Background: Policy experimentation has become a central strategy for governments seeking to navigate complexity in healthcare reform. In China, extensive rounds of county-level healthcare reform pilots aim to strengthen primary care and improve service equity. However, while some pilots expand successfully, others stagnate or are suspended. The underlying mechanisms that generate these divergent outcomes remain insufficiently examined. Objectives: This study investigates how healthcare reform pilots evolve in practice by identifying the key actors involved in pilot management, analyzing the driving forces that shape pilot performance, and explaining the different developmental trajectories of pilots within China's county medical service community (CMSC) reform. Methods: Drawing on large-scale fieldwork across 23 CMSCs, we collected qualitative data through semi-structured interviews and focus group discussions with 127 internal and external stakeholders. Using grounded theory, the data were analyzed through open, axial, and selective coding, and subsequently integrated to construct a typological framework explaining variations in policy pilot outcomes. Results: Drawing on the coding framework, the analysis identifies two overarching forces shaping CMSC pilot implementation: institutional compatibility and policy potential energy. Institutional compatibility reflects the alignment of CMSC policy design, healthcare insurance payment rules, interdepartmental coordination, incentive structures, and resource–benefit allocation. Policy potential energy derives from the redistribution of administrative power, political momentum from higher-level governments, the capacity of policy entrepreneurs, and the contextual foundations of social capital and trust. Mapping these dynamics reveals four pilot trajectories: upscaling, adjustment, suspension, and autonomy.

Exploring the quality of life of disabled elderly individuals in eldercare facilities holds significant importance in the improvement of service quality, the allocation of eldercare resources, and the enhancement of the well-being of the elderly. This study, grounded in the subjective perspective of disabled elderly individuals, aims to investigate their quality of life within eldercare institutions. A grounded theory approach was employed, involving semi-structured interviews with 35 participants. Data analysis revealed that the quality of life of disabled elderly individuals in Chinese elderly care institutions is characterized by "maintaining symbiosis in conflict" and encompasses four dimensions: complex adaptation process, complexities in social interactions, physical pain and the lonely soul. Spending late years in elderly care institutions poses a trial and challenge for disabled elderly individuals, especially within a cultural environment that traditionally revolves around the "family" unit. In these institutions, disabled elderly individuals not only endure physical pain but also grapple with feelings of loneliness. They maintain the facade of family dignity by concealing true emotions, ensuring the harmonious and stable operation of the elderly care institution.Enhancing the quality of life for disabled elderly individuals requires not only an improvement in the service capabilities of elderly care institution staff but also collaborative efforts from policymakers and family members.

This study adopts a systems perspective to examine the persistent effects of China’s One-Child Policy (OCP) on the subjective well-being of older adults, emphasizing structural persistence, reinforcing feedback, and path-dependent lock-in in complex socio-technical systems. Using nationally representative data from the China Longitudinal Aging Social Survey (CLASS-2014), we exploit the OCP’s formal rollout at the end of 1979—operationalized with a 1980 cutoff—as a quasi-natural experiment. A Fuzzy Regression Discontinuity (FRD) design identifies the Local Average Treatment Effect of being an only-child parent on late-life well-being, mitigating endogeneity from selection and omitted variables. Theoretically, we integrate three lenses—policy durability and lock-in, intergenerational support, and life course dynamics—to construct a cross-level transmission framework: macro-institutional environments shape substitution capacity and constraint sets; meso-level family restructuring reconfigures support network topology and intergenerational resource flows; micro-level life-course processes accumulate policy-induced adaptations through education, savings, occupation, and residence choices, with effects materializing in old age. Empirically, we find that the OCP significantly reduces subjective well-being among the first generation of affected parents decades later (2SLS estimate ≈ −0.23 on a 1–5 scale). The effects are heterogeneous: rural residents experience large negative impacts, urban effects are muted; men are more adversely affected than women; and individuals without spouses exhibit greater declines than those with spouses. Design validity is supported by a discontinuous shift in fertility at the threshold, smooth density and covariate balance around the cutoff, bandwidth insensitivity, “donut” RD robustness, and a placebo test among ethnic minorities exempt from strict enforcement. These results demonstrate how demographic policies generate lasting impacts on elderly well-being through transforming intergenerational support systems. Policy implications include strengthening rural pension and healthcare systems, expanding community-based eldercare services for spouseless elderly, and developing complementary support programs.