Behind the decline in the number of people insured by NCMS

Two days ago, Huang Xiaoyun, who works in Zhuzhou, Hunan, received a call from a village cadre in his hometown of Loudi, Hunan, who urged him to hurry up and pay the 2024 basic medical insurance for urban and rural residents (hereinafter referred to as the medical insurance for urban and rural residents), with an individual payment standard of 380 yuan.

In many provinces across the country, the centralized payment period for urban and rural residents' medical insurance in 2024 is from September to December 2023, and urban and rural residents who pay according to the regulations will enjoy the medical insurance treatment for the whole year of 2024. Recently, medical insurance bureaus in many places across the country have issued supplementary payment notices.

There are differences in the time of medical insurance payment for urban and rural residents in different provinces and cities. For example, the deadline for supplementary payment in Xinyang, Xuchang and other cities is February 25, 2024, the deadline for supplementary payment in Zhengzhou, Kaifeng, Luoyang and other cities is March 15, 2024, the window period for supplementary payment in Hunan, Hubei, Shandong and other provinces is from January 6 to February 29, 2024, and the deadline for supplementary payment in Shaanxi, Guangdong and other provinces is as long as half a year, from January 1 to June 30, 2024.

Despite the urging of village cadres, Huang Xiaoyun has made up his mind not to pay the 2024 medical insurance for urban and rural residents, and may not pay it again in the future. The village cadres said on the phone that Huang Xiaoyun's father still has a serious illness subsidy that has not been paid, and as long as Huang Xiaoyun pays the medical insurance for urban and rural residents, this money can be paid. "Then you can directly use this money to help me do it, you don't have to give me the serious illness subsidy, and you don't have to rush me about medical insurance. Huang Xiaoyun said resistantly. In the next few days, the village cadres never looked for Huang Xiaoyun again.

Zhu Minglai, director of the Center for Health Economics and Medical Security Research at Nankai University and director of the Institute of Pension and Health Security of the School of Finance, found in the survey that more and more rural people think that paying medical insurance for urban and rural residents has become a burden, and the payment time for medical insurance for urban and rural residents is also extending. Liu Yiqiang, dean of the Institute of Overseas Chinese Governance and Rural Revitalization at Jinan University, pointed out to China News Weekly that the issuance of notices on the supplementary payment of medical insurance for urban and rural residents sends a signal that the number of residents paying premiums has decreased, and all localities need more time to "remedy" through various means.

A number of experts said that the individual payment of medical insurance for urban and rural residents has increased year by year, which has affected the enthusiasm of residents to voluntarily participate in insurance. A number of experts suggested that next year's individual medical insurance contributions for urban and rural residents should stop rising.

On December 22, 2023, in Xiugu Town, Jinxi County, Fuzhou City, Jiangxi Province, volunteers helped the elderly activate their electronic medical insurance cards at the homes of residents in Yangshan Community. Photo/Zhongxin

The number of insured people is decreasing year by year

After swiping up a Douyin video about NCMS, Huang Xiaoyun left a message in the comment area, "I don't plan to pay it this year."

NCMS actually refers to medical insurance for urban and rural residents. In January 2016, the State Council issued the Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents, which clearly proposes to integrate the basic medical insurance for urban residents (hereinafter referred to as the "urban residents' medical insurance") and the new rural cooperative medical care (i.e., the New Rural Cooperative Medical System) to establish a unified medical insurance system for urban and rural residents. Still, many rural residents, like Huang Xiaoyun, are still accustomed to referring to the annual medical insurance they pay for as NCMS.

According to the Statistical Communiqué on the Development of National Medical Security released by the National Health Insurance Administration in the last four years, the number of people insured by urban and rural residents in medical insurance has gradually declined since 2019, with year-on-year decreases of 0.3%, 0.8%, 0.8% and 2.5% in 2019, 2020, 2021 and 2022, respectively.

