In 1998, the Chinese government proposed a universal health-insurance program for urban employees. However, this reform has been advancing slowly, primarily due to an unpractical financing policy. We surveyed over 2000 families and evaluated the financial impacts of Beijing's reform on public and private enterprises. We found that most state-owned enterprises provided effective health insurance, whereas most private firms did not; overall, 33% of employees had little or no coverage. On average, employees of private firms were healthier and earned more compared to public firms. Because the premium was proportional to income, private firms would pay more for insurance than the predicted health-care expense of their employees. International firms subsidize the most, contributing more than 60% of their insurance premiums to the employees of the public sector. Such an aggressive cross-subsidization policy is difficult to be accepted by private firms.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the winter 2004 quarter. It features articles about:

• a widely publicized study by CHP/PCOR researchers which found that routine HIV screening is cost-effective and would extend the lives of HIV-positive patients;
• publication of the first three volumes of "Closing the Quality Gap," a report prepared by researchers at CHP/PCOR and UCSF that evaluates quality improvement strategies for specific medical conditions;
• a health vouchers plan co-authored by Victor Fuchs, which would provide comprehensive health coverage for all Americans, while maintaining individual choice and free-market competition;
• a research collaboration led by CHP/PCOR that has been awarded a grant to develop a comprehensive Medicare reform plan; and
• the work of former CHP/PCOR trainee Jessica Haberer, who is doing HIV/AIDS research in China for the William J. Clinton foundation, and recently met the former president in this capacity.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the fall 2004 quarter. It features articles about:

• the newly created Center on Advancing Decision Making for Aging (CADMA), a multidisciplinary research collaboration administered by CHP/PCOR that will explore how older Americans make decisions about their health and well-being;
• a roundtable discussion with healthcare and biotech industry leaders, sponsored by CHP/PCOR and led by Sean Tunis, MD, chief medical officer at the Centers for Medicare and Medicaid Services;
• groundbreaking research on the health needs and health status of China's elderly, conducted by trainees in CHP/PCOR's China-U.S. Health and Aging Research Fellowship;
• research by CHP/PCOR faculty and affiliates on racial disparities in the use of implantable cardioverter-defibrillators (ICDs), the drug industry's marketing of low-dose forms of hormone replacement therapy, and the long-term risks of surgery and anesthesia; and
• renewed funding and seed projects for CHP/PCOR's Center on the Demography and Economics of Health and Aging.

Using data from a survey of deaths of children less than 5 years old conducted in 1997 in a county in Shaanxi Province, China, this paper examines gender differences in child survival in contemporary rural China. First, excess female child mortality in the county in 1994-96 is described, followed by an analysis of the mechanisms whereby the excess mortality takes place, and the underlying social, economic and cultural factors behind it. Excess female child mortality in this county is probably caused primarily by discrimination against girls in curative health care rather than in preventive health care or food and nutrition. Although discrimination occurs in all kinds of families and communities, discrimination itself is highly selective, and is primarily against girls with some specific characteristics. It is argued that the excess mortality of girls is caused fundamentally by the strong son preference in traditional Chinese culture, but exacerbated by the government-guided family planning programme and regulations. This suggests that it is crucial to raise the status of girls within the family and community so as to mitigate the pressures to discriminate against girls in China's low fertility regime. Finally, the possible policy options to improve female child survival in contemporary rural China are discussed.

This issue of CHP/PCOR's quarterly newsletter covers news and developments at the centers for the fall quarter 2003.

The issue features articles about a handful of health policy talks sponsored by the centers in the fall quarter; a novel "interactive textbook" on clinical symptom research; the recent arrival from China of the second fellow for CHP/PCOR's China-U.S. Health and Aging Research Training Program; a roundup of the 25th annual conference of the Society for Medical Decision Making; and a summary of last quarter's media coverage highlighting the centers' research work.

It's a girl! My doctor's long-awaited pronouncement heralded one of the most joyous moments of my life. More surprising for this first-time mother was the extent to which so many people shared in our enthusiasm. Not just family and friends but my employer, banker, the owner of the local Chinese restaurant, even the farmers at the local farmer's market. They sent gifts, cards, and messages to demonstrate their affection for the precious addition to our family. The notable exception in this celebration was my health maintenance organization (HMO). When an HMO representative called, it was to deny financial responsibility for my daughter's care.

I have devoted the past ten years of my career to working on ways to make a private, employer-based health care system work more effectively. I believe that HMOs can be part of the solution. From 1997 to 1998 I directed the staff work for the chair of the California Managed Health Care Improvement Task Force. The following year I led a study aimed at improving health coverage decision making in California. To learn that I had been denied health care services was personally disappointing and, considering my professional expertise, ironic. We all hear stories of coverage and claims denials, but when it happened to me, I understood the intense anger people feel about these episodes. My experience resulted in a clearer understanding of why HMOs are so widely disliked.