To implement the Guiding Opinions of the General Office of the State Council on Establishing and Improving the Outpatient Mutual-Aid Protection Mechanism for Employee Basic Medical Insurance, 31 provinces, autonomous regions, municipalities directly under the Central Government, and the Xinjiang Production and Construction Corps have successively issued documents. In line with national requirements, they are improving local employee medical insurance outpatient mutual-aid protection mechanisms, establishing outpatient pooled-payment policies, standardizing outpatient coverage for chronic and special diseases, and adjusting the policy for amounts credited to personal accounts. In some cities in our province, because the proportion previously transferred into personal accounts was higher than the national requirements under this reform, the amount credited to personal accounts has decreased after implementation of the reform.
Although the reimbursement ratio and limits for outpatient pooled coverage have increased substantially, outpatient pooled benefits can only be accessed when medical care is actually needed. As a result, some people have concerns about the outpatient mutual-aid reform: Is outpatient mutual aid using one’s own “money” for others? Is it using young people’s money for the elderly? Why adjust the “money” in personal accounts? Xinhua News Agency reporters interviewed medical insurance experts and industry professionals on these widely discussed questions.
Key Issue One
Is the reform being introduced because the pooled fund has run out of money?
In simple terms, the reform of outpatient mutual-aid protection under employee medical insurance means that outpatient expenses for employees insured under the program, which were previously covered mainly through “personal accounts,” are now reimbursed through “mutual-aid protection,” that is, through pooled coverage.
Some believe the reform is being introduced because the pooled fund has no money and personal account funds are being used to “fill the gap.” In response, Wang Zhen, a researcher at the Institute of Economics of the Chinese Academy of Social Sciences, said this view stems from a lack of understanding of the revenue and expenditure status of China’s employee medical insurance funds.
Data show that in 2019, China’s employee medical insurance pooled fund recorded revenue of RMB 927.9 billion for the year and expenditures of RMB 793.9 billion. In other words, without using accumulated balances, the pooled fund was fully able to balance revenue and expenditure for that year. Therefore, the claim that personal account funds are being used to fill a “gap” in the pooled fund does not hold.
Wang Zhen said the main consideration behind shifting outpatient protection toward a model based primarily on mutual aid and pooled reimbursement is to improve the efficiency of medical insurance fund use, thereby raising the level of outpatient benefits for insured participants.
Key Issue Two
Why adjust the “money” in personal accounts?
After the shift to pooled protection, one obvious change is that a portion of funds previously transferred from the pooled fund into personal accounts is no longer transferred, but remains in the pooled fund for mutual-aid use. As a result, some believe this means “using one’s own money for others” or “using young people’s money for the elderly.”
It is important to understand the meaning of “mutual aid.” It is the essence of insurance, also known as the “law of large numbers”: pooling everyone’s money together for use by those who experience a risk event, such as illness, so that everyone can jointly withstand disease-related risks. Consider this: when people develop a serious illness but their personal account balance is insufficient to pay for it, who will help? And who can guarantee that they will never develop a serious illness while young, or that the money accumulated in a personal account by old age, when illnesses are more common, will be enough to pay for the costs of major disease?
Wang Zhen said that from an insurance perspective, it cannot be said that paying premiums but not using benefits means one has “lost out.” Insurance is designed to respond to risks caused by uncertainty. Of course, individuals can pay medical expenses entirely with their own income and savings, in which case there would be no such thing as “medical insurance.” But both history and reality show that relying completely on individuals to cope with disease risks is unreliable. That is why society values “caring for the elderly in one’s own family and extending that care to the elderly of others; caring for one’s own children and extending that care to the children of others,” and why institutional protection based on “mutual assistance and shared support” has been established.
Key Issue Three
Can outpatient pooled coverage truly reduce the individual burden?
For insured participants, the most direct benefit of including outpatient medical care in pooled coverage is improved benefits: expenses that previously could not be reimbursed can now be reimbursed. However, some are concerned that after outpatient pooled coverage is introduced, certain medicines must be prescribed at hospitals in order to qualify for reimbursement. This could shift many issues that were previously resolved at pharmacies to hospitals, increasing the burden on hospitals and raising individuals’ medical spending.
Wang Zhen explained that, putting aside whether improved outpatient benefits can offset this so-called “increase in medical expenses,” from the perspectives of clinical safety and patient care-seeking behavior, people who needed to go to the hospital before the reform still had to go, and after the reform, those who do not need to go to the hospital still have no reason to do so.
Moreover, the reform has not abolished personal accounts. “Medicines that could previously be purchased at pharmacies can still be purchased at pharmacies, and personal accounts can still be used in the same way as before. Therefore, the personal burden will not increase,” Wang Zhen said.