Why do rural residents in China withdraw from the health insurance system? —A Qualitative Study Based on Y County in S Province, China

Why do rural residents in China withdraw from the health insurance system? —A Qualitative Study Based on Y County in S Province, China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Why do rural residents in China withdraw from the health insurance system? —A Qualitative Study Based on Y County in S Province, China Ying Zuo, Guang Yang, Haoxuan Cheng, Lufa Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5245172/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 May, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version 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 the decision of rural residents in China 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 not enrolled in the medical insurance. Results: The study finds that the primary reasons for rural residents withdrawing from medical insurance are fourfold: heavy economic burdens, unfair design of the medical insurance system, failure of conventional mobilization strategies, and cognitive biases fostered by the internet. Conclusion: The decision of rural residents in China to withdraw from medical insurance is influenced not only by economic factors but also by the design of the system and various aspects of rural governance. In the future, the Chinese government should optimize the design of the medical insurance system, adopt more flexible mobilization and persuasion strategies, and strengthen the control of negative internet rhetoric to stimulate enthusiasm for participation in medical insurance among rural residents, thereby advancing the universal health strategy. Rural residents China's urban-rural residents' medical insurance system content analysis methods Figures Figure 1 1.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's development globally [1]. China's 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's 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 "Regulations on Rural Cooperative Medical Care" issued by the Ministry of Health in December 1979. In January 2003, China introduced a new rural cooperative medical insurance system for rural residents. By January 2016, China had merged the new rural cooperative medical insurance with the urban residents' basic medical insurance, forming a unified basic medical insurance system for urban and rural residents, covering all urban and rural residents except those who should be insured under the basic employee medical insurance scheme. The urban employee medical insurance system achieves mandatory coverage through legal compulsion and employer contributions, while basic medical insurance for residents follows a voluntary principle [3]. In recent years, the Chinese government has elevated the collection of urban and rural residents' 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 [4]. In practice, local governments have explicitly stated their commitment to the political responsibility of "universal insurance coverage" [5, 6]. They are meticulously identifying and ensuring no household or individual is left out, thereby accelerating insurance coverage expansion and improving service efficiency and quality[7]. Additionally, the government's substantial increase in basic medical insurance funding has stimulated public participation in medical insurance [8]. These efforts have rapidly boosted insurance coverage. By the end of 2023, 960 million people in China were covered by urban and rural residents' basic medical insurance, with coverage stabilizing at over 95%. The establishment of China's basic medical insurance system has steadily ensured basic medical coverage for low-income rural populations. It has played a significant role in alleviating the difficulties and high costs of medical care, supporting the development of the medical and health sectors[2], maintaining social harmony and stability [9], and promoting common prosperity [6, 10]. These efforts have notably improved the population's health status and fully protected people's health rights [11]. Figure 1 is here Unlike the urban employee medical insurance system, participation in the urban and rural resident medical insurance (URRMI) system is voluntary, with premiums collected annually. Residents can choose whether to enroll in medical insurance each year. Currently, nearly 5% of China's population remains outside the basic medical insurance system. With approximately 960 million people enrolled in URRMI, this means about 50 million people are uninsured. Moreover, the URRMI system faces severe adverse selection issues, exacerbating the risk to the medical insurance fund[12]. Additionally, satisfaction with the URRMI system is low among Chinese residents, leading many to gradually opt out of the insurance system[13, 14]. This poses a significant challenge to the sustainability of the system[15, 16] and severely hinders China's progress toward achieving universal health coverage[10]. This phenomenon is widespread across various countries and has garnered significant attention in the academic community. The research question, "Why are rural residents reluctant to continue participating in health insurance?" has been extensively studied. Existing research indicates that the key factor determining residents' participation in health insurance is whether the institutional supply of health insurance aligns with the needs and expectations of rural residents[17, 18]. On the demand side, the most critical factor is an individual's objective health status; the better the health, the less likely they are to pay for health insurance[15, 19]. Additionally, an individual's subjective perception of health risks significantly affects their willingness to pay for health insurance [20]. Awareness of health insurance policies is another crucial factor; the less residents know about the policies, the more likely they are to refuse to pay [21, 22]. Beyond objective reasons, residents' experiences during medical treatment also influence their decision to participate in health insurance. If residents encounter unfair treatment or poor service attitudes from healthcare providers [23, 24], they are more likely to opt out of health insurance. On the supply side, factors such as high funding levels for health insurance[25, 26], inflexible payment methods[27], and inadequate medical service capabilities [28–30] directly lead to rural residents' withdrawal from health insurance. Furthermore, the management structure and practices of health insurance institutions can cause residents to distrust the system, thus affecting their willingness to participate. More importantly, the deeper cultural aspects of the system are closely related to residents' willingness to pay for health insurance. If the design of the health insurance system does not adapt to the unique cultural background of the region, residents may refuse to participate. Beyond institutional and behavioral research, some scholars are increasingly reflecting on the concept of "voluntariness" in health insurance [31, 32]. They argue that the principle of voluntariness itself is a significant cause of adverse selection, leading to the unsustainability of health insurance systems [33, 34]. The voluntary contributions and active participation of rural residents are fundamental to ensuring the sustainability of the basic medical insurance system and enhancing public health welfare [35]. Therefore, incorporating populations currently excluded from universal health coverage is both urgent and necessary. Rural residents comprise 80% of the insured under China's medical insurance scheme, and the majority of these residents are among the poorest in the country. Research indicates that, under similar conditions, the likelihood of their continued enrollment is higher than that of other households, suggesting a stronger willingness to participate in the insurance scheme[36, 37]. Given this counterintuitive reality, investigating the reasons for rural residents' withdrawal from the insurance system is of significant practical importance. Existing studies have explored the phenomenon of "residents exiting medical insurance" from various perspectives, providing a rich foundation for understanding this issue. However, these studies predominantly focus on the determinants of voluntary participation in the medical insurance system rather than on the act of withdrawal itself. They lack an exploration of causal relationships and interactions to explain individual and social behaviors, and they do not adequately consider the unique social structures of rural areas that influence the complex decision-making processes behind withdrawing from insurance. Moreover, current research primarily examines top-down medical insurance systems and neglects the significance of these systems for achieving universal health coverage [38]. Therefore, this study, set against the backdrop of the advancement of China's urban and rural resident medical insurance system, employs qualitative research methods to address the aforementioned theoretical issues. 2. Research design 2.1 Methods Regarding the "factors influencing rural residents' withdrawal from the medical insurance system," there is currently no mature theoretical framework or related hypotheses in the academic community. Empirical research on this topic is also scarce. This paper employs content analysis, based on extensively collected qualitative data, to investigate this unclear issue. Content analysis allows researchers to systematically and objectively describe research phenomena at the theoretical level, thereby categorizing phenomena or events for better analysis and interpretation[39]. The sample size for content analysis is primarily determined by whether the content data has reached saturation [40]. Studying specific issues requires representative research samples to ensure the reliability and extensibility of the conclusions, thereby enhancing the research's value and theoretical significance. This study selects Y County in S Province, China, as the research subject. Y County covers an area of 1,212 square kilometers, with a total population of 68,000, of which 53,000 are rural residents, accounting for 77.9% of the total population. This high proportion of rural residents, who are required to enroll in rural medical insurance, provides a sufficient and representative sample for the study. 2.2 Ethics Approval The study protocol was approved by the ethics review committee in China based on the assessment of the study's design and process, by the principles of the Declaration of Helsinki (Approval Number: 021-gskyb-02-372424198012222511). 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’s password-protected computer. 