中金 • 联合研究 | 中国商业健康险系列2）：由医保改革，看多层次保障体系建设之路

Core Viewpoint - The article emphasizes the increasing pressure on basic medical insurance in China, highlighting the need for a multi-tiered healthcare financing system where commercial insurance can play a crucial role in addressing funding gaps and meeting rising healthcare demands [2][3]. Summary by Sections Current State of Medical Insurance - The medical insurance fund is under significant pressure, with a projected total expenditure of 5.8 trillion yuan in 2024, where medical insurance accounts for 51%, commercial insurance for 7%, and out-of-pocket expenses for 42% [4][6]. - The income growth of medical insurance has been declining, with a year-on-year increase of only 3.9% in 2024, which is lower than the growth rate of expenditures [6][11]. Challenges in Medical Insurance - The income side faces challenges due to rising retirement rates, local fiscal pressures, and declining consumer willingness to spend, impacting the basic medical insurance revenue [11]. - On the expenditure side, the aging population and increasing number of retirees are expected to heighten the pressure on medical insurance payments [11][17]. Reform and Cost Control Measures - The article discusses the nationwide rollout of cost control measures inspired by the Sanming model, which has successfully reduced medical costs while maintaining service quality [11][12]. - Significant measures include the promotion of centralized drug procurement and adjustments to medical service pricing, which have led to a noticeable decrease in overall medical expenditures [13][16]. Future Outlook for Commercial Insurance - The article anticipates a golden development period for commercial insurance as it becomes a vital supplementary payment method to meet the growing demand for high-quality medical services [3][21]. - By 2035, a comprehensive and sustainable multi-tiered healthcare system is expected to emerge, with commercial insurance playing a key role in financing and innovation within the healthcare sector [3][24]. Integration of Commercial Insurance - The integration of commercial insurance into the healthcare payment system is being accelerated through initiatives like one-stop settlement processes, which aim to simplify claims and enhance the role of commercial insurance in hospitals [21][23]. - The introduction of a commercial insurance drug list is expected to facilitate reasonable pricing for innovative drugs, thereby supporting pharmaceutical companies and enhancing the overall healthcare ecosystem [24][30]. Comparative Analysis with Developed Countries - The article draws comparisons with developed countries, noting that the U.S. healthcare system, which is primarily driven by commercial insurance, has established a market-oriented pricing mechanism that incentivizes innovation [28][30]. - In contrast, the UK's National Health Service (NHS) model, while providing universal coverage, has faced challenges in service delivery, leading to increased demand for commercial insurance as a supplementary option [31][32]. Conclusion - The article concludes that the evolution of commercial insurance in China is essential for creating a robust healthcare financing system that can adapt to the changing demographics and healthcare needs of the population [3][24].