According to Thomas Zweifel and Patricio Navia, dictatorships are less able to respond to human needs than democracies, not only because of the mismatch between the goals of the dictator and the needs of the citizens but also because dictatorships lack feedback mechanisms or early-warning systems that respond to people’s desires and aspirations (“Democracy, Dictatorship, and Infant Mortality,” Journal of Democracy 11 [2], 2000). In Social Protection under Authoritarianism, Xian Huang challenges this assumption. Her analysis of the expansion of China’s social health insurance in the first decade of the 2000s highlights authoritarian rulers’ interest in improving people’s health care and subnational leaders’ ability to adapt to local conditions in policy implementation. Within a decade, the share of China’s population covered by some form of social health insurance increased from less than one-third to more than 90% (p. 3). The debate over authoritarianism and health has become more relevant during the COVID-19 pandemic as autocratic leaders in China cite low case and death counts as evidence that they care more about people’s health and well-being than their democratic counterparts.

In addition to the incentives of authoritarian leaders in China to expand social welfare and improve people’s health status, Huang explores why enhanced benefits are accorded to both elite groups and marginalized social groups and why there is significant distributive variation across social groups and subnational regions in China (pp. 4–5). According to Huang, to maximize the regime’s prospects for survival and stability, authoritarian leaders intentionally sustained a social welfare regime that is biased toward elites (e.g., government officials and urban employees in the state sector) and that provides only modest social welfare to other social groups, such as urban residents and rural workers in the informal sector. In a decentralized authoritarian structure, this “stratified expansion” of social health insurance exhibits distinct regional patterns corresponding to variations in fiscal constraints and social risks at the local level. Huang’s statistical analysis identifies significant correlations between local socioeconomic conditions and distributive patterns of social health insurance: provinces with high fiscal capacity and high levels of in-migration tend to provide high coverage and above-average benefits, whereas those with weak fiscal capacity and low labor mobility tend to have low coverage and benefits. At the individual level, even though the social health insurance expansion has benefited most people, including peasants, the distribution of benefits continues to reflect recipients’ labor market participation and socioeconomic status. Overall, the odds of an individual joining generous social health insurance programs increase significantly if he or she is a retiree, has urban hukou, or is employed in the state sector.

To empirically test the observable implications of her theory, Huang relies on a multimethod approach that combines quantitative and qualitative data, including central government documents, in-depth interviews with local officials, and survey data at the individual level. After presenting the theory (chap. 2) and an overview of the history and evolution of social health insurance in post-1949 China (chap. 3), the book devotes a chapter to central leaders’ policy preferences and behaviors (chap. 4) and another to local leaders’ incentive structure and policy choices (chap. 5) in social welfare provision. This is followed by a political economy explanation of the provincial variations in China’s social health insurance expansion (chap. 6) and the variation of social welfare benefits along social cleavages such as the urban–rural divide (chap. 7).

Compared to most earlier studies on China’s health care system, Huang’s research is both methodologically rigorous and theoretically novel. Her study also betters our understanding of social welfare provision in authoritarian countries. Instead of only focusing on levels of government spending, she disaggregates the distribution of social welfare benefits into three dimensions: generosity (average level of benefits), coverage (percentage of the population receiving the benefits), and stratification (inequality of benefits received by different social groups or regions). This analysis allows her to explain not only the trend of Chinese social welfare expansion but also its distributive patterns and subnational variation (p. 23). Theoretically, the “stratified expansion strategy” she coined suggests that authoritarian rulers, in maximizing their regime survival and stability, may pursue social policies that are more strategic and nuanced than implied by the existing literature.

