Regarding the problem of the "scissors gap" of medical insurance, we need to worry, but we also need to have confidence in solving it. Although the long-term pressure on medical insurance funds is increasing under the severe situation of population aging, ten years ago, there were still three employees supporting one retired employee. Last year, the ratio of employees' basic medical insurance to retired employees dropped to 2.71. In the long run, there may be fewer and fewer people paying money, and more and more people spending money, and the medical expenses of the elderly will increase with age. This "scissors gap" will undoubtedly bring huge pressure to the sustainability of medical insurance financing and operation.

However, there are always more solutions than difficulties. Referring to Japan, where the aging population is more serious, in addition to drastic price control reforms, Japan has promoted the operation of the national health insurance system through treasury subsidies and multi-insurance combination coordination, providing financial guarantees for the development of the system. This has also led to Japan's continued growth in medical expenditures over the past few decades, and Japanese medical care is also a leader in the global medical system.

Back to China, although we cannot copy Japan's approach, we can also see in the past year that fiscal support remains the same, and the importance attached to commercial insurance is also increasing. This also inevitably indicates that a solution to the "scissors gap" of medical insurance with Chinese characteristics is already on the way.

Under the increasingly severe situation of population aging in my country, the situation of medical insurance funds can basically be summarized in one sentence: there is no need to worry about "not enough" in the short term, but in the long run, we need to be vigilant about expenditure pressure. From 2018 to 2023, total medical insurance revenue increased by 58.9%, while total expenditure increased by 60.2%, and the growth rate was basically balanced, which means that the overall principle of "determining expenditure by revenue and balancing revenue and expenditure" was followed. The balance of the medical insurance fund increased from 348.25 billion yuan to 503.959 billion yuan, and the cumulative balance reached 339.7975 billion yuan, which was 1 trillion yuan more than the year when the Medical Insurance Bureau was established in 2018.

The cumulative balance of nearly 3.4 trillion yuan seems to be a large number, but it does not mean that the money can be used at will. If we look at it separately, the pressure on medical insurance is increasing. Due to the sharp decline in the number of medical treatments in 2022, the base of fund expenditure is low, so the increase in fund expenditure in 2023 is large, which makes the fund surplus fall year-on-year for the first time in five years. The surplus in 2022 is 623.49 billion yuan, and in 2023 it is 503.959 billion yuan.

Going further, the employee medical insurance pooling account is relatively healthy, but the pressure on the employee medical insurance personal account and the resident medical insurance is relatively large. The growth rate of income continues to decline, but the expenditure is still maintaining a relatively fast growth rate, resulting in a significant reduction in the basic surplus of these two accounts in 2023, which are 25.339 billion yuan and 11.206 billion yuan respectively. How great is the pressure on medical insurance? Taking employee medical insurance as an example, due to population problems, the growth rate of the number of insured people in employment has been declining again and again. As shown in the figure below, the number of insured persons in service will be 260 million in 2021 and 271 million in 2023, with a growth rate of 4.2%. The number of retired insured persons will be 93.24 million and 99.96 million, respectively, with a growth rate of 7.2%.

In May 2022, "Ban Yue Tan" published an article stating that from now on to the next 10 years, China will usher in the largest retirement wave in history, and the post-60s group will continue to enter retirement life, retiring at an average rate of 20 million people per year. Since the growth in the number of retired insured persons is significantly higher than the number of insured persons in service, this has also led to a drop in the ratio of in-service retirement from 2.8 in 2021 to 2.71 last year, while 10 years ago, there were still 3 in-service workers supporting 1 retired worker.

This shows that the balance between the income and expenditure sides is slowly being broken, and the pressure is increasing. As the aging trend in my country is irreversible, if fewer and fewer people pay and more and more people spend money in the future, and the medical expenses of the elderly will increase with age, this will mean that the income-expenditure ratio will be seriously unbalanced, and the surplus will be consumed very quickly. This "scissors gap" will bring huge pressure to the sustainability of medical insurance financing and operation. Looking back at the reforms of the Medical Insurance Bureau in recent years, it has become a necessity.

Medical insurance funds are related to the medical treatment of people across the country. Therefore, before the arrival of a deeply aging society, medical insurance must be prepared for various positive responses. It is not the Medical Insurance Bureau alone that is fighting to ensure the sustainability of the financing end. Finance is undoubtedly a strong bottoming support. For example, during the epidemic, the state used the accumulated surplus of the medical insurance fund and fiscal funds to jointly bear the cost of the new crown vaccine and vaccination. While building herd immunity, it did not affect the current income and expenditure of the medical insurance fund, nor did it affect everyone's medical treatment.

