Traditional medical insurance system in China

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First, the establishment and development of China medical insurance system

China's medical insurance system was established in 1950s. For a long time, China's medical insurance system is mainly divided into three types, one is the labor insurance medical system suitable for employees of enterprises, the other is the cost-sharing medical system suitable for staff of government agencies and institutions, and the third is the cooperative medical system suitable for rural residents.

The medical system of labor insurance was established according to the Labor Insurance Regulations of People's Republic of China (PRC) promulgated by the State Council on February 26th, 2004. This system is mainly applicable to employees of state-owned enterprises and some collective enterprises. Labor insurance medical expenses shall be borne by the enterprise before 1953; 1953 changed to 5% ~ 7% of the total wages according to the nature of the industry. 1969, the Ministry of Finance issued a regulation requiring the central state-owned enterprise incentive fund, welfare fund and medical and health expenses to be extracted together, and the employee welfare fund extracted uniformly at 1 1% of the total wages of the enterprise is directly included in the cost. The main contents of labor insurance medical care include: (1) employees declare medical or non-work-related expenses to the group, and the required medical expenses, operation expenses, hospitalization expenses and general medical expenses are all borne by the enterprise, while the expensive medical expenses, hospitalization expenses and medical expenses are borne by myself. If my financial situation is really difficult, I can make appropriate subsidies under the labor insurance fund. (2) If the employee stops working for medical treatment due to illness or non-work-related injury for less than 6 months, the enterprise will pay him sick pay, which is 60% ~ 100% of his salary. If medical treatment in the border areas is stopped for more than 6 months, the monthly disease relief fee will be paid under the labor insurance fund, and the amount is 40% ~ 60% of my salary until I can work or be disabled or die. (three) the employee is sick or injured at work, and after the medical treatment, he is recognized as disabled and completely incapacitated. After resigning, stop paying holiday wages or sickness relief funds, and pay non-work injury relief funds under labor insurance. The criteria for determining disability benefits are: 50% of his salary will be paid to those who need help in daily life, and 40% of his salary will be paid to those who don't need help in daily life until he recovers his working ability or dies. Time limit. (4) When an employee's immediate family member falls ill, he can make a free diagnosis and treatment in an enterprise medical clinic, a hospital, a specialized hospital or a specialized Chinese and Western doctor. The expenses for surgery and general drugs shall be borne by the enterprise 1/2. In view of the heavy burden of enterprises and the state on labor insurance and medical care, the Ministry of Labor and the All-China Federation of Trade Unions issued the Notice on Several Issues Concerning Improving the Labor Insurance and Medical Care System for Enterprise Employees in April, 1966, which made some new provisions on labor insurance and medical care, such as stipulating that the registration fee and visiting fee for employees should be borne by employees; Expensive drugs needed for medical treatment shall be borne by enterprises, but the expenses for taking nourishing drugs shall be borne by employees.

The system of free medical care was established in June 1952, and the State Council issued the Instructions on Free Medical Care for the staff of state organs of people's governments at all levels, political parties, organizations and their subordinate units. The implementation scope of free medical care system includes the staff of state organs, political parties and people's organizations at all levels who are divorced from culture, education, scientific research, health, sports and other institutions, revolutionary disabled soldiers, college students and so on. Free medical care funds come from the financial budgets of the state and governments at all levels, and are managed and used by health administrative departments or financial departments at all levels, and are spent from the "free medical care funds" project of the unit, which is earmarked for special purposes. The medical expenses, operation expenses, hospitalization expenses, outpatient expenses or medicine expenses stipulated by the engineer in the hospital for outpatient and hospitalization of public medical personnel shall be shared by the medical expenses; However, the food and medical expenses for hospitalization shall be borne by the patient himself. According to the actual difficulties, the organ may grant subsidies and reimburse them within the administrative funds.

