The number of residents participating in medical insurance has declined, where is the medical insurance reform going?
With the change of time, when fairness rises to an important keyword, the unification of fragmented systems and the equalization of treatment will become the desire of public opinion.
Li Shushi (Medical Industry Observer)
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Recently, the discussion about the decline in the number of people enrolled in the "urban and rural residents' medical insurance" once occupied the headlines. Statistics show that the number of urban and rural residents with basic medical insurance was 983 million, a decrease of 25.38 million from the end of the previous year, a year-on-year decrease of 2.5%.
Some public opinion believes that the participants of the residents' medical insurance are already low-income people who do not have stable jobs in urban areas, and the premiums are increasing year by year, making some people unwilling to pay for the insurance anymore. Some netizens complained that even with medical insurance, there is still a lot of pressure to see a doctor.
The National Medical Insurance Bureau quickly replied that the reason behind it is that some of the people who originally participated in the residents' medical insurance have switched to participating in the employee medical insurance, and the basic medical insurance participation data shows a trend of "residents are declining and employees are increasing", and more and more people are participating in employee medical insurance. Many local health insurance bureaus have also published articles to continue to educate the public about the benefits of insurance participation in order to consolidate the current insurance base.
Medical insurance is undoubtedly a "good thing", and medical insurance covering almost the whole population can maximize the effect of risk pooling, help individuals resist the financial risks caused by illness, and encourage insurance is the right thing to do. Although the current data changes are due to the migration of policyholders between different insurance pools, some of the concerns mentioned in public opinion cannot be ignored, and they are also opinions that need to be listened to for the "always on-the-go" health insurance reform.
▌Welfare-based medical insurance still brings a certain degree of payment pressure to individuals
No country's health insurance is a panacea, and limited input cannot bring unlimited output, and China is no exception. Under the NHS model, which is modeled in the UK, costs are paid for by taxes, and people have little to no out-of-pocket costs, but they have to face long waiting times and an inefficient service system. China's medical insurance system carries a huge number of medical visits and prescriptions, but all insured people need to pay additional premiums, and the services are not 100% reimbursed, and patients need to bear a part of the cost of medical treatment.
For residents who are not financially adequate, the premiums they need to pay have increased year by year, from 120 yuan per year in 2015 to 380 yuan per year in 2023, but the financial ability of many residents may not improve year by year, especially during the global economic turmoil after the outbreak of the epidemic. In some areas, the pension insurance treatment for urban and rural residents is about 160 yuan per month, which means that the elderly in these areas need to take out nearly 3 months of pension to pay for resident medical insurance.
On the other hand, it is worth noting that the absolute value of the premium is not high, but after paying the premium and participating in the insurance, once you suffer from a serious illness, the cost that will not be reimbursed by the medical insurance may be much higher, which may not be affordable for some insureds.
The author has heard insured people in rural areas mention that the out-of-pocket expenses after a serious illness are too much for them to bear, and even if they have medical insurance, they are not very willing to go to the doctor. In this scenario, medical insurance cannot play a role, leading to the idea that some insured people are unwilling to continue to participate in insurance. Compared with commercial insurance, which often has tens of thousands of premiums, the "welfare" of the national basic medical insurance is already very strong, but it is necessary to further consider the actual impact of system design from the perspective of the insured.
From the perspective of the framework, the domestic basic insurance adopts the classic insurance reimbursement system, for the total amount of products and services that can be reimbursed by the medical insurance regulations, the minimum payment standard and the ceiling line are delineated, and the expenses below the starting line and the expenses above the ceiling line are not reimbursed.
Before these calculations, there was still a part of the pre-emptive self-burden of Class B drugs (drugs that can be used for clinical treatment, have good efficacy, and have a higher price than the "Class A Catalogue" drugs) that need to be borne by the patient, usually about 20%. Hospitalization treatment (minimum payment line, reimbursement ratio, cap line) is generally higher than that of outpatients, and the outpatient co-ordination reform in the last two years is trying to solve this problem, but the annual cap line of outpatient clinics in many regions is designed to be below 4,000 yuan, which is not very high.
In order to solve the problem of long-term medication (hypertension, diabetes, tumors, some rare diseases, etc.) with high outpatient costs, a separate reimbursement system has also been established for outpatient chronic diseases and special diseases, which can break through the reimbursement ceiling line of outpatient clinics, but chronic diseases are selected by each city, and the number is often controlled in dozens, which cannot be perfect, and the selection process is often not open and transparent enough, and there may be unfair problems between different diseases, and some diseases have low ceiling lines and cannot be fully reimbursed.
