China is a medical insurance system.

Since 195s, China has gradually established a medical insurance system with the characteristics of the times, which has played an important role. However, with the development of economy, the defects of the previous medical insurance system are gradually exposed. Starting with the disadvantages of the current medical insurance system, this paper analyzes the causes of the problems, and puts forward to intensify the reform of medical insurance and build a medical insurance system with China characteristics. 1 medical insurance system in China China's employee medical insurance system was established in the early 195s, including free medical care and labor insurance medical care. This system has been implemented for decades, which has played a positive role in ensuring the health of workers, reducing the personal and family burdens of workers, improving the health level of the whole nation, promoting economic development and maintaining social stability, and has played an important role in China's political, economic and social life. However, with the reform and opening up and the development of market economy, the disadvantages in China's medical insurance system are increasingly exposed. Mainly manifested in the following aspects: (1) countries and enterprises over-package medical expenses, with heavy burden, poor management and lack of effective cost control mechanism, resulting in great losses and waste; (2) The coverage of medical insurance is narrow, the socialization of services is low, the basic medical needs of some employees are met and the medical resources are wasted, and the public medical care and labor insurance medical care systems are not unified. Because the original medical insurance system has not adapted to the requirements of the development of market economy, it has even hindered the further deepening of system reform. Therefore, in December 1998, the State Council issued the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees [Guo Fa (1998) No.44] (hereinafter referred to as the "Decision"), which deployed nationwide to comprehensively promote the reform of the medical insurance system for employees, requiring that a new basic medical insurance system for employees be basically established nationwide in 1999. Since the promulgation of the "Decision", all provinces and cities in China have stepped up the construction of the basic medical insurance system for urban workers on the principle of "low level, wide coverage, burden on both sides and combination of unified accounts" and made significant progress. Basically, all provinces and cities have established the basic framework of basic medical insurance for urban workers, set up social medical insurance agencies (Social Security Foundation Office), established social pooling funds and personal accounts of basic medical insurance funds, and the Social Security Foundation Office is responsible for reviewing and selecting designated medical service institutions and pharmacies, and drawing up the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and corresponding management measures. In addition to the basic medical insurance, large medical expenses mutual aid system has been generally established in various places to solve the medical expenses above the maximum payment limit of social pooling funds. 2 The defects of the current social medical insurance system have been obvious to all in the four years since the promulgation and implementation of the Decision. However, with the further deepening of system reform, such as the change of industrial structure, the deepening of property right system reform of state-owned enterprises, and the loosening of household registration system control, some contradictions and problems existing in the current social medical insurance system are gradually exposed, mainly in the following aspects. 2.1 Fairness Although fairness is the primary issue to be considered in establishing the social medical insurance system, which is also reflected in the Decision, this issue has not been well solved due to China's basic national conditions and particularity. First of all, on the whole, so far, the population covered by social medical insurance is less than 1 million, less than 1/12 of the total population, and the vast majority of people, especially farmers, have no medical security. Although we implement a cooperative medical system in rural areas that is different from the urban medical insurance system, the implementation situation is worrying due to many restrictions such as farmers' income and township finance, and the problem of difficulty in seeing a doctor has not been well solved. Moreover, in the long run, it is an inevitable requirement to break the urban-rural divide and establish a unified social security system. Therefore, the rural social medical security should be considered in the overall framework of the social medical insurance system. Secondly, as far as cities and towns are concerned, according to the requirements of the Decision, the coverage of the insured population is all employers in cities and towns, including enterprises, institutions, social organizations, private non-enterprise units and their employees. As for township enterprises and their employees, owners of urban individual economic organizations and their employees, it is up to the provinces, autonomous regions and municipalities directly under the Central Government to decide whether to participate. In fact, all provinces and cities have included the latter in the medical insurance plan in principle. However, from the implementation effect, due to the limited willingness and ability of enterprises (including individuals) to pay, the coverage of the actual insured population has great limitations, resulting in a large number of people's medical needs being insecure, and those who are willing to participate in the insurance and have the ability to pay are mainly employees of government agencies, research institutes and other institutions and employees of state-owned enterprises and collective enterprises with good benefits. However, the participation rate of employees, individual industrial and commercial households, urban residents and urban vulnerable groups (including laid-off workers, low-income workers, seriously ill, seriously ill and special patients, and frail retirees) in private and foreign-funded enterprises is very low. Students in universities and technical secondary schools who used to enjoy free medical care and their immediate family members who enjoy some labor insurance medical insurance benefits are not included in the current medical insurance coverage, and a large number of migrant workers who have flooded into cities and towns have no medical insurance at all. Due to the low participation rate of social groups and the aging age structure of insured employees, the accumulation of insurance funds will be weakened and gradually shrunk: on the one hand, the horizontal social mutual assistance of insurance pooling funds will be poor, and the burden of medical expenses will not be balanced; On the other hand, it will also greatly weaken the vertical accumulation guarantee function of personal accounts. This is not conducive to dispersing medical risks, and does not reflect the economy and fairness of social medical insurance. At the same time, it also endangers the sustainable development of medical insurance system. 