In a certain period of time, a certain historical stage, medical insurance is adapted to the requirements of the times, and when social progress and economic development into another higher level, the original, traditional medical insurance is no longer in line with the requirements of socio-economic development, showing its own lagging behind, and this lagging behind may become the resistance of socio-economic development. Therefore, the reform of the medical insurance system is, in the final analysis, to study and solve the problem of how the medical insurance system, scale, structure and form of realization can be adapted to modern society. After more than 20 years of reform, China has entered the period of socialist market economy, the reform of medical insurance system must be based on the basic socialist political and economic system, national customs and cultural traditions of the specific requirements, according to the general law of the market economy, to correctly deal with the socialist market economy, the relationship between the special and general medical insurance, reflecting the essential requirements of the socialist, but also in line with the operation of the market economy, the traditional medical insurance system. In December 1998, the Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Workers put forward the general idea and specific objectives for the reform of China's medical insurance system, and drew up a clear institutional framework, which provided scientific guidance for the reform of China's medical insurance system.
1. Establishing a reasonable level of access to and protection of basic medical insurance. The traditional two-track system of medical insurance has many drawbacks, the biggest of which is the strict access standards, with clear restrictions on the beneficiaries' occupations and the nature of unit ownership. Reforming the traditional medical insurance system means turning the two-track system of medical insurance for urban workers into a single-track system, lowering the entry standards, and establishing a unified basic medical insurance system for urban workers to achieve broad coverage. The system can be expressed as follows: in accordance with the inherent requirements of the socialist market economy, to construct a safety mechanism for basic medical insurance for urban workers, to include all urban workers in this safety net, and to prevent the production and reproduction of the workforce from being affected by the failure of urban workers to obtain basic medical care, thereby causing major shocks to the operation of the market economy. The criteria for defining basic medical insurance should be the affordability of finances, enterprises and individuals, and where realistically necessary and possible, the policy choice for reform must be to address the most basic medical needs of urban workers. This is entirely determined by China's social situation and level of economic development, and is in line with the basic characteristics of the primary stage of socialism in China. The history of the development of China's medical insurance program tells us that medical needs are a basic condition of survival for workers, and that the state must provide for them as an inevitable trend of social development. Such a medical insurance system should be built on the basis of breaking down the old barriers of ownership and units, and should aim at establishing a unified medical insurance system. However, as far as the current reality of China is concerned, the supply of medical insurance is subject to financial constraints in all aspects at this stage, it can only be basic, and the degree of fulfillment of the demand for medical insurance can only be basic, i.e., a low level, wide coverage, and guarantee of basic medical needs.
2. Selection of a scientific basic medical insurance fund model. The fund is the core of medical insurance, the determination of the fund model is the key to the success or failure of the reform of the medical insurance system. China's medical insurance fund model of choice set of countries around the world and the country's reform experience, emphasizing the employer's obligations on the basis of the individual responsibility and medical insurance treatment hooked up, it is both incentives and at the same time is a constraint. The integrated social fund embodies the "law of large numbers" of mutual assistance in social medical insurance, which is conducive to realizing the integration and transfer of medical insurance funds within a certain social scope, balancing the burden of medical costs, dispersing medical risks, and realizing social fairness. Individual accounts, on the other hand, embody the responsibility that individuals should bear, which is conducive to enhancing the sense of health investment of individual workers and prompting them to accumulate medical insurance funds when they are young and healthy for when they are old and sick, so as to establish a vertical individual accumulation and protection mechanism; at the same time, individual accounts are owned by individuals, which enhances the sense of responsibility of individuals and prompts them to impose self-restraint on their medical consumption, thus reinforcing the constraints on the cost of expenditure. The basic medical insurance fund has a social coordinating system and an individual account, which is owned by the individual. The basic medical insurance fund has implemented a combination of social coordination and individual accounts, realizing the combination of the horizontal social mutual assistance function of the medical insurance fund and the vertical accumulation and protection function of individuals, taking into account both fairness and efficiency, and facilitating the dispersal of medical risks. The practice of reform in recent years in various places has also fully demonstrated this. According to the regulations, employees' basic medical insurance premiums are paid by both employers and employees***. The rate of contribution by the employer should be controlled at about 6% of the total wages of the employee, and the rate of contribution by the employee is generally 2% of his or her wage income. As the economy develops, the contribution rates for employers and employees may be adjusted accordingly. Basic medical insurance utilizes a combination of social coordination and individual accounts, with all individual contributions going into individual accounts, unit contributions going into individual accounts at about 30%, and the remainder being set up into a coordinated fund. The principal and interest on individual accounts are owned by the individual and can be carried forward for use and inheritance. The coordinated fund and the individual account should have their respective scope of payment clarified and be managed separately, with the aim of clarifying their respective responsibilities and avoiding the coordinated fund overdrawing the individual account. The starting standard and maximum payment limit for the integrated fund should be set, with the starting standard controlled in principle at about 10 percent of the average annual wage of local employees, and the maximum payment limit controlled in principle at about four times the average annual wage of local employees. Medical expenses below the threshold are paid from the individual's account or at the individual's own expense. Medical expenses above the starting standard and below the maximum payment limit are mainly paid from the coordinated fund, and individuals are also required to bear a certain percentage. Medical expenses exceeding the maximum payment limit can be settled through commercial insurance and other means.
