万亿规模健康险，带病人群为何“可保难赔”

Core Viewpoint - The health insurance industry in China is facing a transformation as it seeks to expand coverage for individuals with pre-existing conditions, despite the current market being largely focused on healthy individuals. The need for innovative products that cater to the "sick population" is becoming increasingly urgent as the market approaches a premium scale of nearly 1 trillion yuan in 2024, with approximately 4 billion people classified as having pre-existing conditions contributing significantly to medical expenses but only a small fraction of insurance premiums [3][4][6]. Group 1: Market Dynamics - In 2024, China's health insurance premium scale is nearing 1 trillion yuan, reflecting a reversal in growth trends from previous years [3]. - Approximately 4 billion people in China belong to the "sick population," contributing about 60% of medical expenses but only 5% of commercial insurance premiums [3][6]. - The health insurance market has historically focused on healthy individuals, leading to a lack of tailored products for those with pre-existing conditions [7][8]. Group 2: Regulatory and Policy Changes - Recent calls from financial regulatory bodies aim to shift health insurance from "insuring healthy individuals" to "insuring individuals' health," encouraging the development of high-value innovative products [4][6]. - Local governments in cities like Shanghai and Chongqing are promoting insurance products that include coverage for the elderly and those with chronic conditions [6][8]. - The insurance industry is awakening to the need for change, with regulatory support pushing for more inclusive insurance offerings [5][7]. Group 3: Product Innovation and Challenges - The market has seen some product innovation, with insurance companies beginning to offer policies that relax pre-existing condition restrictions, such as "no health declaration" products [3][9]. - Despite these innovations, the scale of insurance for individuals with pre-existing conditions remains limited, with the market for such insurance still around 50 billion yuan [8][9]. - The evolution of insurance products from short-term to long-term coverage is seen as a positive step, allowing for better risk management and customer retention [9][11]. Group 4: Future Directions - The next steps for the sick population insurance market involve enhancing the breadth and depth of coverage, particularly for innovative drugs and therapies [12][14]. - The insurance industry is encouraged to transition from being passive payers to active participants in the healthcare ecosystem, integrating with medical and pharmaceutical services [14]. - The key to successful development in this sector lies in aligning risk with pricing, as high-risk individuals may be unwilling to pay higher premiums, which could hinder product viability [14].