By the end of 2022, the number of people enrolled in basic medical insurance in the country has reached 1.35 billion, and the participation rate has stabilized at more than 95%, but the foundation of universal medical insurance still needs to be consolidated, especially the mechanism of residents' medical insurance participation needs to be further optimized.
On January 9, the National Medical Security Work Conference proposed that while more than 16 million people were repeatedly insured last year, the participation rate of low-income rural people and people lifted out of poverty was stable at more than 99.9%, and this year will consolidate and expand the results of universal insurance. Study and improve the long-term incentive and restraint mechanism for participating in insurance, use the system to ensure that the masses who continue to pay premiums benefit, and ensure that the whole people participate in insurance.
According to the Blue Book of Medical Security: Report on the Development of China's Medical Security (2023) (hereinafter referred to as the "Report") jointly released by the China Social Security Association and the Social Sciences Academic Press, the number of insured residents in medical insurance has declined for four consecutive years since 2019.
Employee medical insurance coverage has doubled in 15 years
The report shows that in the 15 years from 2007~2022, the number of employees participating in medical insurance has doubled from 180 million to 362 million, with an average annual growth rate of 4.77%, of which the number of insured employees has increased from 134 million to 267 million, and the number of retirees has increased from 46 million to 96.36 million, with an average annual growth rate of 4.67% and 5.05% respectively in the past 15 years.
From the perspective of the structure of the insured group, from 2012 to 2021, the proportion of insured persons from enterprises, government institutions and flexible employment groups is also changing, and the participation rate of flexible employment groups has increased from 10.24% to 13.7%, reflecting the gradual expansion of the scope of employee medical insurance.
From the perspective of fund expenditure, at the end of 2021, the per capita expenditure level of the employee medical insurance fund has reached 4,162 yuan, of which the per capita expenditure level of the overall fund is 2,631 yuan, with an average annual growth rate of 11.91% and 12.89% respectively. In 2021, the average expenditure of the employee medical insurance fund was 723 yuan, of which 457 yuan was spent by the overall fund, with an average annual growth rate of 6.95% and 7.01% respectively.
According to the report, under such treatment payment and financing rules, the overall income and expenditure of the employee medical insurance fund is stable, and most areas have a balance of income and expenditure of the fund every year and have a surplus, so a large cumulative balance has been formed. In 2022, the income of the employee medical insurance fund will be 2,063.7 billion yuan, the expenditure will be 1,515.8 billion yuan, the balance of the year will be 547.9 billion yuan, the balance rate will be 26.55%, and the cumulative balance will be 3,500.4 billion yuan. Judging from the overall situation of the country, the employee medical insurance fund is relatively sufficient and in good condition.
Zheng Gongcheng, president of the China Social Security Association, said at a recent symposium on the construction and development of a multi-level medical insurance system that the government-led basic medical insurance has steadily covered more than 95% of the population, becoming the first inclusive and shared social security system arrangement, and hundreds of millions of people have directly benefited from it. However, on the whole, the basic medical security prescribed by the mainland is not yet mature, institutional deficiencies still exist, and the level of protection is still limited.
According to the report, the main shortcomings of the employee medical insurance system are that the participation rate needs to be improved. From the original intention of the system design, the basic medical insurance system for employees covers all salaried workers. For example, at the end of 2021, there were 354.31 million employees enrolled in medical insurance nationwide, including 261.06 million active employees and 93.24 million retired employees. According to the data released by the China Statistical Yearbook, at the end of 2021, the number of employees in the secondary and tertiary industries in the country reached 575.8 million, and there was a gap of 314.74 million between 261.06 million and 575.8 million, indicating that the employee medical insurance system is still far from the goal of "full coverage", and the task of achieving "full coverage" is still very arduous.
The report recommends that non-regular workers who are able to pay should be encouraged and supported to participate in the basic health insurance system for workers so that they have a higher level of basic health insurance.
He Wenjiong, a professor at the School of Public Administration of Zhejiang University and the author of the article "The Improvement of China's Basic Medical Insurance System for Employees", believes that how to share the cost and how to implement the basic medical insurance for employees of informal workers has become an important issue that needs to be solved urgently. The large number of informal workers has increasingly become an important part of the economic and social operation of the mainland, and other social entities, represented by the government, should help reduce their payment burden.
