Anatomy of 70 years of health insurance development history: why is China's health insurance the way it is now?

China's health insurance system was born with the founding of New China and developed with the times, with distinctive characteristics of the times. 70 years, the health insurance system evolution and development of each stage of each institutional arrangement, each policy initiative is in the social and historical context of the people's health care needs of the people's response to the high degree of concern for people's livelihood protection of the party and the government, cohesion of generations of medical insurance people's wisdom and hard work, to protect the health of China, social harmony, economic development plays a very important role. The wisdom and efforts of generations of medical insurance people have played a very important role in safeguarding the health of people's livelihood, social harmony and economic development in China, and have made world-renowned historical achievements, which have provided valuable experience and profound insights for the world today.

First, the state-unit protection: with the planned economy compatible with the system choice

At the beginning of the founding of the new China, the central government from the old government of the Kuomintang took over the hands of a thousand holes in the mess: industrial atrophy, agricultural depression, hyperinflationary inflation, production facilities, serious damage, a large number of factories shut down, a large number of workers are out of work, the chaos of the business order, the people's lives Difficulties. At that time, the top priority in front of the central government was to stabilize the society and at the same time rapidly develop production and the economy to ensure that the people's life was passable and their survival was guaranteed. This is the severe test faced by the Chinese ****production party at the beginning of its rule, but also to appease the people's hearts, stabilize the society, show the ability to govern, consolidate the foundation of the ruling party must pass the hurdle.

Since the new China chose to take the socialist development path, but the specific system model does not come from its own practical experience to follow, the only reference and reference is the former Soviet Union relying on the planned economic system to implement the model of state security, and the former Soviet Union in the implementation of the system at the beginning of the better results. For this reason, the central government assumed the responsibility of the state in a strong position and, through enterprises and public institutions and other grass-roots units, rapidly organized the construction of social security systems such as social relief and labor insurance, thus forming the basic pattern of the state-unit security system model from the very beginning. By 1956, China had initially established a more complete social security system compatible with the planned economic system, with the state as the main body of responsibility, specific policies organized and implemented by the urban and rural units, the state (through the government) and the unit in the implementation of the social security system in the process of increasingly close together.

In August 1966, the Cultural Revolution began, and the country entered a decade of turmoil. Starting with the abolition of the Ministry of the Interior at the end of 1968, the trade unions responsible for labor insurance affairs were paralyzed, and the functions of the labor department were weakened, so the state could no longer effectively control the implementation of the social security system, and the social security system could only rely on the organization of the units to maintain and continue, and the phenomenon of the unit-run society expanded rapidly, and the state-unit security has largely moved towards self-coverage. The state-unit security is to a large extent moving towards self-enclosed unit security.

Since 1978, China has ended a decade of turmoil and entered a phase of reorganization. Although there were some improvements in social security during the 1978-1986 period, they were mainly aimed at solving the historical problems and restoring the retirement system and the public medical and labor insurance medical system that had been destroyed by the Cultural Revolution, although reform experiments were carried out in individual regions in the areas of labor insurance medical care and retirement expense coordination. Although individual regions have carried out reform experiments in the areas of labor insurance medical care and retirement expenses, the fundamentals of the state-unit security system have not been touched, and the essence of the state-unit security system and its unit-centered pattern have remained unchanged, with the original system model still being maintained and consolidated.

Second, the combination of social coordination and individual accounts: the objective need for system transformation

With the transition of China's economic system from planning to the market, enterprises have become self-managed, self-sustaining economic entities, a large number of foreign-funded enterprises, private enterprises, and other non-public enterprises have appeared, the original system and the new system of non-adaptation between the system is becoming more and more prominent: First, the lack of non-public units of the medical protection system for employees Secondly, there are big differences in medical treatment between different units, and the medical burden is abnormally light and heavy; Thirdly, the enterprise's own medical insurance has increased the enterprise's social burden and limited the enterprise's ability to compete in the market; Fourthly, there is a lack of effective cost constraints on medical supply and demand, and the medical resources are seriously wasted, and the medical costs are unreasonably and excessively fast; Fifthly, under the conditions of the market economy, the enterprise independently bears the business risks, and closes, breaks, and stops, Change is the norm, the unit security model is objectively unsustainable and unsustainable. All this shows that the reform of the original medical insurance system model is inevitable.

