China's traditional medical insurance system

I. The Establishment and Development of China's Medical Insurance System

China's medical insurance system was established in the 1950s. For a long time, China's medical insurance system has been divided into three main types, one is the labor insurance medical system applicable to enterprise employees, the second is the sub-fee medical system applicable to the staff of institutions and agencies, and the third is the cooperative medical system applicable to rural residents.

The labor insurance medical system was established in accordance with the Regulations on Labor Insurance of the People's Republic of China published by the State Council on February 26, 1951. The system applies mainly to workers in state-run enterprises and some collective enterprises. Labor insurance medical expenses were fully borne by the enterprises before 1953; in 1953, they were changed to be withdrawn according to the nature of the industry at the rate of 5% to 7% of the total wages, respectively. 1969, the Ministry of Finance issued a regulation requiring the central state-owned enterprises to implement a combined approach to the withdrawal of the incentive fund, welfare and medical and health expenses, and to unify the employee welfare fund withdrawn at the rate of 11% of the enterprise's total wages to be charged directly to the cost. The main contents of the labor insurance medical treatment include: (1) the medical treatment of the employees or the report of non-work-related negative regiment, the required diagnosis fee, operation fee, hospitalization fee and the general medicine fee shall be borne by the enterprise, the expensive medicine fee, the hospitalized meal and the medical treatment fee shall be borne by the person himself or herself, and if the person himself or herself has a really difficult financial situation, he or she may be granted discretionary subsidy under the labor insurance fund. (2) When an employee stops working for medical treatment due to illness or injury not caused by work, the enterprise shall pay sick leave wages, amounting to 60% to 100% of his/her wages, for the period of medical treatment within six consecutive months according to his/her length of service in the enterprise; if he/she stops working for medical treatment for a period of more than six months, he/she shall be paid a monthly sickness relief fee, amounting to 40% to 60% of his/her wages, under the Labor Insurance Fund until he/she is able to work or is determined to be disabled. , until it is possible to work or until it is determined that it is a disability or death. (3) When an employee who has been injured due to illness or non-work-related injury is determined to be disabled at the end of the medical treatment and retired from work with total loss of working capacity, the wages for the sick leave or the sickness relief fee are stopped, and the disability relief fee is paid under the Labor Insurance Fund instead, and the standard for determining the disability relief fee is 50% of the employee's wages for those who need help with their food and daily life, and 40% of the employee's wages for those who don't need help with their food and daily life, until they regain the ability to work or die. The standard for determining the invalidity relief fee is (4) Immediate family members who are dependent on the employee (4) In case of illness of the immediate family members supported by the workers, they can be treated free of charge at the medical clinics, hospitals, contracted hospitals or contracted Chinese and Western medical practitioners of the enterprises, and the operation fees and general medicine fees are borne by the enterprises in 1/2. In response to the situation that the burden of the enterprises and the state in the medical care of the labor insurance is too heavy for the enterprises, the Ministry of Labor and the All-China Federation of Trade Unions issued a "Circular on a number of issues concerning the improvement of the medical care system of the workers in the labor insurance of the enterprises," making some new provisions on the medical care of the labor insurance. Some new provisions, such as the provisions of the workers are sick and non-work-related injuries, in the clinic required registration fees and consultation fees are borne by the workers; medical treatment of expensive medicines required by the enterprise, but the cost of taking nutritional supplements, should be borne by the workers and so on.

The publicly-funded medical care system was established in June 1952 by the State Council's "Instructions on the Implementation of Publicly-Funded Medical Care to Prevent Lying by Staff of the People's Government at All Levels, Party Groups, Organizations, and Affiliated Units of the National People's Government". The scope of implementation of the publicly-funded medical care system includes the staff of State organs at all levels, parties and organizations, people's organizations, and institutions separate from those of culture, education, scientific research, health, and sports, as well as disabled soldiers of the revolution, and students enrolled in institutions of higher learning. Publicly-funded medical care is financed by the State and government budgets at all levels, and is managed and utilized centrally by the health administrative departments or financial departments at all levels, and is paid for out of the unit's "Publicly-funded Medical Care Funds" line item, which is earmarked for specific purposes. The outpatient and inpatient treatment fees, surgical fees, hospitalization fees, outpatient fees, or the cost of medicines prescribed by engineers during hospitalization are paid for by the medical fees; however, meals and travel expenses for hospitalization are borne by the patients themselves, and if there are any difficulties, they may be subsidized by the authorities and reimbursed from within the administrative funds.

