In recent months, there has been an increase in discussion about the decline in the number of urban and rural residents enrolled in medical insurance, which has aroused everyone's attention to topics such as the disparity in medical insurance treatment. Light Knowledge
On July 10, 2023, the National Health Insurance Administration released the "2022 National Statistical Communiqué on the Development of Medical Security", according to which by the end of 2022, 983.49 million people had participated in the basic medical insurance for urban and rural residents (hereinafter referred to as resident medical insurance), a decrease of 25.17 million compared with the end of 2021.
According to the Statistical Communiqué on the Development of the National Medical Security Undertaking over the years, the number of urban and rural residents participating in medical insurance has declined every year in recent years, but it is generally at the million level. At the end of 2022, that number increased to 25 million.
By the end of 2022, in China's dual medical insurance system, resident medical insurance (983.49 million) accounted for the majority of the total number of insured people - 27 times, corresponding to the total amount of medical insurance funds (income 10128.9 billion yuan) only employee medical insurance (income 207932.7 billion yuan).
The National Health Insurance Administration has said that residents' medical insurance** has been in a tight balance in recent years. From a national point of view, in the past five years, except for 2020, the remaining four years of the residents' medical insurance balance rate are less than 10%, and in the most tense 2021, the ** balance rate is 440%。
Health News Consulting has learned that since 2023, the medical insurance of residents in some areas has not been running well, and in some areas, there has been a phenomenon of "bottoming out" in the current period.
On the one hand, the decline in the number of insured people, and on the other hand, the tension of the balance rate - in order to solve the problem of the sustainability of residents' medical insurance, the academic community and the industry have put forward many explorations and propositions.
The number of residents has decreased, and the number of employees has increased".
Regarding the decline in the number of residents participating in medical insurance, the National Health Insurance Administration has specially explained that the basic number of insured people is still stable, and there are two main reasons for the decline.
The first is the change in the insurance structure, that is, some of the people who originally participated in the residents' medical insurance have switched to participating in the employee medical insurance, showing a trend of "fewer residents and more employees". In the past five years, the medical insurance for residents has decreased by 44.29 million, but the medical insurance for employees has increased by 45.62 million.
Second, the quality of insurance participation has been improved, and repeated insurance has been significantly reduced, coupled with the standardization of insurance statistics, etc., the cumulative reduction of more than 40 million data in several years. Especially after the launch of the national unified medical insurance information platform in 2022, it will be more convenient to seek medical treatment in other places, and the phenomenon of duplicate insurance data will be more obvious. Through the use of information technology to "deduplicate" the duplicate insurance situation, the number of insured people decreased by 17.27 million over the same period of the previous year, a year-on-year decrease of 13%。
After the exchange of medical insurance departments in many places, "Health News Consulting" learned the details behind these two reasons.
Now compared to the end of 2020, the number of people enrolled in our 'employee medical insurance' has increased by 500,000. And part of the increase in these people comes from resident medical insurance. Zhang Xiaoming (pseudonym), director of the Medical Insurance Bureau of City A, told "Health News Consulting" that correspondingly, in the past few years, the number of local residents participating in medical insurance has decreased by nearly 100,000.
Now it is very convenient for residents to convert into employee medical insurance. Zhang Xiaoming said that residents who do not have a work unit can participate in employee medical insurance through flexible employment.
In City A, those who participate in the employee medical insurance for the first time can enjoy the treatment the next month, while the original need to wait for 6 months. In addition, the interruption of payment shall not exceed 3 months, and there is no need to wait after the supplementary payment, and only if the payment is interrupted for more than 3 months, it will need to go through a waiting period of 3 months. And for those who are flexibly employed, they can also choose to pay only for health insurance.
Our flexible workers are not even covered by maternity insurance. If they don't want a personal medical insurance account and only participate in the overall planning, they only need to pay 5% of the payment base every month, which is about 200 yuan. ”
In City A, the number of people insured by residents' medical insurance showed a fluctuating downward trend. From the first to the fourth quarter of each year, the number of participants in the resident medical insurance will slowly climb, including the insured who make up the payment and the newborn. In the first quarter of the following year, there will be a significant decline in the number of insured people.
However, on the one hand, the number of employees participating in medical insurance has increased significantly, and on the other hand, the number of residents participating in medical insurance has decreased slightly, so that City A is not too worried about the decline in the number of insured people.
