At present, medical insurance is mainly composed of three insurance systems: free medical care, labor insurance and social medical insurance.
1. medical care at public expense
the system of medical care at public expense was established according to the relevant laws and regulations of the state, and has been implemented throughout the country since 1952. Employees of state organs, institutions and social organizations and students in colleges and universities enjoy free medical treatment. The outpatient and inpatient medical expenses of those who enjoy the medical treatment at public expense shall be paid by the medical expenses at public expense, except for the part that the individual is responsible for according to the regulations. The funds for free medical care come from the government budget.
2. Labor insurance medical treatment
The labor insurance medical treatment system was established according to the relevant national laws and regulations, and has been implemented throughout the country since 1951. Employees of state-owned enterprises enjoy labor insurance and medical treatment. The outpatient and inpatient medical expenses of the personnel who enjoy the labor insurance medical treatment shall be paid by the labor insurance medical funds, except for the part that the individual is responsible for according to the regulations. Labor insurance medical expenses mainly come from the welfare fund of enterprises.
3. Social medical insurance
The social medical insurance system was established on the basis of reforming the free medical care and labor insurance medical care system. From 1996 to 1997, hospitalization medical insurance and outpatient emergency medical insurance were implemented respectively. By the end of 1997, there were 21, enterprises and institutions participating in social medical insurance, and the number of insured employees was 4.89 million, including 1.57 million retirees.
4. development trend
the development trend of medical insurance is to establish a medical security system covering all urban workers with social medical insurance for employees as the main body and supplementary insurance and medical relief. Form a new pattern of medical security that is compatible with the socialist market economic system, with diversified security subjects (state, society, units and individuals), multi-channel funding sources and multi-level security methods.
in p>1995, the national medical insurance system reform was first piloted in Zhenjiang and Jiujiang. In 1998, the State Council issued the Decision on Establishing the Basic Medical Insurance System for Urban Workers (Guo Fa [1998] No.44), and the reform of the medical insurance system began to be vigorously carried out nationwide.
the main task of the reform is to establish the basic medical insurance system for urban workers, that is, to adapt to the socialist market economic system and establish a social medical insurance system to ensure the basic medical needs of employees according to the affordability of finance, enterprises and individuals.
The principles of reform are: the level of basic medical insurance should be adapted to the development level of productive forces in the primary stage of socialism; All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management; The basic medical insurance premium shall be borne by both the employer and the employee; The basic medical insurance combines social pooling with individual accounts.
the coverage of the basic medical insurance system for urban workers is: all employers in cities and towns, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.), organs, institutions, social organizations, private non-enterprise units and their employees.
to meet the needs of social and economic development, in order to bring more people into the basic medical insurance system, the Ministry of Labor and Social Security issued "Guiding Opinions on Flexible Employment of Urban Employees to Participate in Medical Insurance" in May 23, and issued "Opinions on Promoting Employees of Mixed Ownership Enterprises and Non-public Economic Organizations to Participate in Medical Insurance" in May this year, bringing flexible employees, employees of mixed ownership enterprises and non-public economic organizations and rural migrant workers into medical insurance coverage.
It has been more than 1 years since 1994, when China started the pilot reform of medical security system in Zhenjiang City of Jiangsu Province and Jiujiang City of Jiangxi Province. It has been five years since the nationwide medical insurance reform was launched. China's medical reform has made important progress, initially establishing a new medical security system framework and establishing a new medical insurance system model. However, not long ago, the research report "Evaluation and Suggestions on the Medical and Health System Reform in China" by the Social Development Research Department of the State Council Development Research Center put forward the view that "the medical reform in China is basically unsuccessful", including the reform of the medical insurance system. This makes people inside and outside the industry have to re-examine the medical security system reform that has been carried out for so many years.
The puzzling reform of the medical insurance system
The research report makes sense. The mainstream public opinion has been warning everyone that these are "problems in progress" and should be solved by "further deepening reform". However, the feeling of the people is that the deeper the "reform", the more problems it will bring.
As a result, some people inside and outside the industry have recently turned their attention to China's medical system in the planned economy era. Some people expressed the feeling that at that time, China was so poor, and there were "three major medical security systems", namely, public medical care in institutions, labor insurance medical care in enterprises and cooperative medical care in rural areas. Now, it has been 27 years since the reform and opening up, and China's economy has developed rapidly. Compared with the planned economy era, the comprehensive national strength is incomparable, but why do the broad masses of workers and farmers look down on illness instead? Recently, some experts have summed up the "three basic experiences" in the development of medical and health services in China in the planned economy era: first, the layout and service objectives of the medical and health service system are reasonable; Secondly, the intervention focus of health work is reasonable; Third, a wide coverage of medical expenses guarantee mechanism has been formed. At the same time, it is concluded that the decisive factor for the success of medical and health undertakings in the planned economy period is that the government has played a leading role.