3. Realization of effective basic medical insurance management. Socialization is the fundamental principle of the reform of the basic medical insurance system. It breaks the traditional pattern of fragmentation of medical insurance, decentralized management and decentralized decision-making, rationalizes the basic medical insurance management system, and enables urban workers to eliminate the unfair and unreasonable phenomenon of treatment caused by differences in ownership and occupation in a unified basic medical insurance system. To realize the socialized management of basic medical care, it is necessary to establish a system that separates government and affairs, and separates implementation from supervision; the government's main tasks are planning, decision-making and policy guidance, and the social insurance agencies are specifically responsible for fund collection, management and payment of benefits. Supervisory bodies composed of the Government, mass organizations and individual workers effectively monitor the conduct of social insurance agencies. The socialization of basic medical insurance also includes the socialization of basic medical services, the socialization of benefit payments, and higher-quality community services.
4. Constructing a low-cost, high-efficiency supporting system for medicines and health care. Drug production medical institutions distribution and diagnosis and treatment efficiency is directly related to the high and low cost of medical care, and thus directly related to the reform of the health insurance system. According to relevant newspaper reports, since 1978, China's pharmaceutical economy to about 18% per year of sustained growth. Its growth rate tops that of all domestic industries and is higher than that of the major pharmaceutical countries among the developed countries of the world. From the point of view of drug production, as of 1997, there were 6,391 drug production enterprises, including more than 1,700 three-funded enterprises,*** producing more than 1,350 kinds of APIs, more than 4,000 kinds of preparations and more than 8,000 kinds of proprietary Chinese medicines. Among more than 6,000 drug manufacturers, more than 300 enterprises (workshops) meet the requirements of Good Manufacturing Practice (GMP), of which only 59 enterprises, 38 workshops and 13 varieties have obtained GMP certificates. China's pharmaceutical production enterprises are small in scale, the number of enterprises, duplication of products, low technology level, poor economic efficiency, no characteristics of the product, varieties of the same, fewer brand-name products, low-level duplication of production is a very serious problem. Take Norfloxacin as an example, according to incomplete statistics, there are 828 enterprises producing Norfloxacin in China, among which some provinces have as many as 75. In terms of operation, as of the end of 1998, China's drug wholesalers have reached 16,519, and retailers have reached more than 60,000. In the United States, there are only 13 pharmaceutical wholesale enterprises, of which five wholesale enterprises accounted for 85% of the country's total business turnover. In France, there are also only 13 pharmaceutical wholesale enterprises, the largest of which accounts for 45% of the country's total business. In terms of utilization, in 1998, there were 15,219 hospitals in and above counties, 51,535 township and street health centers, and 125,264 individual clinics. Together with sanatoriums, specialized prevention and treatment clinics, maternal and child health-care stations (institutes), health-care stations (institutes), infirmaries and so on, there were 309,007 medical institutions of all kinds nationwide***, with a staff of more than 5,270,000.In 1997, there were 4,045 general hospitals in the national health sector, with a total income of 82.178 billion yuan. Drug income was 42.394 billion yuan, accounting for 51.59% of the total income. Among them, 61.36% of the outpatient income was drug income, and 49.69% of the inpatient income was drug income. The annual income from sales of drug differentials by medical units amounted to 16.56 billion yuan, and sales concessions and rebates by drug companies amounted to about 8 billion yuan, making a total of 24.56 billion yuan. According to statistics from the health sector, in 1997 China's drug consumption amounted to 83.8 billion yuan, with a per capita drug consumption of 66.51 yuan, of which 175 yuan per capita was in urban areas and about 25 yuan per capita in rural areas. In the same period, the average per capita consumption of medicines in medium-developed countries was 40 to 50 U.S. dollars, about 160 U.S. dollars in Western European countries, and more than 300 U.S. dollars in the United States.