From a more intuitive figure, in 2021 and 2022, the number of people insured by urban and rural residents' medical insurance will be 100866 million and 983.49 million respectively, and the number of insured people will decrease by 25.17 million.

Regarding the significant decrease in the number of urban and rural residents participating in medical insurance, Xie Zhangshu, deputy director of the Department of Regulation, Finance and Regulations of the National Health Insurance Administration, explained when participating in the news program "Three Rural Residents" in November 2023 that the basic number of insured people remains stable, and there are two main reasons for the decline: first, "changes in the insurance structure", some flexible employees from participating in urban and rural residents' medical insurance to participate in employee medical insurance, and second, "improving the quality of insurance" In the past, some residents may have participated in the New Rural Cooperative Medical System and urban residents' medical insurance at the same time, and some residents participated in the residents' medical insurance in multiple places.

In addition to these two reasons, some rural residents and village cadres told China News Weekly that in recent years, some rural residents have indeed stopped paying medical insurance for urban and rural residents.

A village cadre in a village in western Hunan said that the number of people who refuse to pay for medical insurance for urban and rural residents is increasing year by year, and that the proportion of people who have not paid may account for about 30 percent in nearby townships. Li Wei, a village cadre in a village in central Hubei, said frankly that as soon as the centralized payment period for medical insurance for urban and rural residents arrives, there is a lot of pressure to collect payments. At the beginning of January, Li Wei also attended a meeting to report on the payment of medical insurance for urban and rural residents, and the meeting asked everyone to do a good job in making up the payment. However, Li Wei said that the number of refunds in his village is not very large, less than 10%.

During the centralized payment period of medical insurance for urban and rural residents, Li Wei will call the villagers more frequently, and will also do more publicity in the WeChat group. In some villages, the village loudspeaker will be used to urge everyone to pay during the centralized payment period, and the proportion of the number of people in the village will be reported.

In order to collect the collection, many places have resorted to all means. In December 2023, a document circulating on the Internet showed that the government of Dayang Town, Qiaocheng District, Bozhou City, Anhui Province, notified the collection and payment of medical insurance for urban and rural residents in 2024, evaluated the progress of collection, and fined village collectives and cadres who did not meet the standards ranging from 200 yuan ~ 500 yuan. Also in December 2023, a screenshot of a chat record went viral on the Internet, and a staff member of a village committee in Baoding, Hebei Province, said in the village information group, "Parents don't pay medical insurance, how can children take the civil service and career editors, and they can't drag their children back."

In addition, there are also some places where the collection has moved towards alienation. In July 2023, the Hunan Provincial Commission for Discipline Inspection and Supervision issued a public notice that the Zhenshang Town Government, in order to improve the ranking of medical insurance collection, violated the rules by taking whether to participate in medical insurance as a precondition for recruitment, civil affairs assistance, homestead approval and other matters. After the incident, Guo Yongzhi, deputy secretary of the party committee and mayor of Zhenshang Town, was admonished and dealt with.

Ren Dapeng, director of the Agricultural and Rural Legal Research Center at China Agricultural University, told China News Weekly that if the proportion of urban and rural residents' medical insurance contributions is used as an assessment indicator for village cadres, it can easily lead to this kind of alienation.

In fact, the indexed assessment of village cadres to call for medical insurance has been around for a long time. A fact that cannot be ignored is that the participation rate of urban and rural residents' medical insurance depends to a large extent on the ability of grassroots institutions to implement the collection policy. Wang Chaoqun, an associate professor at the School of Public Administration of Central China Normal University, pointed out in the article "Who is not insured: A study on the characteristics of the population participating in medical insurance for urban and rural residents in China" published in 2023, before the integration of the medical insurance system for urban and rural residents in 2016, there were often performance appraisal requirements for village cadres to promote NCMS participation, and village cadres would spare no effort to promote it, which is the institutional basis for the high participation rate of NCMS.

Once the willingness of rural residents to pay for urban and rural residents' medical insurance decreases, the pressure on grassroots institutions to collect will also increase.