Some experts have also analyzed and evaluated the current medical and health system in China: since the reform and opening up, the medical and health system in China has undergone great changes and made progress in some aspects, but the exposed problems are more serious. The reason is based on two points: the basic trend of medical and health system reform is commercialization and marketization; The negative consequences are the decline of fairness of medical services and the low macro-efficiency of health investment.
Of course, some people hold different opinions. They think that the medical security in the planned economy era is "low-level" and "not worth mentioning". Modern medical equipment marked by CT and magnetic resonance imaging can't be compared with the luxury of today's big hospitals, such as numerous imported drugs. However, one thing can arouse people's awareness: what the people at the bottom are concerned about is not whether the hospital is luxurious, whether the equipment is advanced, and whether the medicine is imported, but whether there is a minimum health guarantee.
On December 2, 24, the Ministry of Health announced the Main Results of the Third National Health Service Survey. The survey results show that the growth rate of medical service expenses in China has exceeded the growth of per capita income, and medical and health expenditure has become the third largest consumption after family food and education expenditure. This survey found that 48.9% of the residents in China did not go to see a doctor because of economic difficulties and inconvenience in seeking medical treatment, and 29.6% of them were hospitalized after being diagnosed by a doctor.
what's the problem?
since the 199s, with the transition from China's planned economy system to the socialist market economy system, the inherent defects of the original medical insurance system are increasingly exposed: First, the range of people enjoying medical insurance is narrow. The traditional medical insurance system is only applicable to the staff of institutions, state-owned enterprises and some collective enterprises. Other workers, especially those in non-public enterprises, such as employees of private enterprises, employees of foreign enterprises and self-employed workers and their employees, have no basic medical insurance. Second, the medical expenses are completely covered by the state and enterprises, and the increasing medical expenses have increased the burden on enterprises and the state. Third, there is a lack of scientific and effective methods for the management of medical insurance expenses, resulting in serious waste of medical expenses. These are the "three major motivations" for the reform of China's medical security system.
Some experts have commented that China's medical insurance reform has basically realized the system transition and mechanism transformation. Systematically, it has completed the transition from the original welfare-oriented medical care at public expense and labor insurance to social medical insurance, and implemented new operating mechanisms such as the combination of social pooling and personal accounts, cost sharing, medical service competition, cost control and socialized management. At the institutional level, a basic framework of multi-level medical security system with basic medical insurance as the main body, various forms of supplementary medical insurance as the supplement and social assistance as the bottom line has been initially formed. Unexpectedly, however, after five years (1 years from the pilot project of "Two Rivers"), the reform of medical insurance system, which tries to get rid of the disadvantages of the original medical insurance system, has even appeared more problems:
First, the coverage of social medical insurance is narrow. This is one of the drawbacks to be eliminated in the reform, but in terms of the total amount, the current medical insurance coverage is only equivalent to 42% of the urban employed population, which is the lowest participation rate among the three major insurances. Structurally, the basic medical insurance covers employees of state-owned enterprises and some institutions, including employees of some collective enterprises. A large number of other types of workers, informal employees, urban vulnerable groups (low-income or laid-off, unemployed workers, disabled and widowed old people, migrant workers entering the city, "within the system" who retired earlier, etc.) and the broad masses of farmers have not been covered by the system.
Secondly, a multi-level medical security system has not really formed. First, the problem of medical security for rural population has not been fundamentally solved; Second, the operation of all levels in the existing system has not been put on the right track, and the results are not remarkable. Supplementary medical insurance for employees, commercial medical insurance, social assistance medical care, rural cooperative medical care system and community medical services have not been effectively implemented.
thirdly, the reform of medical and health system is not compatible with the reform of medical insurance system. Under the planned economy system, the basic funds of hospitals come from financial or enterprise (unit) grants, and other daily costs of hospitals are compensated by medical service charges. Therefore, hospitals have little motivation to pursue their own interests. With the establishment of the market economy system, the government's compensation policy for state-owned hospitals has changed, and the scale of compensation has gradually decreased. Hospitals focus on operating income, and the pursuit of economic benefits has become the operating motivation of hospitals. For the survival and development of hospitals, the government allows hospitals to get a certain price difference in drugs as compensation. This is the origin of "taking medicine to support doctors" and one of the important reasons for "expensive medical treatment". In addition, the false high pricing of drugs in the field of drug production and circulation has also seriously affected the interests of consumers. The compensation mechanism of "supporting doctors with medicine" in hospitals and the disadvantages of drug production and circulation system have seriously impacted the basic medical insurance system. The basic medical insurance fund not only faces the cost pressure brought by natural reasons such as the aging population, the change of disease spectrum and the improvement of medical technology, but also bears the test brought by the reform of medical and health system. In many areas, the situation that medical pooling funds can't make ends meet has appeared to varying degrees.
