More and more people are giving up health insurance? The state struck

China News Weekly

2024-08-08 10:45Published on the official account of China News Weekly in Beijing

"Those who have participated in the resident medical insurance for 4 consecutive years can enjoy the incentive of continuous insurance for every 1 year after that", "For those who have zero reimbursement for the resident medical insurance in the current year, the maximum payment limit of the critical illness insurance can be increased in the following year", "If the payment has been interrupted for 4 consecutive years or more, the waiting period shall be at least 6 months".

On August 1, the General Office of the State Council issued the "Guiding Opinions on Improving the Long-term Mechanism for Basic Medical Insurance" (hereinafter referred to as the "Guiding Opinions"). Among them, the "Guiding Opinions" are particularly concerned about the incentive mechanism for those who are continuously insured by resident medical insurance and those who have zero reimbursement, and the restraint mechanism for those who have not participated in the insurance or have not been continuously insured during the centralized enrollment period of resident medical insurance.

Li Yaqing, deputy dean of the School of Finance of Guangdong University of Finance and Economics, has been engaged in research on medical security and health economy for many years, and she told China News Weekly that this is the first time that the mainland has specifically designed the incentive mechanism for basic medical insurance from the national level, indicating that the issue of basic medical insurance has been highly valued by the central government in recent years.

Cai Haiqing, former director of the treatment and security department of the Jiangxi Provincial Medical Insurance Bureau, told China News Weekly that in recent years, the basic medical insurance participation rate in the mainland has remained stable at more than 95%, but in the context of deepening urbanization and frequent cross-regional population flow, the phenomenon of floating employment population breaking insurance or even not participating in insurance still exists.

On October 25, 2023, Luohe Yuanhui District, Henan Province provided basic medical insurance services for urban and rural residents for new employment forms. Photo/Visual China

The number of insured people is decreasing year by year

At the end of 2023, Li Hong from Hukou County, Jiujiang City, Jiangxi Province, received a reminder from the village director that he had paid the medical insurance for urban and rural residents to his family according to the standard of 380 yuan per person.

Li Hong told China News Weekly that although he would participate in the insurance on time every year, he did not understand the role that resident medical insurance could play, and he just wanted to feel at ease. In the vicinity of Li Hong, more and more people have chosen to abandon insurance in recent years.

Since 2019, the number of people enrolled in medical insurance for urban and rural residents has begun to decline year by year.

According to the 2023 National Statistical Communiqué on the Development of Medical Security released by the National Health Insurance Administration on July 25, 2024, by the end of 2023, the number of urban and rural residents insured by medical insurance was 962.94 million. Compared with 983.49 million in 2022, the number of urban and rural residents participating in medical insurance in 2023 will decrease by 20.55 million.

Rural residents in many places pointed out to China News Weekly that the year-on-year increase in insurance costs is the main factor affecting their willingness to participate in insurance.

"It's going up all the time, it's a bit expensive." Guo Zifeng, from Shanwangzhuang Town, Qinyang City, Henan Province, said that last year, a family of six spent a total of 2,280 yuan on medical insurance for urban and rural residents, which made him can't help but calculate an account: if he didn't get sick, the money would have been spent in vain.

Many of them are young people who give up their participation. Zhu Minglai, director of the Health Economics and Medical Security Research Center of Nankai University and director of the Institute of Pension and Health Security of the School of Finance, found in the survey that some rural residents think that paying medical insurance for urban and rural residents has become a burden, especially young people, with a certain fluke mentality, thinking that they will not get sick, and participating in insurance is equivalent to paying money in vain.

At the regular policy briefing of the State Council held on August 1, Huang Huabo, deputy director of the National Health Insurance Administration, also pointed out that the most reported problem in the process of research is that many people with good health, especially young people, think that there is no need for them to participate in basic medical insurance.

"In recent years, the pressure on universal insurance is still relatively large, so the national level has been trying to find ways to improve relevant policies." Zhu Minglai believes that the "Guiding Opinions" just issued are mainly from the incentive mechanism and restraint mechanism to alleviate the pressure of promoting universal insurance.