According to Liu Yiqiang's observations, the average number of rural residents in villages who were originally insured but later did not participate in insurance may reach about 6%. He is worried that the pressure on all localities to pay for urban and rural residents' medical insurance will be greater next year, "once there is this trend, if you don't pay it, I won't pay, it may form a local atmosphere, and it will be very difficult to reverse it."

From $10 to $380

In 2003, the new agricultural cooperative cooperative system was piloted and promoted, which effectively alleviated the problem of farmers falling into poverty due to illness and returning to poverty due to illness. The establishment of the medical insurance system for urban and rural residents is to further promote the reform of the medical and health system and realize that urban and rural residents can enjoy the rights and interests of basic medical insurance fairly.

When Li Wei notified the villagers to pay medical insurance, he mentioned that the threshold for medical insurance for urban and rural residents is low, and medical insurance is an important guarantee in case of a serious illness. Zhu Minglai also pointed out that the more families with poor family income status, the more they should care about risk management.

Because of this, it is particularly worth paying attention to why farmers' willingness to participate in insurance has been affected. Rural residents in many places told China News Weekly that the year-on-year increase in insurance costs is the main factor affecting their willingness to participate in insurance.

From 2006 to the present, the individual payment standards of NCMS and the integrated medical insurance for urban and rural residents have continued to grow. In 2006, the individual contribution standard for NCMS was 10 yuan per person per year, and it has increased several times since then. According to the Notice on Doing a Good Job in Basic Medical Security for Urban and Rural Residents in 2023 issued by the National Health Insurance Administration and other three departments in August 2023, the financing standard for residents' medical insurance in 2023 is 1,020 yuan, of which the individual payment standard for urban and rural residents' medical insurance is 380 yuan per person per year.

"From the time when I only had to pay 10 yuan for NCMS, I was paying the money, but last year, I decided not to pay. Huang Xiaoyun believes that the payment standard of 380 yuan is difficult to bear, "For farmers, our income is all dug out of the ground one by one, my family has 4 old people, 3 children, plus two children, almost a year to pay more than 3,000 yuan, which is a lot of expenses."

Huang Xiaoyun added that he could not afford to pay more than 3,000 yuan a year, in fact, his father often used medical insurance when he was alive, but his personal payment continued to increase year by year. "Ten years ago, our income was four or five thousand yuan a month, and now our income is six or seven thousand yuan a month. ”

Zhang Qing from a village in Zhongxiang, Hubei Province, also began to pay when she only had to pay 10 yuan for NCMS, and she and her relatives and friends paid the money in time every year. But she also admits that with the improvement of rural living standards and economic incomes, "although it is also affordable, it is indeed a bit expensive, and it is rising every year".

Zheng Fengtian, director of the Institute of Rural Development of the Chinese People's University, told China News Weekly that when he went to various rural areas to conduct research in recent years, a large number of peasants reported that the individual medical insurance contributions of urban and rural residents had risen too high, "this is a common phenomenon, not just one or two individual peasants." The village cadres who are burdened with the task of collecting payments are also bitter.

As a village cadre, Li Wei also understands the resistance of some villagers in the village to pay medical insurance for urban and rural residents, "It has risen too fast, I remember that when I only had to pay 10 yuan, the enthusiasm of the people was very high."

Zhu Minglai believes that in the past ten years, both the collective economic income of the countryside and the income of individual farmers who go out to work have generally and significantly increased, so everyone's income can support the growth of individual contributions of the NCMS, but in recent years, the collective economic operation of many villages is not good, the employment situation is not good, and the support of individuals and local villages and townships is relatively difficult.

In Liu Yiqiang's view, the formulation of public policies must take into account the acceptance and psychological limits of the masses, "if this development continues, more people may return the medical insurance for urban and rural residents, and the existing security cannot be sustained in order to improve the level of security."

What is equalization?

