Author: Guo Jinhui

　　According to the established timetable, many places began to reform the outpatient security mode at the beginning of this year. The core of the reform is the transformation of the security mode of outpatient medical expenses from the individual accumulation type to the fund mutual aid type.

　　This is the first major reform of personal accounts since the establishment of the employee medical insurance system of "combining pooling and accounting" more than 20 years ago.

Different from previous incremental reforms in the field of social welfare, this reform is to improve the level of outpatient protection through structural adjustment and efficiency improvement within the medical insurance fund without increasing the burden of corporate and individual payment.

　　The medical insurance researchers interviewed by China Business News believe that in the past, in the face of new demands in the field of social welfare, incremental reforms were generally adopted to keep the existing parts unchanged. The cost of such reforms is relatively low, but in the face of economic downturn and social security fee reductions Under many pressures such as economic growth and population aging, there is very little room for incremental reforms such as relying on financial subsidies or increasing corporate individual payment.

It is a realistic choice to improve the level of outpatient protection by seeking stock reform and improving the efficiency of the use of medical insurance funds to allocate resources more reasonably to the stock of funds.

　　Lou Yu, a professor at the School of Civil, Commercial and Economic Law of China University of Political Science and Law and director of the Institute of Social Law, told China Business News that no matter from the practice of medical insurance in my country or from the experience of implementing systems in countries around the world, purely accumulative personal accounts are very important. It is difficult to play the function of the law of large numbers in insurance, and it is impossible to realize the sharing of disease risks and the mutual aid of funds on a larger scale.

　　"The use of personal account funds for the overall planning of high outpatient expenses has formed a social consensus. Any reform is a redistribution of interests. In the short term, the reform will damage the interests of some people. How to make reasonable adjustments to those whose interests have been damaged Compensation is also a major issue related to the success or failure of reform." Lou Yu said.

　　Why Individual Accounts Switch to Outpatient Mutual Aid

　　Lou Yu said that since the basic medical insurance system for employees was fully rolled out in my country in 1997, personal accounts have existed as an important medical insurance system until now.

For more than 20 years, a large amount of funds have been accumulated in personal accounts, which has caused a high moral hazard. This is not in line with the medical insurance principle of "protecting the big but not the small", and it is unfair to insured patients who really need to rely on the medical insurance system to solve high expenses.

　　In reality, it is common for insured employees to "not spend enough if they are sick, and not enough for those who are not sick".

On the one hand, more than 80% of the deposited funds in personal accounts lie in the accounts of young people with better health and healthy people, and some young people’s personal accounts have accumulated tens of thousands of yuan; Too little is not enough, and the individual out-of-pocket burden of outpatient service is heavy.

　　The "2021 Statistical Bulletin on National Medical Security Development" shows that the current balance of the pooling fund (including maternity insurance) is 254.277 billion yuan, and the cumulative balance (including maternity insurance) is 1,768.574 billion yuan.

In 2021, the current balance of employees' medical insurance personal accounts will be 171.361 billion yuan, and the cumulative balance will be 1,175.398 billion yuan.

Based on this calculation, the funds accumulated in personal accounts accounted for 40% of the total amount of employee medical insurance funds (overall funds plus personal accounts).

　　Some places have a higher percentage.

According to data from the Hunan Provincial Medical Insurance Bureau, the cumulative balance of the province's employee medical insurance funds in 2021 is 76.739 billion yuan, of which the overall fund is 37.301 billion yuan, accounting for 48.60%; the personal account fund is 39.438 billion yuan, accounting for 51.40%. The proportion of funds, personal account funds have accumulated a lot, and the mutual aid of funds is not strong.

　　In April 2021, the General Office of the State Council issued the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Basic Medical Insurance for Employees", which determined measures to establish and improve the outpatient mutual aid security mechanism for basic medical insurance for employees, broadened the scope of use of personal account funds, and eased the The medical burden of the masses has been reduced, and provincial governments are required to set a transition period of about three years to gradually and orderly achieve the reform goals.

From the second half of 2022 to the beginning of 2023, many places have launched the reform of the outpatient mutual aid guarantee mechanism.

　　How 354 million policyholders benefit

　　The statistical bulletin shows that by the end of 2021, the number of employees participating in medical insurance will be 354.31 million, an increase of 9.76 million or 2.8% over the previous year.

