A Lancet Study on the Equity of China's Health Insurance Makes Us Rethink the Long-Term Value of Critical-Illness Mutual Aid

A recent study published in The Lancet Regional Health – Western Pacific examined the equity of health financing in China from 2013 to 2023.

One of its conclusions left a deep impression on me:

China already has basic medical insurance covering the vast majority of its population, but equity in medical protection has not been achieved automatically as coverage has risen.

This brings me back to the question: now that China has essentially achieved universal health insurance and commercial insurance is increasingly developed, does online mutual aid still have any value?

If you asked me today, I would say: yes.

And the more I think about it, the more I feel that our past understanding of online mutual aid may itself have contained a misconception.

We should not regard online mutual aid as a "temporary substitute" for a period when health insurance was incomplete.

I. Universal health insurance solved one problem, but not every problem

The development of China's health insurance in recent years has been a tremendous social advance.

From a time when many people had no medical protection at all to today, when basic medical insurance covers the vast majority of the population, this change deserves our full recognition.

But we must distinguish between two concepts: "having protection" and "having adequate protection."

The fact that a person has health insurance does not mean they face no financial pressure when confronting a critical illness.

Health insurance can reimburse part of the medical costs, but there is still an out-of-pocket portion; benefit levels differ between different insurance schemes; and the costs of some critical illnesses, long-term treatment, and rehabilitation can also place a heavy burden on a family.

More importantly, illness never brings only the bill from the hospital.

After a family member falls seriously ill, several things may happen at once:

medical spending increases;

income falls;

family members must stop working to provide care;

children's education is affected;

rigid expenses such as mortgage and rent still remain.

So what really needs to be addressed is not only "how much of the medical costs are reimbursed."

It is rather: can an ordinary family withstand the entire household economic risk brought by a single critical illness?

This is in fact a different question.

II. This study made me recall a very simple truth

When we used to talk about social security, we often focused on one number: the coverage rate.

95%, 96%, 97%……

The coverage rate is of course important.

But if we go one step further, we should keep asking: who bears more of the burden? Who receives more protection? Who actually gets help when they truly need it?

This is exactly where the study's lesson lies.

The study finds that China's health financing as a whole still has a degree of regressivity. Put simply, this means that low-income groups may bear a heavier health financing burden relative to their ability to pay.

At the same time, medical security benefits are not entirely equal across different groups of people.

This shows something very important: a high health insurance coverage rate does not mean that medical risk has already been shared equitably.

And this is precisely the starting point for our renewed discussion of the value of "mutual aid" today.

III. If health insurance keeps improving, should mutual aid disappear?

I don't think so.

Because if we hold that health insurance develops → commercial insurance develops → mutual aid disappears,

then the same logic could lead to: commercial insurance develops → commercial insurance eventually replaces health insurance; or: health insurance develops → commercial insurance disappears.

But clearly that is not what happens.

Why?

Because they serve different functions.

Health insurance is a social security system; it addresses the basic medical protection of all members of society.

Commercial insurance is a contractual risk-management tool; it lets individuals transfer specific risks to an insurer by paying premiums.

Mutual aid addresses something else again: a group of people willing to bear the risks of a few together.

So I prefer to understand them as a multi-tiered protection system:

Health insurance is the foundation. Commercial insurance is an important supplement. Mutual aid is a social mechanism through which people bear risk together.

They are not mutually exclusive.

IV. What is truly precious about mutual aid is not that it is "cheaper than insurance"

If online mutual aid were simply understood as "everyone pays in a little, and whoever gets sick takes out a little,"

then it would indeed be easily replaced by various insurance products.

But that is not what I understand mutual aid to be.

What makes mutual aid truly valuable is that it creates a special relationship: today I help you, and tomorrow someone may help me.

When we join a mutual aid organization, we do not know whether we will be the one who needs help in the future.

The vast majority of participants may go their whole lives without ever becoming a recipient of aid.

But that does not mean their participation today has no value.

Because today what they help is someone else.

This is fundamentally different from commercial insurance.

Insurance is a contractual relationship.

Mutual aid is a community relationship.

A person buys insurance to manage their own risk.

A person who joins mutual aid, besides managing their own risk, is also taking part in a larger community.

This is what is most worth treasuring about mutual aid.

V. The internet turned the traditional "small mutual aid" into "large mutual aid"

In fact, mutual aid was not invented by the internet.

For thousands of years, the Chinese have had a tradition of mutual aid.

In the past, when a person fell ill, those who helped them were often parents, siblings, neighbors, and friends.