The cooperative medical system is mainly applicable to rural areas, and is different from the labor insurance medical care and public medical care in that it is not mandated by national legislation, and there is no financial support from the state, but is a kind of mutual aid system in rural areas, which raises medical funds through collective and individual fund-raising to provide medical care for the rural residents. The cooperative medical system appeared in the late 1950s and became widespread in the mid-1960s, and in 1965 the Central Committee of the People's Republic of China (PRC) approved the report of the Party Committee of the Ministry of Health (MOH) entitled "Report on Putting the Emphasis of Health Work into Rural Areas," which emphasized the strengthening of rural grassroots health-care work and gave impetus to the development of the cooperative medical system in the countryside. By the end of 1965, the cooperative medical care system had been implemented in some cities and counties in more than a dozen provinces, autonomous regions and municipalities directly under the Central Government, including Shanxi, Hubei and Jiangxi, and by 1976, 90 per cent of the country's peasants had participated in the cooperative medical care system. The rural cooperative medical system is based on the collective economy, with voluntary participation by the peasantry as the principle, and the cooperative medical fund takes the form of a combination of collective contributions and individual capitalization or collective investment and individual capitalization. Cooperative medical care is based on the principle of keeping expenditure within the limits of revenues, with the masses paying only a small fee for medical treatment, most of which is reimbursed from the cooperative medical care fund. As a result, the system was generally welcomed by the peasant masses and became an important element of the collective welfare program in the home villages. However, since the late 1970s, due to the implementation of the economic system reform in rural areas, the widespread adoption of the household contract responsibility system, so that the rural cooperative medical system has lost its original economic basis, resulting in the rural cooperative medical system in all parts of the country almost extinct.

Second, China's traditional medical insurance system existing problems and shortcomings of analysis

China's medical insurance system since the 1950s since the establishment of the protection of workers' health, and promote social and economic development has played an important role. However, with the deepening of the reform of the national economic system, the original system has been difficult to adapt to the requirements of the current system, spring the existence of defects and contradictions are becoming increasingly prominent, the main problems are:

First, the scope of people enjoying medical insurance is narrower. China's traditional medical insurance system applies only to the staff of institutions and organizations, state-owned enterprises and some collective enterprises. Other workers in cities and towns, especially those in non-publicly owned enterprises such as workers in private enterprises, most workers in foreign-invested enterprises and employees of individual economic organizations, do not have basic medical insurance, and the medical health of these workers is not effectively safeguarded. In view of the restructuring and reform of China's economy, the development of non-publicly owned enterprises will be faster and faster, and the number of employees will increase, so it is necessary to provide them with the necessary medical protection.

Secondly, medical expenses are entirely borne by the state and enterprises, and the increasing expenditure on medical expenses has aggravated the burden on enterprises and the state. According to the provisions of the traditional medical insurance system, medical expenses are covered by the state and enterprises, and individual workers are not required to make contributions. According to statistics, in 1978, the national expenditure on public medical care and labor insurance was 2.7 billion yuan; in 1990, it reached 27.6 billion yuan; in 1994, it was 55.8 billion yuan; and in 1997, it was 77.4 billion yuan; in 1997, compared with 1978, it had increased by a factor of nearly 28, with an annual growth rate of 19 per cent, whereas during the same period, the national financial income had increased by a factor of 6.6, with an annual growth rate of 11 per cent, meaning that during this period, the medical expenses of the workers had increased by a factor of 6.6, with an annual growth rate of 11 per cent. In other words, the growth rate of employees' medical expenses during this period exceeded the growth rate of State revenue during the same period. The large increase in medical costs has made it difficult for the state treasury to cope, and has also increased the difficulties of enterprises.