Why is the standard of individual medical insurance payment for urban and rural residents constantly rising? Xie Zhangshu, deputy director of the Department of Regulation, Finance and Laws of the State Health Insurance Bureau, once explained on the program "Three Farmers and Three Talkers".

With the economic and social development, the wide application of new medicine and new technologies in the mainland, the people have put forward a higher demand for medical security, including the treatment level of medical expense reimbursement and the scope of medical security have been continuously expanded. Therefore, the improvement of the financing standards for urban and rural residents as a whole is also to better meet everyone's demand for medical security.

In the financing of medical insurance funds for urban and rural residents, financial subsidies have always accounted for the majority, and they are also rising with the improvement of individual financing standards, accounting for about 64% of the annual financing. In 2006, the individual payment standard for NCMS was 10 yuan, and the financial subsidy was not less than 20 yuan per year. In 2010, the individual payment standard of NCMS was 60 yuan, and the financial subsidy was not less than 120 yuan per year. In 2023, the individual payment standard for medical insurance for urban and rural residents will be 380 yuan, and the per capita financial subsidy will not be less than 640 yuan per year.

He also pointed out that at the beginning of the establishment of medical insurance, it mainly covered the medical expenses of residents for serious illnesses. With the expansion of the scope of insurance, medical insurance is now extended to ordinary outpatient clinics, and the catalog scope of drugs, diagnosis and treatment items, and medical consumables within the scope of policy reimbursement is constantly expanding, and the reimbursement ratio is also increasing.

Regarding the rise in individual medical insurance payments for urban and rural residents year after year, the National Health Insurance Administration mentioned in a reply to Xu Yunbo, deputy to the National People's Congress and vice chairman of the Financial and Economic Committee of the Hunan Provincial People's Congress, that with the rapid progress of medical technology, the gradual release of residents' medical needs, and the acceleration of population aging, the sustained and rapid growth of medical expenses has a great impact on the operation of the medical insurance system, and the pressure on the expenditure of the medical insurance fund is greater.

According to data from the National Health Insurance Administration, in recent years, the annual growth rate of medical expenses has been about 8%, and in 2021, compared with 2011, the national average hospitalization cost has risen from 6,632 yuan to 11,003 yuan, an increase of about 66% in ten years. In addition, the medical insurance fund for urban and rural residents has been in a tight balance in recent years. In 2021, the balance rate of the medical insurance fund for urban and rural residents was only 4.4%, and some provinces experienced fund deficits. In 2022, the balance rate of the medical insurance fund for urban and rural residents reached 7.7%, and Gao Guangying, a professor at the School of Public Health of Capital Medical University and vice president of the National Institute of Medical Security, once pointed out that this figure is still low.

According to the data released by the National Health Insurance Administration in December 2023, in January ~ November 2023, the income of the medical insurance fund for urban and rural residents will be 886.317 billion yuan, and the expenditure of the medical insurance fund for urban and rural residents will reach 920.406 billion yuan. This means that in the first 11 months of 2023, the medical insurance fund for urban and rural residents has a deficit of 34.089 billion yuan.

Zhu Minglai pointed out that it is not easy to maintain the balance of the medical insurance fund for urban and rural residents, and he believes that the growth of medical insurance contributions for urban and rural residents is still in a reasonable range compared with the level of medical treatment received by urban and rural residents.

In Liu Yiqiang's view, the dissatisfaction of rural residents with the increase in individual medical insurance premiums for urban and rural residents comes to a certain extent from the fact that they only know that the cost has risen, but they don't know what to do after the cost rises. He believes that after the implementation of public policies, if we cannot effectively communicate with the masses in a way that is felt and accessible, we may go in the opposite direction.

It is worth noting that many social security experts are participating in the discussion of the direction of the reform of the basic medical insurance participation mechanism.

Li Yaqing, deputy dean of the School of Finance of Guangdong University of Finance and Economics, pointed out that the medical insurance funds for urban and rural residents are fixed financing, and residents pay according to the capitation quota, and the government subsidizes the capitation quota, "which is relatively unfair", because compared with the high-income group, the fixed amount of individual payment will be a greater burden for the low-income group.