The cooperative medical system is mainly suitable for rural areas. Different from labor insurance medical care and public medical care, it is not established by national legislation and has no financial support from the state. Instead, it is a mutual aid system in which rural areas raise medical funds through collective and individual funds and provide medical and health services for farmers. The cooperative medical system appeared in the late 1950s and was widely implemented in the mid-1960s. 65438-0965 The Central Committee approved the report of the Party Committee of the Ministry of Health on putting health work in rural areas, emphasizing the strengthening of rural primary health care and promoting the development of rural cooperative medical system. By the end of 1965, some cities and counties in more than ten provinces, autonomous regions and municipalities directly under the central government had implemented cooperative medical care, and by the end of 1976, 90% of farmers in the whole country had participated in cooperative medical care. The rural cooperative medical system is based on the collective economy and the principle of farmers' voluntary participation. The cooperative medical fund takes the form of collective investment and individual fund-raising. The principle of cooperative medical care is to live within our means, and people only need to pay a small amount of medical expenses, most of which can be reimbursed from the cooperative medical fund. Therefore, the system has been widely welcomed by farmers and has become an important part of village collective welfare. However, since the late 1970s, due to the reform of rural economic system, the household contract responsibility system has been widely implemented, which has made the rural cooperative medical system lose its original economic foundation and led to its almost extinction in the whole country.

Second, the problems and disadvantages of China's traditional medical insurance system.

China's medical insurance system has played an important role in protecting workers' health and promoting social and economic development since it was established in the 1950s. However, with the deepening of the national economic system reform, the original system has been difficult to adapt to the requirements of the current system, and the defects and contradictions in spring have become increasingly prominent. The main questions are:

First, the range of people enjoying medical insurance is narrow. China's traditional medical insurance system is only applicable to the staff of government institutions, state-owned enterprises and some collective enterprises. Other workers in cities and towns, especially those in non-public enterprises such as private enterprises, most employees of foreign-invested enterprises and employees of individual economic organizations, do not have basic medical insurance, and their medical health cannot be effectively guaranteed. Judging from the adjustment and reform of China's economic structure, the development of non-public enterprises will be faster and faster, and there will be more and more employees, so they must be given the necessary medical security.

Second, the medical expenses are entirely borne by the state and enterprises, and the increasing medical expenses increase the burden on enterprises and the state. According to the provisions of the traditional medical insurance system, medical expenses are borne by the state and enterprises, and individual employees do not need to pay. According to statistics, from 65438 to 0978, the state spent 2.7 billion yuan on free medical care and labor insurance medical expenses. 1990 reached 27.6 billion yuan, 1994 reached 55.8 billion yuan and 1997 reached 77.4 billion yuan. Compared with 1978, 1977 has increased by nearly 28 times, with an annual growth rate of 19%, while the national fiscal revenue has only increased by 6.6 times, with an annual growth rate of 1 1%. In other words, the growth rate of medical expenses of employees in this period has exceeded the growth rate of national fiscal revenue in the same period. The sharp rise in medical expenses has made the national finance unbearable, and at the same time it has increased the difficulties of enterprises.

Third, there is a lack of scientific and effective methods for the management of medical insurance premiums, resulting in serious waste of medical expenses. Due to the lack of effective control mechanism, some medical units often blindly prescribe drugs beyond the pathogen's condition in pursuit of unit interests and personal interests, and many expensive drugs, nutritional supplements and even non-medical supplies are prescribed, which greatly increases the expenditure of medical expenses. Because employees don't have to pay fees, they also lack the awareness of saving, and even "one person pays at public expense, and the whole family benefits", resulting in many unreasonable medical expenses.

Fourth, the socialization of medical insurance is low, and it is difficult to play the role of insurance socialization. Medical insurance premiums are all allocated by the state or paid from enterprise welfare, and there is no overall mechanism for medical expenses. Especially in the aspect of labor insurance medical care, the medical expenses and management of employees are completely contracted by enterprises, resulting in a heavy burden on enterprises. Some enterprises with poor benefits or enterprises on the verge of bankruptcy cannot reimburse the medical expenses of employees, and the reasonable interests of employees cannot be guaranteed.

Third, the reform of the medical insurance system in China.