2.3 Data collection In this study, we focused on rural residents who had previously participated in the medical insurance system but have since opted out. Additionally, we included stakeholders involved in the rural medical insurance payment process, such as government administrative departments, tax departments, medical insurance departments, and village committees. A total of 42 individuals were interviewed. The basic information of the interviewees is presented in Table 1 . The distribution of the interviewees broadly covers the research questions addressed in this study. The interviews were primarily unstructured, with an average duration of no less than 30 minutes, and the longest individual interview lasting up to one hour. Furthermore, for research purposes, the researchers attended internal meetings of government departments mobilizing medical insurance collection and organized four small seminars. Participants in these seminars included personnel from medical insurance departments, township officials, and rural residents. These materials served as supplementary resources and were used to verify theoretical saturation in our research.In this study, when data analysis no longer yielded new categories, the researchers continued interviewing three disabled elderly individuals to verify if data saturation had been achieved[41]. The coding outcomes revealed no emergence of new categories. Consequently, the study successfully passed the test for theoretical saturation. Table 1 Basic Information and Coding of Study Subjects Interviewees Position (Occupation) and Number Coding Party and government departments Township Mayor (1)、Tax Bureau Staff (2)、 Medical Insurance Bureau Staff (1)、 Medical Insurance Center Staff (1) ZF01-05 Functional departments Village committee director and deputy director (2)、rural grid managers (3). CW01-05 Rural residents Residents(22) JM01-22 Table 1 is here 2.4 Data analysis Data analysis and data collection are conducted simultaneously to ensure the relevance of the data to the analytical framework, thereby maximizing data integrity and ensuring 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. Key statements relevant to the research topic are extracted from the interview transcripts and broken down into units, simplifying them into categories that capture the overall meaning of each response. Building upon this foundation, deeper connections between categories are discovered through continuous comparison and organization of the data, leading to the reintegration of the data to form themes, resulting in the identification of 9 categories and 4 themes. Throughout the data analysis process, the original responses are repeatedly reviewed and compared with subsequent categories and themes to ensure consistency with the intended message conveyed by the research subjects[42]. 2.5 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. [43]To ensure credibility in this study, several measures were implemented. Firstly, the study design was meticulously crafted. The researchers engaged in the project for an extended period and conducted prolonged observations of the participants through semi-structured interviews. Secondly, to maintain the credibility of the researchers, two experienced professionals well-versed in the theoretical framework employed were tasked with independently coding the interview data. Expert opinions were also sought when necessary. [44]Thirdly, the credibility of the research outcomes was ensured as the study reached theoretical saturation. The emerging categories,themes, and their interrelationships were consistently validated during interviews, highlighting the authenticity and value of the recurring concepts and categories[45]. Lastly, the applicability of the research methods was ensured by leveraging the richness of the data obtained through in-depth interviews[46]. 3.Results 3.1 Economic Burden 3.1.1 Persistent Rise in Payment Standards Since the inception of the resident medical insurance system in China in 2003, the minimum payment standards for insured residents have consistently increased, escalating from an initial 10 yuan per person to 380 yuan per person by 2024. Rural residents in China typically earn lower incomes with income variability. The growth in medical insurance payment standards imposes a heavy financial burden on rural families, making it difficult for economically vulnerable rural residents to bear. As one participant noted, "At the beginning, the annual payment was very low, but in just a few years, it has increased to over 300 yuan" (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 "sacrifice" themselves, saving money to pay the insurance premiums for family members at higher risk of illness. As expressed by a participant, "I'm 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 yuan in one go. It's indeed a significant expense. This year, our family couldn't afford it, so I paid for my parents. They are elderly, and we, the younger ones, didn't pay" (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, "Can we pay in installments? This way, our economic pressure would be lighter, and we could pay when we have the money" (Interview Data: CM11). 3.1.2 The inability to significantly alleviate the economic burden of illness Farmers enroll in medical insurance to reduce the cost of diagnosis and treatment when they fall ill. However, the existing reimbursement policies suffer from narrow coverage and low reimbursement rates, leading to negative healthcare experiences for many farmers. "My wife went to the hospital last time and spent over 1000 yuan. When we tried to claim reimbursement with the payment receipt, the staff said it wasn't covered. We don't know what is covered. If they say it's not covered, then it's not. If we pay and still can't get reimbursement, what's the point of paying?" (Interview Data: CM20). Additionally, the removal of "individual accounts" 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. "Our biggest need each year is to buy medicine from the pharmacy. In the past, we had 'individual accounts.' I paid fees every year, even if I didn't go to the hospital, at least I bought some medicine. Now it's canceled. If we don't get hospitalized, we have to pay for medication ourselves, whether it's a major or minor illness, the burden is getting heavier and heavier" (Interview Data: CM16). Due to the inability to use medical insurance cards at pharmacies, some rural residents now seek treatment at hospitals for ailments that could be managed at home, solely to avail themselves of benefits. However, some farmers point out that the cost of medical treatment and medication, even with insurance, is higher than buying medication directly from a pharmacy out-of-pocket. "The same medicine costs me 3 yuan at a street corner pharmacy, but at the hospital, the doctor prescribes the same medicine for 10 yuan. After reimbursement, I still have to pay 5 yuan out of pocket. Isn't that cheating our money?" (Interview Data: CM01). The effectiveness of medical insurance in alleviating the economic burden of illness for farmers has become a subject of doubt among rural residents, who find it challenging to directly benefit from medical insurance reimbursements when they fall ill. 3.2 The Inequity in Health Insurance System Design 3.2.1 Inequitable Funding Standards The funding of China's medical insurance is solely responsible for the medical services within the current year, regardless of whether residents have received medical treatment during that year. However, in the following year, they are required to repay according to the new payment standards. "As a young person like me, if I haven't been sick for a year and haven't 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's unacceptable to me that I pay the money, and then after a year, it's reset to zero, and the next year I'm asked for it again. My money doesn't come out of thin air, and I can't psychologically accept it." (Interview Data: CM17) For many residents, not falling ill means their money has been wasted, creating a sense of unfairness. "I've been paying fees for over ten years, and I've never used it. Can I pay less if I pay again? It's too unfair. Why should I pay if I haven't spent any medical insurance money?" As a result, young people choose to withdraw from the medical insurance payment system, leaving behind mostly elderly individuals with a higher risk of illness. This sense of unfairness not only exists between healthy and unhealthy populations but also between urban and rural residents. "The 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's completely unreasonable for us to pay the same amount as them." (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. "My parents and my younger brother all have some mental illnesses and cannot take care of themselves. My mother couldn't see anything last year, but even after applying several times, we weren't approved. Many people in the village who are in better situations than us have been selected as subsistence allowance recipients and enjoy medical insurance subsidy policies. Why shouldn't we receive them? Then I won't pay for medical insurance." (Interview Data: CM14) 3.2.2 Inequities in Treatment Benefits The inequities in treatment benefits primarily manifest between urban and rural areas. Farmers 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 decrease. This presents a phenomenon where individuals in the same city experience different treatment benefits, thus leading to lower accessibility to quality medical services for farmers. "In 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." (Interview Data: CM05) Additionally, medical insurance reimbursement policies are not favorable to individuals who migrate from rural areas for employment. Discrepancies in medical insurance policies among different cities prevent young people from fully enjoying the benefits of their insurance contributions. "My 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." (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, "From 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." (Interview Data: ZF05) 3.3 Failure of Conventional Mobilization Strategies 3.3.1 Limited Impact of Propaganda Methods A significant portion of rural residents possess a low awareness regarding the reimbursement policies of medical insurance and exhibit a lag in understanding updates to these policies. This leads to cognitive biases among rural residents, with some still perceiving the policies in the context of individual account setups for medical insurance. "In 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't anymore. Yet, I see some people still can, I don't know why." (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. "During the collection period, we go door-to-door to promote this year's medical insurance policies, payment standards, and benefits." (Interview Data: ZF03) Government personnel aim to increase payment rates by encouraging rural residents to contribute. However, from the perspective of rural residents, such promotions often fail to address their most pressing concerns, providing little assistance. "The 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't provided us with this information." (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, leading to discrepancies between the information disseminated and the reality of reimbursement. "They told us we could claim reimbursement when we paid, but in reality, we couldn't. The policy changes too quickly, and now we have no idea what the rules are." (Interview Data: CM18) It can be argued that the current stage of medical insurance policy promotion has not addressed the issue of information asymmetry. 