In today's world, there are four main models of medical insurance systems, namely: the national health insurance system model represented by the United Kingdom, the social health insurance system model represented by Germany, the commercial health insurance system model represented by the United States, and the savings-based health insurance system model represented by Singapore.

The main problem with the UK's national health insurance model is the rigidity, inefficiency, and poor service quality of the medical service providers, which often results in waiting in line for months or even half a year for an operation. At the same time, due to the lack of cost cost consciousness of doctors and patients, the level of medical consumption grows too fast, the waste of medical resources is serious, the financial burden is too heavy. This fact has been constantly verified by the labor insurance medical care and public medical care in our country in the past, as well as by the policy of free enrollment and high treatment and enjoyment for poor households with documented records in many places in the past few years, and there is no need for us to repeat yesterday's story. Those experts and scholars who always stand on the moral high ground and enthusiastically advocate that our country should learn from the United Kingdom to implement the so-called free medical care are either forgetting history or ignoring the facts.

The United States is a country that advocates freedom and emphasizes individual self-help, which has led to the emergence of a system model based on commercial medical insurance. The main problem is that, based on the profit-seeking nature of commercial insurance companies, some people with poor payment ability and high risk of disease are rejected, which does not reflect the social equity and mutual **** relief. Although the government has established medical care programs for the elderly and medical assistance programs for low-income people, there are still more than 50 million nationals without any health insurance. As a socialist country, seeking happiness for all the people is the fundamental aim of the party, realizing universal healthcare is the responsibility of the government, and providing healthcare coverage for no less than one person and no less than one person is the goal that we have been striving for, and the combination of fairness and efficiency, and the unification of mutual aid and self-help should be the basic principle of our system design.

The savings-based health insurance system model represented by Singapore emphasizes the sense of self-protection and personal responsibility, and weakens the individual's trust in the government. The main problem is the lack of social mutual **** relief, less fair, social risk **** sharing function as a relatively weak.

The main features of the social health insurance system model represented by Germany: First, mandatory participation. All eligible persons must participate; Second, the establishment of the fund. The fund is formed by employees and employers *** with the formation of contributions, in accordance with the "pay-as-you-go" and "to income, expenditure, revenue and expenditure" principle of mobilization; third, only to provide basic medical services; fourth, to take the "third-party payment "mechanism, the establishment of a specialized agency to manage the fund collection and treatment payment.

China's new health insurance system to solve the main problems: First, to meet the needs of China's market economic system reform and development, the establishment of a medical insurance system covering all employers, independent of the employer, the implementation of socialized management; Second, the responsibility for medical care from the past by the state and the unit fully assume the responsibility of the State to the country, the unit, the community and the individual to share the burden of the establishment of a mechanism of constraints on the behavior of medical care to control the unreasonable growth of medical costs; the medical care of the State, the unit, the community and the individual. Third, the system design insists on the unity of fairness and efficiency, the relative equality of rights and obligations, and the combination of mutual aid and self-help. Therefore, the establishment of a social medical insurance system with reference to the German model became the choice of the new medical insurance system. As the state-unit guarantee model was practiced before the reform of China's system, this is the logical starting point and path dependency to be followed in the reform of China's health insurance system. Therefore, the biggest challenge facing the reform of the system is the shift from the free individual coverage of the past to participation and contribution and cost-sharing. Without a well-thought-out system design, the acceptance of the new system by employees will inevitably be affected, thus hindering the advancement of the health insurance system reform. It is fortunate that before the implementation of the new system, pilot explorations such as linking medical expenses to individual beneficiaries and reforming the management of publicly-funded medical expenses were generally carried out in various places, thus laying the foundation for the system design of individual contributions and cost-sharing. Considering that the mainstream understanding of the economic system reform at that time was to break the "big pot of rice", the implementation of complete social coordination of medical insurance may form a new "big pot of rice", in order to enhance the awareness of individual costs and control waste, Singapore and other countries of individual account system is undoubtedly worthwhile to learn from, the design of individual account. The design of individual accounts can not only reduce the burden of unit contributions, but also, to a certain extent, solve the problem of the burden of medical expenses on the insured for minor and common illnesses, thus resolving the psychological gap before and after the reform of the medical insurance system. Therefore, the new health insurance system to implement a combination of social integration and individual account model, is undoubtedly the best choice in the dilemma.

