The Impact of China’s Family Floating Population on the Participation of Medical Insurance in the Inflow Areas

Introduction

Since the 1980s, a large number of surplus rural laborers have flooded into cities, actively participating in economic and social construction. While a large number of migrant populations were advancing the modernization process of Chinese cities, they also faced great mobility risks. Predominantly residing and working in challenging conditions, coupled with factors such as poor awareness of health risks and inadequate health management services, they often grappled with various health issues. These issues include infectious diseases, reproductive system disorders, occupational hazards, and production accidents.¹ Therefore, some migrant populations suffered serious health losses, resulting in poor overall health conditions, and thus had a greater demand for basic health services and medical security.

However, under the urban-rural dual structure, the medical security of the migrant population remained compromised. Despite existing institutional arrangements, their implementation is often ineffective, preventing the migrant population from enjoying the same social rights as urban residents. Between 2011–2012, the insurance coverage rate for China’s migrant population was about 69%, compared to an urban insurance coverage rate of about 26%, indicating a significant Matthew effect.² In 2013, only 82.88% of migrant workers participated in social medical insurance. The majority opted for insurance in their “registered residence”, predominantly choosing the new rural cooperative medical insurance. This led to an increase in the number of insured employees and instances of duplicate insurance participation.³ Recent years have seen a significant increase in medical insurance participation among domestic migrants and an improvement in the phenomenon of duplicate insurance. However, 10.9% of domestic migrants still lack any medical insurance coverage.⁴ To address this problem, the 19th National Congress of the Communist Party of China pointed out that, in accordance with the requirements of helping those most in need, building a tightly woven safety net, and building the necessary institution, a multi-level social security system covering the entire population, coordinating urban and rural areas, clarifying rights and responsibilities, ensuring moderate protection, and promoting sustainability should be comprehensively established. As an important part of the social security system, medical insurance is a vital means for migrant populations to prevent uncertainty and mitigate health risks. Improving the coverage and benefits of medical insurance for migrant populations, allowing more migrant populations to obtain comprehensive and appropriate medical security, and promoting equity in basic health care services are pivotal and challenging aspects for the future development and construction of the social security system.

At the same time, the magnitude of China’s migrant population is undergoing an adjustment adjustment phase after a prolonged period of rapid expansion. The 2017 Report on China’s Migrant Population Development shows that as of 2016, the migrant population in China was 245 million, accounting for 17.5% of the total population; meanwhile, the average size of family households remained above 2.5 people, with households comprising of 2 or more migrants accounting for over 81.8%.⁵ The trend in population movement has shifted from individual mobility to family mobility.⁶ The migrant population has evolved from merely being “urban passers-by” to relocating with their spouses, children, and parents, and even settling in the city, inevitably leading to varied demands for public services and social security. Therefore, this study uses a non-systematic literature review to analyze whether the family-based floating population will have an impact on their participation in medical insurance in the inflow place, and provides a certain reference for the medical insurance participation of the floating population.

Current Research Status on Family-Oriented Migrant Population

Research on Types of Migrant Families

The migrant population has various methods of movement, including single-person mobility, joint mobility of couples, separate mobility of couples, mobility of couples with elderly or children, and mobility of couples with both children and elderly.⁷ According to different emphases on migration methods, there are also many types of migrant families. Li Qiang (1996) believed that the family types of migrant worker groups are different from traditional concepts and family models.⁸ Most members of migrant families are in a state of long-term separation. Migrant families can be divided into five basic patterns based on family relationships: unmarried children moving out, siblings moving out, couples living separately, couples with children living separately, and whole families moving out. Sun Qiuxia (2016) deemed that family-oriented migration focuses more on the family process. According to the different characteristics of migration in different eras, family-oriented migration can be divided into four stages: individual migration, couple migration, core family, and extended family. The process of family-oriented migration in China has completed the second stage.⁹ When conducting analysis, some scholars divided migrant families into three types: non-family-oriented migration, semi-family-oriented migration, and complete family-oriented migration, based on the differences in the migration behavior of family members and the degree of family-oriented migration. They also found that core family migration has become the primary migration mode through the analysis of the 2013 national dynamic monitoring data of the migrant population.¹⁰ Sheng Yinan (2014) argued that China’s migrant families follow a multi-stage migration mode, which can be divided into two categories: completed migration and incomplete migration. They can also be further divided into one-time family migration, family migration in batches, first-batch migration, and incomplete migration in batches based on the order of migration completion.¹¹