3.3.2 Erosion of Traditional Persuasion Mechanisms The primary sphere of rural life unfolds within limited villages, where intimate "social bonds" tie individuals together, fostering a "familiarity-based society" rooted in geographical factors. Rural dwellers are reluctant to sever these social ties easily. Throughout past instances of health insurance levy, village cadres played pivotal roles, leveraging their geographical connections to engage in extensive "persuasion" campaigns among rural residents. Despite incomplete understanding of health insurance policies among many residents, trust in village cadres and the maintenance of interpersonal relationships prompted adherence to their mobilization efforts for medical insurance contributions. However, in recent years, with the rapid urbanization in China, this rural traditional social structure and operational norms have faced challenges, as material interests gradually supersede personal sentiments. "Nowadays, 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." (Interview Data: CW01) Geographical connections in rural areas no longer wield the same influence over villagers' payment decisions. "In 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." (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. "My parents still respond actively to the village cadres' calls. Why should I listen to them? I seek tangible benefits, not just relationship maintenance." More alarmingly, intervention through traditional mobilization tactics exacerbates the younger generation's aversion. "They (village cadres) keep calling me to pay and even visit my home to press me, which is really annoying. They don't give prior notice before coming, regardless of what you're doing, disrupting my normal life." (Interview Data: CM06) 3.3.3 Excessive Implementation of Supervisory Measures For a long time, schools have assumed the role of "supervisors" in the process of medical insurance collection. Leveraging their significant influence, schools' supervision has notably increased the insurance participation rate among children and adolescents. "My 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's insurance through class meetings and class group chats" (Interview Data: CM04). However, this supervisory approach is not a sustainable solution and has, to some extent, led to adverse consequences. "Not being insured means you can't enroll in school. Education and insurance are now 'tied' together, creating 'implicit' pressure. Initially, we could have communicated and paid, but now we choose not to" (Interview Data: CM22). While this mobilization tactic is not the direct cause of rural residents' non-payment of insurance, the unreasonable supervisory measures have prompted hesitant farmers to opt out of payment. Moreover, they have strained the relationship between rural residents and government personnel. Interestingly, government workers still maintain that this action does not constitute coercion, as rural residents' insurance participation is still based on voluntary principles. One government official remarked, "Now, medical insurance follows the principle of voluntariness. If they really don't want to, they don't have to pay. But if we don't urge them, hardly anyone voluntarily pays. We don't want to resort to measures that prevent children from attending school; we just 'remind' them, but we're obligated by our superiors to collect this money" (Interview Data: ZF01). 3.4 The Internet's Impact on Residents' Cognitive Biases 3.4.1 Internet Reduces Subjective Identification with Welfare In recent years, the widespread availability of the Internet has significantly increased, providing rural residents with avenues to access various healthcare insurance plan information. Rural residents are no longer constrained by time and space; they can utilize the Internet to search for and browse health information and obtain healthcare resources. Prior to the Internet's penetration in rural areas, rural residents primarily perceived medical insurance benefits through comparison with other villagers. However, in recent years, the Internet's ubiquity has provided rural residents with more reference points. "I saw comments from others in a video's comment section, people in situations similar to mine, and their reimbursement rates are much higher than mine" (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' relative sense of achievement and gradually reduces their identification with medical insurance benefits. Government officials resonate with this sentiment: "They (rural residents) don't 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" (Interview Data: ZF04). 3.4.2 Dissemination of False Health Information Online 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, the internet harbors a plethora of unreliable information sources. Coupled with the limitations in rural residents' knowledge and experience, they are prone to being misled by media propaganda, resulting in irrational cognitive biases towards their own health status and the level of medical insurance coverage. "I 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." (Interview Data: CM10) Such misinformation weakens the judgment of rural residents with limited discernment, leading to erroneous tendencies in medical insurance payments. Despite repeated efforts by government personnel to disseminate information, the impact remains minimal. "We've explained to them that these so-called 'experts' 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." (Interview Data: CW03) 4.Discussion China is dedicated to promoting extensive and profound coverage of basic medical insurance, and ensuring the complete coverage of the medical insurance system for urban and rural residents is a crucial component in achieving this objective. The urgent inclusion of populations currently excluded from the basic medical insurance system is imperative. This study tracks the process of medical insurance collection in Y County, S Province, China, in 2023. It involves interviews with governmental, medical insurance, and taxation departments of Y County, as well as rural residents who have not paid medical insurance premiums. The research addresses the core question of why rural residents in China choose to opt out of the medical insurance system. The findings suggest that the primary reasons for rural residents' 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 study also reveals that this behavior is not solely an economic obstacle; it represents a deeper challenge faced by China's medical insurance system and rural governance. The primary reason for voluntary withdrawal from medical insurance among rural residents in China stems from the economic burden imposed by insurance premiums. On one hand, the rapid escalation of medical insurance premiums has objectively heightened the financial strain on rural residents. China's rapid urbanization has fostered increasing expectations among farmers for high-quality medical services, prompting many rural residents to bypass local township health centers and county-level medical institutions in favor of larger urban medical facilities [14]. This surge in demand for quality medical services, coupled with rising costs of healthcare provision, has led to a collective increase in healthcare expenditure within society [7], ultimately translating into a rapid elevation of individual medical insurance contribution standards. Should the rate of increase in medical insurance premiums continue to outpace the growth rate of rural residents' incomes, the number of individuals opting out of medical insurance may escalate further[13]. The improvement of healthcare quality inevitably entails an increase in healthcare costs; hence, policies must strike a balance between ensuring a steady enhancement in healthcare service quality and controlling healthcare service costs[16]. 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 "underpurchase demand-side anomaly" proposed by Kunreuther[24]. Conversely, adverse selection gradually increases with the rise in premium standards, leading to a moral hazard phenomenon of "bad money driving out good," significantly elevating operational risks for medical insurance funds. On the other hand, the effectiveness of medical insurance in alleviating economic pressure caused by illness among rural residents is inadequate. The primary reason for this phenomenon is the imperfect mechanism for dynamic adjustments to the basic medical insurance catalogue. Many drugs, consumables, and medical services remain unreimbursed, requiring rural residents to bear the costs themselves[9]. Consequently, from the perspective of farmers, despite their urgent need to reduce medical expenses and seek high-quality medical services, they harbor a logical reluctance to pay for medical insurance. Farmers 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, prompting them to opt out of medical insurance[13, 18]. 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. Although the medical insurance system for urban and rural residents in China stipulates equal adherence to the same payment base, the dual urban-rural system influences rural residents' per capita income, which 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[14]. This disparity has resulted in an unfair allocation of medical and health financing between urban and rural residents, leading to adverse selection [26]. 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[25, 34]. This necessitates, at the policy level, adjustments to the financing mechanism for rural residents based on "income levels" and "payment capacity"[8]. Additionally, extending the payment period and allowing rural residents to pay in installments should be considered, along with exploring payment mechanisms that align with seasonal income fluctuations resulting from agricultural production. Concurrently, to mitigate the risk of rural households falling back into poverty due to illness, the Chinese medical insurance system is linked with low-income and poverty alleviation policies. Medical insurance policies have evolved not only as a system to bear the risk of illness but also as a policy to safeguard against broader societal risks [9]. 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[3]. 