The study also advances our knowledge of China’s politics and policy making. The stratified expansion of health insurance explains why China, in moving away from the out-of-pocket health care model, rejects a centralized single-payer system like the United Kingdom’s National Health Service or the national health insurance model popular in countries such as Canada and South Korea. The book also contributes to the debate over “authoritarian resilience,” or the ability of China’s one-party state to revamp itself through institutional adaptations and policy adjustments (Andrew Nathan, “China’s Changing of the Guard: Authoritarian Resilience,” Journal of Democracy, 14 [1], 2003). The willingness and ability of unelected officials to accommodate social and local needs, according to Huang, demonstrate an “indirect accountability” in Chinese politics that in part explains the resilience and adaptability of the authoritarian regime (p. 194). Furthermore, the fragmented and stratified social welfare system hinders horizontal mobilization among societal groups that might pose a threat to regime stability while creating incentives for the Chinese middle class to maintain the status quo (pp. 197–98). This book should therefore appeal and be of use to scholars who are interested in studying Chinese politics or social welfare in authoritarian states.

Nevertheless, it is noteworthy that, except for the story of a young couple in the introduction, the voices of the beneficiaries of policies are barely heard in the study. Indeed, almost all the interviewees cited in the book are government officials (appendix B). Without clearly identifying people’s actual wants and desires, Huang’s model runs the risk of overlooking crucial variables or factors in theory building. As indicated by the access and affordability problems in China’s health care reform, social groups care not only about reimbursement levels but also the distribution of important health care resources such as hospitals and physicians. Rural people’s response to the maldistribution of health care resources, evidenced in their bypassing of rural clinics and seeking care first in major urban health centers, has generated additional demands that justify investment in urban health care to the detriment of rural health care. In that sense, the reproduction and reinforcement of social inequalities in China discussed in the book may reflect more the effects of a policy feedback loop than the regime’s bias toward elites in providing welfare benefits.

Regarding policy implementation, Huang’s subnational comparative study uses provinces as the unit of analysis. This makes sense given data availability issues. Yet because the financing of health care insurance schemes in China is still pooled (tongchou) at the subprovincial level, where local leaders’ distributive choices might be shaped by factors uniquely different from those of provincial leaders, the empirical analyses in chapters 5 and 6 may not fully capture local officials’ motivations and distributive consequences. Corrupted county leaders may take advantage of their access to the pooled social insurance funds to misappropriate them as income to cover their administrative outlays (p. 69). They may also use fiscal straits as an excuse for underspending on social welfare in their jurisdiction. Here the local welfare regime is neither protective nor productivist (where social policy is subordinate to economic growth). Instead, it would reflect a “decentralized predatory state,” described in Minxin Pei’s (2006) China’s Trapped Transition, in which local party bosses use the state’s authority to feather their own nests rather than improve people’s health and well-being. Detailed comparative case studies at the county/city level would help uncover the political dynamics not identified in the book.

Finally, Xi Jinping’s 10-year reign since 2012 has raised questions about some of the conclusions of the book, which cover the years of the Hu Jintao administration (2002–11). Compared to Hu, Xi feels even more insecure about the regime’s stability and is advancing a significantly different agenda. In pursuing so-called common prosperity, the central government is moving to increase coverage and benefit levels while reducing inequality in the social welfare regime. Today, most of the status-quo type provinces claim more than 95% insurance coverage. The government has also kicked off an urban–rural integration policy for social health insurance. The objective, according to Xi in a recent Politburo speech, is to build a multilevel social protection system that “covers the entire population, promotes urban-rural integration, is fair and unified, and is sustainable.” These policy profile changes do not fundamentally challenge the underpinnings of the book’s central argument: glaring inequalities across social groups and regions continue to exist, and policy immobility at the grassroots level is exacerbated by the concentration of political power in a superordinate figure. But the rise of a “Xi-in-command” polity also mitigates the implementation bias in China’s policy process, generating strong incentives for local leaders to jump onto Xi’s bandwagon to show their early and zealous support for his favored policy agenda. Given Xi’s preference for universalism and equality, local leaders who directly bear the growing cost of maintaining social welfare stratification will also be in a more secure position politically to move away from the status quo. Such new political and policy dynamics at the central and local levels may be signs that the stratified expansion is not an equilibrium strategy.