Since 1980s, China began to reform the medical insurance system. . 1988 with the participation of relevant departments in the State Council, a national seminar group on medical system reform was set up, and on the basis of extensive investigation, research and demonstration, the "Trial Scheme for the Reform of Employees' Medical Insurance System (Draft)" was drafted. The proposed reform direction is: gradually establish a multi-form and multi-level employee medical insurance system suitable for China's national conditions, with reasonable expenses shared by the state, units and individuals and high degree of socialization. After the proposal was put forward, we began to choose to reform the employee medical insurance system in some cities. From 65438 to 0989, Dandong, Siping, Huangshi and Zhuzhou became pilot cities for medical reform. 1993165438+10, the third plenary session of the 14th CPC central Committee made the "the Central Committee of the Communist Party of China's decision on some issues concerning the socialist market economic system", which clearly put forward the reform direction of "the pension and medical insurance for urban workers shall be shared by units and individuals, and the social pooling and individual accounts shall be combined". In order to meet the requirements of the socialist market economic system,1April 1994, with the approval of the State Council, the State Commission for Economic Restructuring, the Ministry of Finance, the Ministry of Labor and the Ministry of Health issued the "Pilot Opinions on the Reform of Workers' Medical System", proposing that the goal of the reform of workers' medical security system is to establish a social insurance system for all urban workers by combining medical pooling funds with individual medical accounts. According to the pilot opinions, the State Council decided to carry out the pilot reform of medical insurance system in Jiujiang and Zhenjiang. 1in may 1996, the general office of the State Council, on the basis of summing up the reform experience of Jiujiang and Zhenjiang, forwarded the "notice on expanding the pilot reform of the medical insurance system for employees" issued by the state commission for economic restructuring and other four ministries, and decided to expand the pilot market of the medical insurance system reform from the second half of 1996. By June 1998 and 1, 40 cities across the country had carried out pilot medical reform, which accumulated experience for establishing the national basic medical insurance system for urban workers.

In order to promote the comprehensive reform of the medical insurance system, in February, 1998+65438, the State Council issued the "Decision on Establishing the Medical Insurance System for Urban Employees" (hereinafter referred to as the "Decision"), and decided to reform the medical insurance system for urban employees nationwide. The main task of medical insurance system reform is to establish the basic medical insurance system for urban workers, that is, to adapt to the socialist market economic system and to establish a social medical insurance system to ensure the basic medical needs of employees according to the affordability of finance, enterprises and individuals. The decision also clarified the principles of establishing a medical insurance system for urban workers: first, the level of basic medical insurance should be compatible with the development level of productive forces in the primary stage of socialism; Second, all employers and their employees in cities and towns should participate in basic medical insurance and implement the principle of territoriality; Third, the cost of basic medical insurance is shared by both employers and employees; Fourth, the basic medical insurance fund combines social pooling with individual accounts. The specific contents include:

1, coverage rate

The basic medical insurance covers all employers in cities and towns, including enterprises, organs, institutions, social organizations, private non-enterprise units and their employees. Enterprises include state-owned enterprises, collective enterprises, foreign-invested enterprises and private enterprises. As for township enterprises and their employees, owners of urban individual economic organizations and their employees, due to their particularity, whether to participate in basic medical insurance is decided by the people's governments of provinces, autonomous regions and municipalities directly under the central government. In terms of coverage, the basic medical insurance system has the widest coverage among all social insurance projects in China at present.

2. Overall planning level

At the level of overall planning, we should not only consider the mutual aid function of medical insurance fund and its anti-risk ability, but also consider the difference of medical consumption level in regional economic development. The "Decision" requires that the basic medical insurance system should, in principle, take the administrative region at or above the prefecture level as the overall planning unit, or take the county (city) as the overall planning unit, and the three municipalities directly under the Central Government of Beijing, Tianjin and Shanghai should, in principle, implement overall planning within the whole market.

3, the principle of territorial management

The basic medical insurance implements the principle of territorial management and does not engage in industry co-ordination. All employers and their employees shall participate in the basic medical insurance in the overall planning area in accordance with the principle of territorial management, implement unified policies, and implement unified collection, use and management of basic medical insurance funds. Cross-regional enterprises and their employees with large production activities such as railways, electric power and ocean transportation can participate in basic medical insurance in different places in a relatively centralized way.

4. Payment ratio

The basic medical insurance premium is paid jointly by the employer and the employees. The employer's contribution rate is controlled at about 6% of the total wages of employees, and the employee's contribution rate is generally 2% of his salary. With the development of economy, the contribution rates of employers and employees can be adjusted accordingly.