Zhang Xiaoming said that based on the construction of a unified national medical insurance information platform, in recent years, City A has also strengthened the "deduplication" work, and the province will send duplicate insurance data to various cities from time to time, requiring local screening and comparison. The amount of data received by city A each time is more or less, and these must be confirmed with the parties to choose to participate in medical insurance in **.
From a national point of view, this comparison is difficult. Because the local medical insurance information system not only covers the latest insurance data, but also records historical data. After years of precipitation, the formats and forms of these databases are very different, and it is inevitable that they will be a little complicated and confusing to sort them into the 'language' of the national unified medical insurance information platform. ”
In 2022, there will be about 7.65 million local residents enrolled in medical insurance, and "under the unified clean-up nationwide, a total of about 60,000 repeat insurers will be reduced," the person in charge of the city's medical insurance center told Health News Consulting.
An industry source also told "Health News Consulting" that due to the reduction of repeated insurance and the conversion of resident medical insurance to employee medical insurance, the birth rate is declining year by year, the lack of understanding of the protection role of basic medical insurance, and economic factors, the insured population has dropped by about 3-40 million, "the data should be real".
Shanghai Weiming Ningkang Technology Co., Ltd. has some business to help local medical insurance bureaus do resident medical insurance collection and publicity, and Yu Junqi, marketing director of the company's commercial insurance business, learned that the elimination of duplicate insured people is the main reason for the decline in the number of insured people in some places in 2022. "Some of them are paid by the family or the whole village is paid by the collective ** in the countryside, and I don't know if I work in the field. There are quite a few similar situations. ”
After eliminating duplicate insurance, the insured people seem to have become a stock resource that needs to be fought for in various places, and they need to be seized in advance. "Some local medical insurance bureaus joked that they would start collecting fees some time in advance next year to strive for a higher participation rate. Yu Junqi said.
What exactly is an individual's waiver?
In addition, among the 25.17 million insured people who will be reduced in 2022, there are also some cases of voluntary abandonment. This group of people may be the group that needs the most attention, and it is also the source of heated discussions about the decrease in the number of insured people.
The number of people insured by residents' medical insurance in City B this year has changed particularly significantly. In previous years, the number of people insured by residents' medical insurance decreased by about 10,000 per year, but this year it has decreased by tens of thousands. To this end, City B specially selected several typical villages to conduct grassroots research, and the results of the questionnaire survey showed that in these villages with a population of 2,000 to 3,000, an average of 6 to 7 people are unwilling to participate in insurance.
There are two main reasons for voluntary abandonment, one is that the individual payment (this article refers to the individual payment part of the basic medical insurance for urban and rural residents, the same below) is too high, which exceeds the ability of the masses;Second, the treatment is insufficient, and the masses cannot feel the benefits of participating in insurance. Moreover, the two major causes often work together and influence the decisions of the masses.
In the communication with all walks of life, "Health News Consulting" found that the people who abandoned the insurance showed two characteristics: "calculating the general ledger and marginal households". "Calculate the general ledger" means that when paying for residents' medical insurance, it is often based on the family unit, and when paying, the masses often multiply the individual payment part of 380 yuan by the number of family members. Although 380 yuan is not much, it is also a large expense for a family with a large population.
Most of the marginal households are families whose income has just crossed the line, and their conditions are slightly better, and they do not belong to the poor households with registered cards, and it is difficult to enjoy the insurance subsidies for special difficult groups, but it is also a lot of pressure for them to fully bear the personal part of residents' medical insurance.
Taking a western province as an example, in 2023, rural families with an annual per capita net income of 7,300 yuan or less can enjoy different levels of medical assistance. Suppose there is a family of six here, the two elderly people are old, the two children are still studying, and only the husband and wife have a stable income in the whole family, and the per capita annual income of the family is 7,500 yuan, which does not meet the medical assistance standard. Then the annual income of this family is 45,000 yuan, and the total cost of medical insurance for six residents is 2,280 yuan, and the premium burden exceeds 1 20 of the total income of this family.
Yu Junqi also feels that in recent years, more and more local medical insurance departments want to seek professional third-party services in the collection and payment of residents' medical insurance fees. "In recent years, the collection of medical insurance has become more and more difficult and stressful, and it is necessary to invest more manpower and material resources to increase publicity, so that the masses can understand the role of basic medical insurance and improve the willingness of residents to participate in insurance. ”
However, due to the limitation of staffing and the hope of citing some professional promotion and publicity, the medical insurance department will improve residents' understanding of basic medical insurance and willingness to participate in insurance through overall publicity planning, revitalization and utilization of government resources and government resources, building a publicity matrix such as building a first-class number, and easy-to-understand slogans. For example, through the village broadcast, explain to the villagers why they pay the premium**, and the community grid staff will come to explain the protection rights and interests of residents' medical insurance.
