The participation in basic medical insurance is the foundation and premise for the stable and healthy operation of the medical insurance system. It has taken more than 20 years for the mainland to achieve full coverage of basic medical insurance, and the participation rate has stabilized at more than 95%, which is a great achievement of the medical security system with Chinese characteristics. In recent years, the number of residents participating in medical insurance covering urban and rural residents has fluctuated, which has aroused concern from all sectors of society. In this regard, it is necessary to conduct an objective analysis of the insurance data and understand the development logic of China's modernization process. Secondly, from the perspective of improving the quality of residents' medical insurance, it is necessary to comprehensively analyze and grasp the current obstacles and difficulties faced by residents' medical insurance, put forward corresponding ideas and countermeasures, and consolidate the foundation for the high-quality development of the medical security system.
Objectively analyze the data of residents' medical insurance participation
Judging from the superficial statistics, the number of people insured by mainland residents' medical insurance has indeed dropped by more than 25 million from 2021 to 2022. For this number, the first thing to do is to eliminate the data of duplicate insurance in recent years. The medical insurance for mainland residents is the integration of the New Rural Cooperative Medical System and the medical insurance for urban residents, and before the integration, due to multiple management and poor information, there was actually a huge number of duplicate insurance participants. For example, in 2013, the total number of participants in the three systems of medical insurance for workers in mainland China, the New Rural Cooperative Medical System and the medical insurance for urban residents exceeded the total population of the country, with a participation rate of 101.1%.
Specifically, the duplicate insurance is mainly for students studying abroad and migrant workers who go out to work. They have not only participated in the NCMS in their hometowns, but also some have participated in the medical insurance for urban residents or employees in their places of study and employment. An important reason for urban-rural integration is to solve the problem of duplicate insurance.
Not only that, the previous regional segmentation of the medical insurance information system led to the inability of a large number of floating populations to return to the place of outflow, which is also the main reason for repeated insurance.
After the establishment of the National Health Insurance Administration in 2018, on the one hand, the integration of medical insurance for urban and rural residents was realized in the system, laying the institutional foundation for eliminating duplicate insurance; On the other hand, the national unified medical insurance information system has also been gradually completed and put into operation. In particular, in 2022, the national unified medical insurance information platform will be put into operation in most provinces, and the insurance information of the insured will be searchable and comparable across the country. Therefore, in recent years, a large part of the decline in the number of residents participating in medical insurance is due to the elimination of duplicate insurance. According to the data of the National Health Insurance Administration, more than 40 million people have been excluded from repeated insurance in recent years, of which more than 16 million will be excluded in 2022. Based on this calculation, only about 9 million of the more than 25 million people who will have a decline in residents' medical insurance participation in 2022 are actually declining.
Of the more than 9 million people who have fallen insured, a large part of them is due to the participation of residents in urban areas to participate in employee medical insurance. In 2022, the number of mainland workers covered by medical insurance increased by 8.12 million, a considerable part of which is the population who moved to urban areas. The number of people who have participated in the medical insurance has declined by about one million. And this decline should be combined with the current trend of declining population size on the mainland. In 2022, the total population of the mainland will decline, and the population in rural areas will decline even more rapidly.
Residents' medical insurance participation and the reform of the grassroots governance system in mainland China
Of course, even if the above-mentioned reasons such as duplicate insurance, participation in employee medical insurance, and the decline in the total size of the population are excluded, the participation situation of mainland residents' medical insurance is still not optimistic, and there are still major problems and challenges in improving the quality of residents' insurance. In some places, mobilizing urban and rural residents, especially rural residents, to participate in insurance has become a "heavy burden" for local grassroots governance.
One of the principles of medical insurance for mainland residents is voluntary participation. From the perspective of practical advancement, voluntary participation in insurance is undoubtedly an important condition for the mainland to achieve full policy coverage in a very short period of time, but it must be recognized that the principle of voluntary participation and compulsory participation in social insurance is actually in conflict. The reason why social insurance has the principle of compulsory participation is to solve the problem of adverse selection in the process of medical insurance participation, that is, young and healthy groups withdraw or avoid insurance, resulting in unsustainable insurance.
The participation rate of mainland residents' medical insurance can still exceed 95% despite voluntary participation, mainly relying on a strong and efficient grassroots governance system. Mobilizing urban and rural residents to participate in insurance and providing convenient conditions for residents to participate in insurance has always been an important task of grassroots governance in the mainland. The advantage of this governance model is an important guarantee that mainland residents' medical insurance can overcome adverse selection in the case of voluntary participation.