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[14], there are significant disparities in healthcare resources and service levels across regions. High-quality medical resources are typically concentrated in major cities, giving urban residents greater access to healthcare services[7]. In contrast, rural residents utilize fewer medical services due to geographical barriers and budget constraints [16]. When local primary healthcare facilities cannot meet their needs, rural residents must travel to higher-level medical institutions, but current Chinese health insurance policies offer low reimbursement rates for cross-regional medical expenses, or none at all. This results in lower net healthcare benefits for rural residents[35]. Furthermore, healthcare reimbursement rights are defined by geographic boundaries, with varying coverage and benefits across regions, and eligibility is based on the household registration location. This regional disparity directly affects young people working across different areas[15]. Overall, this situation leads to a significantly lower utilization of quality medical resources by rural residents compared to urban residents, with government subsidies intended to promote universal healthcare coverage disproportionately benefiting urban residents[25]. Therefore, it is necessary to increase the reimbursement range and rate of basic medical insurance for rural residents, gradually narrowing the gap between urban and rural healthcare benefits, and achieving equal access to basic medical services[38]. The failure of conventional mobilization strategies has somewhat intensified the willingness of Chinese rural residents to withdraw from health insurance, undermining their trust in both health insurance and the government. China’s health insurance system, based on voluntary participation, allows residents to decide whether to enroll according to their economic conditions and needs, demonstrating respect for individual choice and embodying democratic principles [34]. Under this voluntary principle, the promotion of health insurance policies becomes crucial [22]. Despite this, the Chinese health insurance policy suffers from deficiencies in its promotion methods, content, and timing. Consequently, when rural residents fall ill, the lack of essential reimbursement information may hinder their ability to receive compensation, eroding trust in health insurance's expected utility [36].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, due to close local ties, interact frequently with village officials who can mobilize and urge residents to enroll in insurance through various channels such as home visits, phone calls, and broadcasts. This creates a de facto "quasi-mandatory insurance" characteristic in rural areas [37].As China modernizes, traditional local relationships are gradually disintegrating, rendering previously effective relationship-based persuasion and school-based supervision methods ineffective, leading many to opt out of renewing their health insurance. The urgent task for China’s health insurance system is to adopt governance methods suited to the rural social structure, establish governance norms in villages, and confine collection actions within institutional frameworks to regulate grassroots officials’ behavior. Additionally, it is crucial to establish negotiation channels to align farmers' demands with national policies, build a consensus on health insurance contributions, maintain spontaneous order under formal authority, and enhance the system's acceptance and recognition, thereby gaining farmers' understanding, support, and participation. Finally, the cognitive biases induced by the internet have also reduced the willingness of rural residents to maintain continuous health insurance coverage. The rapid development of the internet has significantly impacted the subjective consciousness of rural Chinese residents. According to prospect theory, decisions are often based on the gap between actual gains and losses and psychological expectations[36]. 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 "reference points" for rural residents[47]. 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[18]. Additionally, due to insufficient regulation of internet information, many users disseminate inaccurate information, which, coupled with media coverage, subtly fosters negative attitudes toward health insurance policies among rural residents. This misinformation influences their decisions regarding participation in health insurance.In the future, it is essential to strengthen the regulation of misinformation and proactively use internet platforms to convey accurate and scientific health insurance policies. This will help rural residents understand the importance, mechanisms, and benefits of health insurance, ultimately influencing their attitudes and gradually increasing their willingness to participate[20]. 5.Conclusion Ensuring the health and well-being of the populace is a fundamental task of socialist states. In China, residents' medical insurance serves as the "last line of defense" 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[6, 10]. 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 farmers [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's medical insurance system. The healthcare insurance system for Chinese residents should first disentangle itself from the low-income support and poverty alleviation systems, returning to the inherent logic of health insurance. It should develop differentiated funding standards, reimbursement scopes, and reimbursement ratios tailored to rural residents based on economic and health conditions. Additionally, a health incentive mechanism should be established, providing financial rewards and policy incentives to patients who do not incur outpatient expenses within a year, achieving a dynamic balance between the health insurance system and regions with diverse social and cultural backgrounds. More importantly, during policy implementation, government officials must employ differentiated mobilization strategies for the poorest and most vulnerable groups. This involves exploring selective mobilization mechanisms for health insurance payments and adopting varied persuasion and mobilization methods for different villagers. A multi-channel, integrated approach to mobilization can transform the "disorderly" state and avoid the disruption of rural social structures by a top-down, efficiency-driven logic. Furthermore, the government should enhance the control of harmful online information and actively use 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's healthcare insurance system. Declarations Contributions: Ying Zuo: Conceptualization, Methodology, Data Curation, Writing-Original Draft, Writing-Review & Editing. Guang Yang: Conceptualization, Methodology, Writing-Review & Editing. Haoxuan Cheng: Writing-Review & Editing, Data Curation. Zhang Lufa: Conceptualization, Writing-Review & Editing, Project administration, Funding acquisition. Availability of data and materials ： The data supporting this study will be made available upon reasonable request by contacting the corresponding author. Funding: This work was supported by the National Social Science Fund of China [grant numbers 22AZD082] Ethics approval and consent to participate: The study protocol was approved by the ethics review committee of Shanghai University of Medicine & Health Sciences, China based on the assessment of design and process of the study, and was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable Declaration of competing interest: the authors do not report any conflicts of interest. References Organization WH: Reaching universal coverage via social health insurance: key design features in the transition period . In . : World Health Organization; 2004. Zhou Y, Li C, Wang M, Xu S, Wang L, Hu J, Ding L, Wang W: Universal health coverage in China: a serial national cross-sectional study of surveys from 2003 to 2018 . The Lancet Public Health 2022, 7 (12):e1051-e1063. 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Wang C: Research on the Characteristics of Uninsured Individuals: A Study on the Enrollment in China's Urban and Rural Residents' Medical Insurance . Social Security Review 2023, 7 (02):76-93. Zhang Y, Sun Y, Xie M, Chen Y, Cao S: Health shocks, basic medical insurance and common prosperity: Based on the analysis of rural middle-aged and elderly groups . Frontiers in Public Health 2022, 10 :1014351. Harwood TG, Garry T: An overview of content analysis . The marketing review 2003, 3 (4):479-498. Krippendorff K: Content analysis: An introduction to its methodology : Sage publications; 2018. Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, Grimshaw JM: What is an adequate sample size? Operationalising data saturation for theory-based interview studies . Psychology and health 2010, 25 (10):1229-1245. Hsieh H-F, Shannon SE: Three approaches to qualitative content analysis . Qualitative health research 2005, 15 (9):1277-1288. 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Cite Share Download PDF Status: Published Journal Publication published 02 May, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 14 Oct, 2024 Editor assigned by journal 13 Oct, 2024 Submission checks completed at journal 13 Oct, 2024 First submitted to journal 11 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5245172","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":365757029,"identity":"9d4a3610-b089-4b7c-a3fb-c72d838b77e0","order_by":0,"name":"Ying Zuo","email":"","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zuo","suffix":""},{"id":365757030,"identity":"a85c491a-1e88-4556-8558-20ae142298d1","order_by":1,"name":"Guang Yang","email":"","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Guang","middleName":"","lastName":"Yang","suffix":""},{"id":365757032,"identity":"c25d1a8e-fb32-49f5-a663-202a24d0d45b","order_by":2,"name":"Haoxuan Cheng","email":"","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Haoxuan","middleName":"","lastName":"Cheng","suffix":""},{"id":365757033,"identity":"e9f02fd3-3499-4856-97a8-c20bd7f6250f","order_by":3,"name":"Lufa Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYDACCRBRICfHwHAAxGImVouBsTEDw2EStSQ2QFQToUV+dvOzh18MDNLnN54/JsFQYZ3YwH72AF4tjHOOmRvLGBjkbjhwmE2C4Ux6YgNPXgJeLcwSCWbSEgZ/cjcwALUwth1ObJDgMcCrhU0i/RtQi0G6fANIyz8itPBI5JhJfjAwSGAAOYyxgQgtEhI5ZdIMBgaGQL8YWyQcSzdu48nBr0V+Rvo2yR8VBvLyMw4+vPGhxlq2n/0Mfi0gwMwDtu8AA0MCyHcE1QMB4w8Qyd9AjNpRMApGwSgYiQAAaxc/e606fc4AAAAASUVORK5CYII=","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":true,"prefix":"","firstName":"Lufa","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-10-11 09:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5245172/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5245172/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-22882-2","type":"published","date":"2025-05-02T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71858270,"identity":"47bbeecd-4b1a-4b8e-a0c2-6fc65ddfd9dd","added_by":"auto","created_at":"2024-12-19 08:35:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":126451,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1DevelopmentofChinasHealthcareInsuranceSystem.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5245172/v1/eaaafabd5048a0567b12489b.jpg"},{"id":81987688,"identity":"c66bfee3-0630-4600-885b-42a8ad7f466e","added_by":"auto","created_at":"2025-05-05 16:04:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2866539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5245172/v1/c4e92868-9410-4eab-9c89-25f647ae33f7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Why do rural residents in China withdraw from the health insurance system? —A Qualitative Study Based on Y County in S Province, China","fulltext":[{"header":"1.Introduction","content":"\u003cp\u003eUniversal 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's development globally [1]. China's 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].