After the issuance of the "Guiding Opinions", the National Health Insurance Administration issued a policy interpretation article on the "Guiding Opinions", which pointed out that compared with the employee medical insurance, the residents' medical insurance is not compulsory, and the incentive mechanism is relatively lacking since its establishment, and there is a lack of incentive policies for the masses who have continuously participated in the insurance, have not been sick, and have not been reimbursed by medical insurance. "This document proposes to establish an incentive policy for residents' medical insurance, implement classified policies, encourage self-health management of insured personnel, and encourage continuous insurance."

Specifically, in terms of the incentive mechanism for continuous insurance, the "Guiding Opinions" proposes that for those who have participated in the resident medical insurance for 4 consecutive years, the maximum payment limit of serious illness insurance can be increased by no less than 1,000 yuan per year for each consecutive year of insurance. Fan Weidong, director of the Department of Treatment and Security of the National Health Insurance Administration, introduced at the regular policy briefing of the State Council held on August 1 that if the insurance is interrupted, the number of years accumulated in the previous continuous insurance will be automatically cleared, and the number of years will need to be recalculated when re-enrolled. The reward amount accumulated in the previous period will continue to be retained.

In terms of the incentive mechanism of zero reimbursement of the fund, the "Guiding Opinions" proposes that the maximum payment limit of serious illness insurance can be increased in the following year for those who participate in the resident medical insurance with zero reimbursement by the fund. After the resident is reimbursed for serious illness and the reward amount is used, the zero reimbursement incentive amount accumulated in the previous period will be cleared.

It is worth noting that, in principle, the continuous insurance incentive and the zero reimbursement incentive of the fund shall not be less than 1,000 yuan each time, and the cumulative total increase shall not exceed 20% of the original cap line of critical illness insurance in the overall planning area. In this regard, Fan Weidong said, for example: "If the maximum payment limit of critical illness insurance for urban and rural residents in a region is 400,000 yuan, then the incentive mechanism can be increased by 80,000 yuan after the 'reward', that is, the maximum payment limit of critical illness insurance is 480,000 yuan." ”

Li Yaqing said that the fund's zero reimbursement incentive mechanism in a sense borrowed from the incentive policy of commercial insurance, "car insurance is the most typical, the first round of car insurance reform launched in 2016 adopted the principle of 'rewarding the good and punishing the inferior', that is, the fewer times the insured vehicle is insured in the insurance year, the cheaper the premium for the next year."

In addition to incentives, there are also constraints. Fan Weidong explained that the "Guiding Opinions" set up "two waiting periods", namely a fixed waiting period and a change waiting period. The "Guiding Opinions" make it clear that from 2025, except for special groups such as newborns, for those who have not participated in the centralized insurance period of resident medical insurance or have not been continuously insured, a fixed waiting period of 3 months will be set after enrollment, of which those who have not been continuously insured will be given a change waiting period of 1 month on the basis of the fixed waiting period of 3 months for every additional year of insurance.

"It should be noted that if the payment has been interrupted for 4 years or more, the waiting period for changes after repair shall not be less than 3 months, and the original fixed waiting period of 3 months will still need to wait for at least 6 months. During the waiting period, medical insurance reimbursement is not available. Fan Weidong said that in order to safeguard the rights and interests of personal medical insurance, it is recommended that everyone actively participate in insurance and pay on time.

Wang Chaoqun, an associate professor at the Department of Labor and Social Security at Central China Normal University, told China News Weekly that the Guiding Opinions' uniform provisions on the waiting period are a major highlight, because the current regulations on the waiting period vary greatly from place to place, with six months in some places and two months in others.

In Cai Haiqing's view, previously, the annual payment of residents' medical insurance is more dependent on the propaganda of local grassroots organizations, if there is a lack of incentive and restraint mechanism, the work of the grassroots is actually lacking in the grip, the current resident medical insurance has an incentive and restraint mechanism, and the work of the grassroots has a grasp.

Do incentives and constraints work?

Before the issuance of the "Guiding Opinions", local governments have begun to explore the incentive and restraint mechanism for continuous participation in medical insurance for urban and rural residents.

