Aging Is Not Frightening — Losing Fairness Is: The Challenge Aging Poses to Critical-Illness Mutual Aid

China is undergoing a profound change in its demographic structure.

There are fewer and fewer young people and more and more elderly people. Such change will affect pensions, healthcare and insurance, and it will certainly make itself felt, gradually, in medical mutual aid organizations like KangAi Commune.

So does aging mean mutual aid will become ever harder, and ultimately unsustainable?

Not necessarily.

If a mutual-aid community can maintain a relatively stable age structure, then even though every individual in it grows older, the risk level of the group as a whole will not keep rising simply because of the passage of time.

And even to go one step further: even if the whole society ages in the future, and the average age of KangAi Commune members keeps rising, that still does not mean mutual aid must be unsustainable.

The real problem is not age — it is fairness.

Young people generally have lower illness rates, and the elderly generally have higher ones; that is an objective difference in risk. As the age structure of members changes, what we truly need to watch over the long term is not only “how much contributions have risen,” but another, more important question:

Has there been an increasingly obvious cross-subsidy between different age groups? And is that cross-subsidy something everyone knows about and accepts?

Of course, cross-subsidy is not inherently a bad thing.

Healthy people helping the sick, those who have not been afflicted helping those who have, young people helping the elderly to a reasonable degree — this is part of what mutual aid is. If everyone paid strictly according to a precise calculation of their own risk, mutual aid would gradually lose the meaning of “mutual.”

So we can neither pursue absolute equivalence of risk, nor turn a blind eye to the growing cost differences between age groups.

A balance has to be found in between:

Allow cross-subsidy that has warmth, but avoid cross-subsidy that is out of balance; allow young people to help the elderly, but let that help be transparent, moderate and grounded in rules everyone accepts.

I believe this may be one of the questions most worth studying as KangAi Commune faces aging in the years ahead.

In the future we should look not only at annual changes in contributions, but gradually also at the age structure of members, the incidence of mutual-aid claims at different ages, and roughly how much each age group contributes and receives.

Only by gradually getting these things clear will we know whether the original rules are still fair, and whether we should keep to them or adjust them as the population structure changes.

Rising contributions in themselves do not mean mutual aid is unsustainable.

Even if, in the future, everyone taking part in mutual aid were elderly, as long as they face similar risks and share fairly according to commonly accepted rules, this mutual-aid community could still continue — even if the per-person cost were far higher than today.

So the question aging truly poses to KangAi Commune is not “how do we find more young people to bear the costs of the elderly,” but rather:

Once the population structure changes, how do we keep upholding a fairness that all age groups can accept?

This is also what we understand by long-termism.

Long-termism does not mean guaranteeing that the rules never change, nor that contributions never rise. On the contrary, when the external environment changes, we may need even more actively to study and adjust the rules.

Hold to what should be held to; adjust what should be adjusted; and in the end, safeguard fairness, transparency and shared responsibility.

The population structure can change, members’ ages can change, the cost of mutual aid can change. As long as the rules remain fair and participants are willing to share the burden together, mutual aid still has a basis for long-term existence.