Tracing the Origins, Operational Logic, and Optimization Pathways of the Critical Illness Insurance System for Urban and Rural Residents

doi:10.19546/j.issn.1674-3830.2025.9.007

China Health Insurance ›› 2025, Vol. 0 ›› Issue (9) : 57-67. DOI: 10.19546/j.issn.1674-3830.2025.9.007

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Abstract

The critical illness insurance system for urban and rural residents is an important part of the multi-level healthcare security system, which is of great significance for preventing poverty and coordinating urban and rural development. By sorting out the relevant research and institutional context of critical illness insurance, starting from the theory of institutional logic and applying grounded theory, this paper deeply analyzes the underlying mechanisms and internal logic of the system's operation. It is found that the operational field of the critical illness insurance system includes key mechanisms such as the organizational mobilization mechanism of the National Healthcare Security Administration, the coordination and management mechanism of local governments, the contractual cooperation mechanism of commercial health insurance companies and the negotiation and participation mechanism of insured personnel. Under the interactive influence of the triple logic of the state, market and society, the operation of the critical illness insurance system still faces problems such as blurred institutional boundaries, intensified implementation conflicts, increased revenue and expenditure tensions, and upgraded cooperation losses. In view of this, suggestions are put forward such as clarifying positioning, stabilizing sources, enhancing efficiency, promoting cooperation, and empowering with digital intelligence.

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critical illness insurance for urban and rural residents / institutional origins / operational logic / institutional optimization

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Tracing the Origins, Operational Logic, and Optimization Pathways of the Critical Illness Insurance System for Urban and Rural Residents[J]. China Health Insurance. 2025, 0(9): 57-67 https://doi.org/10.19546/j.issn.1674-3830.2025.9.007

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