Zhu Minglai, director of the Center for Health Economics and Medical Security Research at Nankai University, pointed out that in the past, in many areas, the individual payment part was actually covered by the village collective. In recent years, the income of many village collectives has fluctuated and they have been forced to shrink their expenditures, "which means that farmers really need to pay for it themselves, and it takes a process to change mentality and behavior." ”
In fact, the fact that the individual pays the fee faster** is the most discussed issue.
In 2023, the individual payment will be 30 yuan higher than that in 2022**, although the proportion is not high, but the absolute value is not a lot. In the early years, individual contributions mostly increased by 10 yuan and 20 yuan per year – until 2019, individual contributions were only 250 yuan. In the last five years, the fee has risen by $30 or $40 – until $380 today. This may remind many people of 2003, when NCMS was first established, when individuals only had to pay 10 yuan.
Along with individual contributions, there is also a financial subsidy.
In 2023, the individual payment will be 380 yuan, and the financial subsidy will be 640 yuan. Local economic conditions are different, and the proportion of financial subsidies at all levels is different. As Jilin Province clarifies, in 2023, the fiscal sharing ratio of ** provinces, cities and counties will be 6:24:1.6, that is, the first financial 384 yuan, the provincial financial 1536 yuan, city and county finance 102$4. Among them, Yanbian enjoys the preferential policies for the development of the western region of the country, and the financial sharing ratio of provinces, cities and counties is 8:12:0.8。
Premiums are being paid year after year**, and there are still many residents in the co-ordination area who are facing the risk of bottoming out in the current period. This is due to the fact that medical costs are growing faster than premiums.
The growth rate of medical expenses in city A can reach about 24% when it is fast, and about 18% when it is slow, but the growth rate rarely exceeds 10%. Zhang Xiaoming revealed that in recent years, there has been a situation in which the current medical insurance of residents in City A has been bottomed out, but fortunately, there are still a lot of balances in history, so there will be no absolute deficit. In the province where City A is located, the number of months that the residents' medical insurance balance in various cities can support is about 6 months of the red line, and it can still be maintained.
In addition, the bottom of the residents' medical insurance will also lead to an increase in the part of individual contributions. "For example, the national standard rose by 30 yuan this year, but this place overdrafted 100 million yuan in residents' medical insurance last year, and 5 million people participated in residents' medical insurance, so it can only be considered to charge 20 yuan more per person, plus 30 yuan of the national standard, which eventually led to 50 yuan for individual payment in the current year." Zhang Xiaoming said that once there is a large-scale overdraft or bottoming, it will have to consider the ** individual payment standard.
In addition to ensuring safety, the excessive speed of individual payment is also due to the large gap between employee medical insurance and resident medical insurance. In the view of medical insurance researchers, China's dual medical insurance structure is relatively rare in the world, and there is a big difference in treatment between employee medical insurance and resident medical insurance - especially in outpatient clinics.
Generally speaking, the difference between the reimbursement ratio of employee medical insurance and resident medical insurance hospitalization treatment is between 10% and 20%, and the reimbursement ratio of both ** hospitals can basically reach about 70%.
In contrast, the outpatient reimbursement of the two is more like a difference between the haves and the haves. In many areas of the country, after the overall planning of outpatient services, the reimbursement of residents' medical insurance is limited to community health centers or the maximum payment limit is limited to four or five hundred yuan, while the medical insurance for employees can enjoy outpatient reimbursement at hospitals at all levels, and the maximum payment limit is also several times higher.
As a social insurance product, medical insurance adheres to the principle of corresponding rights and obligations, that is, how much you pay, you will enjoy as much treatment. According to the 2022 National Statistical Communiqué on the Development of Medical Security, it can be calculated that the average payment of the employee medical insurance is 5,737 yuan (including the individual payment and the unit payment part, including maternity insurance), while the average resident medical insurance is 1,030 yuan, the difference between the two is more than 5 times, but the difference in treatment is not so wide.
Not long ago, some netizens broke out that in an area where DIP reform was implemented, the point value of employee medical insurance was 98 yuan, and the resident medical insurance is only 76 yuan. Such a distinction may seem like a "differential treatment", but it is in fact in line with the principle of correspondence between rights and obligations.