Research on the Scale and Structure of Family-Style Migrant Population

Unlike the traditional one-time family migration model in Western countries, family migration in China can be roughly divided into two types: simultaneous migration of family members and batch-based migration. The larger the family size, the smaller the proportion of those migrating to the destination.¹² Among the migrant families entering the destination in batches, the husband is the primary migrant or both husband and wife migrate together.¹³ Research shows that the number of family members in the family-style migrant population is mainly 3-person households, accounting for 31.82%, followed by 2-person households and 1-person households, accounting for 25.71% and 21.52% respectively.¹⁴ Scholars have found through research on migrant population families in Beijing that the majority of migrant families are core families, mainly consisting of married couples or parents with unmarried children living together in the destination.¹⁵ The number of generations of migrant families is lower than that of the total population in Beijing, with one- or two-generation households being the main types.¹⁶ Both at the national and regional levels, the migrant population shares a common characteristic, which is that they are currently mainly composed of core families.

Research on the Factors Influencing the Family-Oriented Mobility

The family migration of domestic migrants is also influenced by various factors, including individual and family factors, economic and social factors, and migration characteristics. Research has shown that women, young people, married individuals, and those with smaller mobility ranges, longer mobility times, and higher employment freedom have stronger mobility intentions and are more likely to achieve family-oriented mobility.¹⁷ For migration in batches, the age, gender, education, migration year, and family size of the first batch of “important individuals” all have a positive impact on the mobility of the second and third batch of family members.¹⁸ In terms of the completeness of the family, the higher the monthly income of the migrant family in the destination city, the greater the possibility of the entire family migrating; the age of first marriage and first childbirth of the migrant couple is an important factor affecting the completeness of the migrant family.¹⁹ The probability of achieving complete family migration and partial family migration is lower for people with fewer children. People with fewer migration experiences and longer duration of migration are more likely to achieve complete family migration.²⁰

Research on the Impact of Family-Oriented Migrant Population on the Participation Rate of Medical Insurance

Research on Health Insurance for Foreign Immigrants

Usually, immigrants cannot benefit from social security programs implemented by their home country and the host country, which greatly reduces the well-being and security of immigrants and their families. In many low-income countries, the lack of administrative capacity to implement social security programs is often a bigger problem.²¹ This also reflects the significant differences in accessing social protection in international migration, where immigrants from developing countries, especially South-South migrants, are in a disadvantaged position.²² As the immigrant population ages, restrictions on obtaining health insurance may result in inconsistent or no insurance coverage for elderly immigrants.²³

There is evidence that the fear and uncertainty caused by laws have an impact on the coverage of immigrant health insurance. For example, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) has had a negative impact on the health insurance of low-educated, unmarried, immigrant women and their children.²⁴ In the United States, after welfare reform imposed strict non-citizen eligibility rules, immigrants’ opportunities to obtain federally funded medical assistance have been limited, and eligibility plays an important role in the health insurance coverage of elderly immigrants.²⁵ In addition, the significant increase in the uninsured rate among immigrants is due to a decrease in the rate of medical insurance provided by immigrant employers.²⁶

In addition to differences in policy and system, the acquisition of immigrant medical insurance is also influenced by other factors. A community survey targeting Asian Americans shows that among East Asians, the insured rate is higher for females, those in good health, and those who seek private doctors when sick or injured. In contrast, among South Asians, the insured rate is related to education level, routine health check-ups, and other factors.²⁷ The insurance that immigrant groups value the most is the one that can cover emergencies, make medical expenses affordable, and protect family members.²⁸ The main obstacles to obtaining insurance include costs, concerns about discovering immigrant status, and communication issues. Therefore, English skills can improve immigrants’ chances of obtaining employer-sponsored health insurance. Medical subsidies cover most children who do not have employer-sponsored health insurance due to their immigrant parents’ poor English proficiency. Immigrants with poor English proficiency are likely to be uninsured.²⁹ Occupational status is also an important influencing factor, and the scope of health insurance coverage varies by occupation, with high-skilled occupations maintaining a higher level.³⁰

Research on the Participation of the Domestic Migrant Population in Medical Insurance

The factors influencing the participation of the migrant population in medical insurance are complex, mainly including individual characteristics, economic and social characteristics, and mobility characteristics.

