Vietnam Immigrant Fund

The new rural cooperative medical system is an important policy to benefit farmers under the background of the government's continuous efforts to solve the "three rural issues" and build a harmonious society. The key point is to help farmers reduce the economic burden caused by major diseases, and the policy goal is to reduce the phenomenon of rural residents' "poverty caused by illness" and "returning to poverty due to illness". Since the pilot implementation of the new rural cooperative medical system in 2003, the first batch of pilot counties (cities, districts) have been launched, which increased to 333 in 2004. By the end of June 2005, 64 1 county (city, district) had carried out the pilot work, and 65438+63 million farmers had participated in the cooperative medical care.

Recently, the central decision-making level further revealed the firm determination to speed up the opening up of this pilot policy. In September 2005, the "National Conference on the Pilot Work of the New Rural Cooperative Medical System" decided: In which counties will the pilot be carried out in 2006? City, district? From the current 2 1% in China to about 40%. By 2008, the new rural cooperative medical system will basically cover all rural residents in China, two years ahead of the original target of 20 10. On the basis of the original 10 yuan, the subsidy standard of the central government for farmers participating in the cooperative medical system will be increased by 10 yuan per person every year to 20 yuan. At the same time, municipal districts with a large agricultural population in the central and western regions and some difficult counties in the eastern region will participate in the pilot project? City? Included in the scope of central financial subsidies.

The establishment of a new rural cooperative medical system is a strategic policy aimed at promoting social equity and coordinated development, which is of far-reaching significance for narrowing the gap between urban and rural areas, reversing the unbalanced social development structure, building a harmonious society and realizing five overall development. However, this policy, which benefits 760 million rural people, still has some defects in system design and faces many challenges. If we don't pay attention to these problems and some negative incentives, it may reduce the guarantee effectiveness of this system or lead to the deviation of policy objectives, and affect the healthy operation and sustainable development of the new rural cooperative medical system.

First, the medical compensation policy based on serious illness deserves further scrutiny.

The new rural cooperative medical system is a serious illness insurance based on high probability, and the policy direction is mainly serious illness, that is, the per capita 20 yuan subsidized by the government and the per capita 10 yuan paid by farmers are "mainly subsidizing large medical expenses or hospitalization expenses".

First of all, the guarantee based on serious illness is easy to induce adverse selection, which is not conducive to the establishment of a stable financing mechanism. Because the probability of serious illness and hospitalization service is small, it will reduce the expected income of the insured. Healthy people often underestimate the importance of participating in insurance, while high-risk groups are very willing to participate. This kind of adverse selection, namely "selective participation" and "selective withdrawal", may threaten the sustainability of new rural cooperative medical system financing. After one year of operation, a very strange phenomenon appeared in quite a few counties and townships, that is, farmers who participated in the merger of new farmers in the previous year and received serious illness reimbursement subsidies often chose not to join at this time. This is because farmers often have some kind of psychological expectation: "It will not be so unlucky, and they will get seriously ill in the first year and continue to get seriously ill in the second year."

Secondly, the current financing level is difficult to provide effective medical security for rural residents. In 2003, the rural per capita health care expenditure was 1 15 yuan, but the total financing level of cooperative medical care was only 30 yuan per capita. Spending the annual cooperative medical care fund on the per capita 30 yuan is far from solving the problem of rural residents' poverty and returning to poverty due to illness, and the lack of security may eventually make cooperative medical care a chicken rib. Even for serious illness relief, under the current arrangement, * * * payment is still very high (in most areas, the proportion of * * * payment reaches 30-50%), which limits the use of this insurance for poor families, because in many cases they are still unable to pay medical expenses.