Ren Dapeng found that in the face of diseases, low-income groups in rural areas always choose treatment with a more conservative mentality, "If you want to spend 100,000 yuan to see a doctor, even if he only has to bear 10,000 yuan, he feels that it is a burden, and it comes down to the root because he can't get the money." Ren Dapeng believes that if public medical services only emphasize formal equalization and pay equal proportions, it may be unequal, because this equalization ignores the differences in the ability of urban and rural residents to pay, and "cannot turn equalization into a rigid thing."

In recent years, Li Zhen, a professor at the School of Public Administration of the Chinese University of China, has been calling for changing the fixed amount of medical insurance financing for urban and rural residents to a rate system. In an article, Li Zhen mentioned that residents' capitation contributions have caused a series of problems, including the unfair burden of contributions, which violates the principle of fair burden of social insurance premiums. Taking the 250 yuan individual contribution standard in 2019 as an example, it accounts for 3.39% of the per capita disposable income of the lowest income group and only 0.33% of the highest income group, and the payment burden of low-income people is ten times that of high-income people. In order to take care of the affordability of the lowest income earners, it is difficult to raise the individual payment standard, and as a result, the relative level of medical insurance for urban and rural residents has declined. Li Zhen suggested that the medical insurance for urban and rural residents should be changed to a rate system based on per capita disposable income, and the responsibility of individual payment should be moderately increased.

Li Yaqing told China News Weekly that she has always advocated improving the financing mechanism for medical insurance for urban and rural residents, and she believes that the key is to improve the actuarial mechanism for financing adjustment. Li Yaqing pointed out in an article that theoretically, the influencing factors that need to be considered for the adjustment of the level of medical insurance financing are very complex, not only in the short term to consider the operation effect of the medical insurance system and problem feedback, but also to consider the growth of medical costs caused by social and economic environmental factors such as aging, disease spectrum changes, population migration, and medical technology progress at the medium and long-term level; She believes that actuarial modeling for health insurance can comprehensively consider the dynamics of the above factors and determine the financing adjustment from the perspective of long-term sustainability.

However, Li Yaqing also stressed that actuarial science should be based on data, which also depends on perfect statistics, and should consider various factors such as residents' income, the growth law of medical expenses, the degree of population aging, and the flow of personnel, "as long as one of the key indicators is not available, or not accurate enough, it will affect its adjustment."

Li Yaqing said: From a theoretical point of view, social security experts have various opinions, but in the view of the practical departments, there are still more aspects to be considered in the adjustment of the financing mechanism, and at the present stage we can only continue to adhere to the financing method of fixed revenue and expenditure, balance between revenue and expenditure, slight surplus, fixed amount of financing, and dynamic adjustment on an annual basis.

However, in recent years, under the suggestions of all parties, the National Health Insurance Administration has begun to study and improve the dynamic adjustment mechanism of residents' medical insurance financing.

During the two sessions of the National People's Congress in 2022 and 2023, deputies to the National People's Congress suggested that "the increase in the individual payment standard for basic medical reimbursement for urban and rural residents should be reasonably controlled, and the standard should be increased once every 3~5 years". The National Health Insurance Administration has replied publicly twice, acknowledging the objective existence of the problem, and saying that it will promote the adjustment of residents' medical insurance contributions to be linked to the level of social development and the per capita disposable income of residents. The reply in January 2024 pointed out that the National Health Insurance Administration is currently working with the Ministry of Finance to carry out special research and actively promote relevant work.

As for the 2025 medical insurance for urban and rural residents, which will be paid in the second half of the year, Zheng Fengtian and Liu Yiqiang both suggested that they hope to stop the pace of rise. Zhu Minglai also said that the growth of individual medical insurance contributions for urban and rural residents can be slowed down or increased slightly.

How else can it be optimized?