fourthly, the government has not invested enough in medical resources. Since the reform, the proportion of funds invested by the government in medical and health undertakings has been decreasing year by year, while personal expenditure has increased rapidly. The lack of national medical and health funds is one of the reasons for the shortage of medical insurance funds on the macro level. At present, the financing ratio of basic medical insurance in China is generally: the unit pays about 6% of the total wage income of employees, and the individual pays about 2% of his own wage income (the specific payment ratio varies from province to province). Because there is no accumulation and precipitation of medical funds, for the "old people" who have retired when the new system is implemented, their medical insurance funds constitute an "invisible debt". This debt depends on the contributions of employees to pay for the medical expenses of themselves and the retired elderly, which will definitely increase the pressure on the medical insurance fund. As a result, there is a shortage of medical insurance funds, and every employee has to bear more and more medical insurance responsibilities. The limitation of medical insurance fund raising and the infinity of medical demand are a pair of contradictions in the operation of medical insurance. This contradiction is more prominent under the background of insufficient investment in medical and health undertakings in China today.
what's the way forward?
Looking back at history, China's public health and medical security undertakings had a glorious period. In those years, the system led by the state (government) was fully implemented. From urban to rural areas, an advanced medical system was established in the world at that time. Especially at that time, China's rural medical security model was widely recognized by all countries in the world in solving the practical problems of farmers. From the historical experience, can we think that in the reform of the medical security system, it may be a practical way for the future medical security system reform to learn from the reasonable components of our traditional system and combine the social conditions in the transitional period to create a new social medical security system led by the government and mobilize the positive factors of all sectors of society.
First, the general idea
The general idea is to establish a multi-level medical security system. Although due to the constraints of socio-economic development strategy and productivity level, China's medical security can not be a unified system for the whole people at present, it is still possible to establish a medical security system suitable for different groups.
The basic medical insurance system for employees is a social insurance system enforced by the state, and its purpose is to ensure the basic medical needs of working employees and retired employees. However, at present, many enterprises in our country can't afford medical insurance due to operational difficulties, which makes it difficult for these enterprises to be covered by the basic medical insurance system. Therefore, the important countermeasure to improve the basic medical insurance system is to ensure that all employees outside the system can enter the scope of the system.
It is necessary to speed up the construction of supplementary medical insurance system, so that the insured employees, especially those with difficulties, can get compensation through supplementary medical insurance once they have large medical expenses. There are many forms of supplementary medical insurance, and commercial insurance that takes advantage of the market should be a better choice.
In recent years, flexible employment groups have emerged, and this group will expand in the future. The government should take advantage of the situation and establish a special medical reimbursement system for flexible employment, a new form of employment. Flexible management methods should be adopted for flexible employment, and different arrangements should be made in the aspects of insurance participation, payment method, treatment payment, fund management and service.
the medical treatment system is also very important. More help should be given to the social members (such as the disabled) who are unemployed or unable to work in the vulnerable groups to seek medical treatment, so that the vulnerable groups can enjoy the right to health like other social members.
This year, the CPC Central Committee and the State Council put forward the guiding principle of "promoting agriculture through industry and bringing rural areas through cities". The new rural cooperative medical system led by the government is an important way to ensure the health of rural residents, which systematically ensures farmers' access to public health products. In order to promote this system smoothly, we should consider the issue of urban and rural overall planning in the system. We should actively explore the merger and centralized management of the new rural cooperative medical system and the basic medical insurance system for urban workers, and implement unified management mechanism, unified fund management and unified operation mode (differences are allowed in financing channels and reimbursement ratio), so as to establish a medical security system that breaks through geographical boundaries, breaks the identity of rural and urban residents and covers the whole people.
In short, China's medical security system should be: medical insurance with China's national conditions and China's characteristics, which consists of basic medical insurance for urban workers, supplementary medical insurance, commercial medical insurance, special medical insurance for flexible employees, medical assistance for vulnerable groups and new rural cooperative medical system.