There are significant differences in conclusions in terms of personal characteristics. In previous studies, age is generally considered an important factor affecting the participation of the migrant population in medical insurance. The older and the worse the physical condition, the higher the probability of participating in medical insurance.³¹ However, some scholars’ analysis also shows that age does not have a significant impact.³² Some scholars believe that the higher the educational level of the migrant population, the higher the possibility of participating in insurance, while others have come to the opposite conclusion.³³ Some studies have shown that the probability of being insured for married individuals is higher than that for unmarried individuals, but there are also studies that show no significant impact.³⁴ In addition, there are factors such as gender and health conditions.³⁵

In terms of economic and social characteristics, the degree of regularization and organization of employment, the nature of ownership of the company, the industry, and the scale of the company have a significant impact on the coverage of medical insurance.³⁶ Some scholars have also found from the perspective of occupational stability that the participation rate of medical insurance is higher among the migrant population with strong occupational stability.³⁷ Migrant population who have changed jobs or worked in cities in the East and West have a lower willingness to participate in medical insurance.³¹ In addition, the social participation of the migrant population has a significant positive effect on the participation rate; community factors such as the proportion of the migrant population in the community and the quality of community services have a dual effect on the participation rate.³⁸

In terms of mobility characteristics, household registration status, reasons for migration, and frequent return to hometown are the main influencing factors for the participation rate of medical insurance among the migrant population.³⁹ The participation rate of the migrant population in agricultural households, those who have not purchased houses, do not intend to stay long, and those who move to central and western regions is higher. The smaller the range of mobility, the higher the participation rate.⁴⁰

Problems with Domestic Medical Insurance for the Migrant Population

China is still a developing country with many unofficial sectors.⁴¹ In addition to employees in private and public industrial and commercial enterprises, the non-official sector is mainly composed of unregistered employees, such as vendors and part-time workers.⁴² Their employment scale is often small and their income is unstable Even if most migrant workers are employed, companies do not sign formal labor contracts with them, and their wages and basic guarantees are different from those of formal employees. One of the main problems with medical insurance for the migrant population in China is that it is not flexible, has a long payment cycle, imposes a heavy burden on enterprises, and lacks effective supervision. At the same time, employers find it difficult to actively provide basic medical insurance for them.⁴³

The income of domestic migrants in China is generally low, and most of them are poor. The inequality between migrant workers and urban residents is particularly prominent. The high threshold for urban medical insurance hinders low-income internal migrants from obtaining insurance.⁴⁴

Even the domestic migrant population members who are insured still face problems such as inter-provincial and long-distance medical care.⁴⁵ Previously, China’s medical insurance reimbursement method was that insured individuals seeking medical treatment outside the pooling area could not settle the medical insurance fund in real time, and individuals could only pay first and then return to the insured area for reimbursement.⁴⁶ With the promotion of direct payment of medical expenses for out-of-town medical treatment in China, real-time settlement of hospitalization expenses for medical personnel from other regions has been achieved (as of July 2020, the proportion of cross-province direct payment for hospitalization expenses is 58.6%⁴⁷). However, the expenses of ordinary outpatient and outpatient major disease patients still cannot be reimbursed by the medical insurance fund.

Previously, the main purpose of the domestic migrant population migrating from rural areas to cities was to seek economic improvement. However, in recent years, the internal migrant population in rural areas has tended to focus on urban development, and population mobility has shifted from temporary residence to permanent residence. Therefore, in order to ensure that their medical needs are met, it is necessary to improve the medical insurance system for the migrant population.⁴⁸

Policy Recommendations

Coordinate and Integrate the Medical Insurance System to Promote the Adaptability of Medical Insurance to Family Mobility

Although China has basically achieved universal coverage of medical insurance, the administrative barriers, the dual urban-rural structure, and the institutional division of the medical insurance system are gradually showing their incompatibility with the family-oriented nature of the migrant population. The participation rate of the migrant population in medical insurance at the destination is low, and many members of migrant families cannot enjoy medical insurance normally in the destination, and the level of benefits is inconsistent. Therefore, it is recommended to coordinate and integrate the medical insurance system to promote the adaptability of medical insurance to the mobility of families.

