Special Report
Highlights China’s healthcare expenditure is projected to rise due to the increasing affluence and rapid aging of its population. The desire to access healthcare services beyond the basic coverage provided by the public health insurance will increasingly prompt people to purchase health insurance products from private insurers. We recommend going long Chinese insurance stocks in absolute terms. We also recommend accumulating and overweighting Chinese healthcare stocks on a 15% correction. Feature The aging population and the rapidly expanding middle class in China entail that healthcare expenditures will remain on a secular growth trajectory. The COVID-19 outbreak will function as a catalyst for the rapid transformation of China's healthcare system. In fact, many game changing trends in global healthcare systems will probably be attributed to the COVID-19 pandemic. Healthcare Expenditures: Still Low Health expenditures per capita in China grew substantially over the same period of time, but their level is still below those in most countries. Chart 1Chinese Healthcare Expenditure Will Grow 10% CAGR Health expenditures in China have grown considerably since the economic reforms started in 1978. Between 1978 and 2018, total health expenditures in China grew at a compound annual growth rate (CAGR) of 17% in nominal terms, higher than the 15% growth in nominal GDP (Chart 1, top panel). Notwithstanding the rapid expansion of China’s healthcare market, expenditures remained at a modest 6.4% of China’s GDP in 2018 (Chart 1, bottom panel), far below the OECD average of 9%. Health expenditures per capita in China grew substantially over the same period of time, but their level is still below those in most countries. In 2017, health expenditures per capita in China were $841 in PPP (purchasing power parity) terms, ranking 92nd worldwide. Japan, by comparison, ranks 18th with $4,550, and Korea ranks 31th with $3,000, both in PPP terms (Chart 2). Chart 2China Ranks Low In Health Expenditure Per Capita Worldwide Healthcare Capacity And Healthy China 2030 Chart 3China Healthcare Capacities Are Rising Fast Access to adequate healthcare is crucial to social and economic development, as healthy human capital fosters productivity and economic growth. In China, healthcare capacity is still subdued. After the pandemic, authorities will divert resources to this sector to ensure it expands quickly. In 2018, the number of physicians and nurses per 1000 Chinese people was 2.6 and 2.9, respectively (Chart 3), far below the OECD average of 3.5 physicians and 8.8 nurses per 1,000 people. Hospital beds per 1000 people is 4.3 in China, compared to an average of 4.7 across OECD countries. In Japan and Korea, the measure is much higher, at 13.1 and 12.3 beds per 1,000 people, respectively (Chart 3, bottom panel). China released the Healthy China 2030 (HC 2030) blueprint in 2016, covering public health services, environmental management, the medical industry, and food and drug safety. The five specific goals of this blueprint are to improve the population’s health, control against major risks, increase the capacity of healthcare services, grow the scale of the healthcare industry, and improve the health service system generally. This program has set targets for health service capacity, including an increase in the number of doctors, nurses and beds per 1,000 people to 3, 4.7 and 6, respectively, by the year 2030. The blueprint also aims to further ease the financial burden imposed on the population by the cost of healthcare and medical treatments. Currently, in China, 29% of health costs are paid by individuals; HC 2030 recommends a reduction to 25%. We will discuss these objectives in the next section. Healthcare Financing: A Looming Funding Crunch The aging population, along with its rising income, will drive up health expenditures in the years to come. Chart 4China Elderly Population Will Rise Significantly There are currently more than 167 million people over the age of 65 in China. By this measure, China is already the largest eldercare market in the world in terms of the absolute number of elderly people. What is more, China’s elderly population is growing rapidly and is expected to reach almost 200 million by 2025 (Chart 4). The aging population, along with its rising income, will drive up health expenditures in the years to come. As health expenditures grow, so will investment opportunities. Global healthcare systems can generally be classified into the three categories shown in Table 1. China’s health insurance system more closely resembles Germany’s national social health insurance system than the US commercial health insurance model. China’s healthcare system and insurance scheme is illustrated in Table 2. Table 1Overview Of Major