\u003c/p\u003e \u003cp\u003eIn the early years of the People's 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 \"Regulations on Rural Cooperative Medical Care\" issued by the Ministry of Health in December 1979. In January 2003, China introduced a new rural cooperative medical insurance system for rural residents. By January 2016, China had merged the new rural cooperative medical insurance with the urban residents' basic medical insurance, forming a unified basic medical insurance system for urban and rural residents, covering all urban and rural residents except those who should be insured under the basic employee medical insurance scheme. The urban employee medical insurance system achieves mandatory coverage through legal compulsion and employer contributions, while basic medical insurance for residents follows a voluntary principle [3].\u003c/p\u003e \u003cp\u003eIn recent years, the Chinese government has elevated the collection of urban and rural residents' 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 [4]. In practice, local governments have explicitly stated their commitment to the political responsibility of \"universal insurance coverage\" [5, 6]. They are meticulously identifying and ensuring no household or individual is left out, thereby accelerating insurance coverage expansion and improving service efficiency and quality[7]. Additionally, the government's substantial increase in basic medical insurance funding has stimulated public participation in medical insurance [8]. These efforts have rapidly boosted insurance coverage. By the end of 2023, 960\u0026nbsp;million people in China were covered by urban and rural residents' basic medical insurance, with coverage stabilizing at over 95%.\u003c/p\u003e \u003cp\u003eThe establishment of China's basic medical insurance system has steadily ensured basic medical coverage for low-income rural populations. It has played a significant role in alleviating the difficulties and high costs of medical care, supporting the development of the medical and health sectors[2], maintaining social harmony and stability [9], and promoting common prosperity [6, 10]. These efforts have notably improved the population's health status and fully protected people's health rights [11].\u003c/p\u003e \u003cp\u003eFigure 1 is here\u003c/p\u003e \u003cp\u003eUnlike the urban employee medical insurance system, participation in the urban and rural resident medical insurance (URRMI) system is voluntary, with premiums collected annually. Residents can choose whether to enroll in medical insurance each year. Currently, nearly 5% of China's population remains outside the basic medical insurance system. With approximately 960\u0026nbsp;million people enrolled in URRMI, this means about 50\u0026nbsp;million people are uninsured. Moreover, the URRMI system faces severe adverse selection issues, exacerbating the risk to the medical insurance fund[12]. Additionally, satisfaction with the URRMI system is low among Chinese residents, leading many to gradually opt out of the insurance system[13, 14]. This poses a significant challenge to the sustainability of the system[15, 16] and severely hinders China's progress toward achieving universal health coverage[10].\u003c/p\u003e \u003cp\u003eThis phenomenon is widespread across various countries and has garnered significant attention in the academic community. The research question, \"Why are rural residents reluctant to continue participating in health insurance?\" has been extensively studied. Existing research indicates that the key factor determining residents' participation in health insurance is whether the institutional supply of health insurance aligns with the needs and expectations of rural residents[17, 18]. On the demand side, the most critical factor is an individual's objective health status; the better the health, the less likely they are to pay for health insurance[15, 19]. Additionally, an individual's subjective perception of health risks significantly affects their willingness to pay for health insurance [20]. Awareness of health insurance policies is another crucial factor; the less residents know about the policies, the more likely they are to refuse to pay [21, 22].\u003c/p\u003e \u003cp\u003eBeyond objective reasons, residents' experiences during medical treatment also influence their decision to participate in health insurance. If residents encounter unfair treatment or poor service attitudes from healthcare providers [23, 24], they are more likely to opt out of health insurance. On the supply side, factors such as high funding levels for health insurance[25, 26], inflexible payment methods[27], and inadequate medical service capabilities [28\u0026ndash;30] directly lead to rural residents' withdrawal from health insurance. Furthermore, the management structure and practices of health insurance institutions can cause residents to distrust the system, thus affecting their willingness to participate.\u003c/p\u003e \u003cp\u003eMore importantly, the deeper cultural aspects of the system are closely related to residents' willingness to pay for health insurance. If the design of the health insurance system does not adapt to the unique cultural background of the region, residents may refuse to participate. Beyond institutional and behavioral research, some scholars are increasingly reflecting on the concept of \"voluntariness\" in health insurance [31, 32]. They argue that the principle of voluntariness itself is a significant cause of adverse selection, leading to the unsustainability of health insurance systems [33, 34].\u003c/p\u003e \u003cp\u003eThe voluntary contributions and active participation of rural residents are fundamental to ensuring the sustainability of the basic medical insurance system and enhancing public health welfare [35]. Therefore, incorporating populations currently excluded from universal health coverage is both urgent and necessary. Rural residents comprise 80% of the insured under China's medical insurance scheme, and the majority of these residents are among the poorest in the country. Research indicates that, under similar conditions, the likelihood of their continued enrollment is higher than that of other households, suggesting a stronger willingness to participate in the insurance scheme[36, 37]. Given this counterintuitive reality, investigating the reasons for rural residents' withdrawal from the insurance system is of significant practical importance.\u003c/p\u003e \u003cp\u003eExisting studies have explored the phenomenon of \"residents exiting medical insurance\" from various perspectives, providing a rich foundation for understanding this issue. However, these studies predominantly focus on the determinants of voluntary participation in the medical insurance system rather than on the act of withdrawal itself. They lack an exploration of causal relationships and interactions to explain individual and social behaviors, and they do not adequately consider the unique social structures of rural areas that influence the complex decision-making processes behind withdrawing from insurance. Moreover, current research primarily examines top-down medical insurance systems and neglects the significance of these systems for achieving universal health coverage [38].\u003c/p\u003e \u003cp\u003eTherefore, this study, set against the backdrop of the advancement of China's urban and rural resident medical insurance system, employs qualitative research methods to address the aforementioned theoretical issues.\u003c/p\u003e"},{"header":"2. Research design","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Methods\u003c/h2\u003e\n \u003cp\u003eRegarding the \u0026quot;factors influencing rural residents\u0026apos; withdrawal from the medical insurance system,\u0026quot; there is currently no mature theoretical framework or related hypotheses in the academic community. Empirical research on this topic is also scarce. This paper employs content analysis, based on extensively collected qualitative data, to investigate this unclear issue. Content analysis allows researchers to systematically and objectively describe research phenomena at the theoretical level, thereby categorizing phenomena or events for better analysis and interpretation[39]. The sample size for content analysis is primarily determined by whether the content data has reached saturation [40]. Studying specific issues requires representative research samples to ensure the reliability and extensibility of the conclusions, thereby enhancing the research\u0026apos;s value and theoretical significance. This study selects Y County in S Province, China, as the research subject. Y County covers an area of 1,212 square kilometers, with a total population of 68,000, of which 53,000 are rural residents, accounting for 77.9% of the total population. This high proportion of rural residents, who are required to enroll in rural medical insurance, provides a sufficient and representative sample for the study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Ethics Approval\u003c/h2\u003e\n \u003cp\u003eThe study protocol was approved by the ethics review committee in China based on the assessment of the study\u0026apos;s design and process, by the principles of the Declaration of Helsinki (Approval Number: 021-gskyb-02-372424198012222511). 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\u0026rsquo;s password-protected computer.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Data collection\u003c/h2\u003e\n \u003cp\u003eIn this study, we focused on rural residents who had previously participated in the medical insurance system but have since opted out. Additionally, we included stakeholders involved in the rural medical insurance payment process, such as government administrative departments, tax departments, medical insurance departments, and village committees. A total of 42 individuals were interviewed. The basic information of the interviewees is presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The distribution of the interviewees broadly covers the research questions addressed in this study.\u003c/p\u003e\n \u003cp\u003eThe interviews were primarily unstructured, with an average duration of no less than 30 minutes, and the longest individual interview lasting up to one hour. Furthermore, for research purposes, the researchers attended internal meetings of government departments mobilizing medical insurance collection and organized four small seminars. Participants in these seminars included personnel from medical insurance departments, township officials, and rural residents. These materials served as supplementary resources and were used to verify theoretical saturation in our research.In this study, when data analysis no longer yielded new categories, the researchers continued interviewing three disabled elderly individuals to verify if data saturation had been achieved[41]. The coding outcomes revealed no emergence of new categories. Consequently, the study successfully passed the test for theoretical saturation.