中金 • 联合研究 | 中国商保支付系列1）：现状、困境与破局

Core Viewpoint - The article discusses the current status, challenges, and potential breakthroughs of commercial health insurance in China, emphasizing its significant social management function in addressing the medical expense payment gap and improving healthcare accessibility [2][10]. Current Status - On a macro level, self-paid medical expenses account for a high proportion of total healthcare costs in China, with personal out-of-pocket expenses reaching 2.5 trillion yuan, representing 27% of total healthcare expenditure in 2023 [12]. - The commercial health insurance payout in 2023 was only 0.4 trillion yuan, accounting for 4% of total healthcare costs, indicating a significant gap in coverage [12]. - The basic medical insurance system covers over 1.3 billion people, achieving a participation rate of around 95%, but it is constrained in its ability to further increase payment proportions due to rising healthcare costs and demographic changes [15][21]. Challenges - The effective supply of commercial health insurance is insufficient, primarily due to a lack of industry infrastructure and product development capabilities [5][25]. - The perception of adequate coverage from basic medical insurance leads to a "sufficient protection illusion," which hinders the demand for commercial health insurance [36]. - The insurance industry has historically focused on rapid expansion through high-premium critical illness insurance, which has limited the development of more integrated health insurance products [43][44]. Potential Breakthroughs - Key variables for breaking the current deadlock include reforms in medical insurance payment systems and support from regulatory bodies to enhance industry infrastructure [5][51]. - The promotion of personal account-based medical insurance and long-term care insurance could provide comprehensive health solutions and open new avenues for industry growth [64][65]. - The increasing income levels and the growing middle-income population in China are expected to drive demand for commercial health insurance, creating a favorable environment for its development [62]. Investment Opportunities - The article identifies four main investment themes: leading internet platforms and large insurance groups building commercial health insurance systems, efficient corporate group insurance channels, reinsurers benefiting from health insurance market growth, and pharmaceutical companies gaining from increased commercial insurance payments [6][66].