Thirdly, the lack of scientific and effective methods for the management of medical insurance premiums has resulted in a serious waste of medical expenses. Due to the lack of effective constraints on the mechanism, some medical units in order to pursue the interests of the unit and personal interests, often beyond the patient's condition blind prescription, many expensive drugs, nutritional supplements, and even non-medical supplies are prescribed as a prescription drug, greatly increasing the expenditure on medical care. Because employees do not have to pay, but also lack of awareness of saving, and even "one public expense, the whole family benefit", resulting in many unreasonable medical expenses.

Fourth, the low degree of socialization of medical insurance makes it difficult to play the role of socialization of insurance. Medical insurance premiums are allocated by the state or from the welfare of the enterprise retained expenses, did not establish a mechanism for the coordination of medical expenses, especially in the labor insurance medical, medical expenses and management of employees are completely covered by the enterprise, resulting in the burden of the enterprise is abnormally light and heavy, some of the poor efficiency of the enterprise or on the verge of bankruptcy of the enterprise is also out of the staff can not be reimbursed for the situation of medical expenses, the staff's reasonable interests can not be safeguarded.

Three, the reform of China's health insurance system

Since the 1980s, China has begun to reform its health insurance system. In 1988, with the participation of the relevant departments of the State Council, a National Medical System Reform Seminar Group was set up, and on the basis of extensive investigation, research and demonstration, it drafted the "Concept of Reform of the Employees' Medical Insurance System (Draft)", which proposes the direction of the reform: to gradually set up a multi-form, multi-level employees' medical insurance system suitable for China's national conditions, with the costs reasonably borne by the state, the unit and the individual, and with a high degree of socialization. . After the program was put forward, it began to select some cities to carry out pilot reforms of the employees' medical insurance system. in 1989, four cities, including Dandong, Siping, Huangshi, and Zhuzhou, became pilot cities for medical reform. in november 1993, the third plenum of the fourteenth session of the CPC made the "Decision of the Central Committee of the C*** on Several Issues Concerning the Socialist Market Economy System," which explicitly proposed that The Third Plenary Session of the 14th CPC Central Committee made the "Decision of the Central Committee on Several Issues of the Socialist Market Economic System", which clearly put forward the direction of reform that "urban workers' pension and medical insurance should be borne by both the unit and the individual***, and the combination of social integration and individual accounts should be implemented. In order to meet the requirements of the socialist market economic system, in April 1994, with the approval of the State Council, the National Reform Commission, the Ministry of Finance, the Ministry of Labor, and the Ministry of Health issued the Pilot Opinions on the Reform of the Employee Medical Care System, which put forward the goal of the reform of the medical care system for employees as: to set up a social insurance system combining a co-ordinated medical care fund and an individual medical care account and to make it progressively available to all workers in towns and cities. In conjunction with this pilot opinion, the State Council decided to carry out pilot reforms of the medical insurance system in the Jiujiang and Zhenjiang markets. in May 1996, on the basis of summarizing the experience of the reforms in Jiujiang and Zhenjiang, the General Office of the State Council forwarded a circular from the National Commission for Reform and Development of the State Council and four other ministries and commissions entitled "Opinions on the Expansion of Pilot Reforms of the Employees' Medical Insurance System", and decided to expand the pilot reforms of the medical insurance system from the second half of 1996 onwards. market. By January 1998, 40 cities nationwide had carried out pilot medical reforms, accumulating experience for the nationwide establishment of a basic medical insurance system for urban workers.