China's health care system has been consistent for decades, has been in many ways can not adapt to the needs of the health insurance system reform. Medical and health service system structure imbalance, medical and health resources are over-concentrated in large cities, in the city over-concentration in large hospitals, and close to the life of the workers, the convenience of the workers to seek medical treatment, the service cost of low-cost community medical services are not developed, the workers of small injuries and illnesses, but also the need to go to a large hospital. The irrational distribution of medical and health resources increases the cost of medical services, which is an important reason for the waste of medical insurance funds. The structure of medical services is irrational, and pharmaceutical services account for too large a proportion of medical services. Some medical institutions pursue revenue one-sidedly, focusing their services on the provision of pharmaceutical services and high-precision large-scale equipment inspection, and the phenomenon of irrational inspection and irrational use of medicines is serious, which is another important reason for increasing the expenditure of the medical insurance fund; at the same time, the chaotic system of drug circulation, high discounts and high pricing have contributed to the irrational use of medicines. The internal management mechanism of medical institutions is not sound, there are a large number of redundant staff, increasing the labor cost of medical services, but also directly lead to the rise in medical costs, this higher medical costs ultimately transformed into medical insurance fund expenditure, so that the financial budget constraints of medical insurance continued to soften. Therefore, drug production, sales system, health system reform must be carried out in conjunction with the reform of the medical system, around the reform of the medical insurance system, rationalization of drug production, sales and health management system, in due course, the development of the basic medical insurance designated hospitals, designated pharmacies, the basic medical insurance drug directory, diagnostic and therapeutic items, service facilities standards, standardize the drug market and medical behavior. This is an important part of optimizing the allocation of medical resources, reducing medical costs, reducing the waste of medical resources, and ensuring the smooth progress of the reform of the medical insurance system.
5. Actively and steadily establish a supplementary medical insurance system. The goal of the State Council's Decision on the Establishment of a Basic Medical Insurance System for Urban Workers is to establish a social medical insurance system that guarantees the basic medical needs of urban workers. This basic medical need is quantitatively defined in terms of a maximum payment limit, and medical needs beyond this quantitative definition are not basic needs; they can only be resolved through such means as commercial insurance. Theoretically, basic medical insurance is universal, i.e., it is universally implemented throughout society and is designed to safeguard the basic needs of workers' health, and the government enforces its implementation throughout society through legislation. Supplementary medical insurance is in addition to the basic medical insurance guaranteeing the basic medical needs of workers; employers or individuals, according to their own characteristics and financial resources, appropriately increase their medical programs and choose more advanced treatment techniques. The level of insurance can be high or low, the number of insurance items can be large or small, and the forms of insurance are flexible and varied. At present, some places have made some attempts. Zhenjiang City, Jiangsu Province, provides that each insured employee and retiree shall pay 30 yuan per person per year by the individual as a comprehensive fund for large medical expenses. For medical expenses exceeding the maximum payment limit of RMB 30,000 yuan but below RMB 100,000 yuan, the individual no longer pays, the insured unit pays 20%, and the integrated fund pays 80%; for the portion of medical expenses exceeding RMB 100,000 yuan, the individual pays 10%, and the insured unit pays 90%. This model is characterized by the fact that supplementary medical insurance is managed directly by the social insurance agency, and the risks are borne by the social insurance agency, the employer and the individual***. Xiamen City stipulates that each person withdraws 18 yuan per year from his or her personal account and 6 yuan from the Social Coordination Fund to take out an insurance policy with an insurance company. The portion of medical expenses exceeding the maximum payment limit of 40,000 yuan or more is paid 10 per cent by the individual and 90 per cent by the insurance company, with an annual maximum payment limit of 150,000 yuan. This model is characterized by the fact that the social insurance agency collects the fees and then reinsures them with the insurance company, with the risk being borne by the insurance company and the individual. The Employees' Kangfu Mutual Aid Supplementary Insurance organized by the Nanjing Federation of Trade Unions is actually also a kind of supplementary medical insurance. It is characterized by being run by mass organizations themselves, with the purpose of mutual *** relief, not for profit, with voluntary participation by employees, and with contribution standards, insurance items, and treatment levels determined independently.
All of the above supplementary medical insurance models have their advantages and shortcomings, and need to be constantly supplemented and improved in the reform process. Basic medical insurance is the basic content of the medical insurance system and the core of the system, and supplementary medical insurance is also an important part of the medical insurance system. In the process of implementing the basic medical insurance system, multi-level and flexible supplementary medical insurance should be actively carried out according to the diversified characteristics of the needs of medical consumers, so as to enhance the ability of workers to withstand the risk of serious illness and meet their higher-level medical consumption needs, thus truly establishing a medical insurance system with basic medical insurance as the leading role, supplemented by commercial insurance and other means, and reflecting the characteristics of the current stage of China's medical insurance system. At the same time, actively study and explore the specific realization of rural residents' medical insurance forms and ways.