Four worlds of welfare: Understanding subnational variation in Chinese social health insurance

China's social health insurance has expanded dramatically over the past decade. The increasing number of beneficiaries and benefits, however, has aggravated rather than mitigated regional disparities in health care. How can the regional variation in Chinese social health insurance be explained? This paper argues that the subnational variation in China's social health insurance results from the policy choices of central and local states. The central leadership, which is concerned about regime stability, delegates substantial discretionary authority to local state agents to accommodate diverse social needs and local circumstances. Local officials, who care about their political careers in the centralized personnel system, proactively design and implement social health insurance policy according to local situations such as fiscal resources and social risk. In specifying the rationale, conditions and patterns of regional variation in Chinese social health insurance, this paper addresses the general issue of how political leaders in an authoritarian regime respond to social needs.