The mechanism for residents' medical insurance participation needs to be optimized
According to the 2022 Statistical Communiqué on the Development of National Medical Security, by the end of 2022, there were 983.49 million people in basic medical insurance (resident medical insurance) for urban and rural residents. Among them, adults, primary and secondary school students, children, and college students accounted for 73.26%, 24.77%, and 1.97% of the total number of residents participating in the insurance, respectively.
According to the report, the resident medical insurance system has made great achievements in the past 20 years, enabling nearly 1 billion urban and rural residents to achieve the basic goal of medical insurance from scratch, from limited protection to increasingly effective protection.
From the perspective of fund income and expenditure, in 2019~2022, the average annual growth rate of fund income and fund expenditure will be 5.5% and 4.2% respectively. In 2022, the fund's income exceeded 1 trillion yuan for the first time, a year-on-year increase of 3.5%, the expenditure was 927.3 billion yuan, a year-on-year decrease of 0.2%, and the cumulative balance at the end of the year hit a record high of 753.7 billion yuan, which can be paid for 9.8 months.
At the beginning of this year, the National Health Insurance Administration mentioned in its reply to Recommendation No. 7458 of the first session of the 14th National People's Congress that the resident medical insurance fund has been in a tight balance in recent years, with an income of 1,012.89 billion yuan and an expenditure of 935.34 billion yuan in 2022, with a balance rate of only 7.6%, and fund deficits in individual provinces.
The National Health Insurance Bureau said that the problem of "the rise in individual payment affects the enthusiasm of the masses to participate in insurance payment" put forward by the representatives objectively exists, and the corresponding proposal of "reasonably controlling the increase in the individual payment standard of basic medical insurance for urban and rural residents and raising the standard once in 3~5 years" is of great reference value to the work of the Medical Insurance Bureau.
According to the 2022 National Statistical Communiqué on the Development of Medical Security, by the end of 2022, the number of people participating in basic medical insurance for urban and rural residents was 983.49 million, a decrease of 25.17 million compared with the end of 2021. Since 2019, the number of people enrolled in resident medical insurance has declined for four consecutive years, and in 2022, the largest decline will reach 2.5%.
Previously, the responsible comrades of the relevant departments of the National Medical Insurance Bureau said in an interview on the basic medical insurance participation that the main reasons for the decline in the number of residents participating in medical insurance are: first, some of the people who originally participated in the residents' medical insurance have switched to participating in the employees' medical insurance; second, the number of people who have repeatedly participated in the insurance has decreased.
According to the data, since the establishment of the National Health Insurance Administration, the cumulative reduction of duplicate insurance in many places has exceeded 40 million, and more than 16 million duplicate insurance will be handled in 2022 alone.
According to the report, the number of people insured by residents' medical insurance has been declining year after year, because of the elimination of duplicate insurance factors, and there are also problems with the system itself. For example, the practice of paying the same amount of medical expenses according to the capitation deviates from the law that the social medical insurance system should be held accountable according to the size of the capacity, resulting in low-income people losing their enthusiasm to participate in the insurance due to the heavy burden.
Hua Ying, an associate researcher at the Institute of Population and Labor Economics of the Chinese Academy of Social Sciences, has shown that the current capitation payment method actually violates the principle of fairness in financing, and that the burden of contributions in the rural low-income group, which is the heaviest, is more than 20 times that of the low-income urban population with the lightest burden, as measured by the ratio of individual contribution standards to per capita disposable income. Even if more than 100 million of the 1 billion insured people have received medical assistance subsidies, the fixed amount of financing has directly caused the low-income group to pay for insurance and even lost insurance, and at the same time, it also restricts the increase of personal contributions for high-income earners who have the ability and should bear more obligations, affecting the sustainable development of the system and the improvement of the level of protection.
The report recommends that the mechanism of residents' medical insurance participation should be optimized, and the coverage boundary of employee and resident insurance should be clarified, and the insurance policy should be adjusted, while improving the sustainability and adequacy of financing.