Healthcare Systems Worldwide Table 2Main Features Of China's Three Basis Social Health Insurance Schemes In 2000, just over 20% of Chinese citizens had healthcare coverage. The SARS outbreak in 2003 was a wake-up call for Chinese leaders. Thanks to heavy government subsidies and political commitments, China achieved universal health insurance coverage in 2011, when nearly 95% of its 1.4 billion people had health insurance. This represents the largest and fastest expansion of insurance coverage in human history. Chart 5Individuals Health Expenditures Remain High However, the government-sponsored health insurance plan provides for only basic coverage. Government budgetary spending accounted for 28% of total health expenditures in 2018 and the population’s out-of-pocket costs amounted to 29%, such that the remaining 43% was covered by the public social health insurance contributions (Chart 5). China’s health insurance is supervised at the national level and guided by the principle that all citizens are entitled to receive basic healthcare. Nevertheless, local governments are ultimately responsible for funding and offering these health services. This leads to unevenly distributed healthcare capacities across different provinces, as more resources are concentrated in wealthier jurisdictions. People can only receive a reimbursement for healthcare costs from their province of residence, as indicated on their hukou registration documents. Migrant urban professionals and laborers have to return to the place of their household registration to access healthcare. Chinese policy makers have been working on reforming the reimbursement system now for many years. As of the end of 2019, 3.95 million people have benefited from inter-provincial health insurance settlements. Relying heavily on local government contributions to healthcare expenditures is the primary reason why government spending on healthcare is relatively low, at only 1.7% of GDP and 7% of total general (central and local) government spending1 (Chart 6). Government expenditures on social security (which includes contributions to social health insurance, pension, unemployment and work injury insurance) make up 12% of overall government spending.1 The outbreak of COVID-19 sounded the alarm across Chinese society. Building a comprehensive and effective healthcare system with adequate capacity will become one of the most important priorities over the coming decade. The people’s well-being will be critical to social stability as its increasingly affluent population is asking for better healthcare services. Chart 6Government Spending In Healthcare Chart 7China: A Rapidly Aging Population However, the overall sustainability of the current healthcare financing scheme is questionable. Chart 7 shows the old age-dependency ratio, defined as the ratio of older dependents (people over the age of 64) to the working-age population (25 to 64-year old). The ratio is expected to increase from the current 19% to 30% in 2030. This means a decreasing contribution to social insurance budgets from the working population and an increase in healthcare spending on seniors. What makes the situation worse is the opacity of the National Social Security Fund (SSF). The SSF manages money reserved for pension and insurance disbursements related to medical, unemployment and injury needs for future use. Of the 2.6 trillion RMB under SSF management, at the end of 2019, over 90% are invested domestically. The fund’s average 10-year investment return is close to 6%, which is lower than the average nominal GDP growth rate of 11%, over the same period. With declining revenues from workforce contributions and rising healthcare costs, the ability of the social security system to finance proper healthcare service provisions is endangered. Furthermore, the replenishing of the SSF, so far, has depended on central government contributions and asset transfers from state-owned enterprises to the SSF. Bottom Line: As demand for healthcare services increases, the current public scheme for financing healthcare is going to be increasingly unable to cover the costs. Private Health Insurance Private health insurance offers a more extensive level of protection than the state-based coverage. Currently, most private health insurance plans provide supplementary insurance products to complement public health insurance plans. Supplementary insurance and critical illness products are the most popular because the public insurance systems cannot fully cover the cost of catastrophic illnesses. The private health insurance industry has been thriving in recent years and is expected to continue growing because of increased consumer awareness. The written premiums attributed to health insurance registered a compound annual growth rate of 36% between 