On the whole, in 2022, among all the hospitalization expenses incurred, 84.2% of the hospitalization expenses of the employee medical insurance will be paid by the fund, and 68.3% of the hospitalization expenses of the resident medical insurance will be paid by the fund, which has been the result of years of efforts. This figure is even lower if you include products and expenses that are not yet included in the Medicare list. Therefore, in areas with underdeveloped economies and insufficient medical insurance funds, it is inevitable that some residents will feel that they still have difficulties after participating in the insurance.
In response to this problem, a multi-level medical security system has been established, including serious illness medical insurance and medical assistance systems, weaving a "bottom net". However, although medical assistance has benefited some of the most economically stressed residents, including extremely poor households and low-income households, many rural families who are not in good financial condition are not among them, and they still face the problem of not being able to afford medical expenses. Critical illness medical insurance often has its own starting line, and the part below the minimum payment line may also become unbearable for some patients.
For example, in an eastern city, the payment condition for residents' serious illness medical insurance is that the out-of-pocket expenses of individuals exceed 20,000 yuan. Although 70% of expenses above 100,000 yuan can be reimbursed, and there is no clear upper limit, 100,000 yuan is already a large amount of expenses for many patients, and may even lead to family poverty return.
▌The medical insurance deficit has emerged, and the payment and continuation of the fund itself are under pressure
If a free health insurance package is not good enough, it may lose the insured. From the perspective of economic accounting, if the loss of unhealthy participants who may incur large expenses, the balance of the fund will not be hit too hard, but if many healthy participants are lost, the fund itself will also face pressure. The lower the treatment, the more reluctant people, especially the healthy people with a small risk of illness, to participate in the insurance, and the scale of the fund will further shrink, let alone attract people to participate in the insurance, and it will not be able to play a role in guaranteeing.
There is an important indicator when analyzing the operation of the medical insurance fund - the number of months of payment, that is, assuming that there is no new premium income, how long the accumulated balance of medical insurance funds over the years can support the expenditure of the fund. If it is more than 6 months, it is in the safe zone. At present, the cumulative balance of the two systems of urban employee medical insurance and resident medical insurance has exceeded 4.2 trillion yuan, the balance of the national employee medical insurance pool fund can be paid for about 21.9 months, and the balance of the national resident medical insurance fund can be paid for about 9.0 months, showing that the fund has sufficient support capacity.
However, does this mean absolute security? Dismantling the income and expenditure of residents' medical insurance over the years, it can be found that between 2012 and 2021, there were 8 years when the growth rate of expenditure was higher than the growth rate of income, and the number of months that can be paid has gradually decreased from 13.5 months in 2012. Without intervention, the Fund may be in the alert zone for the next 10-20 years.
At the same time, the above analysis is based on a game of chess in the country, in fact, the overall level of medical insurance is not in the center, but in each city, each place is in charge of the capital pool, and is also responsible for adjusting the level of medical insurance treatment, so the medical insurance support capacity in different regions is very different. It is still difficult to support and replenish funds in the province from the wealthy areas to the economically difficult areas, let alone to help each other between the eastern and western provinces.
According to the data of local funds released over the years, in 2021, Tianjin had the highest number of months of medical insurance payment for residents, at 18.3 months, followed by Guangdong with 14 months, and 4 provincial-level regions with less than 6 months. In 2019, before the outbreak of the new crown epidemic, the order of diagnosis and treatment has not been affected by factors such as the epidemic and lockdown, and there are about 10 provincial-level regions that have been less than 6 months. If we further consider the uneven economic development within the provinces, such as Guangdong, Henan, Chongqing, etc., more regions will encounter the problem of limited funds.
According to the analysis of the recent reply of the National Health Insurance Administration, the reduction of the number of participants in the resident medical insurance is mainly from the resident medical insurance fund pool, to the urban staff medical insurance group, they are more relatively healthy, can get formal jobs of the population, and the remaining group includes many rural elderly, this change of the advantages of the fund itself is also a pressure.
In the context of the significant aging trend and the faster and faster entry of new drugs and technologies into the market, in order to cope with the increasing demand for medical treatment and diagnosis and treatment costs, and to ensure that the medical insurance treatment does not decline, the resident medical insurance tries to expand its own capital scale by increasing the premium every year. According to statistics, in the two decades from 2003 to 2023, the individual premiums of the insured increased by 37 times, with an average annual growth of 19.78%, reaching about 400 yuan per year.
