医保制度改革如何平衡可持续性和公平性？

近年来，随着国内老龄化趋势加剧，医疗需求快速增加，医保基金的压力也随之增大。伴随新医疗技术的不断出现，医疗费用也不断上升，给医保基金带来收支平衡的压力。根据国家医疗保障局发布的《2023年全国医疗保障事业发展统计公报》数据显示，居民医保参保人数已经连续五年下降，然而医保基金支出却年年增高。2023年医保基金支出增长率为14.7%，而收入增长率仅为8.3%，医保基金支出增长速度超过收入增长速度引发社会对医保基金可持续性的担忧。

就在统计公报发布的一周之后，国务院出台了《关于健全基本医疗保险参保长效机制的指导意见》，重点完善基本医保筹资政策，鼓励居民长期参保，提升医保基金安全。指导意见特别针对一些平时不生病、不愿缴纳医保费用，但生病后立刻参保并享受保障的现象，提出了新的约束措施。对于断保或未连续参保人员设置医保报销等待期，参保人员在等待期内将无法获得医保报销。为鼓励连续参保，指导意见提出为连续参保人员和零报销人员提供激励机制，允许其在申请大病保险报销时获得更高的报销额度。

职工、居民医保“双轨制”是否公平？

值得注意的是，指导意见中提出的约束和鼓励措施主要针对居民医保。其实在指导意见出台之前，各地职工医保早已设置参保等待期。以北京职工医保为例，参保人中断缴费超过3个月以上，重新缴费参保需等待6个月才能开始享受医保报销待遇。此次改革将职工医保的等待期引入居民医保，有助于提升居民医保的公平性。然而，目前职工、居民医保的二元分割制度是否会影响社会保障制度的公平性，是否会对医保基金的安全性和可持续性带来不稳定的影响？

目前职工与居民医保的人均缴费金额相差巨大，而两者医疗待遇之间的差异与缴费金额不成正比。根据2023年统计公报数据计算，2023年职工医保人均筹资额6182元，居民医保人均筹资额只有1098元。在医保待遇方面，两者在三级医院的报销比例均能达到70%¹。这意味着职工医保参保人平均每年缴费超过居民医保参保人五倍之多，而两者的医保报销比例却相差不大。

随着DRG/DIP改革深化以及各地区医保基金面临不同程度的压力，一些地方的职工和居民医保DRG费率可能出现断层，导致“同病不同价”的问题。以西安市为例，每年年末在制定下一年DRG付费区域总额预算时，职工和居民两个群体的预算分开测算。西安市医保局测算2024年全市DRG职工和居民DRG付费住院总病例分别为95.51万人次、99.13万人次，而DRG区域预算总额分别为88.44亿元、55.99亿元，²与之对应的是西安市职工和居民的DRG支付预算分别为平均每人9260元和5648元。如此巨大的支付标准差距可能导致同一种疾病的职工医保患者和居民医保患者所享受的医疗服务存在差异。

实现医疗公平所不能忽视的问题

实现社会保障制度公平统一，需要遵循权利义务相对等原则，逐步解决职工、居民医保“双轨制”存在的问题。然而，除了职工和居民之外，还有一些人群的医疗保障权益需要得到更多重视。其中一部分是低收入人群。这些人的收入刚刚超过贫困线，因此无法获得困难群体参保资格，无法享受政府的医疗救助。对于上有老下有小的低收入家庭，全家人的参保费用以及医保个人支付部分可能为家庭带来巨大的经济压力，这些家庭面对疾病时是最脆弱的。

还有一部分人群，虽然能够承担参加医保的费用，却面临买不到或者用不起医保药的难题。许多创新药，特别是罕见病药，因为价格等原因未能纳入医保目录。有医疗需求的患者承担不起自付用药。此外，许多乙类医保药品疗效更好，但是医保只报销一部分费用，还需要个人自付一定比例。许多患者为追求治疗的经济性而不得不放弃更好的治疗体验。

随着公众对医疗服务质量和医保待遇的期望不断提高，如何可持续且高质量地满足这些需求将成为医保制度发展的重点。这些挑战需要通过深化医保改革、提高资金使用效率、促进价值医疗等多方面的努力来应对。处理好医保可持续性和公平性之间的平衡关系注定会是一个复杂的问题。

Increasingly ageing populations and surging demand for healthcare services in China have created more pressures on basic medical insurance (BMI) funds. With the continuous emergence of new medical technologies, medical expenses have also continued to rise, bringing more challenges when it comes to balancing the income and expenditure of BMI funds. According to the 2023 National Healthcare Security Development Statistical Bulletin released by the National Healthcare Security Administration (NHSA), the number of resident BMI policyholders has declined for five consecutive years, but BMI expenditure has increased year after year. In 2023, BMI expenditure grew by 14.7 per cent, while the income growth rate was only 8.3 per cent. In exceeding the income growth rate, BMI expenditure growth has caused widespread concerns about the sustainability of BMI funds.