\u003c/p\u003e\n \u003cp\u003eTable 1 Basic Information and Coding of Study Subjects\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eInterviewees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003ePosition (Occupation) and Number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eCoding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eParty and government departments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eTownship Mayor (1)、Tax Bureau Staff (2)、 Medical Insurance Bureau Staff (1)、 Medical Insurance Center Staff (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eZF01-05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eFunctional departments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eVillage committee director and deputy director (2)、rural grid managers (3).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eCW01-05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eRural residents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eResidents(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\n \u003cp\u003eJM01-22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e is here\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Data analysis\u003c/h2\u003e\n \u003cp\u003eData analysis and data collection are conducted simultaneously to ensure the relevance of the data to the analytical framework, thereby maximizing data integrity and ensuring 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. Key statements relevant to the research topic are extracted from the interview transcripts and broken down into units, simplifying them into categories that capture the overall meaning of each response. Building upon this foundation, deeper connections between categories are discovered through continuous comparison and organization of the data, leading to the reintegration of the data to form themes, resulting in the identification of 9 categories and 4 themes. Throughout the data analysis process, the original responses are repeatedly reviewed and compared with subsequent categories and themes to ensure consistency with the intended message conveyed by the research subjects[42].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Research Validity and Reliability\u003c/h2\u003e\n \u003cp\u003eCredibility 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. [43]To ensure credibility in this study, several measures were implemented. Firstly, the study design was meticulously crafted. The researchers engaged in the project for an extended period and conducted prolonged observations of the participants through semi-structured interviews. Secondly, to maintain the credibility of the researchers, two experienced professionals well-versed in the theoretical framework employed were tasked with independently coding the interview data. Expert opinions were also sought when necessary. [44]Thirdly, the credibility of the research outcomes was ensured as the study reached theoretical saturation. The emerging categories,themes, and their interrelationships were consistently validated during interviews, highlighting the authenticity and value of the recurring concepts and categories[45]. Lastly, the applicability of the research methods was ensured by leveraging the richness of the data obtained through in-depth interviews[46].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3.Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Economic Burden\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Persistent Rise in Payment Standards\u003c/h2\u003e \u003cp\u003eSince the inception of the resident medical insurance system in China in 2003, the minimum payment standards for insured residents have consistently increased, escalating from an initial 10 yuan per person to 380 yuan per person by 2024. Rural residents in China typically earn lower incomes with income variability. The growth in medical insurance payment standards imposes a heavy financial burden on rural families, making it difficult for economically vulnerable rural residents to bear. As one participant noted, \"At the beginning, the annual payment was very low, but in just a few years, it has increased to over 300 yuan\" (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 \"sacrifice\" themselves, saving money to pay the insurance premiums for family members at higher risk of illness. As expressed by a participant, \"I'm 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 yuan in one go. It's indeed a significant expense. This year, our family couldn't afford it, so I paid for my parents. They are elderly, and we, the younger ones, didn't pay\" (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, \"Can we pay in installments? This way, our economic pressure would be lighter, and we could pay when we have the money\" (Interview Data: CM11).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 The inability to significantly alleviate the economic burden of illness\u003c/h2\u003e \u003cp\u003eFarmers enroll in medical insurance to reduce the cost of diagnosis and treatment when they fall ill. However, the existing reimbursement policies suffer from narrow coverage and low reimbursement rates, leading to negative healthcare experiences for many farmers. \"My wife went to the hospital last time and spent over 1000 yuan. When we tried to claim reimbursement with the payment receipt, the staff said it wasn't covered. We don't know what is covered. If they say it's not covered, then it's not. If we pay and still can't get reimbursement, what's the point of paying?\" (Interview Data: CM20). Additionally, the removal of \"individual accounts\" 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. \"Our biggest need each year is to buy medicine from the pharmacy. In the past, we had 'individual accounts.' I paid fees every year, even if I didn't go to the hospital, at least I bought some medicine. Now it's canceled. If we don't get hospitalized, we have to pay for medication ourselves, whether it's a major or minor illness, the burden is getting heavier and heavier\" (Interview Data: CM16). Due to the inability to use medical insurance cards at pharmacies, some rural residents now seek treatment at hospitals for ailments that could be managed at home, solely to avail themselves of benefits. However, some farmers point out that the cost of medical treatment and medication, even with insurance, is higher than buying medication directly from a pharmacy out-of-pocket. \"The same medicine costs me 3 yuan at a street corner pharmacy, but at the hospital, the doctor prescribes the same medicine for 10 yuan. After reimbursement, I still have to pay 5 yuan out of pocket. Isn't that cheating our money?\" (Interview Data: CM01). The effectiveness of medical insurance in alleviating the economic burden of illness for farmers has become a subject of doubt among rural residents, who find it challenging to directly benefit from medical insurance reimbursements when they fall ill.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 The Inequity in Health Insurance System Design\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Inequitable Funding Standards\u003c/h2\u003e \u003cp\u003eThe funding of China's medical insurance is solely responsible for the medical services within the current year, regardless of whether residents have received medical treatment during that year. However, in the following year, they are required to repay according to the new payment standards. \"As a young person like me, if I haven't been sick for a year and haven't 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's unacceptable to me that I pay the money, and then after a year, it's reset to zero, and the next year I'm asked for it again. My money doesn't come out of thin air, and I can't psychologically accept it.\" (Interview Data: CM17) For many residents, not falling ill means their money has been wasted, creating a sense of unfairness. \"I've been paying fees for over ten years, and I've never used it. Can I pay less if I pay again? It's too unfair. Why should I pay if I haven't spent any medical insurance money?\" As a result, young people choose to withdraw from the medical insurance payment system, leaving behind mostly elderly individuals with a higher risk of illness. This sense of unfairness not only exists between healthy and unhealthy populations but also between urban and rural residents. \"The 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's completely unreasonable for us to pay the same amount as them.\" (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. \"My parents and my younger brother all have some mental illnesses and cannot take care of themselves. My mother couldn't see anything last year, but even after applying several times, we weren't approved. Many people in the village who are in better situations than us have been selected as subsistence allowance recipients and enjoy medical insurance subsidy policies. Why shouldn't we receive them? Then I won't pay for medical insurance.\" (Interview Data: CM14)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Inequities in Treatment Benefits\u003c/h2\u003e \u003cp\u003eThe inequities in treatment benefits primarily manifest between urban and rural areas. Farmers 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 decrease. This presents a phenomenon where individuals in the same city experience different treatment benefits, thus leading to lower accessibility to quality medical services for farmers. \"In 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.\" (Interview Data: CM05) Additionally, medical insurance reimbursement policies are not favorable to individuals who migrate from rural areas for employment. Discrepancies in medical insurance policies among different cities prevent young people from fully enjoying the benefits of their insurance contributions. \"My 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.\" (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, \"From 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.\" (Interview Data: ZF05)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Failure of Conventional Mobilization Strategies\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Limited Impact of Propaganda Methods\u003c/h2\u003e \u003cp\u003eA significant portion of rural residents possess a low awareness regarding the reimbursement policies of medical insurance and exhibit a lag in understanding updates to these policies. This leads to cognitive biases among rural residents, with some still perceiving the policies in the context of individual account setups for medical insurance. \"In 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't anymore. Yet, I see some people still can, I don't know why.\" (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. \"During the collection period, we go door-to-door to promote this year's medical insurance policies, payment standards, and benefits.\" (Interview Data: ZF03) Government personnel aim to increase payment rates by encouraging rural residents to contribute. However, from the perspective of rural residents, such promotions often fail to address their most pressing concerns, providing little assistance. \"The 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't provided us with this information.