Why Do Poor Patients with Chronic Disease Keep Starting Over? A Comparison of Coverage Continuity in the U.S. and China

Abstract

This paper examines why low-income patients with chronic diseases repeatedly lose access to healthcare despite having insurance coverage. Through comparative analysis of the United States Medicaid system and China's Urban-Rural Resident Basic Medical Insurance (URRBMI), I identify geographic fragmentation as a common mechanism disrupting care continuity. Using policy documents, patient testimonies, and health outcome data, I trace a four-link causal chain: geographic fragmentation creates coverage instability, instability disrupts continuous care, disrupted care worsens health outcomes and increases costs. In the U.S., state-level Medicaid rules create administrative barriers when patients move or change jobs. In China, provincial financing disparities create similar barriers for rural-to-urban migrants. Both systems tie coverage to place rather than people, making mobility a clinical risk for chronic disease patients who require consistent treatment. The findings suggest that measuring coverage rates without tracking continuity misses the fundamental vulnerability of fragmented systems. This research contributes by connecting parallel literatures that have rarely been in conversation and reframing health insurance success metrics to prioritize continuity over static enrollment counts.