In retrospect, the combination of social coordination and individual accounts has been relatively successful in resolving the social contradictions of the transition of the economic system, and at the same time realizing the smooth transition of the employee health insurance system from public funds and labor insurance to social health insurance system, in which the design of the individual accounts has contributed to the success of the system. However, the individual account system has not fully realized the original design intention of alleviating the aging problem, and with the basic completion of the individual account's historical mission, its unique shortcomings and inherent defects have become more and more prominent, which has brought a lot of trouble to the management of medical insurance and caused the discussion on the existence or abolition of the individual account in the society, and there are even some individuals who deny the correctness of our country's road of social medical insurance with the problem of the individual account, and this tendency of cutting off the history deserves a high degree of attention. This tendency to split history deserves a high degree of vigilance.

Third, the reform of the system is gradually deepening: the difficult practice of a large developing country

According to the former vice minister of the Ministry of Labor and Social Security, Wang Dongjin, president of the China Health Insurance Research Association, the reform of China's health insurance system can be roughly divided into the following four periods.

First, the exploration and pilot period (from the mid-1980s to the end of 1998).

This period can be divided into three stages:

1. Before 1994, for the local spontaneous experimental exploration stage. Some places (such as Siping City, Jilin Province, Huangshi City, Hubei Province, etc.) witnessed the increasingly prominent shortcomings of the public, labor insurance medical system and unsustainable situation, spontaneous exploration of the reform, the content of the main medical costs and personal appropriate linkage, etc., in order to curb the irrational growth of medical costs and a serious waste of medical resources.

2. 1994 to 1996, for the organization and leadership of the urban workers in the basic medical insurance system reform pilot phase. The National Reform Commission and other four ministries issued a "pilot guidance", the establishment of the State Council Leading Group on Health Care Reform and the Office of the State Council, the organization and guidance in Zhenjiang City, Jiangsu Province, Jiangxi Province, Jiujiang City, to carry out a pilot project (known as the "Two Rivers Pilot"). Specifically to explore how to establish a basic employee health insurance system path and approach.

3. April 1996 to December 1998, for the expansion of the pilot phase. The General Office of the State Council "on the reform of the employee medical insurance system to expand the pilot views" as a guide, the scope of the pilot from the "two rivers" to more than 40 cities across the country. The main purpose is to test the results of the "Two Rivers Pilot" on a wider scale, conduct in-depth research, identify problems, summarize experience, grasp the law, improve policies, and compare and determine the mode of the system.

Second, the establishment of the basic medical insurance system for urban workers period (from 1999 to 2003)

After more than four years of exploration of the pilot and the expansion of the pilot, the various departments and parties to the direction of the reform and the reform of the importance of the urgency of the reform of the reform of the tasks, objectives, paths, and the reform of the system model, the policy framework of the major issues such as the formation of a basic understanding of the ****. On this basis, in December 1998, the State Council made the Decision on the Establishment of a Basic Medical Insurance System for Urban Workers, formally initiating the historic change of establishing a basic medical insurance system for urban workers generally throughout the country.44 Document 44 also explicitly stipulated that enterprises should be encouraged to establish supplemental medical insurance, implement medical subsidies for civil servants, and support the development of commercial health insurance as complementary and supporting measures. As a result, the public-funded, labor-insured medical system that had been in place for more than 40 years was ended, and the unit (enterprise) security system was transformed into a modern social security system ("unit people" became "social people"). Realized a historic transformation and leap.

Third, the establishment of a universal health insurance system period (from 2003 to 2017)

Because of the experience of establishing employee health insurance and the health insurance team honed in practice, this period is also the construction of the universal health insurance system, the fastest development, the most significant achievements of the period. It can be roughly divided into six phases with their own focus:

1. Establishment of a new rural cooperative medical system (referred to as "New Rural Cooperative Medical System") phase (from 2003 onwards)

Mainly through the government's financial subsidies, the past rural cooperative medical care into the "New Rural Cooperative Medical System", which has solved the problem of the majority of rural areas, including the rural areas of the countryside. "

2.