On the one hand, there is a continuous increase in the cost of insurance, so that the willingness of the insured population to participate in the insurance has declined, and on the other hand, there is an obvious gap between the resident medical insurance and the employee medical insurance and the problem that the current period of the resident medical insurance is becoming more and more frequent, which has brought some challenges to the benign development of the residents' medical insurance.
Compulsory Insurance", is it feasible?
The decline in the number of insured people in the national medical insurance has actually become one of the key problems encountered in the development of China's basic medical insurance system.
In the view of Lai Shiqing, president of the Fujian Provincial Medical Security Research Institute, the fundamental way out to improve the enthusiasm of urban and rural residents to participate in insurance may lie in reforming the financing mechanism of basic medical insurance for urban and rural residents.
The current financing mechanism of China's resident medical insurance is still a "fixed payment" system, regardless of personal income, everyone pays the same amount. There is a huge gap in the perceived economic burden for groups with very different income levels, and such contribution standards will be unfriendly to those with lower incomes.
Lai Shiqing believes that only by raising funds according to a certain proportion of the per capita income of families can the burden of the groups with large income levels be equalized. "At the very least, the financing mechanism of medical insurance for urban and rural residents should be reformed first, and the quota should be changed to a certain proportion of the per capita income of the family, so as to reflect the real social fairness. ”
However, this ideal reform also faces many difficulties, the biggest problem is that China's investigation mechanism for residents' household assets has not yet been perfected, and it is not possible to achieve a very accurate thorough investigation. In addition, the income structure of farmers, the main group of residents' medical insurance, is highly diversified, and it is extremely arduous to do data statistics under such a huge population base.
There are many policy proposals to further increase the participation rate of medical insurance. It is advisable to make enrollment compulsory. Wang Chaoqun, an associate professor at the Department of Labor and Social Security at Central China Normal University, recently gave his answer in an article.
There are two main modes of compulsory insurance, one is to require all residents to participate in resident medical insurance in the form of legal provisions, just like employee medical insurance. Given that almost all households have bank accounts, there is a technical guarantee for the compulsion. The second is to cancel the individual payment of residents' medical insurance, which will be completely subsidized by **, and at the same time reduce some benefits (such as reducing outpatient treatment), increase the starting line of medical insurance, and focus on protecting serious diseases.
Both approaches are more radical. An industry person said that China's employee medical insurance is compulsory insurance under the "Social Insurance Law", and the resident medical insurance has always adhered to the principle of voluntariness.
Even if the law is amended to force residents to participate in insurance, it is necessary to consider some problems that may be encountered in the specific implementation. Does the method of compulsory insurance capture the core of the problem and can truly solve the problem of the current decline in the number of insured people?
Wang Chaoqun also put forward detailed suggestions for compulsory insurance: establish a differentiated payment policy. The core of this is to set premiums according to the same proportion of per capita disposable income of urban and rural residents, such as 1% or 2%.
The health insurance tax rate should be stable, but the tax base can fluctuate. For example, different regions have different levels of economic development, and different resident medical insurance payment bases can be set. Zhang Xiao, director of the Medical Insurance and Social Security Research Center of Southeast University, said that for example, individual contributions can be made with income levels. Design several different individual payment bases, and design different medical insurance benefits according to the principle of equal rights and obligations.
In the design of the resident medical insurance participation and security system, it may be possible to learn from the methods of commercial insurance, such as the adoption of a continuous insurance incentive mechanism, and the individual payment of individual insurance will be reduced or increased for the insured who has participated in the insurance for several years and the reimbursement amount is low.
This may be the direction of reform in the future. The above-mentioned industry insiders believe.
Zhang Xiao believes that the reduction in the number of insured people is only the appearance, and the core lies in accurately finding the people who abandon the insurance, improving the design of the medical insurance system, and truly protecting the people in need.
Health News Consulting noticed that there are actually some subsidy policies for residents' medical insurance payment in various places. For example, Anshan City, Liaoning Province, in 2024, the requirements for urban and rural residents to participate in medical insurance premiums propose, "For family members on the verge of subsistence allowance identified by the civil affairs department, a fixed amount of subsidy will be given according to 60% of their individual contributions to urban and rural residents' medical insurance, with adults only need to pay 164 yuan and minors only need to pay 108 yuan." ”
However, the existing subsidy and coverage still need to be further improved. Zhu Minglai said that in addition to the marginal households of the subsistence allowance, there are also some people who are "temporarily poor" due to serious illness expenses or natural disasters, all of which are within the scope of medical assistance that needs to be further expanded in the future.
