China’s public health insurance system covers 95% of its population. That figure conceals a significant gap: an estimated 280 million people were in flexible employment in 2025 – delivery riders, ride-hailing drivers, domestic workers, and livestreamers – the majority of whom sit outside the employee insurance tier that carries the broadest benefits.
Beijing’s 15th Five-Year Plan, covering 2026 to 2030, makes closing that gap a stated priority. For the insurance industry, the plan marks out the outer edge of state responsibility – and the territory that lies beyond it.
The National Healthcare Security Administration (NHSA) laid out its priorities at a State Council Information Office press conference in early September 2026.
The 2025 China Blue-Collar Employment Research Report, published in June 2026 by the China New Employment Forms Research Center – a think tank co-founded by Capital University of Economics and Business and the China Association for Employment Promotion – estimated that flexible workers numbered 280 million in 2025 and projected the figure would reach 320 million in 2026, accounting for over 40% of urban employment. The total enrolled in the employee medical insurance tier stood at 69.82 million in 2025, according to Xinhua – well short of the broader flexible workforce.
The gap persists largely because costs are prohibitive. In cities such as Beijing, contributions to the employee insurance tier approach minimum wage levels, pushing many workers onto the cheaper resident insurance scheme with narrower benefits instead.
To address this, the NHSA and six other ministries issued a special action plan to remove residency restrictions on enrolment and allow monthly, quarterly, and annual payment options. Huang Huabo, deputy head of the NHSA, confirmed more than 6.98 million flexible workers newly joined the employee insurance system by 2025 – a 5.54% year-on-year increase.
The expansion of public coverage matters to commercial insurers because it signals where state responsibility ends. China’s health protection gap stood at an estimated US$377 billion in 2024 – approximately double the 2014 level – with around 30% of potential healthcare risk remaining uncovered, according to the Swiss Re Institute. Commercial health insurance premiums reached US$133.9 billion in 2023, up at a 20% compound annual growth rate from 2014, though premium growth softened to 8.2% in 2024.
China included commercial health insurance in its 2026 government work report for the first time. Premier Li Qiang stated the government would “work faster to develop commercial health insurance” to better meet people’s diverse needs, according to the South China Morning Post. Analysts attributed the emphasis to an ageing population and slower government revenue growth – structural pressures that constrain how much the public system can absorb.
Health insurance was one of the fastest-growing segments of China’s non-life market in 2025, recording 6.0% growth. The Swiss Re Institute expects that to rise to between 6.5% and 7.5% in 2026, supported by demand for supplementary health protection and the continued expansion of digital distribution.
Aon’s inaugural 2025 Insurer Wellbeing Benchmarking Report, which surveyed 12 insurers across mainland China, found that competition is pushing the sector to rethink its product mix. “Insurers are expanding their offerings and rethinking how they deliver care – moving beyond traditional coverage to focus on prevention, personalisation, and measurable outcomes,” said Susan Fanning, head of wellbeing solutions for APAC at Aon.
The treatment of gig workers across China’s insurance lines points to a deliberately tiered system – one that creates explicit space for commercial products to sit alongside state schemes.
Provincial rules accompanying the July 2026 nationwide rollout of China’s occupational injury insurance scheme direct authorities to support the development of commercial insurance that connects with the state program. By June 2026, that scheme covered nearly 30 million platform workers across 14 companies and 17 provinces – but set against an estimated 84 million platform workers and over 200 million flexible workers, the enrolled population remains well short of the full workforce.
On long-term care, the State Council launched a national program in March 2026, designating it the “sixth insurance” alongside existing schemes for pension, healthcare, work-related injuries, unemployment, and maternity. Wang Wenjun, deputy head of the NHSA, confirmed that 22 provincial regions have issued implementation plans covering more than 320 million participants, with nationwide coverage targeted by the end of 2028.
The NHSA has encouraged commercial insurers to develop long-term care products that complement the public scheme. In a 2022 joint research project, the Swiss Re Institute and the Insurance Association of China (IAC) estimated that China’s long-term care protection gap for urban elderly would reach CNY1.9 trillion (US$296 billion) by 2030.
Since 2018, the NHSA’s dynamic adjustment mechanism has added 949 drugs to the national reimbursement list, including 199 innovative ones. Annual updates will continue throughout the 15th Five-Year Plan period, covering cancer, rare diseases, chronic conditions, and paediatric health.
The NHSA also plans to standardize reimbursement lists for medical services and consumables, which are currently set at provincial level. For insurers managing supplemental products across multiple provinces, that change carries implications for both product design and pricing assumptions.
The NHSA’s plan to deploy big data and AI for proactive fraud detection sits within a wider regulatory shift. On June 18, 2026, China's National Financial Regulatory Administration (NFRA) issued the Guidelines on the Safe Development and Application of Artificial Intelligence in the Banking and Insurance Industry – the country’s first comprehensive AI governance framework for financial services, comprising 32 guiding principles across seven pillars, according to The Asian Banker.
Underwriting and claims settlement are classified as high-risk applications requiring risk management committee approval before deployment. For insurers already using AI in health insurance operations in China, the NFRA guidelines introduce compliance obligations that run parallel to the NHSA’s own fraud supervision agenda.
Huang said the NHSA’s fraud targets include fabricated disability assessments and false service claims in maternity and long-term care schemes. The goal, he said, was “to build a comprehensive, multilayered regulatory framework that combines deterrence, smart monitoring, and institutional safeguards to protect the ‘lifesaving money’ of the insured.”