In order to push forward the comprehensive reform of the medical insurance system, in December 1998, the State Council issued the Decision on the Establishment of a Medical Insurance System for Urban Workers (hereinafter referred to as the "Decision"), deciding to carry out the reform of the medical insurance system for urban workers on a nationwide scale. The main task of the reform of the medical insurance system was to establish a basic medical insurance system for urban workers, i.e., to adapt to the socialist market economic system and to establish a social medical insurance system that would safeguard the basic medical needs of workers in accordance with the affordability of finances, enterprises and individuals. The Decision also specifies the principles for the establishment of a medical insurance system for urban workers: first, the level of basic medical insurance should be commensurate with the level of development of the productive forces at the primary stage of socialism; second, all urban employers and their employees should participate in basic medical insurance, and the principle of territoriality should be applied; third, the basic medical insurance premiums should be borne by the employers and the employees on an equal footing; and, fourth, a combination of social coordination and individual accounts should be applied to the basic medical insurance fund. The basic medical insurance fund to implement a combination of social coordination and individual accounts. Specific contents include:

1. Scope of coverage

Basic medical insurance covers all employers in cities and towns, including enterprises, institutions, public institutions, social organizations, private non-enterprise units and their employees, including state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises and so on, and as for the township and village enterprises and their employees, the owners of individual economic organizations and their employees, due to their special characteristics, the basic medical insurance fund is a combination of social coordination and individual accounts. As for township and village enterprises and their employees, owners of urban individual economic organizations and their employees, due to their special characteristics, it is up to the people's governments of the provinces, autonomous regions and municipalities directly under the central government to decide whether or not to participate in basic medical insurance. In terms of coverage, the basic medical insurance system has the widest coverage of all social insurance programs in China.

2. Coordination level

The coordination level should take into account not only the function of mutual assistance and the ability of the medical insurance fund to withstand risks, but also the differences in the level of consumption of medical care between regions in terms of economic development. The Decision calls for the basic medical insurance system to be co-ordinated, in principle, by administrative regions at or above the prefecture level, or by counties (cities), with the three municipalities directly under the central government, Beijing, Tianjin and Shanghai, co-ordinating, in principle, on a market-wide basis.

3. Principle of territorial management

Basic medical insurance is based on the principle of territorial management, and there is no industry co-ordination. All employers and their employees are required to participate in the basic medical insurance in their co-ordinated areas in accordance with the principle of territorial management, the implementation of a unified policy, the implementation of the basic medical insurance fund unified collection, use and management. Enterprises and their employees in railroads, electric power, ocean shipping and other cross-region enterprises with large production activities may participate in the basic medical insurance of the co-ordination area in a relatively centralized manner.

4, the contribution rate

Basic medical insurance premiums are paid by employers and employees **** the same. The contribution rate of the employer is controlled at about 6% of the employee's gross salary, and the contribution rate of the employee is generally 2% of his/her salary. With the development of the economy, the employer and employee contribution rate can be adjusted accordingly.

5. Integration of the unified account

That is, the establishment of a basic medical insurance fund and individual accounts. The medical insurance fund consists of a coordinated fund and an individual account, the basic medical insurance premiums paid by individual employees are all credited to the individual account, and the basic medical insurance premiums paid by the employer are divided into two parts, one of which is used to set up the coordinated fund, and the other part is credited to the individual account. The proportion to be transferred to the individual account is generally about 30% of the employer's contribution, with the specific proportion to be determined by the co-ordinating region on the basis of factors such as the scope of payment of the individual account and the age of the employee. The coordinated fund and the individual account should have their own scope of payment, be accounted for separately, and not be crowded out by each other. The starting standard and maximum payment limit for the coordinated fund must be determined, with the starting standard controlled in principle to be about 10 percent of the average annual wage of local employees, and the maximum payment limit controlled in principle to be about four times the average annual wage of local employees. Medical expenses below the starting standard are paid from individual accounts or by individuals. Medical expenses above the threshold and below the maximum payment limit are mainly paid from the integrated fund, with individuals also bearing a certain percentage. Medical expenses above the maximum payment limit can be solved through commercial medical insurance and other means. The specific starting standard and maximum payment limit of the coordinated fund, as well as the proportion of medical expenses above the starting standard and below the maximum payment limit to be borne by individuals, shall be determined by the coordinated area in accordance with the principles of "income meets expenditure" and "balance of income and expenditure".

