宏 观 研 究 "十五五"规划系列 2025 年 08 月 26 日 社保改革，新的"破局点"？ ——"十五五"规划系列之二 人口结构快速变化下，社保制度的完善及改革可能是"十五五"期间重点推进领域之一。当前，我国社保 体系现状如何，面临哪些压力？海外社保制度有何经验？ 本文系统分析，供参考。 一、我国社保改革的历史沿革？我国社保体系正从"广覆盖"迈向高质量发展与全国统筹阶段 我国社会保障制度随经济社会发展需求历经多阶段演进。1951 年《中华人民共和国劳动保险条例》初步 建立城镇职工社保制度；1986 年养老保险探索企业与个人共缴的社会统筹，1991 年明确国家、企业、个 人三方共担机制，标志从"企业保险"向"社会保险"转型。1998 年起社保体系加速建设，劳动和社会 保障部成立实现行政统一。2010 年《社会保险法》推动社保制度进入法治化阶段。 眼下，我国社会保障体系正从"广覆盖"迈向高质量发展与全国统筹阶段。2014 年，我国整合新农保与 城镇居民养老保险，建立统一的城乡居民基本养老保险制度，逐步打破城乡社保二元分割；2018 年，通 过建立企业职工基本养老保险基金中央调剂制度。2022 年第三支柱个人 ...

Core Viewpoint - The article discusses the achievements and future plans of China's medical insurance system during the "14th Five-Year Plan" period, highlighting improvements in coverage, fund management, and the introduction of long-term care insurance [1][3]. Group 1: Medical Insurance Coverage - The national basic medical insurance coverage rate remains stable at around 95%, with a cumulative expenditure of 12.13 trillion yuan, averaging an annual growth rate of 9.1% [1][3]. - By 2024, the number of people covered by basic medical insurance is expected to reach 1.327 billion, with long-term care insurance coverage at 190 million [1][3]. - The direct settlement rate for cross-provincial medical expenses exceeds 90%, and the national medical insurance drug list has been unified, totaling 3,159 types of drugs [1][3]. Group 2: Long-Term Care Insurance - The long-term care insurance system is expected to be implemented nationwide soon, as the current pilot programs have shown positive results [4][7]. - As of June 2025, 253 million people are participating in maternity insurance, with cumulative expenditures of 438.3 billion yuan, benefiting 96.14 million people [6]. - The long-term care insurance aims to alleviate the financial burden of daily care for elderly individuals who have lost their ability to care for themselves, addressing the increasing demand for elderly care services [6][7]. Group 3: Fund Management and Regulation - The medical insurance fund is under increasing pressure, and the focus will be on ensuring fund safety and risk assessment during the "15th Five-Year Plan" period [4][8]. - The reform of payment methods has transitioned from a "post-payment" to a "pre-payment" system, promoting efficiency in medical institutions and reducing patient out-of-pocket expenses by approximately 5% year-on-year [9][10]. - The National Medical Insurance Administration has intensified efforts to combat fraud and misuse of medical insurance funds, recovering 16.13 billion yuan in the first half of the year through inspections of 335,000 medical institutions [10][11]. Group 4: Drug Price Governance - The article emphasizes the importance of drug price governance, with the government supporting market-driven pricing while also maintaining oversight to prevent price manipulation [12][13]. - Since 2018, the government has conducted 10 rounds of centralized drug procurement, covering 435 types of drugs, which has helped lower drug prices and improve accessibility [13][14]. - The National Medical Insurance Administration is committed to ensuring fair pricing practices and encourages public reporting of unusually high drug prices [14].

Core Viewpoint - The article highlights the achievements and future plans of China's medical insurance system during the "14th Five-Year Plan" period, emphasizing the stability and expansion of coverage, the financial support for the healthcare industry, and the ongoing reforms to improve the quality and efficiency of medical services [1][2]. Group 1: Medical Insurance Coverage and Financial Support - The basic medical insurance coverage rate has remained stable at around 95%, with 1.327 billion people enrolled in 2024 [1][3]. - Cumulative medical insurance fund expenditure reached 12.13 trillion yuan, with an annual growth rate of 9.1%, providing robust financial support for healthcare services [1][2]. - Nearly 200 billion medical insurance reimbursements were utilized by patients from 2021 to 2024, marking a 1.6 times increase compared to 2020 [3]. Group 2: Multi-tiered Medical Security System - A multi-tiered medical security system is being established, consisting of a unified medical insurance information platform, basic medical insurance, critical illness insurance, and medical assistance [4]. - As of June 2025, 253 million people participated in maternity insurance, with cumulative expenditures of 438.3 billion yuan [4]. - Long-term care insurance has covered 190 million people, addressing the care needs of disabled individuals [5]. Group 3: Regulation and Management of Medical Insurance Funds - The National Medical Insurance Administration has intensified efforts to regulate medical insurance funds, focusing on reducing fraud and ensuring proper fund usage [6][7]. - In the first half of the year, 335,000 medical institutions were inspected, recovering 16.13 billion yuan in misused funds [7]. - The administration has implemented data-driven approaches to enhance the precision of fund management and fraud detection [7]. Group 4: Drug Price Governance - Drug pricing remains a significant concern, with the government encouraging market-driven pricing while maintaining oversight to prevent price manipulation [9][10]. - Since 2018, ten rounds of centralized drug procurement have been conducted, covering 435 drugs, which has helped lower drug prices and improve accessibility [11]. - The administration has taken measures to address abnormal drug pricing, urging companies to adhere to fair pricing practices [12].