First, efforts should be made to coordinate and simplify management to achieve one-stop service. Originally, medical insurance was managed by multiple departments such as the social security department and the health department, which easily led to interdepartmental disputes, excessive administrative costs, and a relatively backward e-government level in some areas. The lack of information sharing in social security posed invisible barriers to the participation of migrant families in medical insurance. It is recommended that the National Healthcare Security Administration take the lead in organizing and implementing unified management and services based on the social security public information service platform, in order to promote the integration of the medical insurance system in terms of funding, benefits, and management; enhance cross-system, cross-regional, and cross-departmental applications, achieve interconnection and real-time query of insurance information, promote “transparent information” and “less errands for the people”, and facilitate the migrant population to handle various medical insurance services in different places.

Secondly, measures should be taken to coordinate and integrate differences to achieve institutional fairness. Most of the migrant population participate in the new rural cooperative medical insurance project in their registered residence. However, after being employed in the destination, there is a high probability that they need to change to the basic medical insurance for urban employees. However, after becoming unemployed, they can no longer enjoy the basic medical insurance for urban employees. With the integration of urban residents’ medical insurance and new rural cooperative medical care, China’s basic medical insurance system has been further unified, to some extent narrowing the urban-rural gap, but there still exists a dualistic opposition between urban-rural medical insurance and employee medical insurance. On the one hand, it is necessary to continue to promote the integration of basic medical insurance for urban and rural residents, strengthen the connection before and after integration, and timely study and solve the problems in the integration process. On the other hand, we should actively explore the deep integration of the basic medical insurance system, improve the medical insurance for employees and urban and rural residents, allocate medical resources reasonably, focus on the reform of the linkage among pharmaceuticals, medical care, and medical insurance, and improve the multi-level medical security system.

Guarantee the Welfare Needs of Migrant Families and Increase the Willingness to Participate in Medical Insurance at the Destination

Family is not only the basic unit of social life, but also an important topic in social welfare. The family policy not only has the function of uniting family strength, which is also known as familyization, but also has the practical effect of separating family relations. The social welfare system, characterized by regionalization and identification, results in “unfriendly families” or “absent families” of the current migrant population.⁴⁹ Some scholars believe that current social policies are mostly based on labor migration. With the trend of family-oriented migration, migration should be understood within the context of the family system and family processes. Family development should be considered in the migration process, and attention should be paid to the overall welfare of migrant families.⁵⁰ Empirical results also indicate that the family-oriented migrant population has a promoting effect on their participation in medical insurance at the destination. The higher the mobility is based on core families, the higher the possibility of participation in insurance. The mobility of families makes the welfare needs of the migrant population in the destination become complex and diverse. If these needs are met, it will increase their enthusiasm for participating in medical insurance at the destination, which in turn will enhance the overall interests and well-being of migrant families and promote the realization of family mobility. Therefore, it is necessary to guarantee the welfare needs of migrant families and improve their willingness to participate in local medical insurance.

On one hand, it is necessary to build a public service system based on migrant families, improve the well-being of migrant families, and promote the co-construction and sharing of urbanization development. With the increasing degree of population mobility and familyization, the welfare needs of the migrant population have become complex and diverse, leading to an increased demand for basic public services such as employment, education, social security, and public health. Relevant social policies should expand from focusing only on the labor and economic rights of mobile workers in the past to education, medical care, pension, etc., in order to meet the practical needs of migrant population families, expand welfare coverage, and achieve a transition from “working” to “living”. Family-based migrants are not only builders of the city, but also participants and integrators, as well as members who live and reside in the city. Efforts should be made to effectively guarantee the basic well-being of family members of the migrant population, improve the overall development and protection capabilities of the migrant population, and better reflect the value concept of the new urbanization in enhancing people’s well-being and promoting shared development.