2.2 Fund balance problem Fund balance is the key to the effective operation of the medical insurance system and the prerequisite for the sustainable development of the medical insurance system. At present, the basic medical insurance funds for employees in all provinces, cities and towns in China have the same problems, that is, the fund income and expenditure are unbalanced, the social pooling fund has a low degree of protection, and the personal account payment ability is weak, which can not meet the basic medical consumption needs of the insured. The current situation: On the one hand, due to the low participation rate of social groups and aging structure, the accumulation of the fund is weakening or even shrinking, and the government has not given financial support to the fund. In addition, many units should not participate in the insurance, delay the payment of premiums without reason, and omit or conceal the salary base to avoid payment, resulting in a low level of fund raising; On the other hand, from the perspective of actual medical consumption, even if you participate in basic medical insurance and enjoy basic medical insurance benefits, because the "threshold" set by the co-ordination fund qifubiaozhun is too high, the risk of high medical expenses above the capping line is high, and the insured person bears a high proportion of medical expenses, coupled with the lack of reasonable and effective supplier control mechanism, such as arbitrary charges, drug abuse, indiscriminate inspection and inflated pricing in drug production and circulation. Once suffering from a serious illness, serious illness or chronic disease, the overall fund and personal account payment will be seriously insufficient, and there is a big gap. The insured has to pay high medical expenses in cash, which brings unbearable economic burden to low-income people and the infirm. 2.3 Supplementary medical insurance The social medical insurance system includes basic medical insurance and supplementary medical insurance. At present, China's productivity level is low, and the basic medical insurance can only be "low level and wide coverage", and its gap in insurance depth and breadth needs to be supplemented by supplementary medical insurance, that is, commercial medical insurance. Commercial medical insurance is flexible and convenient, with strong freedom and selectivity, which can improve the level of social medical security and meet the needs of different groups and levels. And its professional and market-oriented operation mechanism can also be used for reference for the management of basic medical insurance, so as to promote the standardization and scientificity of basic medical insurance management. Therefore, only by effectively linking basic medical insurance with commercial medical insurance can the medical insurance system be more scientific and perfect. China's commercial medical insurance started soon, and there are still considerable obstacles to its development. It is mainly manifested in: (1) the medical reform is not in place and the relevant laws and regulations are not matched; (2) Lack of policy support to encourage the establishment of health insurance; (3) The professional management level of insurance companies needs to be improved. Medical insurance is a business with strong professionalism, high technical requirements and relatively difficult management. Because medical insurance started late in China and has been treated as a subsidiary business or additional insurance for a long time, insurance companies generally lack experience and technology in medical insurance, and the level of risk management and control is low; Talent training is not enough, and a professional talent team has not yet been established; The product innovation ability is not strong, and the types of insurance are monotonous and repetitive, which makes it difficult to meet the different requirements of the market. 2.4 Reform of medical institutions The main problems existing in China's medical service market at present are that the administrative monopoly has not been broken and there is no environment for fair competition. The government directly owns and manages medical institutions, focusing on running hospitals, and to some extent, consciously or unconsciously becomes the protector of the interests of public hospitals. This restricts the development of other medical institutions with property rights. The market is inefficient in resource allocation because of the lack of competition. Public medical institutions use their monopoly position to pursue economic benefits unilaterally, charging fees, inspecting and prescribing drugs indiscriminately, and the service quality is poor, which directly hurts ordinary medical service consumers. Vertically, the unreasonable regional health planning is the main problem. It is mainly manifested in the fragmentation of health resources allocation, repeated construction, unbalanced structure, coexistence of waste and shortage of resources, high operating cost and low overall utilization efficiency, which can not meet the medical and health needs of the people well. Therefore, medical institutions need to be reformed urgently and medical and health resources need to be re-integrated. 