But this kind of mutual aid has a natural limit: the circle is too small.

How many relatives and friends do you have?

How many people are there in a village?

How many people are there in a workplace?

The internet changed this boundary.

A person can establish some kind of common relationship with hundreds of thousands or millions of people they have never met.

So a single person's risk can be borne jointly by a much larger group.

It used to be: one family helps one person.

Later it became: one circle of acquaintances helps one person.

In the internet era, for the first time we can achieve: a huge community of strangers helps one person.

I believe this is the most important innovation of online mutual aid.

What it changes is not simply "how much money is raised."

What it changes is: the scale on which people bear risk together.

VI. So what has KangAi Commune truly insisted on for 15 years?

As KangAi Commune has come this far, one thing has become ever clearer to me:

What we have truly wanted to do has never been to create a "cheaper insurance."

Nor should we position ourselves as a replacement for health insurance or commercial insurance.

What we want to do is something else: to give ordinary people back the ability to face the risk of critical illness together.

Over 15 years, we have seen many families that received aid.

When an ordinary person is suddenly struck by a critical illness, to them it may be a disaster.

But when tens of thousands of people reach out together, that disaster is no longer borne entirely by one family alone.

I think this is the simplest meaning of mutual aid: turning one person's risk into a group's responsibility.

VII. But this does not mean "all mutual aid deserves to exist"

Nor do I believe that anything flying the banner of "mutual aid" is automatically of long-term value.

Quite the opposite.

If online mutual aid is truly to become a long-term social mechanism, it must become more and more professional.

The rules must be transparent.

The funds must be clear.

The risks must be measurable.

The boundaries must be well-defined.

The governance must withstand scrutiny.

More importantly, the goodwill of participants must not be treated as a resource that can be consumed without limit.

Mutual aid that can truly endure cannot rely on sentiment alone.

Ultimately it must be built on scientific risk management, transparent rules, and stable organizational capacity.

This is perhaps the question that every online mutual aid platform today must answer.

VIII. What the future truly needs is "one more layer of protection," not "another health insurance system"

So I do not think online mutual aid should compete with health insurance in the future, nor that it should replace commercial insurance.

Quite the opposite.

I believe the mutual aid that truly has vitality in the future should find its own place.

Health insurance addresses basic medical protection.

Commercial insurance addresses contractual risk protection.

Social mutual aid addresses the sharing of risk among people.

Together the three form an even more diverse social security system.

Because no matter how far society develops, one thing will never change:

Risk will not disappear.

Illness will not disappear.

Accidents will not disappear.

The vulnerability of families facing major risk will not disappear automatically just because health insurance coverage reaches 95% or 99%.

As long as risk exists, people need to share risk.

As long as people need to share risk, mutual aid has a reason to exist.

IX. So I am not worried that "universal health insurance will make mutual aid disappear"

On the contrary, I believe the continuous improvement of universal health insurance is an opportunity for mutual aid to rediscover its own value.

Once society has solved the question of "whether you have health insurance," we can begin to seriously discuss:

Is protection sufficient?

Is protection fair?

What risks remain uncovered?

Beyond institutional protection, can we also build a community of shared risk among people?

This, I think, is what online mutual aid should truly be thinking about.

In the 15 years of running KangAi Commune, China's health insurance system, commercial insurance, and the entire social security system have undergone enormous changes.

But one thing has not changed:

When an ordinary person faces a critical illness, they still should not have to bear the entire risk alone.

In the past, we hoped relatives and friends could help them.

Today, we have health insurance, commercial insurance, and the internet.

So why can't we let more people who have never met each other help one another too?

Conclusion: Mutual aid is not the past—it is the future

I have come to believe more and more: mutual aid is not a "patch" for when a modern social security system is incomplete.

It may be precisely a kind of social capacity that modern society still needs to keep, even after it has established solid institutional protection.

Because a society that truly has warmth should not ask only:

"How much can the system reimburse you?"

It should also have people willing to ask:

"If that is not enough, can we help you together?"

Health insurance gives people institutional protection.

Insurance gives people contractual protection.

And mutual aid gives people something else: trust that comes from strangers.

When you run into difficulty, you are not necessarily alone.

This is our ever-deepening understanding of the word "mutual aid" in running KangAi Commune.

What we are making is not a product of a transitional era.

What we want to leave behind is a society's ability to help one another when facing risk.

As long as human beings still fall ill, as long as life still holds uncertainty, as long as we still believe people can help one another—

mutual aid will never go out of date.