Benefits or Insurance?Where is the medical insurance for residents going?
Since 2000, medical security systems have been established for urban non-employed residents and peasant groups, forming two medical insurance systems: basic medical insurance for urban residents (hereinafter referred to as "urban residential insurance") and new rural cooperative medical care (referred to as "new rural cooperative medical system").
However, these two independent medical insurance systems separate urban and rural groups based on the restrictions of urban and rural household registration, resulting in a gap between the medical insurance treatment of urban non-employed residents and rural groups, and a hidden challenge to fairness.
On January 12, 2016, the "Opinions on the Integration of the Basic Medical Insurance System for Urban and Rural Residents" (hereinafter referred to as the "Opinions") was issued, requiring the integration of "urban residential insurance" and "new rural cooperative medical system" to establish a medical insurance system for urban and rural residents.
The two systems have been operating independently of each other for many years, and it is not easy to suddenly require them to be merged into one, so the above-mentioned "Opinions" do not give a specific time limit.
On the contrary, in 2018, the National Health Insurance Administration, the Ministry of Finance and other departments issued the "Notice on Doing a Good Job in Basic Medical Insurance for Urban and Rural Residents in 2018", which clearly mentioned that in 2019, a unified medical insurance system for urban and rural residents nationwide will be fully launched.
According to the system design of "resident medical insurance", its financing is mainly based on the first, supplemented by the individual, and the improvement of the financing level is restricted by the personal economic affordability.
For example, in 2020, the individual payment of medical insurance for urban and rural residents nationwide will be 302.9 billion yuan, and the financial subsidy will be 5,936200 million yuan, with a total income of 9114500 million yuan, with a total expenditure of 8165100 million yuan, the proportion of financial subsidies in total revenue and total expenditure reached 651% and 727%。
Li Yunting and others from the School of Public Administration of South China Agricultural University pointed out that the development of "resident medical insurance" has gradually emerged a trend of pan-welfare, and with the aging of the population and the increase of the burden of chronic diseases, as well as the growing demand for medical services by residents, the sustainability of medical insurance for urban and rural residents is highlighted.
Compared with the financing model of "employee medical insurance", which is borne by individual employees and enterprises, the identity of "resident medical insurance", which plays the main role in financing, seems to be somewhat ambiguous - especially when the self-payment part of some poor people is also paid by **, "resident medical insurance" seems to show a more similar characteristics of social welfare.
In fact, as for how to treat "resident medical insurance", the consensus of the academic community still seems to be that it hopes that it will not continue to slide to the end of "social welfare" in terms of social cognition and practical operation.
However, there is still a debate in the academic community about how different types of residents in the "resident medical insurance" should be protected, and how much responsibility should be borne by different levels of residents. More importantly, the answers to the latter series of questions are actually closely related to the previous consensus.
* The responsibility to the poor is eternal", Zhu Minglai told "Jianwen Consulting", referring to the financing model of employee medical insurance, urban and rural residents should pay "resident medical insurance" should be a basic obligation.
Zhu Minglai believes that the economic situation of some groups can be taken into account, and these groups can be exempted from individual contributions by expanding the scope of assistance, but it is also necessary to explain the insurance nature of "resident medical insurance" to this part of the population.
Zhang Xiao believes that at present, residents' medical insurance is carried out in the form of insurance, which is promoted and has a welfare guarantee. "It's not impossible to be completely subsidized by **, but the pace of reform is too large and a transition is needed. ”
Yu Baorong, a professor at the School of Insurance of the University of International Economics, said that the full financial subsidy is the national health service model, and China belongs to such a model during the planned economy periodLater, the national health service model could not continue to operate, let alone adapt to the establishment of a market economy system. Since the reform of employee insurance in 1998, the social insurance model of individual participation and payment has been gradually established, which was extended to the rural population and urban residents in 2003 and 2007 respectively, and in 2011, the full coverage of social medical insurance in the population (covering more than 95% of the population) was realized.
If the full financial subsidy is implemented, it is actually back to the national health service model, deviating from the positioning of the current social medical insurance model, and improving this problem should be committed to "improving the efficiency of the use of medical insurance, improving the sense of access of the vast number of insured people, so that they have the motivation to continue to participate in insurance." Yu Baorong said.
Resident medical insurance is social insurance, not social welfare. Social insurance requires equal rights and obligations, that is, you must pay a fee, even if you only pay a dollar, it means that you have paid the corresponding obligations. Lai Shiqing said.