However, with the acceleration of the mainland's modernization process, especially the rapid progress of new industrialization and urbanization, the mainland's traditional grassroots governance model is also facing great challenges. This challenge is also reflected in the issue of residents' medical insurance mobilization. Traditionally, grassroots governance on the mainland has been based on the registered population, and on the basis of the normalization of the management of the registered population, the management of a small number of foreign populations is different from that of the local population. But large-scale population movements have changed this basis, and household separation has become the norm. Under such circumstances, the policy orientation of grassroots governance and the provision of public services at the grassroots level proposed by the mainland is based on the permanent population. For residents' medical insurance participation, the requirement put forward by the higher authorities is to use the permanent resident population as the base number of insurance, but at the grassroots level, the permanent resident population is the data estimated by the statistical department through sample surveys, and there is no one-to-one correspondence with the permanent resident population. This is not a big problem for other "anonymous" or "anonymous" public service provision and public management, but for medical insurance participation, without a specific list corresponding, it is impossible to determine who is the "insured", and it is difficult to achieve "full participation". In some areas, there is only a total number of insurance tasks issued to subordinates, and there is no corresponding base number of "insured persons", and the mobility of the permanent resident population is large, and the insurance tasks issued by the permanent residents of the previous year are not necessarily the same as the population of the current year.
Secondly, the current problems encountered by residents in participating in insurance are also related to the design of the medical insurance payment system for mainland residents. The fixed-rate payment system is used for medical insurance for mainland residents, which seems to be "fair", but it is not consistent with the fairness of social insurance. In the contribution design of social insurance, an important principle is vertical equity, that is, those with high incomes pay more and those with low incomes pay less, so as to achieve the function of income redistribution. Under the fixed payment system, the actual rate of the same contribution amount is different for different income groups, and the lower the income group, the higher the actual rate. According to the data of the National Bureau of Statistics, the per capita disposable income of the low-income group, lower-middle-income group, middle-income group, upper-middle-income group, and high-income group of rural residents in that year was 6.97%, 2.93%, 2.01%, 1.42%, and 0.76%, respectively. The high rate of 6.97% for the low-income group is close to the medical insurance rate for employees in some areas, while the actual rate for the high-income group is less than 1%.
Three aspects to improve the quality of residents' medical insurance
Adverse selection, the inaccurate participation base of the permanent population, and the unfairness of the fixed payment are the three main obstacles to grassroots mobilization and participation. Solving these three obstacles is the main challenge to improve the quality of residents' medical insurance participation.
The first is to solve the problem of incentives for participation in insurance under the condition of voluntary participation. Under the principle of maintaining voluntary participation, there are also some experiences that can be used for reference, that is, the establishment of incentive and restraint mechanisms for participation. For example, for those who have been insured for a certain number of years, their medical insurance benefits can be appropriately adjusted, such as lowering the starting line, increasing the reimbursement ratio, or increasing the limit of outpatient reimbursement. For those who interrupt their participation and avoid their participation, they should design a corresponding waiting period to prevent the opportunistic behavior of interrupting the insured to temporarily participate in the insurance when they are sick. Incentives to participate in insurance are widely used in commercial insurance. In fact, the medical insurance for mainland employees can no longer be paid after retirement after meeting a certain number of payment periods, which is a measure to encourage long-term continuous participation.
In connection with the measures to encourage participation in insurance, it is to gradually improve the fairness of residents' medical insurance from the financing system, and gradually transition from the fixed financing system to the benchmark rate system, so as to effectively reduce the payment burden of low-income groups. The establishment of a benchmark rate system is a policy that has been determined by the central government, and has been clearly stated in the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System".
In addition, it is very important to make full use of the national unified medical insurance information platform to check and clean up the information of the insured, the uninsured and their household registration, permanent residence, and insured place nationwide, form a list of available insured persons, and reasonably allocate the insurance information to the overall planning area according to the place of household registration, permanent residence, and insured place, so as to lay the foundation for improving the quality of insurance. （ZGYB-2023.03）
Original title: Improve the quality of residents' insurance and consolidate the foundation of the medical insurance system
Author | Wang Zhen, Institute of Economics, Chinese Academy of Social Sciences
Source | China Medical Insurance
Edit | Yang Zixuan, Zhang Wenqing
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