6, medical insurance fund management and supervision

In the management of the basic medical insurance fund, it is required that the fund medical insurance fund into the financial account management, earmarked for specific purposes, and shall not be crowded out and misappropriated. Social insurance agency is responsible for the basic medical insurance fund raising, management and payment, and to establish a sound budgeting system, financial accounting system and internal audit system. The business expenses of the social insurance agency shall not be extracted from the z fund, and the financial departments at all levels shall strengthen the supervision and management of the basic medical insurance fund. The audit department shall regularly audit the fund income and expenditure and management of the social insurance agency, and the coordinated area shall establish a medical insurance fund supervisory organization attended by representatives of the decentralized people's department, representatives of the employing unit, representatives of the medical institution, representatives of the trade union and relevant experts to strengthen the social supervision of the basic medical insurance fund.

7. Strengthening the management of medical services

In the management of medical services, the main reform measures are: first, to determine the scope and standard of services for basic medical insurance. The labor department, in conjunction with the Ministry of Health, the Ministry of Finance and other relevant departments, formulated the scope and standards of basic medical services and the methods of accepting medical expenses. The national catalog of basic medical insurance drugs, diagnostic and treatment items, standards for medical service facilities, and the corresponding management methods are formulated. Second, the management of designated medical institutions and designated drugstores is implemented. Social insurance agencies are responsible for identifying medical institutions and designated drugstores, and signing contracts with designated medical institutions and designated drugstores to clarify their respective responsibilities, rights and obligations. A competitive mechanism should be introduced whereby employees choose a number of designated medical institutions to seek medical treatment, purchase medicines, or sign contracts with a number of designated pharmacies with a prescription, clarifying their respective responsibilities, rights and obligations. A competitive mechanism should be introduced, with employees choosing a number of designated medical institutions to seek medical treatment and purchase medicines, or purchasing medicines from a number of designated pharmacies with prescriptions. Third, cost accounting should be carried out for medical institutions, and a system of separate accounting and management of medicines should be implemented to reasonably control the level of medical costs, regulate the behavior of medical services, and rationalize the prices of medical services. Fourth, the active development of community health services, optimize the allocation of medical and health resources, community health services in the basic medical services into the scope of basic medical insurance.

8, to solve the medical treatment of the personnel concerned

For the reform of the medical insurance system, the medical treatment of the personnel concerned, adhere to the following principles: First, the retirees, the medical treatment of the old Red Army will remain unchanged, and the medical expenses will be resolved in accordance with the original funding channels. Secondly, the medical treatment of the second grade B or above revolutionary disabled soldiers will remain unchanged, and the medical expenses will be solved according to the original funding channels, and will be managed by the social insurance agency in a separate account. Third, retirees participate in basic medical insurance, and individuals do not pay basic medical insurance premiums. Fourth, national civil servants enjoy the medical subsidy policy on the basis of their participation in basic medical insurance. Fifth, in order not to lower the existing level of medical consumption of workers in some specific industries, the establishment of enterprise supplementary medical insurance is permitted on the basis of participation in basic medical insurance. The part of the enterprise supplementary medical insurance premiums within 4% of the total wage bill shall be charged to the employee's welfare expenses, and the part of the welfare expenses which is not sufficient to be charged shall be included in the cost after approval by the financial department at the same level.

After the issuance of the State Council's Decision in 1998, reforms of the medical insurance system have been carried out in various parts of the country. By the end of 2000, all provinces, autonomous regions and municipalities directly under the central government in China, except Tibet, had introduced general specifications for the reform of the medical insurance system. Of the country's 349 medical insurance co-ordination areas above the prefecture level, 320 prefectures and municipalities, or 92 per cent of the total, have had their implementation plans approved and introduced by the provincial government, of which 284, or 81 per cent, have begun to organize and implement them, and the number of people covered by medical insurance has reached 43 million. This fully demonstrates that the basic medical insurance system for urban workers is being gradually established.

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