Bazhong City, Sichuan Province, has implemented an incentive policy for urban and rural residents to continuously participate in insurance since 2021. If the local insured person has been insured for a certain number of consecutive years and has not been reimbursed for the medical expenses in the year of hospitalization, the reimbursement ratio of basic medical insurance within the natural year of the first reimbursement of inpatient medical expenses shall be increased: 1% for the fourth consecutive year of insurance, 2% for the fifth consecutive year of insurance, and 3% for the sixth consecutive year or more.

Tianjin will start to explore the incentive mechanism for continuous insurance participation from 2023: for insured persons who continue to participate in resident medical insurance (excluding those who make up payments), the maximum payment limit for outpatient (emergency) medical treatment will be increased by 1,000 yuan to 5,000 yuan, and the payment ratio will be implemented in accordance with the current policy.

However, the previous incentives for continuous insurance participation were mainly to increase the reimbursement ratio for hospitalization and increase the maximum payment limit for outpatient (emergency) treatment, which is significantly different from the incentive for the long-term mechanism of basic medical insurance participation - the latter is to increase the maximum payment limit for serious illness insurance.

Why does the long-term mechanism of basic medical insurance include an increase in the maximum payment limit of critical illness insurance as an incentive? Zhu Minglai pointed out that the important principle of medical insurance for urban and rural residents is to protect against serious illnesses and prevent poverty due to illness and return to poverty due to illness.

The other is to maintain the sustainability of the medical insurance fund. "Taking the reimbursement ratio of hospitalization as an example, the reimbursement ratio within the scope of medical insurance policies for urban and rural residents is not low, about 90% for first-level medical institutions, about 80% for second-level medical institutions, and about 60% for third-level medical institutions, and the space for continuing to increase the reimbursement ratio is very limited." Cai Haiqing said that if the increase in the proportion of hospitalization reimbursement is used as an incentive for urban and rural residents to participate in the medical insurance continuously, it may lead to the inversion of the payment and treatment of medical insurance for employees, which will induce employees to participate in medical insurance for urban and rural residents, which is not conducive to the sustainable development of the basic medical insurance system for employees.

Cai Haiqing pointed out that one of the purposes of the introduction of the long-term mechanism of basic medical insurance is to attract a small number of people who are not insured to participate in the insurance, if it is only to attract a very small number of people to participate in the insurance, and generally improve the basic medical insurance treatment of most people, it is not appropriate from the perspective of the efficiency of the use of the fund, and will further increase the payment pressure of the medical insurance fund.

What role can the incentive and restraint mechanism of continuous insurance participation and zero reimbursement of funds play in reversing the decline in the number of urban and rural residents?

Wang Chaoqun believes that the long-term mechanism of basic medical insurance to increase the maximum payment limit of critical illness insurance as an incentive means for young people who are not willing to participate in insurance, the effect may not be obvious, "young people may think that they will not get sick, will not be hospitalized, and will not need serious illness insurance."

"China News Weekly" found after searching on social platforms that netizens seem to be more concerned about the restraint mechanism of continuous insurance, and many people asked: How long is the waiting period for the treatment of re-insurance after a few years of payment?

Cai Haiqing believes that the restraint mechanism may have a greater impact on young people, "to let young people know that there is a waiting period for treatment when they participate in insurance after the insurance is broken, and they can enjoy the treatment as soon as they get sick, which is also the protection of all insured people."

In Zhu Ming's view, the introduction of a long-term mechanism for basic medical insurance will play a positive role in the stability of the number of insured people, at least in the short term, the number of insured people will not decline significantly. Cai Haiqing believes that after the introduction of the long-term mechanism of basic medical insurance, there may not be earth-shaking changes immediately and the idea of uninsured people will be reversed immediately, but in the process of implementing the policy, there will be changes slowly.

How fundamentally

Boost the motivation of the insured?

In fact, to enhance the enthusiasm of the insured, it is not only necessary to rely on the incentive and restraint mechanism. In the long-term mechanism of basic medical insurance participation, the relaxation of restrictions on household registration is also an important highlight.