In fact, since the birth of resident medical insurance, all levels of finance have been required to provide subsidies to premiums, and in addition to the nearly 400 yuan that individuals need to pay, the financial subsidy will reach 640 yuan per person in 2023. This treatment has been rigidly increased by about 30 yuan per year.
▌Unfair treatment caused by dualization makes vulnerable groups more vulnerable
In the case of high personal burden and pressure on the entire fund, another problem that needs to be considered in medical insurance is the "binary difference", which is also the reason for the decline in the number of participants in the "urban and rural residents' medical insurance" mentioned at the beginning of the article.
The basic medical insurance mainly includes the medical insurance for employees and the medical insurance for urban and rural residents, the latter was previously divided into basic medical insurance for urban residents and new rural cooperative medical insurance, that is, there is a difference between urban and rural areas. At present, the two have been merged into resident medical insurance, but there is still a huge difference between its treatment and employee medical insurance.
The proportion of fund payment within the policy of employee medical insurance is higher than that of resident medical insurance, the number of months of payment is also significantly more, and the fund is significantly safer.
This is distorted in a way. The urban low-level residents and the elderly in rural areas who need medical security the most can get relatively weak residents' medical insurance. While they do get the opportunity to enroll at lower premiums and are supported by financial subsidies when they do, the level of protection they actually receive is still not high.
In contrast, some countries are beginning to learn to use policy tools to make help more accessible to vulnerable groups. In Spain, for example, people with relatively low incomes can receive more preferential reimbursement benefits. In the case of outpatient reimbursement of medicines, 40% is reimbursed for those earning more than 100,000 euros per year, 60% for those earning less than 18,000 euros per year and 90% for retirees.
As a part of the secondary distribution of national income, domestic medical security has mainly played a regulating role within urban workers, with individual wages as the basis for payment, the payment rate is the same, the high income pays more, the low income pays low, and the medical insurance reimbursement treatment is the same, helping low-income urban workers. However, it has not had an impact on bridging the gap between urban workers and urban and rural residents. Coordinating urban and rural development is one of the long-term keywords in the country's economic development, but it still faces great challenges in all fields.
At the beginning of the establishment of the traceability system, we can understand why there is a fragmented design: it is not easy to build a high-rise building from the ground, it is difficult to reach a consensus among different stakeholders, and different systems can only be designed according to the conditions and demands of different groups. However, with the change of time, when fairness rises to an important keyword, the unification of fragmented systems and the equalization of treatment will become the desire of public opinion.
Many regions have gone through a similar path, such as mainland Taiwan, where universal health insurance has undergone a process of gradual improvement. The earliest medical insurance system began in 1950 with the Labor Insurance Method, and then 13 types of medical insurance, including health insurance for civil servants, labor insurance, and health insurance for farmers, were implemented one after another. After the reform in the 90s of the 20th century, the medical insurance was integrated, the whole people were forced to participate, the people were divided into different categories according to their identity and economic ability, and the payment methods and burden ratios were different, taking care of low- and middle-income groups, and the premiums of low-income people, soldiers and other groups were completely borne by the government, but the medical insurance treatment obtained at the time of treatment was completely consistent.
In the face of a wider region, more unbalanced inter-provincial and intra-provincial economic conditions, it is not easy to unify the system, and various management obstacles will be encountered.
However, this does not mean that the ice cannot melt, and there are many measures that can be taken at this stage to bridge the gap and gradually achieve urban-rural convergence. For example, according to the suggestions of some scholars, more financial resources should be developed to enrich the residents' medical insurance fund, such as taxing unhealthy foods such as sugary drinks to supplement the medical insurance funds, stabilize the individual payment part without a significant increase, and stabilize the willingness of all residents to continue to participate in insurance.
At the same time, some differentiated subsidies can be adopted to further reduce or reduce the premiums of residents according to their financial situation, such as the elderly in rural areas of retirement age, to reduce their insurance pressure. In addition, explore some new types of insurance designs to supplement and improve medical insurance benefits. Huimin Insurance, which is being promoted in many cities and has the endorsement of the government, is a good example, regardless of the identity of residents and employees, all people are insured at an inclusive price, ensuring the expenses beyond the reimbursement part of the basic medical insurance, effectively reducing the financial burden of patients, and also ensuring fairness among different groups of people.
For a country with a population of 1.4 billion, huge geographical differences, and diverse group interests, it is not easy to build a broad and fair health care system from scratch so that everyone can get the protection they deserve. But this is not a reason to abandon reform, which requires wisdom and faith, and since we all live in the same society, it is the proper duty of building a good society to improve mutual aid so that the unfortunate among us do not fall into a situation of hardship or even destruction due to illness.