Thirdly, the security goal is to ensure a serious illness, which actually gives up the responsibility of ensuring the basic medical needs of most people, and it is impossible to obtain good investment performance. In rural real life, common diseases and frequently-occurring diseases really affect the overall health level of rural residents. The serious illness of many rural residents is also because "there is no money to treat minor illnesses". Judging from the performance of health investment, the health effect of intervention on serious diseases is far less than that of timely intervention on common diseases and frequently-occurring diseases. In addition, the critical illness security model leads to the moral hazard of "minor illness and great doctor". A survey found (Tang Shenglan, 2005) that in a pilot county in Gansu, many patients who could not have been hospitalized were hospitalized for treatment.

Second, financing is difficult and operation and management costs are high.

First of all, cooperative medical care is difficult to raise funds and has high cost.

Every year, the financing of the new rural cooperative medical system requires the staff of the "joint management office" to come to raise funds, and the financing cost is quite high. At the beginning of the cooperative medical system, it is difficult for grassroots health cadres to reach the participation rate stipulated by their superiors. The participation rate of cooperative medical care in some pilot areas is up to standard and even discussed one by one. At the same time, due to various unreasonable charges in the name of "cooperation" in history, some farmers have a rebellious attitude towards the work of township cadres, and some township cadres have low quality, which makes it more difficult to raise funds. This situation directly restricts the rapid popularization and promotion of rural cooperative medical care.

Secondly, the management cost of cooperative medical care is high, and the related expenses are difficult to implement effectively.

Analysis on the lack of organizational ability and management cost of the new rural cooperative medical system. On the surface, the level of overall planning is already very low. But the reality is that most counties have hundreds of thousands or even millions of people, and rural residents live in scattered areas. The cooperative medical service institutions face thousands of households, with great differences in health status and limited records. The county government is embarrassed in organizational management ability, and the management cost is unbearable.

The new rural cooperative medical system is organized by the government, and governments at all levels in the pilot counties should set up a set of corresponding management institutions. The county should set up a rural cooperative medical management bureau (usually a public institution under the county health bureau), and the townships (towns) should set up a rural cooperative medical office, and the personnel and office expenses should be included in the financial budget. This is not a small expenditure for the county and township governments with poor financial situation and low financing level of cooperative medical care. And these are just direct institutional costs. In addition, county-level finance should not only arrange supporting expenditures, but also bear a considerable amount of publicity and organization expenses and operation and management expenses. Many county-level governments are forced to arrange this part of the expenses and pass it on to health institutions, including county hospitals, township hospitals and village clinics, and these institutions will eventually pass this part of the expenses on to patients in their operations.

Third, reverse subsidies and regressive burdens are obvious.

First of all, the payment form of "poll tax" is obviously unfair, and the burden of retrogression is more obvious.

Perhaps for the sake of simple management, the current new rural cooperative medical system adopts the basic payment form of per capita 10 yuan, but this is actually a form of "poll tax", which does not take into account the difference in payment ability between rural residents and families, which will obviously cause a heavier payment burden to poor families. In contrast, under the medical security system for urban workers, the individual contribution rate is 2% of his salary, and the unit pays 6% of the total wages of employees. To some extent, the issue of fair burden is also considered.

At the same time, due to the combination of government subsidies and voluntary participation in the new rural cooperative medical system, and the implementation of the medical expenses reimbursement system, a high self-payment ratio has been set, which objectively forms the cost threshold, and poor families still give up medical treatment because they are unable to pay the full amount of medical expenses for serious illness. This situation not only leads to this group of people can not benefit, but also leads to reverse transfer payment. Because the rich are relatively more able to pay, it is easier to enjoy the subsidies provided by the government and the corresponding medical insurance. In this way, the rich are rich and secure, and the poorer the poor, the less secure they are. It aggravates the inequality in rural medical and health fields and violates the basic principle that the social security system should transfer payments to the poor and alleviate social inequality. In addition, the system of voluntary participation will inevitably form a group distinction between inside and outside the system, and it is difficult to effectively avoid the erosion of resources within the system by people outside the system.

Second, there is the problem of diminishing regional subsidies.

