China’s current basic health insurance reform aims at promoting equity in the economic accessibility of health services for all citizens, to better ensure healthcare justice. Therefore, it is important to assess equity not only from a socioeconomic perspective but also from an ethical angle. This article investigates the basic health insurance system of Hunan Province in China by focusing on insurance types as well as their classification standards, mechanisms, and utilization according to local policy documents and data. This study demonstrates the reforming achievements and the inequity of institutional design according to two interrelated dimensions: equal opportunity of access to healthcare insurance and reducing inequality in insurance benefits. The article concludes that to achieve opportunity equity and outcome fairness, the reform should focus on designing the system to promote equity with respect to procedures and rules and to be more attentive to the interests of vulnerable groups and especially to rural residents.