Although Huang Xiaoyun did not participate in the medical insurance for urban and rural residents, he chose to buy commercial insurance for himself and his family, including accident insurance and minor illness insurance. Huang Xiaoyun believes that the reimbursement scope of commercial insurance is relatively wider, so although the premium of commercial insurance far exceeds the medical insurance of urban and rural residents, he still chooses the former.

Some rural residents, including Huang Xiaoyun, told China News Weekly that their willingness to pay for urban and rural residents' medical insurance has been affected, not only because individual payments have risen year after year, but also because they believe that the scope of reimbursement is relatively small, mainly for hospitalization, and for outpatient services.

Zhu Ming said that many rural residents said that they did not have a "sense of benefit" or "sense of gain" after participating in medical insurance. He pointed out that this is because the important principle of medical insurance for urban and rural residents is to protect against serious illnesses, and the adjustment of the level of protection in recent years is mainly aimed at serious illnesses to prevent the problem of "poverty due to illness and return to poverty due to illness". "I don't advocate the 'pepper-sprinkling' model, which is fully reimbursed for outpatient treatment, or everyone who goes to the outpatient clinic can be reimbursed a little, and this 'pepper-sprinkling' model is not conducive to the management of the entire medical insurance fund. Zhu Minglai believes that from this point of view, rural residents should adjust their concepts and understand that medical insurance is to protect against serious illnesses and accidents, and grassroots organizations should make more efforts in publicity.

However, Li Yaqing pointed out that the promotion of outpatient co-ordination has begun to solve the problem of benefiting most people. Since the medical insurance system is mainly based on the overall planning at the prefectural and municipal levels, the promotion speed of various localities is fast and slow, "but the national policy guidance is already very clear, not only to protect major diseases, but also to protect minor diseases."

There are also some rural residents who believe that even if they pay for medical insurance for urban and rural residents, they still have to spend a lot of money when they get sick. Zhang Qing's mother was admitted to the hospital for cancer in 2011, spending about 100,000 yuan, but the actual reimbursement was less than 40,000 yuan, and she needed to pay 60,000 yuan. The medical expenses incurred by insured residents in hospitalization within the scope of the policy have different payment lines and reimbursement ratios for different levels of hospitals. Taking Jingzhou's latest policy as an example, the proportion of urban and rural residents receiving medical treatment in tertiary hospitals is 60%, while the proportion of medical treatment in first-level hospitals is 85%. Zhang Qing believes that it doesn't cost too much money to solve minor illnesses in townships and towns, but it costs a lot of money to get sick and can't be cured in towns and towns, so they can only go to big hospitals, but going to big hospitals means that the reimbursement ratio is also decreasing, and people have to pay a lot, which she doesn't quite understand.

Ren Dapeng said that now that the space for village doctors and township health centers to play a role is gradually decreasing, how to strengthen the ability of medical services at the grassroots level may be a key issue in the future.

In addition, some rural residents have reported that although they have paid for urban and rural residents' medical insurance, the money spent does not seem to be reduced, because hospitals may choose more expensive treatment options and prescribe more expensive medicines.

"How to curb over-treatment" has always been a hot topic. Zhu Minglai has studied whether there is an unreasonable increase in medical costs in the process of merging urban and rural residents' medical insurance, and he found that residents with low economic level and low education are more susceptible to the moral hazard of medical service providers due to the higher marginal utility of economic incentives and the lower ability to discriminate information. In other words, when individual hospitals face greater operational pressure and pass on the operational pressure to patients through unreasonable increases in medical costs, residents with low economic standards and low education will be more affected. How to curb excessive medical treatment, especially to reduce the impact on residents with low economic level and low education, is also a key issue that needs to be considered in the future.

(Huang Xiaoyun, Li Wei, and Zhang Qing are pseudonyms in the article, and our reporter Xie Xuewei also contributed to this article)

Published in the 1127th issue of China News Weekly magazine on January 29, 2024

Magazine title: Behind the decline in the number of people insured by the NCMS

Reporter: Zhang Xinyu