Objective: As a key supplement to a multi-tier healthcare security system, city-customized commercial health insurance has persistently low enrollment, revealing a supply-demand paradox of enthusiastic provision but lukewarm uptake. This study dissects heterogeneity in enrollment decisions across population groups and identifies micro-level causes of inadequate coverage and the loss of healthier enrollees from the risk pool, providing evidence to increase participation. Methods: Using the Andersen model and nudge theory as the analytic framework, we conducted a qualitative study with in-depth interviews of 21 residents from four prefecture-level cities in Shandong Province, representing never-enrolled, continuously-enrolled, and discontinued-enrollment profiles. We identified themes that captured differences in enrollment decisions. Results: The three groups exhibited markedly divergent decision rationales. Never-enrolled individuals refrained from enrolling because they underestimated risk and lacked product knowledge; continuously-enrolled individuals renewed coverage, driven by risk aversion, trust in the industry, and a sense of social responsibility; discontinued enrollees withdrew because of unsatisfactory claim experience and the spread of negative word-of-mouth. Conclusions: UCCMI should shift from generic mass publicity to precise nudges, deploying differentiated strategies that address group-specific information and trust gaps to balance expanded coverage with system sustainability.
Key words
city-customized commercial health insurance /
enrollment rate /
qualitative interviews /
strategy research
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