5. Unified account combination

That is, the establishment of basic medical insurance funds and personal accounts. The medical insurance fund consists of overall funds and individual accounts. All the basic medical insurance premiums paid by employees are credited to personal accounts. The basic medical insurance premium paid by the employer is divided into two parts, one part is to establish a unified fund, and the other part is to establish a personal account. The proportion of individual accounts is generally about 30% of the employer's contribution, and the specific proportion is determined by the overall planning area according to the payment scope of individual accounts and the age of employees. The overall fund and individual account shall delimit their respective payment ranges, and shall be accounted for separately, and shall not occupy each other. Determine the qifubiaozhun and the maximum payment limit of the overall fund. In principle, the qifubiaozhun is controlled at about 10% of the average annual salary of local employees, and the maximum payment limit is controlled at about 4 times of the average annual salary of local employees. Medical expenses below Qifubiaozhun shall be paid by individual accounts or individuals. Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid from the overall fund, and individuals also have to bear a certain proportion. Medical expenses exceeding the maximum payment limit can be solved by means of commercial medical insurance. The specific qifubiaozhun, maximum payment limit and personal burden ratio of medical expenses above the qifubiaozhun and below the maximum payment limit of the overall planning fund shall be determined by the overall planning area according to the principle of balance of payments.

6, medical insurance fund management and supervision

In the management of the basic medical insurance fund, it is required to bring the fund medical insurance fund into the management of special financial accounts, which shall be used for special purposes and shall not be misappropriated. Social insurance agencies shall be responsible for the collection, management and payment of basic medical insurance funds, and shall establish and improve the budget and final accounts system, financial accounting system and internal audit system. The business funds of social insurance agencies shall not be drawn from Z fund, and financial departments at all levels shall strengthen the supervision and management of basic medical insurance funds. Audit departments should regularly audit the fund revenue and expenditure and management of social insurance agencies, and the overall planning area should establish a medical insurance fund supervision organization attended by representatives of decentralized customs departments, employers, medical institutions, trade union representatives and relevant experts to strengthen social supervision of basic medical insurance funds.

7. Strengthen the management of medical services.

In terms of medical service management, the main reform measures are as follows: First, determine the service scope and standard of basic medical insurance. The labor department shall, jointly with the Ministry of Health, the Ministry of Finance and other relevant departments, formulate the scope, standards and methods for accepting medical expenses for basic medical services. Formulate the national basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and corresponding management measures. The second is to implement the management of designated medical institutions and designated pharmacies. Social insurance agencies are responsible for determining medical institutions and designated pharmacies, and signing contracts with designated medical institutions and designated pharmacies to clarify their respective responsibilities, rights and obligations. It is necessary to introduce a competitive mechanism to allow employees to choose a number of designated medical institutions for medical treatment and drug purchase, or sign contracts with prescriptions in a number of designated pharmacies to clarify their respective responsibilities, rights and obligations. It is necessary to introduce a competitive mechanism so that employees can choose a number of designated medical institutions for medical treatment and purchase medicines, or they can buy medicines at a number of designated pharmacies with prescriptions. The third is to carry out cost accounting of medical institutions, implement a separate accounting and management system for medicines, reasonably control the level of medical expenses, standardize medical service behavior, and rationalize the price of medical services. Fourth, actively develop community health services, optimize the allocation of medical and health resources, and include basic medical services in community health services into the scope of basic medical insurance.

8, solve the medical care of relevant personnel.

In view of the medical treatment of relevant personnel after the reform of the medical insurance system, the following principles are adhered to: First, the medical treatment of retirees and the old Red Army remains unchanged, and the medical expenses are solved according to the original funding channels. Second, the medical treatment of disabled revolutionary servicemen above Grade B remains unchanged, and the medical expenses are solved according to the original funding channels, which are accounted for and managed separately by social insurance agencies. Third, retirees participate in basic medical insurance, and individuals do not pay basic medical insurance premiums. Fourth, civil servants enjoy the Medicaid policy on the basis of participating in the basic medical insurance. Fifth, in order not to reduce the existing medical consumption level of employees in some specific industries, enterprises are allowed to establish supplementary medical insurance on the basis of participating in basic medical insurance. The part of enterprise supplementary medical insurance premium within 4% of total wages is paid from employee welfare funds, and the part with insufficient welfare funds is included in the cost after being approved by the financial department at the same level.

1998 after the State Council's "decision" was issued, the reform of the medical insurance system was carried out nationwide. By the end of 2000, all provinces, autonomous regions and municipalities in China, except Tibet, had promulgated the general norms for the reform of the medical insurance system. Among the 349 prefecture-level medical insurance co-ordination areas in China, 320 prefecture-level implementation plans have been approved and promulgated by the provincial government, accounting for 92% of the total, of which 284 prefecture-level implementation plans have been started, accounting for 8 1% of the total, and the number of people covered by medical insurance has reached 43 million. This fully shows that the basic medical insurance system for urban workers is gradually being established.