2013 and 2019 (Chart 8). However, penetration into China’s health insurance market remains far behind that of more developed markets, signaling huge growth potential. One measure of insurance industry penetration is insurance depth. It is defined as the percentage of the GDP attributed to the total written premium for insurance. China’s insurance depth is currently 0.7% for health insurance and 4.2% for overall insurance (Chart 9), whereas the overall insurance depth is 11% in South Korea, 9% in Japan, and 7% in the US. Chart 8Health Insurance Premiums Are Skyrocketing Chart 9China: Health Insurance Penetration Faced with financial strains and a growing demand for healthcare services, the government is supporting private healthcare providers by relaxing regulatory restrictions and offering tax incentives to Chinese consumers when they buy health insurance. Private health insurance offers the growing middle-income class a more extensive level of protection than the state-based coverage. In regard to insurance companies’ asset management, the regulators raised the equity investment cap for all insurers earlier this month from 30% to 45% of total assets. In May of this year, regulators also allowed insurers to invest in the secondary capital bonds issued by banks, as well as in perpetual bonds. This expanded investment opportunity should help insurers diversify their investment portfolios and therefore increase the efficacy of their asset/liability management (ALM). Bottom Line: Private health insurance offers the growing middle-income class a more extensive level of protection than the state-based coverage. This underdeveloped private insurance market presents substantial opportunities. Investment Conclusions As China’s population ages, incomes rise and private healthcare services expand, investment opportunities will also increase. In short, the growth trajectory of China’s healthcare sector warrants investors’ attention. To play on this healthcare theme in China, we are initiating two strategic investment positions: First, go long Chinese insurance companies in absolute terms. Chinese insurer stocks have rallied in absolute terms since March lows, but then lagged relative to the benchmark (Chart 10 & 11); Chart 10Chinese Insurance Stocks: Rising In Absolute Terms... Chart 11…But Underperforming The Benchmark Double-digit CAGR of insurance premiums entails a steady asset expansion (Chart 8 on page 8). High and steady growth at a time of a low discount factor warrants high equity multiples. The private insurance industry’s gross profit margin proxy, calculated as insurance premiums minus insurance payments, divided by insurance premiums, amount to a whopping of 67%, with health insurance at 65% and life insurance at 87% (Chart 12). The equity valuations are reasonable. Unlike the tech and media sectors of the new economy, that have sky-high multiples, the trailing price to earnings ratio for insurers is still 8.8, 45% lower than the 10-year average. (Chart 13). Chart 12Chinese Insurance Companies: Outstanding Gross Profit Margins Chart 13Attractive Valuations Insurance company assets will be better managed going forward due to the new asset/liability management (ALM) requirements imposed by the regulators. The ALM requirements were announced in March 2018 and then fully implemented in July 2019. The rules introduced quantitative risk-adjusted measurements to help insurers more accurately capture the risk of duration mismatch, negative spread and liquidity strain. The CBIRC regularly evaluates and ranks the competence of insurers’ ALM against peers. The key risk to shareholders of insurance companies is the credit risk of their portfolio. 39% of insurance sector portfolios are invested in other investments, which include long-term equity investments, project-based debt schemes, trust plans and asset management (Chart 14). Credit risks stemming from credit claims and asset management products warrant careful investor consideration. Chart 14Investment Portfolio Of The Insurance Industry Chart 15Healthcare Stocks Have Rallied Massively... Second, accumulate Chinese healthcare stocks on a 15% correction in absolute terms (Chart 15). While we believe that healthcare stocks are in a secular bull market, they have already rallied a lot since recent lows, and they are pricing in a lot of short-term good news. Chinese investable healthcare stocks registered 55% returns since the outbreak of COVID-19. The trailing P/E ratio reached 51, a decade high since 2010 (Chart 16). We are reluctant to buy and overweight this sector now and would wait for a better entry point. Chart 16...And Are Now Too Expensive Lin Xiang, CFA Research Analyst LinX@bcaresearch.com Footnotes 1Does not include quasi-fiscal (off-balance sheet) government spending.