\" (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, leading to discrepancies between the information disseminated and the reality of reimbursement. \"They told us we could claim reimbursement when we paid, but in reality, we couldn't. The policy changes too quickly, and now we have no idea what the rules are.\" (Interview Data: CM18) It can be argued that the current stage of medical insurance policy promotion has not addressed the issue of information asymmetry.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Erosion of Traditional Persuasion Mechanisms\u003c/h2\u003e \u003cp\u003eThe primary sphere of rural life unfolds within limited villages, where intimate \"social bonds\" tie individuals together, fostering a \"familiarity-based society\" rooted in geographical factors. Rural dwellers are reluctant to sever these social ties easily. Throughout past instances of health insurance levy, village cadres played pivotal roles, leveraging their geographical connections to engage in extensive \"persuasion\" campaigns among rural residents. Despite incomplete understanding of health insurance policies among many residents, trust in village cadres and the maintenance of interpersonal relationships prompted adherence to their mobilization efforts for medical insurance contributions. However, in recent years, with the rapid urbanization in China, this rural traditional social structure and operational norms have faced challenges, as material interests gradually supersede personal sentiments. \"Nowadays, 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.\" (Interview Data: CW01) Geographical connections in rural areas no longer wield the same influence over villagers' payment decisions. \"In 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.\" (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. \"My parents still respond actively to the village cadres' calls. Why should I listen to them? I seek tangible benefits, not just relationship maintenance.\" More alarmingly, intervention through traditional mobilization tactics exacerbates the younger generation's aversion. \"They (village cadres) keep calling me to pay and even visit my home to press me, which is really annoying. They don't give prior notice before coming, regardless of what you're doing, disrupting my normal life.\" (Interview Data: CM06)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Excessive Implementation of Supervisory Measures\u003c/h2\u003e \u003cp\u003eFor a long time, schools have assumed the role of \"supervisors\" in the process of medical insurance collection. Leveraging their significant influence, schools' supervision has notably increased the insurance participation rate among children and adolescents. \"My 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's insurance through class meetings and class group chats\" (Interview Data: CM04). However, this supervisory approach is not a sustainable solution and has, to some extent, led to adverse consequences. \"Not being insured means you can't enroll in school. Education and insurance are now 'tied' together, creating 'implicit' pressure. Initially, we could have communicated and paid, but now we choose not to\" (Interview Data: CM22). While this mobilization tactic is not the direct cause of rural residents' non-payment of insurance, the unreasonable supervisory measures have prompted hesitant farmers to opt out of payment. Moreover, they have strained the relationship between rural residents and government personnel. Interestingly, government workers still maintain that this action does not constitute coercion, as rural residents' insurance participation is still based on voluntary principles. One government official remarked, \"Now, medical insurance follows the principle of voluntariness. If they really don't want to, they don't have to pay. But if we don't urge them, hardly anyone voluntarily pays. We don't want to resort to measures that prevent children from attending school; we just 'remind' them, but we're obligated by our superiors to collect this money\" (Interview Data: ZF01).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.4 The Internet's Impact on Residents' Cognitive Biases\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Internet Reduces Subjective Identification with Welfare\u003c/h2\u003e \u003cp\u003eIn recent years, the widespread availability of the Internet has significantly increased, providing rural residents with avenues to access various healthcare insurance plan information. Rural residents are no longer constrained by time and space; they can utilize the Internet to search for and browse health information and obtain healthcare resources. Prior to the Internet's penetration in rural areas, rural residents primarily perceived medical insurance benefits through comparison with other villagers. However, in recent years, the Internet's ubiquity has provided rural residents with more reference points. \"I saw comments from others in a video's comment section, people in situations similar to mine, and their reimbursement rates are much higher than mine\" (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' relative sense of achievement and gradually reduces their identification with medical insurance benefits. Government officials resonate with this sentiment: \"They (rural residents) don't 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\" (Interview Data: ZF04).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Dissemination of False Health Information Online\u003c/h2\u003e \u003cp\u003eRural 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, the internet harbors a plethora of unreliable information sources. Coupled with the limitations in rural residents' knowledge and experience, they are prone to being misled by media propaganda, resulting in irrational cognitive biases towards their own health status and the level of medical insurance coverage. \"I 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.\" (Interview Data: CM10) Such misinformation weakens the judgment of rural residents with limited discernment, leading to erroneous tendencies in medical insurance payments. Despite repeated efforts by government personnel to disseminate information, the impact remains minimal. \"We've explained to them that these so-called 'experts' 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.\" (Interview Data: CW03)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4.Discussion","content":"\u003cp\u003eChina is dedicated to promoting extensive and profound coverage of basic medical insurance, and ensuring the complete coverage of the medical insurance system for urban and rural residents is a crucial component in achieving this objective. The urgent inclusion of populations currently excluded from the basic medical insurance system is imperative. This study tracks the process of medical insurance collection in Y County, S Province, China, in 2023. It involves interviews with governmental, medical insurance, and taxation departments of Y County, as well as rural residents who have not paid medical insurance premiums. The research addresses the core question of why rural residents in China choose to opt out of the medical insurance system. The findings suggest that the primary reasons for rural residents' 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 study also reveals that this behavior is not solely an economic obstacle; it represents a deeper challenge faced by China's medical insurance system and rural governance.\u003c/p\u003e \u003cp\u003eThe primary reason for voluntary withdrawal from medical insurance among rural residents in China stems from the economic burden imposed by insurance premiums. On one hand, the rapid escalation of medical insurance premiums has objectively heightened the financial strain on rural residents. China's rapid urbanization has fostered increasing expectations among farmers for high-quality medical services, prompting many rural residents to bypass local township health centers and county-level medical institutions in favor of larger urban medical facilities [14]. This surge in demand for quality medical services, coupled with rising costs of healthcare provision, has led to a collective increase in healthcare expenditure within society [7], ultimately translating into a rapid elevation of individual medical insurance contribution standards. Should the rate of increase in medical insurance premiums continue to outpace the growth rate of rural residents' incomes, the number of individuals opting out of medical insurance may escalate further[13]. The improvement of healthcare quality inevitably entails an increase in healthcare costs; hence, policies must strike a balance between ensuring a steady enhancement in healthcare service quality and controlling healthcare service costs[16].\u003c/p\u003e \u003cp\u003eThe 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 \"underpurchase demand-side anomaly\" proposed by Kunreuther[24]. Conversely, adverse selection gradually increases with the rise in premium standards, leading to a moral hazard phenomenon of \"bad money driving out good,\" significantly elevating operational risks for medical insurance funds. On the other hand, the effectiveness of medical insurance in alleviating economic pressure caused by illness among rural residents is inadequate. The primary reason for this phenomenon is the imperfect mechanism for dynamic adjustments to the basic medical insurance catalogue. Many drugs, consumables, and medical services remain unreimbursed, requiring rural residents to bear the costs themselves[9]. Consequently, from the perspective of farmers, despite their urgent need to reduce medical expenses and seek high-quality medical services, they harbor a logical reluctance to pay for medical insurance. Farmers 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, prompting them to opt out of medical insurance[13, 18].\u003c/p\u003e \u003cp\u003eThe 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. Although the medical insurance system for urban and rural residents in China stipulates equal adherence to the same payment base, the dual urban-rural system influences rural residents' per capita income, which 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[14]. This disparity has resulted in an unfair allocation of medical and health financing between urban and rural residents, leading to adverse selection [26]. 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[25, 34]. This necessitates, at the policy level, adjustments to the financing mechanism for rural residents based on \"income levels\" and \"payment capacity\"[8]. Additionally, extending the payment period and allowing rural residents to pay in installments should be considered, along with exploring payment mechanisms that align with seasonal income fluctuations resulting from agricultural production. Concurrently, to mitigate the risk of rural households falling back into poverty due to illness, the Chinese medical insurance system is linked with low-income and poverty alleviation policies. Medical insurance policies have evolved not only as a system to bear the risk of illness but also as a policy to safeguard against broader societal risks [9]. 