2. Establishment of the social medical assistance system stage (from 2003)

The main purpose is to solve the basic medical protection problem of the special hardship group (such as the "low-income households" in the city, the "five-guarantee households" in the countryside, and people with severe disabilities, etc.), and to embody the basic medical protection function of social policy and the government's ability to provide the bottom-up function and the government's ability to provide the bottom-up function. The basic medical insurance problem, reflecting the bottoming-out function of social policy and the responsibility of the government.

3. Establishment of the basic medical insurance system for urban residents stage (from 2007)

From the State Council's "Guiding Opinions on Carrying Out the Pilot of the Basic Medical Insurance System for Urban Residents" (Guofa 〔2007〕 No. 20) began a pilot program, which was fully launched one year later. The main purpose is to solve the problem of basic medical insurance for those who are not employable in the towns (commonly known as "one old and one young").

4. Establishment of a system of protection and assistance for serious illnesses (mechanism) stage (from 2012)

The 18th CPC National Congress explicitly proposed the establishment of a system of protection and assistance for serious illnesses, and the Decision of the Third Plenary Session of the 18th CPC Central Committee further clarified this. Later, in practice, it evolved into a "major illness insurance system", with different perceptions in terms of conceptual connotation, functional positioning and implementation methods, which need to be further corrected and improved.

In 2013, the Premier of the State Council formally announced in the Government Work Report that a universal health insurance system has basically been established in China. It has basically formed a pattern of universal medical insurance with basic medical insurance as the main body, supplemented by enterprise supplementary medical insurance, civil servants' medical subsidies, commercial health insurance, etc., and social medical assistance as the bottom of the universal medical insurance pattern.

5. Integration of urban and rural residents' basic medical insurance system stage (from 2013)

After the 18th National Congress of the CPC, the central government put forward the requirement of integrating the urban and rural residents' medical insurance system, and the State Council also determined the integration of the "timetable" in 2013 (in place by the end of June of that year). However, due to various resistance and interference, it was not until 2016 that the State Council issued "Document No. 3" before "entering the fast lane". By the end of 2017, most of the provinces (*** there are 24 provinces and municipalities) will be transferred to the department of human resources and social services business management, to achieve the "six unified", only a few provinces and municipalities of the "new rural cooperative" is still in the health sector.

6. Explore the establishment of long-term care insurance system stage (from 2016)

According to the spirit of the Fifth Plenary Session of the 18th CPC Central Committee, the Ministry of Human Resources and Social Security issued the "Guidance Opinions" on the development of long-term care insurance system pilot. Starting in 2016, the pilot program has been carried out in 15 cities across the country. At present, preliminary results have been achieved, for the surface of the establishment of this new type of security system, improve the social security system system, to resolve the risks of the aging society, explored the path, accumulated experience.

Fourth, the period of comprehensively building China's medical insurance system (from 2017)

Marked by the implementation of the "Healthy China" strategy, the reform of China's medical insurance system has entered a new stage of development centered on the health of the entire population. With the 19th National Congress of the Communist Party of China (CPC), the reform and development of China's health insurance system has entered a period of comprehensively building a health insurance system with Chinese characteristics.

Fourth, to enhance the sense of access to health insurance: deepen the reform of the times

After more than three decades of unremitting efforts, "health insurance" reform has made brilliant achievements, the establishment of a universal health insurance system, the initial solution to the problem of the people's medical treatment, medical insurance, but the people's difficulties in accessing medical care, the problem of the high cost of medical care has not been fundamentally alleviated, the people's difficulties, the problem of the people's medical care. Fundamentally alleviated, the people's sense of access to health insurance has to be further enhanced, the health insurance sector is faced with internal potential to improve the efficiency of the use of funds, external help, prying the health care reform to the deep development of the double pressure, the role of health insurance to play an effective need to solve a series of problems from the external and internal.