The new cooperative medical system adopts the principle of combining individual payment, collective support and government funding, which determines that the more participants, the more state financial subsidies and the stronger cooperative medical fund. In richer counties and cities, local governments and rural residents have strong ability to pay fees, so it is relatively easy to develop new rural cooperative medical care. In some areas, there is even a phenomenon that the pavement is quickly opened for the purpose of obtaining central subsidy funds. In order to produce demonstration-driven effect, all provinces and cities basically take counties with good local economic development and strong financial strength as pilot areas, which makes relatively rich areas enjoy more preferential subsidies from higher levels of government, resulting in obvious diminishing subsidy effect.

For local governments, the new rural cooperative medical system is unlucky. Because China is abolishing several agricultural taxes, this means that the fiscal revenue of towns and counties will be further reduced. Although the central government's compensatory transfer payment to local governments has weakened the negative impact of local tax reduction to a certain extent, the problem of financial difficulties at the grassroots level is still very prominent. In economically underdeveloped areas, township enterprises are underdeveloped, coupled with the abolition of agricultural taxes, the rural level relies entirely on state transfer payments to maintain its operation, and the rural level is heavily in debt, resulting in a serious shortage of investment in cooperative medical care, insufficient financial investment and start-up funds, low participation rate of farmers, small fund scale and low system coverage.

Fourth, it is difficult for the voluntary insurance mechanism to avoid adverse selection.

In the cooperative medical system before the reform and opening up, although farmers were required to participate voluntarily, most farmers were guaranteed because of the strong administrative mobilization force and the system based on people's communes at that time. In the efforts to restore and rebuild the cooperative medical system since the middle and late 1980s, farmers were still allowed to participate voluntarily, but their willingness to participate voluntarily was particularly low, which eventually led to the failure of the reconstruction efforts. At present, with the weakening of administrative coercive power, farmers have greater choice, which leads to low-risk people's enthusiasm for participating in insurance.

Because the new rural cooperative medical system only covers less than 20% of the average household health expenses, many farmers may feel that this plan will not play a role in reducing the risk of medical expenses, and their support for the new rural cooperative medical system will be reduced. Therefore, they either don't participate or surrender. If the low-risk policyholders (young healthy people) surrender their insurance first, which is very likely, then the cooperative medical care plan will start to lose money, and then the financing standard may be raised. This will further encourage low-risk policyholders to surrender, so that the insurance plan will gradually shrink and eventually collapse. This is the so-called adverse selection.

Because of adverse selection, that is, healthy people choose not to participate in insurance, the voluntary insurance system is almost unsustainable. International experience shows that adverse selection will quickly destroy and eventually lead to the disintegration of insurance plans based on complete voluntariness. There are high-risk policyholders and low-risk policyholders in any crowd. If insurance is based on voluntary participation, low-risk policyholders will be more willing to insure themselves. Therefore, the basic medical insurance system in industrialized countries is generally mandatory and adopts social insurance.

Five, the designated medical institutions may become the biggest winners, farmers failed to get real benefits.

First of all, health institutions use the new cooperative medical care policy to generate income, which may trigger a new round of focusing on governance and neglecting prevention. The more leading the system reform, the easier it is for health institutions to occupy a leading position in the tilt of serious illness policy and obtain economic benefits. The attention of health institutions is focused on medical treatment, which easily leads to blind increase of equipment and facilities and improvement of treatment level regardless of actual needs, while ignoring the actual improvement of service and preventive health care.

Secondly, transferring funds to public health institutions may lead to backward security and low efficiency. Because the reimbursement of the expenses of the new cooperative medical system is basically limited to the public health system, this not only eliminates the competition between the public health system and the private system, but also partially relieves the market pressure of the unreformed health institutions. As long as it is a public medical institution with poor service and high price, it can also gain some market share through the new cooperative medical care policy. Township hospitals, in particular, were at a disadvantage in the market competition in the past, but due to the tilt of the new policy, township hospitals came back to life.

