城乡居民基本医疗保险基金运行状况研究——基于覆盖、筹资、待遇的视角

Research on Financial Status of Basic Medical Insurance Fund for Urban and Rural Residents——From the Perspective of Coverage,Financing and Benefits

城乡居民基本医疗保险基金(以下简称居民医保基金)的运行状况取决于基金收支大小,受覆盖面、筹资标准、医保待遇等因素影响。这些因素如何影响居民医保基金的可持续运行?本文运用精算模型发现,若维持2020年的覆盖面、医保待遇等条件不变,居民医保基金将于2036年出现累计赤字,不能实现长期持续运行,且至2050年累计赤字额为99535.25亿元,会出现较大幅度的基金亏空。扩大覆盖面会影响基金收支,但不会改变基金发生当期赤字和累计赤字的节点。无论是2035年还是2050年实现全民医保,基金开始发生当期赤字和累计赤字的节点都分别是2026年和2036年。2050年实现全民医保相较于参保率不变,累计赤字额多出4123.68亿元。由此可见,扩大覆盖面不利于居民医保基金的可持续运行。当基准情境下出现累计赤字时,若只用个人缴费额弥补赤字,2050年个人缴费金额将增加至3249.87元,政府补助金额与个人缴费金额的比例为0.89;若以财政补贴弥补赤字,财政累计额外补贴将达到99535.25亿元;若降低门诊保障待遇以减少基金支出,即使门诊费用报销比例降为0,居民医保基金仍会在2049年出现累计赤字;若降低住院保障待遇以减少基金支出,当住院费用实际报销比例最低降至49.4%时,可以使医保基金2050年不出现累计赤字;若同时降低门诊和住院保障待遇,则门诊和住院费用报销比例最低分别降至41.1%和51.1%的组合可以使2050年不出现累计赤字,实现医保基金的长期平稳运行。

The financial status of the basic medical insurance fund for urban and rural residents(hereinafter referred to as the resident medical insurance fund)depends on the size of the fund's income and expenditure,and is affected by factors such as coverage,financing standards,and benefits.How do these factors affect the sustainable operation of the residents'medical insurance fund?In this paper,the actuarial model is used to find that if the coverage and benefits of 2020 remains unchanged,the resident medical insurance fund will have a cumulative deficit in 2036,which cannot achieve long-term sustainable operation,and the cumulative deficit by 2050 will be 9953.525 billion yuan,and there will be a large fund deficit.The expansion of coverage will affect the fund income and expenditure,but will not change the node where the fund has current deficit and cumulative deficit.Whether universal coverage will be achieved in 2035 or in 2050,the point at which the fund starts to run current and cumulative deficits is 2026 and 2036,respectively.To achieve universal medical insurance by 2050,the cumulative deficit will be 412.368 billion yuan more than the participation rate will remain unchanged.It can be seen that the expansion of coverage is not conducive to the sustainable operation of residents'medical insurance funds.When the cumulative deficit occurs in the baseline scenario,if only the individual contribution amount makes up the deficit,the individual contribution amount will increase to 3249.87 yuan in 2050,and the ratio between the government subsidy amount and the individual contribution amount is 0.89,and if the deficit is covered by government subsidies,the cumulative additional subsidies will reach 9953.525 billion yuan.If the outpatient insurance benefits are reduced to reduce the fund expenditure,even if the reimbursement ratio of outpatient expenses is reduced to 0,the resident medical insurance fund will still show a cumulative deficit in 2049.If the hospitalization insurance benefits are reduced to reduce the fund expenditure,when the actual reimbursement ratio of hospitalization expenses is reduced to 49.4%at least,the accumulated deficit of the medical insurance fund will not appear in 2050.If the outpatient and inpatient insurance benefits are reduced at the same time,the combination of the minimum reimbursement ratio of outpatient and inpatient expenses reducing to 41.1%and 51.1%,respectively,can prevent the cumulative deficit in 2050 and realize the long-term stable operation of the medical insurance fund.