3 Establish a medical insurance system with China characteristics 3.1 Coordinate social and economic development, plan scientifically, and strengthen the macro guidance of the medical insurance system. As an important social policy, the medical insurance system involves a wide range of social activities and becomes an inseparable and closely related social activity with the insured. Therefore, it is necessary to formulate a medium-and long-term medical insurance development plan that is in line with the level of social and economic development and can meet people's medical needs, so as to guide social development, coordinate the relationship between social and economic development, and make it a guide for people's social behavior. Through the planning of medical insurance, we will provide the insured with basic medical security commensurate with the level of social and economic development, and strive to achieve coordinated and sustainable development of social economy and medical insurance. From a long-term perspective, based on the long-term, scientifically and democratically plan the future medical insurance, correctly understand and handle the relationship between social and economic development and medical insurance development, coordinate the scale, speed and proportion of social and economic development and medical insurance development, and determine the fund raising and use, cost sharing and cost control mechanism that meets the requirements of social and economic development. Accurately grasp the overall and local, immediate and long-term, overall and unit and other indicators of scale, speed and proportion, correctly handle the interests of the state, the collective and the individual, coordinate various medical insurance relationships such as medical insurance managers, medical service providers and insured persons, rationally allocate social resources according to social needs, realize rational allocation of resources and avoid waste. Seek balance in dynamics, development in balance and balance in development, so that the operation of medical insurance system is in a virtuous circle, promote the continuous progress of medical insurance, and enable more members of society to enjoy more benefits brought by medical insurance. 3.2 Accelerate the legislative pace of medical insurance, and build a medical insurance legal guarantee. The reform of medical insurance system is enforced by the state in order to protect the basic medical needs of all workers, and has the characteristics of compulsion, mutual assistance and fairness. Therefore, in order to ensure the realization of its goal, only through legal channels can it be implemented by national legislation. Medical insurance fund is a health safety net established to provide financial guarantee for the insured when there is a disease risk, and it is the "life-saving money" for all the insured, and its role is far-reaching and significant. However, at present, the relevant legislation is imperfect and lagging behind, and the relevant laws and regulations are not targeted and the punishment is weak, and even the law enforcement punishment is unfounded, so it is difficult to effectively play the powerful role of legal punishment to achieve the purpose of disciplinary warning. Therefore, it is suggested that medical insurance should be included in the legislative plan as soon as possible, and the legislation of medical insurance laws and regulations should be accelerated, so as to build a legal defense line for the safety of medical insurance funds and ensure the operation of medical insurance system, which is an urgent task of medical insurance work at present. 3.3 Strengthening the dynamic research of medical insurance policy is an important prerequisite for scientific decision-making in the reform of medical insurance system. With the development of social economy, the progress of science and technology and the improvement of people's health awareness, people's demand for medical care has been continuously improved. The old medical insurance policy can only adapt to the original basic medical needs, but can't solve the changed objective situation, and even cause new problems to solve the previous contradictions or problems. There are many relationships that affect the development and change of medical insurance, all kinds of contradictions are complicated, all kinds of reasons are different, and all kinds of factors interact and cause each other, so the situation is more complicated. The policy research of medical insurance system is to prevent new contradictions that may occur in the implementation of medical insurance system and solve new situations and problems in the implementation of medical insurance system in time, which is an important prerequisite for scientific decision-making of medical insurance system reform. Therefore, only by strengthening the process management and dynamic research of the medical insurance system, adjusting the medical insurance policy at the right time, avoiding or reducing the impact and waste on the medical insurance system and medical insurance fund caused by the lagging medical insurance policy, and constantly improving the medical insurance system, can we effectively play the role of the medical insurance policy, meet the ever-changing medical needs and ensure the steady operation of the medical insurance system. 3.4 It is an important way to implement the sustainable development strategy of medical insurance to open up sources and reduce expenditure at the same time, focusing on reducing expenditure and making rational use of medical insurance funds. The introduction of the new Regulations on Handling Medical Accidents has higher and stricter requirements on medical safety in hospitals, and medical safety must be seriously considered. The development of various new medical technology projects, the continuous investment of new diagnosis and treatment equipment and the application of high-tech medical materials have greatly reduced medical risks. Therefore, as a medical provider, all hope to reduce medical disputes through the safe use of high-tech equipment, and at the same time, it can also bring rich economic benefits. However, this has led to the increase of medical cost and social medical burden, which has caused new pressure on medical insurance fund expenditure. With the acceleration of population aging, the proportion of the elderly population in the insured population structure is rising. The income of medical insurance fund has not kept pace with the growth of medical insurance fund expenditure, and it is faced with the dual pressure of difficulty in raising medical insurance fund and accelerated medical demand growth. This is not conducive to the smooth operation and sustainable development of the medical insurance system. If it is not studied and solved in time, it will inevitably lead to the shortage of food and food, which will turn the medical insurance into a passive water and a tree without roots, and will eventually make the whole medical insurance system reform fall short and lose the trust of the people. Therefore, at present, it is necessary to increase revenue and reduce expenditure simultaneously, give priority to reducing expenditure, strengthen the control of medical expenses, improve the efficiency of the use of medical insurance funds, and make rational and effective use of medical insurance funds to ensure the sustainable development of medical insurance. 3.5 Strengthen guidance, introduce competition, rationally allocate medical resources, and promote the construction of community medical institutions. Due to the particularity of the medical service market, medical providers are in a monopoly position and form a seller's market.