Thirdly, the rigid selection mechanism of designated hospitals may bring many new problems. Especially in rural areas where the population is scattered, this may mean that patients have to spend more money to see a doctor and go further, or it may mean that the new rural cooperative medical system only brings families from private doctors to public institutions, but it does not actually increase the number of patients seeing a doctor.

Sixth, it is still a difficult problem to control the cost of the new cooperative medical system reasonably.

Another big challenge of the new rural cooperative medical system is the reasonable cost control, that is, the stability and sustainable development of the fund. Like the urban medical security system, the design of the new rural cooperative medical system lacks the synchronous matching of rural medical service system reform and payment mode reform, so that it has to highlight the constraints on patients. In the system design, the deductible line, the capping line, the higher proportion of * * * and the proportional reimbursement by segments are introduced. These practices are conducive to maintaining the balance of the fund, but too strict constraints on patients, especially the high proportion of patients paying, will inevitably lead to a decline in the enthusiasm of participating in insurance.

At present, cooperative medical care still lacks effective institutional constraints on supplier behavior. In many areas, the new rural cooperative medical system is the same as or similar to public medical insurance and labor insurance, and all of them passively reimburse the medical expenses of the insured. This mode of operation is likely to lead to moral hazard of medical suppliers and even patients, which may eventually lead to a sharp increase in medical expenses. Some surveys have found that irrational drug use, unreasonable treatment and examination problems in some designated medical institutions are more prominent, and the average hospitalization expenses and outpatient expenses have risen rapidly; There are too many prescription drugs and inspection items other than the basic drug list and the prescribed inspection items, and many expenses are not reimbursed, which not only increases the cost burden of farmers, but also increases the expenditure of cooperative medical fund. Some rural residents have reported that although the medicines bought by the cooperative medical system are expensive, some of them can be reimbursed, but the part they bear has not been effectively reduced, which is no different from buying medicines in other places. After the implementation of cooperative medical care in some places, the overall medical expenses showed an upward trend, and the reimbursable part of rural patients was offset by the rising medical expenses. It is difficult to reduce the medical burden of farmers through cooperative medical care.

Seven, medical insurance does not take care of the growing floating population.

At present, there are about 1 100 million rural floating population in China every year, and more and more rural population flows into cities, which is an important factor to promote economic growth. However, the floating population from rural areas to cities is in a vacuum of medical insurance-they are not eligible to participate in urban medical insurance because they don't have a formal hukou, and the new rural cooperative medical system is likely to require them to go back to their original place of residence for medical treatment, or if they see a doctor in the city where they work, they will bear the risk that the cooperative medical system will only reimburse some medical expenses.

In order to give full play to the economic benefits brought by labor transfer, it is very important to ensure that medical insurance can flow with the migration of policyholders. In the long run, with the further weakening of the gap between urban and rural areas, it may be more reasonable to bring all residents in China into a unified universal insurance system, just as other countries, such as the Philippines, Thailand and Viet Nam, have achieved or are achieving it.

In a word, although the rural medical and health situation in China is still grim, the government is trying to provide medical security for nearly 800 million uninsured people, and has clearly put forward the responsibility of the government to increase investment. The pilot of the new rural cooperative medical system is a bold and historic start. Of course, no policy can be perfect, and there are some defects or many challenges. It is always relatively easy to point out problems, and more challenges come from how to solve these problems and then constantly improve policies, but after all, this is the first step to solve problems. Fortunately, there are many experiences to learn from, including the experience of urban medical reform in the 1990s, several attempts to revive rural cooperative medical care in the past, and the experience of foreign medical and health development. It is reasonable to believe that with the continuous improvement of the policy theme and system of the new rural cooperative medical system, it will promote the rural economic and social development in a better direction and promote the formation of a harmonious society with coordinated urban and rural development.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.