Just one week after the Statistical Bulletin was released, the State Council issued the Guiding Opinions on Improving Long-Term BMI Enrolment, focusing on strengthening the financing policy, encouraging residents to keep up their BMI premiums, and improving the security of BMI funds. The Guiding Opinions proposed new restrictive measures on those who go without BMI while healthy, but immediately sign up for BMI to claim healthcare benefits right after they fall ill. The new measures call for establishing a waiting period for BMI reimbursement to deter such behaviours. During the waiting period, BMI policyholders will not be able to claim any reimbursement. To encourage policyholders to commit to the BMI scheme and pay contributions consistently, the Guiding Opinions propose providing an incentive mechanism. With the new mechanism in place, continuously insured individuals and those who have not yet claimed any reimbursement since enrolment would be granted higher maximum reimbursement amounts when applying for BMI reimbursement.

Is it fair to have two different sets of BMI rules for residents and employees?

It is worth noting that the constraints and incentives proposed in the Guiding Opinions are only applicable to BMI resident policyholders. Before the Guiding Opinions were issued, BMI for employees had already been subject to a waiting period. Taking Beijing's BMI for employees as an example, if a previous BMI employee policyholder had stopped paying premiums for more than three months, they would then have to wait six months after resuming their monthly payments before they could start claiming reimbursement again. Introducing a waiting period for residents as well is expected to help improve the fairness of the insurance programme. However, are the current separate BMI rules for residents and employees affecting the fairness of the social security system? Will it have a negative impact on the security and sustainability of BMI funds?

Currently, there is a significant gap between the per capita BMI enrolment fees for residents and employees. However, the difference in healthcare benefits between the two groups is not proportional to the gap in their respective enrolment fees. According to the 2023 Statistical Bulletin, the average BMI enrolment fees for employees is CNY 6,182 per person per year, whereas for residents it is only CNY 1,098. In terms of healthcare benefits, both resident and employed policyholders are entitled to reimbursement for about 70 per cent of healthcare expenses incurred from tertiary public hospitals¹. This means that BMI employee policyholders pay more than five times in BMI contributions on average than resident policyholders, while the healthcare benefits the two groups receive are not significantly different.

As DRG/DIP reforms deepens and local BMI funds face different pressures, gaps between healthcare benefits for insured employees and residents could grow even further. At the end of each year, local healthcare security bureaus calculate the budgets for DRG payments for the next year. Budgets for employees and residents are calculated separately. Taking Xi'an as an example, the Xi'an Healthcare Security Bureau estimated that, in 2024, the total number of DRG paid in-patient cases among insured employees and residents in the city would be 955,100 and 991,300 respectively. However, the total DRG in-patient payment budgets will be CNY 8.844 billion for employees and CNY 5.599 billion for residents². That means the average DRG in-patient payment budget for employees would be CNY 9,260 per person, whereas residents would only be given a budget of CNY 5,648 per person. Such a significant gap in DRG payment budgets may lead to major differences in the quality of healthcare services provided for insured employees and residents.

Issues that should not be ignored when aiming for healthcare equity

To improve fairness across the social security system, it is important to follow the principle of equal rights and obligations when resolving existing issues with BMI. Although BMI does manage to cover the majority of the Chinese population, there are still marginalised groups whose healthcare security rights require more attention. These include low-income populations, some of which have incomes barely above the poverty line, making them ineligible for government healthcare subsidies. For low-income families with young children and elderly members, BMI fees for the whole family and out-of-pocket healthcare expenses may cause huge economic pressures, making them the most vulnerable when facing illnesses.

There is another group of people who can afford to enrol in BMI but still face the problem of not being able to afford or have adequate access to certain BMI drugs. Many innovative medicines, especially rare disease medicines, have not been included in the National Reimbursement Drug List (NRDL) for various reasons. As a result, patients wishing to use such medicines may shy away from them due to the high out-of-pocket expenses and absence of BMI reimbursement. In addition, many Class B NRDL drugs have better efficacy, but BMI only reimburses part of the cost, and individuals are required to pay a certain proportion out of pocket. Many patients may have to forego a better treatment experience in pursuit of a more economical solution.

As people’s expectations for effective healthcare services and BMI benefits continue to rise, meeting these needs in a sustainable and high-quality manner will become a priority for the future development of BMI. These challenges need to be addressed through a range of efforts, including deepening healthcare security reform, improving the efficiency of BMI fund utilisation, and promoting value-based healthcare services. For China’s healthcare security system, striking the right balance between sustainability and fairness is bound to be a complex issue.

参考文献:

1.参保人数下降，居民医保基金如何可持续发展？健闻咨询 https://mp.weixin.qq.com/s/fKTCcMi8bVP_oMY9rtyz2Q

2.关注！DRG支付方式改革的西安实践。西安市医疗保障局 https://mp.weixin.qq.com/s/8s6lSz0wjtS8YsM0uAsBGA