externally: First, due to the delay in the reform of public medical institutions, the administrative monopoly formed by the management of the Office of the formation of administrative monopoly, so that the public medical institutions can not make a sensitive response to the social needs and the role of health insurance payments, resulting in the "three medical linkage" disjointed, resulting in the inability of health insurance to medical services on the supply side of the realization of the effective checks and balances, the majority of the medical cost of medical care to compensate for the funding of the health insurance fund, the basic loss of the guidance of medical resources allocation and diagnosis and treatment of doctors and patients. The medical insurance fund has basically lost the ability to guide the allocation of medical resources and the diagnosis and treatment behavior of doctors and patients, and has degenerated into a second financial institution that only provides financial compensation for public medical institutions. Secondly, public medical institutions have not become real market players, unable to obtain sunshine income through healthy competition and standardized operation, and the value of medical services of medical personnel has not been truly reflected, making kickbacks and red packets prevalent, and distorted behaviors such as large prescriptions and excessive inspections proliferate, resulting in the high-speed growth of the medical insurance financing not only fails to reduce the burden of urban and rural residents' medical care, but also induces the high-speed expansion of public hospitals, and the people's sense of The public's sense of access has declined rather than increased. Third, it restricts the smooth promotion of the hierarchical diagnosis and treatment system. The current hospital hierarchy has led to the concentration of high-quality medical resources in high-grade hospitals, and with the improvement of the people's standard of living and the enhancement of health insurance benefits, the tendency of patients to seek authoritative specialists in high-grade hospitals has been strengthened, and the original way of adjusting the direction of patients' medical treatment through the difference in the price of medical services is gradually failing, and the tendency of patients' concentration in high-grade hospitals has been intensified, resulting in the "three-tier hospitals are crowded". "The three-tier hospitals are full of people, and the grassroots hospitals are full of people.

internally:First, because the previous medical insurance programs and funds are managed by different departments, there are large differences in the level of protection, the standard of protection and the level of protection, in the design of the information system, the operation and management of the fund and the policy objectives are not the same. This decentralized management model reduces the efficiency of the administration, increases the cost of running the system, and creates difficulties in coordinating and linking the various systems. Secondly, due to the limitations of the number of establishments, the serious shortage of supervisory and law enforcement personnel, lagging behind in the construction of supervisory teams, and insufficient supervisory capacity has not been well resolved, the problem of excessive medical care and the phenomenon of fraudulent insurance fraud has not been effectively curbed, which has led to improper loss of the health insurance fund, inefficiency, which affects the treatment of the insured persons' security, and also affects the sustainable development of the health insurance system.

Therefore, the integration of health insurance resources, the establishment of a specialized agency, give full play to the power of the third party group purchaser of health insurance, to help promote the reform of the health care system, it is inevitable. Because of this, the state announced the establishment of the National Health Security Bureau at the first meeting of the 13th National People's Congress, specializing in health insurance duties of the health security departments in various places came into being.

As State Councilor Wang Yong pointed out in the description of the State Council's institutional reform program, the formation of the National Health Security Bureau is intended to achieve two goals: first, to improve the unified health insurance system, improve the level of protection, to ensure the rational use of funds, safety and control; second, to promote the medical care, health care insurance, medicine, "three medical linkage" reform, to better protect the health of patients. The second is to promote the reform of medical care, medical insurance, and medicine "three medical linkage" to better protect the sick for medical treatment. This passage clearly defines the role of the medical insurance bureau in the health care reform, namely: through the integration of the medical insurance system, convergence of management strength, co-ordination of fund payment, to change the reality of the previous management of fragmentation, decentralization, sloppiness, so as to achieve the purpose of improving the management efficiency, to prevent the fund risk, to ensure that the system can be sustainable; at the same time, so that the health care department to use their hands in the hands of the medical insurance fund, to become a powerful, based on the market mechanism, resource allocator, to ensure the rational use of medical care. The market mechanism of resource allocation, thus becoming the key pryer of health care reform.