Among them, there were 261.06 million active workers, an increase of 2.7% over the previous year; 93.24 million retired workers, an increase of 3.3% over the previous year.

　　The reform of the outpatient mutual aid security mechanism of employee medical insurance refers to the outpatient expenses of employees covered by medical insurance. In the past, it was mainly guaranteed through personal accounts, but now it is reimbursed through mutual aid, that is, through overall planning.

　　This is a reform that concerns the vital interests of 354 million insured persons. The content of the reform is mainly in three aspects: one is to improve the method of entering personal accounts; the other is to implement family mutual aid; Outpatient reimbursement and coverage.

It not only reduces the size of individual accounts and invests more funds in outpatient insurance, but also expands the scope of use of 1.2 trillion existing individual account funds, improving the efficiency of the use of individual account funds.

　　The pooling of general outpatient clinics is a new guarantee mechanism. Through the internal structural adjustment of the fund, the guarantee level of outpatient clinics has been improved under the premise of not raising additional funds and increasing the payment burden of units and individuals.

The pooling of general outpatient clinics has brought about an increase in security. The sources of funds involved include not only the adjustment funds included in the adjustment of personal accounts, but also the potential tapping within the pooling fund, which reflects the participation and enjoyment of social insurance by everyone.

　　The Hunan Provincial Medical Insurance Bureau stated in the "Policy Interpretation on Improving the Ways of Retiring Employees' Personal Accounts" that from the perspective of rights and interests protection, the rights and interests of personal accounts have not been eroded, and the funds accumulated in the previous personal accounts are still personal rights and interests, which can be used It is suitable for paying personal medical expenses, and at the same time, it is extended to the use of mutual aid among family members.

After the reform, the new credits of general personal accounts will be reduced, but this does not mean that personal protection will be lost, but will be put into the large pool of mutual aid protection, forming a new protection mechanism.

　　Zhu Minglai, director of the Health Economics and Medical Security Research Center of Nankai University, said that the original intention of this reform is to hope that the sick and the elderly who are not in good health can benefit more.

Now some elderly people think that the transfer of funds from their personal accounts has decreased and their interests have been damaged. They are mainly those who are relatively healthy and have enough funds in their personal accounts to buy medicines on a daily basis. For the elderly, the funds in their personal accounts are insufficient. For the elderly with high outpatient expenses, not only will their interests not be damaged, but they can get a higher reimbursement level.

　　"If you only look at the reduction in personal account funds, after the reform, unit payments will no longer be included, and the size of the personal accounts of active employees will shrink, especially for some high-salary workers. There is no question of 'who suffers'." According to Zhu Ming, because social insurance is a risk diversification mechanism, the funds in personal accounts are not salary income, but part of the medical insurance fund. Look everyone will benefit from this reform.

　　Employee medical insurance personal accounts are self-protection and cannot play the role of mutual assistance in social insurance. It is difficult to deal with the economic risks brought about by diseases only by personal strength; Jointly assume and resolve disease risks, realizing healthy people helping sick people, young people helping old people, and people with relatively high income helping people with relatively low income, which reflects the redistribution function of social security and guarantees more support.

　　The Hunan Provincial Medical Insurance Bureau stated in the above-mentioned policy interpretation that the outpatient mutual aid mechanism uses the law of large numbers to resolve the risks of social groups. The number of individual medical insurance accounts differs from the current individual, but from the perspective of the system It is said that mutual aid security has more risk prevention functions.

Employee medical insurance not only includes personal accounts and general outpatient services, but also a series of policies such as outpatient treatment for chronic special diseases, hospitalization treatment, etc., and thus constitutes a complete security system.

　　According to its calculations, after improving the method of crediting personal accounts, Hunan will have a fund of about 9 billion yuan in that year to strengthen outpatient protection.

This money can be turned into a real fund investment in the current period, which can be really used for the sick, especially the elderly, and really used for the payment of medical services.

　　Liao Zangyi said that after the reform of outpatient mutual aid, the amount directly credited to personal accounts will decrease. On the surface, the funds at the disposal of individuals will decrease, but ordinary outpatient medical expenses can be directly reimbursed, which will save money for insured persons in the long run , which is essentially a game between immediate short-term damage and future long-term gain.

For individuals, their medical costs will not increase because of this reform.