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[3].\u003c/p\u003e \u003cp\u003eThe 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[14], there are significant disparities in healthcare resources and service levels across regions. High-quality medical resources are typically concentrated in major cities, giving urban residents greater access to healthcare services[7]. In contrast, rural residents utilize fewer medical services due to geographical barriers and budget constraints [16]. When local primary healthcare facilities cannot meet their needs, rural residents must travel to higher-level medical institutions, but current Chinese health insurance policies offer low reimbursement rates for cross-regional medical expenses, or none at all. This results in lower net healthcare benefits for rural residents[35]. Furthermore, healthcare reimbursement rights are defined by geographic boundaries, with varying coverage and benefits across regions, and eligibility is based on the household registration location. This regional disparity directly affects young people working across different areas[15]. Overall, this situation leads to a significantly lower utilization of quality medical resources by rural residents compared to urban residents, with government subsidies intended to promote universal healthcare coverage disproportionately benefiting urban residents[25]. Therefore, it is necessary to increase the reimbursement range and rate of basic medical insurance for rural residents, gradually narrowing the gap between urban and rural healthcare benefits, and achieving equal access to basic medical services[38].\u003c/p\u003e \u003cp\u003eThe failure of conventional mobilization strategies has somewhat intensified the willingness of Chinese rural residents to withdraw from health insurance, undermining their trust in both health insurance and the government. China\u0026rsquo;s health insurance system, based on voluntary participation, allows residents to decide whether to enroll according to their economic conditions and needs, demonstrating respect for individual choice and embodying democratic principles [34]. Under this voluntary principle, the promotion of health insurance policies becomes crucial [22]. Despite this, the Chinese health insurance policy suffers from deficiencies in its promotion methods, content, and timing. Consequently, when rural residents fall ill, the lack of essential reimbursement information may hinder their ability to receive compensation, eroding trust in health insurance's expected utility [36].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, due to close local ties, interact frequently with village officials who can mobilize and urge residents to enroll in insurance through various channels such as home visits, phone calls, and broadcasts. This creates a de facto \"quasi-mandatory insurance\" characteristic in rural areas [37].As China modernizes, traditional local relationships are gradually disintegrating, rendering previously effective relationship-based persuasion and school-based supervision methods ineffective, leading many to opt out of renewing their health insurance. The urgent task for China\u0026rsquo;s health insurance system is to adopt governance methods suited to the rural social structure, establish governance norms in villages, and confine collection actions within institutional frameworks to regulate grassroots officials\u0026rsquo; behavior. Additionally, it is crucial to establish negotiation channels to align farmers' demands with national policies, build a consensus on health insurance contributions, maintain spontaneous order under formal authority, and enhance the system's acceptance and recognition, thereby gaining farmers' understanding, support, and participation.\u003c/p\u003e \u003cp\u003eFinally, the cognitive biases induced by the internet have also reduced the willingness of rural residents to maintain continuous health insurance coverage. The rapid development of the internet has significantly impacted the subjective consciousness of rural Chinese residents. According to prospect theory, decisions are often based on the gap between actual gains and losses and psychological expectations[36]. 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 \"reference points\" for rural residents[47]. 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[18].\u003c/p\u003e \u003cp\u003eAdditionally, due to insufficient regulation of internet information, many users disseminate inaccurate information, which, coupled with media coverage, subtly fosters negative attitudes toward health insurance policies among rural residents. This misinformation influences their decisions regarding participation in health insurance.In the future, it is essential to strengthen the regulation of misinformation and proactively use internet platforms to convey accurate and scientific health insurance policies. This will help rural residents understand the importance, mechanisms, and benefits of health insurance, ultimately influencing their attitudes and gradually increasing their willingness to participate[20].\u003c/p\u003e"},{"header":"5.Conclusion","content":"\u003cp\u003eEnsuring the health and well-being of the populace is a fundamental task of socialist states. In China, residents\u0026apos; medical insurance serves as the \u0026quot;last line of defense\u0026quot; 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[6, 10]. 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 farmers [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\u0026apos;s medical insurance system.\u003c/p\u003e\n\u003cp\u003eThe healthcare insurance system for Chinese residents should first disentangle itself from the low-income support and poverty alleviation systems, returning to the inherent logic of health insurance. It should develop differentiated funding standards, reimbursement scopes, and reimbursement ratios tailored to rural residents based on economic and health conditions. Additionally, a health incentive mechanism should be established, providing financial rewards and policy incentives to patients who do not incur outpatient expenses within a year, achieving a dynamic balance between the health insurance system and regions with diverse social and cultural backgrounds.\u003c/p\u003e\n\u003cp\u003eMore importantly, during policy implementation, government officials must employ differentiated mobilization strategies for the poorest and most vulnerable groups. This involves exploring selective mobilization mechanisms for health insurance payments and adopting varied persuasion and mobilization methods for different villagers. A multi-channel, integrated approach to mobilization can transform the \u0026quot;disorderly\u0026quot; state and avoid the disruption of rural social structures by a top-down, efficiency-driven logic. Furthermore, the government should enhance the control of harmful online information and actively use 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\u0026apos;s healthcare insurance system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYing Zuo: Conceptualization, Methodology, Data Curation, Writing-Original Draft, Writing-Review \u0026amp; Editing.\u003c/p\u003e\n\u003cp\u003eGuang Yang: Conceptualization, Methodology, Writing-Review \u0026amp; Editing.\u003c/p\u003e\n\u003cp\u003eHaoxuan Cheng: Writing-Review \u0026amp; Editing, Data Curation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZhang Lufa: Conceptualization, Writing-Review \u0026amp; Editing, Project administration, Funding acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe data supporting this study will be made available upon reasonable request by contacting the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp; \u0026nbsp;This work was supported by the National Social Science Fund of China [grant numbers 22AZD082]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the ethics review committee of Shanghai University of Medicine \u0026amp; Health Sciences, China based on the assessment of design and process of the study, and was conducted in accordance with the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest:\u003c/strong\u003e the authors do not report any conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOrganization WH: \u003cstrong\u003eReaching universal coverage via social health insurance: key design features in the transition period\u003c/strong\u003e. 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This study aims to investigate the complex reasons behind the decision of rural residents in China to forgo participation in the medical insurance system by examining causal relationships and interactions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 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 not enrolled in the medical insurance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study finds that the primary reasons for rural residents withdrawing from medical insurance are fourfold: heavy economic burdens, unfair design of the medical insurance system, failure of conventional mobilization strategies, and cognitive biases fostered by the internet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The decision of rural residents in China to withdraw from medical insurance is influenced not only by economic factors but also by the design of the system and various aspects of rural governance. In the future, the Chinese government should optimize the design of the medical insurance system, adopt more flexible mobilization and persuasion strategies, and strengthen the control of negative internet rhetoric to stimulate enthusiasm for participation in medical insurance among rural residents, thereby advancing the universal health strategy.\u003c/p\u003e","manuscriptTitle":"Why do rural residents in China withdraw from the health insurance system? —A Qualitative Study Based on Y County in S Province, China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 08:35:10","doi":"10.21203/rs.3.rs-5245172/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-14T10:41:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-13T23:03:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-13T23:01:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-10-11T09:47:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3412bd04-9201-4498-ac60-46e6ce5c51e5","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T15:59:48+00:00","versionOfRecord":{"articleIdentity":"rs-5245172","link":"https://doi.org/10.1186/s12889-025-22882-2","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-05-02 15:57:16","publishedOnDateReadable":"May 2nd, 2025"},"versionCreatedAt":"2024-12-19 08:35:10","video":"","vorDoi":"10.1186/s12889-025-22882-2","vorDoiUrl":"https://doi.org/10.1186/s12889-025-22882-2","workflowStages":[]},"version":"v1","identity":"rs-5245172","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5245172","identity":"rs-5245172","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}