Specifically, the main embodiment of the three aspects: First, after the establishment of the Health Insurance Bureau, the health insurance fund will be able to a high degree of aggregation. Previously dispersed in the human society, health planning and civil affairs and other departments of the employee health insurance, residents health insurance, maternity insurance and medical assistance funds centralized by the Bureau of Health Insurance unified management, give full play to the group purchasing power for effective guidance of the rational allocation of medical resources, standardize the diagnosis and treatment of doctors and patients to provide strong economic support. Secondly, the consequent integration is the long-term decentralized management authority. The Medical Insurance Bureau has centralized the catalog determination, price management and procurement functions of drugs, medical consumables and medical service items, as well as the functions of contracted fixed-point medical institutions, fee payment and service supervision, which is expected to solve the problem of "multiple government departments and tug-of-war" caused by the previous overlapping of functions and dispersed powers, so as to improve the administrative effectiveness and give full play to the strategic purchasing role of the medical insurance fund. This will improve administrative effectiveness, maximize the strategic purchasing role of the medical insurance fund, and provide a strong organizational guarantee for achieving the reform goal of rationally using the fund and continuously improving the level of protection. Thirdly, with the concentration of power on the demand side, the key to deepening the reform will focus on the implementation of the "separation of management and operation" of the medical service system and the breaking of the administrative monopoly of public medical institutions, so as to realize effective competition on the supply side. This is the realization of medical insurance to guide the rational allocation of medical resources and promote the rationalization of diagnosis and treatment behavior of doctors and patients, but also to promote the reform of the health care system is an important lever.

V. Playing the role of a good strategic buyer: an important issue facing the health insurance sector

The so-called strategic purchase, in the words of Chen Jinfu, deputy director of the Department of Health: it is "near to fight the systematic improvement and trend optimization: to fight the price of the quantity, to enhance the performance of the fund of the purchase of the health insurance group; to win the quality of the value of leading the health care service system; compatible with the **** life, to build a future coordinated health, innovation-driven, to build a better future. Build a future coordinated and healthy, innovation-driven development pattern". First, "establish a manageable and efficient health insurance payment mechanism, improve the efficiency of fund use", through the continuous improvement of the health insurance payment method, so as to exert a strategic influence on the medical behavior, hospital management, the operation of the pharmaceutical system, and promote the transformation of hospitals from sloppy management to refined management. Secondly, the strategic thinking of future investment is used to strengthen the direction of health insurance purchase, and the current purchase is regarded as future strategic investment. For example, it is difficult to meet the needs of basic medical services at the present level of family doctor services with basic improvement, but the present purchase is precisely an investment in future growth; and the purchase of services from private medical organizations is aimed at fuller competition. The third is to enhance the strategic purchasing function of the medical insurance fund, steadily increase the level of integration, make the municipal level of medical insurance, pilot provincial level of integration, improve the direct settlement of foreign medical treatment, eliminate the separation of accounts, reduce the level of management, realize the centralization of data, and continue to strengthen the strategic purchasing function of the medical insurance fund, and promote the synchronization of the reform of the medical insurance, medical treatment, and pharmaceuticals and synergistic development.

From the point of view of concrete implementation, mainly through improving the health insurance system, strengthening fund management, promoting the "three medical linkage", and enhancing the service capacity and other initiatives, give full play to the strategic purchasing role of the health insurance fund, to provide more equitable and accessible health insurance services for the people, and to further improve the sense of access to health insurance for the people.

In terms of improving the health insurance system. First, to clarify the connotation and extension of the basic health insurance basic, clearly define the responsibility boundary, through the development of health insurance treatment payment list management system, to strengthen the management of health insurance treatment payment, to realize the sustainability of the health insurance system. Second, further improving the unified basic medical insurance system for urban and rural residents, and establishing and improving a stable and sustainable financing mechanism for basic medical insurance for residents. Thirdly, we are comprehensively promoting general outpatient coordination for urban and rural residents; exploring improvements to the management mechanism of individual accounts for employees' health insurance; steadily advancing the transition of individual accounts for employees' health insurance to outpatient coordination; and enhancing the mutual assistance***redeeming capacity of individual account funds. Fourthly, it is actively building a multi-level medical insurance system that integrates basic medical insurance, major disease insurance and medical assistance. Fifth, to further deepen and expand the pilot long-term care insurance system.

In terms of strengthening fund management. The first is to strengthen the agreement management.