The "Guiding Opinions" pointed out that the household registration restrictions on participating in basic medical insurance in the place of permanent residence and employment will be further relaxed. Megacities and megacities should earnestly implement the policy of holding residence permits to participate in insurance, and promote primary and secondary school students and preschool children with household registration in other places of residence to participate in resident medical insurance; Megacities should abolish the household registration restrictions on flexible employees, migrant workers, and new forms of employment to participate in basic medical insurance at the place of employment, and do a good job in participating in employee medical insurance at the place of employment; Encourage college students to participate in resident medical insurance in their place of residence.

Huang Huabo introduced that the vast majority of cities have canceled the household registration restrictions for insurance, and the masses can participate in the insurance in their permanent residence after holding a residence permit or meeting a certain number of years. He said that the abolition of household registration restrictions will further help new urbanization achieve new results.

According to the statistics of the Ministry of Human Resources and Social Security, the number of flexible employees in mainland China has reached about 200 million. And the problem of insurance participation of this large group has always been more prominent.

Wang Chaoqun pointed out in the article "Adapting to Population Flow: Urban and Rural Residents' Medical Insurance from the Place of Household Registration to the Place of Permanent Residence" that among the citizens who have not participated in the basic medical insurance, the floating population is the main uninsured group.

"For flexible employees, migrant workers, and new forms of employment, a more prominent household registration restriction is the household registration restriction for participating in urban and rural residents' medical insurance." Li Yaqing said that many new forms of employment do not sign formal labor contracts, and therefore do not have units to share the contributions, so the burden of participating in the medical insurance for employees is heavier, while the burden of participating in the medical insurance for urban and rural residents is much lighter.

However, for a long time, it was not easy for migrants to participate in medical insurance for urban and rural residents in their usual place of residence. Wang Chaoqun found in his research that under the full payment system and the residence permit system, the proportion of floating population participating in the medical insurance for urban and rural residents in their permanent residence is not high, but this is not the root cause of the discouragement of the floating population from participating in the medical insurance for urban and rural residents in their permanent residence.

He believes that the fundamental reason is that the design of the medical insurance system for employees and urban and rural residents is completely different, the payment of medical insurance for employees is mainly paid by enterprises and individuals, and governments at all levels do not provide financial support in the payment stage, and the participation of the floating population in the medical insurance for employees in the place of permanent residence will not bring financial burden to the government of the place of permanent residence. The medical insurance payment for urban and rural residents is mainly financed by governments at all levels, supplemented by individual payments, and the financial subsidies of the central government to the provincial level, provincial to municipal level and municipal to county level basically follow the principle of "supplementing the poor", so the more developed the area, the less financial subsidies for urban and rural residents from the higher levels, and the heavier the financial subsidy burden to the government of the place of permanent residence. This means that in order to reduce the financial subsidy burden on the floating population to participate in the local urban and rural residents' medical insurance, the local government will often prevent the floating population from participating in the local urban and rural residents' medical insurance through household registration restrictions, full payment systems and residence permit systems.

"Judging from the "Guiding Opinions", there is no problem for flexible employees, migrant workers, and new forms of employment to participate in employee medical insurance, but the difficulty is still in participating in resident medical insurance." Wang Chaoqun said that the sharing mechanism of financial subsidies from the central and local governments is the deep-seated reason that affects the floating population to participate in the medical insurance for urban and rural residents in their permanent places of residence, and this needs to be solved by adopting methods such as "money goes with the people" under the current central and local financial sharing system.

However, in the opinion of experts, it is already a great progress to fully relax the household registration restrictions for this group to participate in employee medical insurance in the place of employment.

The "Guiding Opinions" on "improving service quality and strengthening the sense of insurance" has also attracted Li Yaqing's attention, which she believes is a highlight of the document.

"This is the first time that the term 'feeling to be insured' has been proposed." Li Yaqing believes that in the future, the state will pay more attention to the subjective psychological feelings of most insured personnel, emphasizing the sense of experience and gain of the insured personnel.

A number of interviewees pointed out to China News Weekly that the experience of using medical insurance for urban and rural residents is not good, because the reimbursement scope is relatively small, the reimbursement for outpatient clinics is not strong, and the reimbursement rate for cross-provincial medical treatment is low. Li Hong said that a few years ago, when his family was sick, he spent a total of about 100,000 yuan, because he made a special trip to Shanghai for treatment, and the reimbursement was about 10%, which is not a high proportion. "If you treat the disease directly in the county, the reimbursement ratio will be higher, but who dares to treat a serious illness in the county?"