The support of fiscal appropriations for medical insurance is not small. According to statistics from "AirGuest", in the past few years, the fiscal subsidies for medical insurance funds were around 650 billion yuan, mainly used for urban and rural residents' medical insurance. Although it has declined, it has dropped from 25% in 2019 to 21% in 2022, still above 20%. Considering that the domestic government is currently willing to expand its budget, it means that the support for medical insurance in the future is likely to remain at a high level.

Referring to our neighboring country Japan, one of the countries with the most serious aging population in the world, the current elderly dependency ratio in Japan is around 1.8, that is, an average of 1.8 people "support" one elderly person, and the situation is extremely serious.

Forced by the sharp rise in medical insurance expenditure pressure with the intensification of aging, Japan began to launch cost-control medical reform in the 1980s, and reduced medical insurance expenditure in multiple ways. Due to Japan's high welfare policy and rapid aging trend, in addition to medical reform and cost control, Japan has also embarked on the road of fiscal guarantee. In 1950, an average of 12 young people in Japan "supported" one elderly person, and by 2007, this ratio became 3 young people "supporting" one elderly person. This has led to unprecedented pressure on Japan's medical insurance revenue and expenditure, with the gap between insurance premium income and expenditure becoming increasingly larger, and the government has to rely on public finance to make up for the expenditure deficit.

Taking 2017 as an example, excluding the self-paid part and medical insurance financing, the government budget in 2017 needs to pay about 16 trillion yuan (about 40%), of which the central government directly pays about 11 trillion yuan. In contrast, Japan's national public construction budget in the same year was about 6 trillion yuan, and the education budget was about 5 trillion yuan, which is less than the medical insurance budget when added together. According to data from the Ministry of Health, Labor and Welfare of Japan, a large proportion of the financial resources for medical expenses come from public funds, accounting for more than 1/3. This support mainly comes from the national treasury and local governments, with a ratio of roughly 2:1.

Taking the burden structure of medical expenses in Japan in 2019 as an example, public funds accounted for 38.3%, of which local finances borne 12.8% and the national treasury borne 25.4%. For Japan, additional fiscal investment is the main framework to ensure the sustainability of medical insurance. The main direction of subsidies is to support the elderly in the later stages of the elderly, some employee medical insurance subsidies, and local government medical insurance subsidies. Although Japan's support for medical expenses fluctuates with the economic cycle. But overall, against the background of an aging population, Japan's medical expenses are continuing to grow, and the proportion of GDP is also increasing.

In addition to fiscal guarantees, a multi-level insurance system may also share the pressure of medical insurance. There is still a large blank area between basic medical insurance and commercial insurance in my country. Although commercial insurance has entered a period of rapid development in recent years, with the national commercial health insurance premium income of 903.5 billion yuan in 2023, data show that the overall compensation of commercial health insurance in 2023 is only 300 billion yuan, accounting for only 3.3% of the total health expenditure of 9 trillion yuan. Compared with the world average, there is still a lot of room for improvement. Behind this is that although the health insurance has a high level of protection, its insurance threshold and premium are relatively high, resulting in a low coverage. In addition, commercial insurance still faces problems such as insufficient credit, high marketing verification costs, and inconvenient claims, and the overall development is not optimistic.

Against this background, Huiminbao came into being and became a well-deserved phenomenal product in the insurance industry in the past two years. However, due to its stricter claim conditions than health insurance and its relatively low penetration rate, in order to further ease the medical pressure on medical insurance funds and individuals, it is also necessary to further expand the compensation support capacity of commercial insurance channels and further enrich the multi-level medical security system.

At present, this is also the work that the Medical Insurance Bureau is accelerating. For example, exploring the one-stop settlement of "medical insurance + commercial insurance", some places are also accelerating reforms. For example, the "Zhejiang Smart Medical Insurance Brain" created by Zhejiang has included the province's Huimin Insurance into the one-stop settlement channel of medical insurance through built-in rules, providing one-stop settlement services for the Huimin Insurance participants in the province. At the beginning of the month, the Medical Insurance Bureau also organized a symposium on the development of commercial health insurance empowered by medical insurance platform data held by insurance companies, and discussed related contents such as empowerment scenarios, business needs, path methods, and guarantee conditions.

Prior to this, China Banking and Insurance Information Technology Management Co., Ltd. organized a national medical insurance information sharing data service training and exchange meeting, introduced the latest progress of the medical insurance information platform and commercial health insurance information sharing work, and stated that the next step will be under the guidance of the Financial Supervision Administration, with customer information authorization as the premise, to promote the industry to carry out the application of medical insurance information sharing platform in batches.

The liberalization of the sharing of medical insurance data will undoubtedly remove some existing development barriers of commercial health insurance, which will help enrich the supply of health insurance products and meet the people's multi-level medical insurance needs. This means that Huimin Insurance and commercial insurance will work together to become two important pieces of the puzzle to complete the resident medical insurance system.

https://mp.weixin.qq.com/