residents to decide whether to enroll based on their economic circumstances and needs. This approach reflects respect for individual choice and upholds democratic principles [36]. Under this voluntary principle, the promotion of health insurance policies becomes crucial [23]. Despite this, the Chinese health insurance policy is hindered by shortcomings in its promotion methods, content, and timing. As a result, when rural residents become ill, the absence of crucial reimbursement information may prevent them from accessing compensation, thereby diminishing trust in the perceived benefits of health insurance [38].Moreover, the decision-making behavior of Chinese rural residents aligns with behavioral economics theories, influenced by psychological and social factors rather than being fully rational. Compared to urban areas, rural residents often have closer local ties and engage more frequently with village officials. These officials can mobilize and encourage residents to enroll in insurance through various channels, such as home visits, phone calls, and broadcasts. As a result, rural areas exhibit a de facto 鈥渜uasi-mandatory鈥� insurance characteristic [39].As China modernizes, traditional local relationships are gradually eroding, undermining the effectiveness of previously successful methods of relationship-based persuasion and school-based supervision. As a result, many individuals are choosing to withdraw from renewing their health insurance. The pressing challenge for China鈥檚 health insurance system is to implement governance strategies tailored to the rural social structure, establish governance norms at the village level, and ensure that collection activities are confined within institutional frameworks to regulate the behavior of grassroots officials.Additionally, it is crucial to establish negotiation channels to align rural residents鈥� demands with national policies, build a consensus on health insurance contributions, maintain spontaneous order under formal authority, and enhance the system鈥檚 acceptance and recognition, thereby gaining rural residents鈥� understanding, support, and participation.

Finally, cognitive biases induced by the internet have diminished rural residents鈥� willingness to maintain continuous health insurance coverage. The rapid expansion of the internet has significantly influenced the subjective perceptions of rural residents. According to prospect theory, decision-making is often shaped by the disparity between actual gains and losses and individuals鈥� psychological expectations [38]. The widespread use of the internet has altered the traditional reference groups of rural residents, providing them with external decision-making benchmarks. The benefits enjoyed by other groups online have become new 鈥渞eference points鈥� for rural residents [51]. Upon comparison, they find significant disparities between their own health insurance benefits and those of others, leading to a perceived sense of injustice and amplifying feelings of unfairness. This psychological process causes rural residents to feel disadvantaged and dissatisfied with the health insurance system [19].Additionally, due to the lack of effective regulation over internet-related information, many users promote and disseminate misleading content. This misinformation, often intertwined with rural residents鈥� healthcare experiences, emotions, and cognitive biases, generates significant social and psychological effects. Furthermore, the rapid dissemination of such content by the media subtly fosters 鈥渘egative emotions鈥� among rural residents toward the health insurance system. This not only influences their decision to participate in the health insurance system but also erodes their trust in it. Moving forward, it is essential to strengthen the regulation of online discourse and actively utilize internet platforms to establish authoritative channels for disseminating accurate health insurance policies. Additionally, media literacy education for rural residents should be enhanced to improve their ability to critically assess information. This will help them understand the importance, functioning, and benefits of health insurance, thereby influencing their attitudes toward it and gradually increasing their willingness to participate in the insurance system [21].

Conclusion

Ensuring the health and well-being of the populace is a fundamental task of socialist states. In China, residents鈥� medical insurance serves as the 鈥渓ast line of defense鈥� for the poorest and most vulnerable groups, playing a crucial role in preventing rural residents from falling back into poverty due to illness and in achieving common prosperity [7, 11]. The withdrawal of rural residents from the medical insurance system is not due to their unwelcoming attitude towards the policy. In fact, nearly all rural residents are most concerned about medical expenses; a serious illness for one person can cause suffering for the entire family. Reducing the risk of disease and the financial burden after illness are paramount concerns for all rural residents [2]. Therefore, the social phenomenon of rural residents voluntarily exiting the medical insurance system requires deeper understanding and explanation. This study deconstructs the reasons behind this withdrawal from multiple perspectives, offering new insights for optimizing China鈥檚 medical insurance system.

China鈥檚 medical insurance system should be decoupled from other social welfare programs, such as the subsistence allowance and poverty alleviation systems, and return to its core operational logic. Tailored financing standards, reimbursement scopes, and ratios should be developed based on economic and health conditions to better meet the needs of rural residents. More importantly, during policy implementation, government officials should adopt differentiated mobilization strategies to address the most impoverished and vulnerable groups. This includes exploring selective mobilization mechanisms and employing varied persuasion methods tailored to different villagers, utilizing multi-channel, integrated approaches to bring order to previously uncoordinated mobilization efforts. Furthermore, the government should focus on the identification and governance of misleading information and rumors while actively utilizing internet platforms to promote health insurance policies, thereby fully activating the intrinsic motivation of farmers to voluntarily pay for medical insurance, fostering the sustainable development of China鈥檚 healthcare insurance system.

The limitations of this study are as follows: Given the vast geographic scope of China, significant regional differences exist in factors such as economic development and population structure. Moreover, the study only selected 42 research subjects, resulting in a small sample size. Therefore, the findings based on the sample from Y County in S Province can only provide one possible explanation for the research questions. Future research should expand the sample size and explore cross-regional comparative studies. By increasing the sample size and conducting quantitative research with statistical inference, future studies can examine the impacts of factors such as policy implementation, fiscal subsidies, and residents鈥� burdens across different regions, thereby further validating the broader applicability of the findings and enhancing the depth and scope of the research.