On the other hand, various barriers to family-oriented mobility need to be eliminated in order to achieve orderly and free population mobility. Public services have long been dependent on household registration. Household registration is not just an identity, but also entails various rights and benefits attached to it. The segregation and lock-in of the household registration system have resulted in uneven distribution of basic public services and hindered population mobility. The household registration system reform should be the starting point to promote equalization of basic public services, allowing both registered and non-registered residents to enjoy urban public services. We need to break down the barriers of the household registration system, gradually relax the restrictions on urban settlement, and allow household registration to flow freely with the population; we need to remove the label of household registration identity, shift from population statistics and management to management and service, and bear more urban welfare and human care. Whether it is individual labor migration or family-oriented mobility, it is an economic behavior. When weighing the benefits and costs of migration, migrant individuals will naturally make rational migration decisions. However, past social systems and cultural traditions still exclude them and impose excessive administrative interventions on population mobility. In the context where population movement has become the norm and family-oriented migration has become the main characteristic, we should respect and adapt to the free movement of people, effectively promote family reunification of the migrant population, guarantee the welfare needs of migrant population families, and thereby improve their willingness to participate in medical insurance at the destination.

Pay Attention to the Interaction and Integration of Migrant Families, Understand and Guide Their Participation in Medical Insurance

Obviously, the family-oriented migrant population can not only achieve family reunion, play a role in maintaining the emotional connection among family members, and prevent and resolve family conflicts, but also make greater contributions to the urbanization of the destination. The migrant population, who bring their spouses and children with them, are no longer simple temporary laborers and passers-by in the city. While seeking a livelihood, they actively participate in and integrate into the new urban life, aspiring to become part of the city. Furthermore, the promotion effect of medical insurance on the family-oriented migrant population is closely related to the social network resources they obtain and the degree of social integration, which can be summarized as two theoretical mechanisms: “family-social” network and “economic-behavior” integration. Therefore, it is important to focus on the integration of migrant families’ interactive communication, cognitive understanding, and guidance for participation in medical insurance.

In terms of the social network of migrant families, the dilemma of self-isolation and exclusion should be changed, and their social relationship network should be optimized and reconstructed, enriching their relationship network and social resources in the destination. To encourage and absorb the migrant population to participate in social organizations, such as hometown associations, alumni associations, and fellow countrymen’s chambers of commerce, and to build their own networks of colleagues, peers, and relatives. This can not only improve teamwork and mutual assistance in funding but also broaden channels for obtaining information and connections. Efforts should be made to actively encourage the participation of the migrant population in community activities, volunteer work, and cultural and recreational activities in the destination areas, further enhancing neighborhood interactions, and establishing good social relationships, especially with the local residents. By building information bridges through homogeneous networks mainly composed of acquaintances and heterogeneous networks mainly composed of locals or non-locals, the migrant population is provided with information resources including medical insurance.

In terms of the social integration of migrant families, the status of the migrant population should be changed from being marginalized and discriminated against to accelerating their social integration process, achieving integration in economic, cultural, behavioral, and identity dimensions, and gradually participating in the medical insurance of the destination, so as to standardize the employment of the migrant population, protect their labor rights in accordance with the law, ensure a certain level of income and employee benefits, and provide an economic foundation for participating in medical insurance at the destination areas. At the same time, efforts should be made to strengthen professional skills training and education services, enhance the human capital of the migrant population, and enhance their ability to become citizens. Meanwhile, the construction of settlement projects should also be enhanced for the migrant population, so that they have a place to settle down and establish a career in the destination, and to accept and adapt to the local culture, customs, and behaviors in their work and life. Finally, it is also necessary to improve urban inclusiveness, recognize and respect the migrant population, enhance communication and interaction between the migrant population and local residents, eliminate barriers and prejudices between each other, and make migrant families feel more comfortable and at ease when seeking medical treatment in the destination.

Conclusion

Population mobility in our country has shifted from individual migration to family migration. This is not only a simple gathering of individuals or geographical displacement but also an adjustment of the migrant population’s family lifestyle and social welfare needs. However, currently, there are still some problems with medical insurance, such as the imperfect payment system for certain professions, difficulties in obtaining local residency, and excessive burden on low-income individuals, which result in migrant workers being unable to receive fair medical treatment and experiencing a significant decline in health levels in the destination areas. It is necessary to coordinate and integrate the medical insurance system to promote the adaptability of medical insurance to family mobility; guarantee the welfare needs of migrant families and increase the willingness of incoming areas to participate in medical insurance; pay attention to the interaction and integration of migrant families, understand and guide their participation in medical insurance to improve the current situation.