Li Yaqing believes that "strengthening the sense of insurance" is aimed at the problem that some people do not participate in insurance because of poor experience in recent years.

Can an insured person have easy access to basic medical services when he or she is sick? Is it easy and fast to get reimbursement for medical expenses? Will the needy people give up on seeking medical care because of the heavy burden of out-of-pocket expenses? Can participants who have never applied for reimbursement of expenses receive tangible benefits in terms of health education, disease prevention, renewal benefits, etc.? These problems will directly affect the sense of achievement of the insured.

In the process of medical treatment and medical insurance reimbursement, the connection between different protection items such as basic medical insurance, serious illness insurance, and medical assistance is not good enough, and various medical insurance and medical service links are not in place, which will also greatly affect the insurance experience of the insured. Li Yaqing pointed out that it is not enough to have a good system, but also to make a good system as much as possible to maximize the operational efficiency and service efficiency, so that the insured people feel that "it is beneficial to participate in insurance".

As for how to effectively improve the medical experience, the "Guiding Opinions" put forward a number of measures, including strengthening the management of designated medical institutions and enhancing the accessibility of medical services; Actively create conditions to include voluntary applications and eligible village clinics into the scope of medical insurance settlement, and promote real-time settlement; Promote the rational allocation of national centralized procurement drugs in village clinics, facilitate rural residents to seek medical treatment nearby, and better promote hierarchical diagnosis and treatment; Strengthen the supervision of designated medical institutions, increase the rectification of fraud and insurance fraud and other violations of laws and regulations, make good use of medical insurance funds, and reduce the burden of medical expenses on the masses.

It is worth noting that the "Guiding Opinions" also proposes to promote the linkage of residents' medical insurance contributions with the level of economic and social development and the per capita disposable income of residents, and maintain a reasonable proportion structure of financial subsidies and individual contributions.

In fact, a number of rural respondents previously told China News Weekly that the individual payment standards for medical insurance for urban and rural residents seem to have risen too fast. In 2006, the individual contribution standard for NCMS was 10 yuan per person per year. In 2023, the integrated individual payment standard for medical insurance for urban and rural residents will be 380 yuan per person per year.

"If the growth of per capita disposable income in the past 20 years is compared with the growth of medical insurance payment standards for urban and rural residents, it will be found that it is actually an equal proportion of growth, so the growth of payment standards is relatively reasonable." Zhu Ming said that it is now clearly proposed to promote the promotion of residents' medical insurance payment and the level of economic and social development and the per capita disposable income of residents, which means that if the payment standard continues to increase next year, there is a clear basis, "If there is an extreme situation, assuming that the growth of per capita disposable income next year is zero, then the payment standard next year can at least not rise again, which is equivalent to giving a more open and transparent mechanism."

In recent years, many social security experts have been participating in the discussion of the direction of the reform of the basic medical insurance participation mechanism. Some experts suggested changing the fixed amount of medical insurance financing for urban and rural residents to a rate system, and some experts suggested improving the actuarial mechanism for financing adjustment.

Li Yaqing pointed out that the medical insurance funds for urban and rural residents are fixed financing, residents pay according to the capitation quota, and the government subsidizes the capitation quota, "which is relatively unfair", because compared with high-income groups, the fixed amount of individual contributions will be a greater burden on low-income groups.

She believes that in the future, the issue of financing equity needs to be further addressed in order to increase the enthusiasm of the insured to a greater extent.

Cai Haiqing believes that this statement is actually a foreshadowing for future changes in financing policies, "for example, the subsidy for residents' medical insurance payment is linked to the local per capita disposable income, and some places have implemented different payment standards according to different age groups."

Although it is still unknown what will happen to the future financing policy of residents' medical insurance, it is undeniable that this statement has paved the way for future policy design.

(Li Hong and Guo Zifeng are pseudonyms in the article, and intern Li Hao also contributed to this article)

Published in the 1152nd issue of China News Weekly magazine on August 12, 2024

Magazine title: The first long-term mechanism for basic medical insurance participation was announced

Reporter: Zhang Xinyu

Editor: Xu Tian

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