Group 1: Healthcare Insurance and Coverage - The national basic medical insurance coverage rate remains stable at around 95%, with an expected 1.327 billion people insured by 2024, representing a 1.6 times increase from 2020 [1][3] - Cumulative expenditure of the medical insurance fund during the 14th Five-Year Plan period reached 12.13 trillion yuan, with an annual growth rate of 9.1% [1] - The multi-tiered medical security system is being established, including basic medical insurance, serious illness insurance, and medical assistance [3] Group 2: Long-term Care Insurance - As of June 2025, 253 million people are expected to participate in maternity insurance, with cumulative expenditures of 438.3 billion yuan [3][4] - The long-term care insurance system aims to alleviate the financial burden of daily care for the elderly and disabled individuals [3][4] Group 3: Medical Fund Management and Regulation - The National Medical Insurance Administration is enhancing the regulation of medical insurance funds to combat fraud and misuse, with 335,000 medical institutions inspected in the first half of the year, recovering 16.13 billion yuan [7] - The transition from a "post-payment" to a "pre-payment" system is being implemented, promoting efficiency in medical institutions and reducing patient out-of-pocket expenses by approximately 5% year-on-year [6] Group 4: Drug Price Governance - The 11th batch of centralized drug procurement has been initiated, emphasizing principles such as maintaining clinical stability and ensuring quality [9] - Since 2018, 10 batches of drug procurement have been conducted at the national level, covering 435 types of drugs, which has helped lower drug costs and improve accessibility [9]

Group 1 - The core viewpoint of the news is the progress in social security reforms and the expansion of coverage for new employment forms, highlighting the significant growth in pension fund management and the implementation of various protective measures for workers [1][3][4] Group 2 - As of June 30, the scale of pension fund investment operation reached 2.55 trillion yuan, indicating a stable management of social security funds [1][4] - The pilot program for occupational injury protection for new employment forms has seen positive results, with 12.34 million insured individuals, reflecting the effectiveness of the program in safeguarding against major accidents [3] - The Ministry of Human Resources and Social Security (MoHRSS) is advancing the national coordination of basic pension insurance and the gradual implementation of delayed retirement age reforms [3][4] - The number of social security card holders reached 1.39 billion, covering 98.9% of the population, with 1.097 billion electronic social security cards issued, covering 77.9% of the population [4] - The MoHRSS is focusing on enhancing fund supervision and management, including measures to combat fraud and improve the regulatory framework for pension fund operations [4]

Group 1 - The annual cap for serious illness insurance for urban and rural residents in Sichuan Province is set uniformly at 300,000 yuan [1][2] - Starting from 2025, for residents who have participated in the medical insurance for four consecutive years, the maximum payment limit for serious illness insurance will increase by 4,000 yuan for each additional year of continuous participation [1][2] - For residents whose medical insurance fund reimbursement is zero in the current year, the maximum payment limit for serious illness insurance will also increase by 4,000 yuan in the following year [1][2] Group 2 - The incentives for continuous participation and zero reimbursement can be combined, with a total increase not exceeding 20% of the original cap for serious illness insurance [1][2] - For individuals who have interrupted their insurance, the maximum payment limit for serious illness insurance will be reduced by 4,000 yuan for each year of interruption, with a cumulative reduction not exceeding 20% of the original cap [2] - Individuals who re-enroll after a break will have their continuous participation years recalculated, but previously accumulated rewards for continuous participation will be retained [2] Group 3 - A waiting period for benefits will be established for individuals who have interrupted their insurance, with a fixed waiting period of three months for those who do not enroll during the concentrated enrollment period [3] - For each additional year of interruption, the variable waiting period will increase by one month, which can be reduced by paying additional premiums [3] - The total waiting period for those who have interrupted their insurance for four years or more will not be less than six months after restoration [3]

Investment Rating - The report does not explicitly state an investment rating for the pharmaceutical industry Core Insights - The report addresses key issues regarding the trends in medical insurance income and expenditure for 2024, the relationship between insurance income and macroeconomic factors, and the policy drivers behind data changes [2] - The basic medical insurance coverage rate is maintained at 95% by the end of 2024, with 1.32662 billion insured individuals, a decrease of 7.27 million from the previous year [4][5] - Basic medical insurance income for 2024 is projected at 3.4913 trillion yuan, a year-on-year increase of 4.2%, with employee insurance income at 2.3733 trillion yuan (up 3.5%) and resident insurance income at 1.1181 trillion yuan (up 5.8%) [21][36] - Basic medical insurance expenditure for 2024 is expected to reach 2.9764 trillion yuan, reflecting a year-on-year growth of 5.5% [36] - The report highlights significant disparities in the surplus rates of resident medical insurance across provinces, with 17 provinces showing positive rates and 14 negative [2] Summary by Sections 1. Medical Insurance Coverage - By the end of 2024, the basic medical insurance coverage rate is solidified at 95%, with 1.32662 billion insured individuals [4][5] - The structure of insured individuals shows an increase in employee insurance participants while resident insurance participants have decreased [7] 2. Income and Expenditure Trends - Basic medical insurance income for 2024 is projected at 3.4913 trillion yuan, with a 4.2% increase year-on-year [21] - Employee insurance income is expected to be 2.3733 trillion yuan, growing by 3.5%, while resident insurance income is anticipated to be 1.1181 trillion yuan, increasing by 5.8% [21] - Basic medical insurance expenditure is projected at 2.9764 trillion yuan, with a year-on-year growth of 5.5% [36] 3. Provincial Analysis - The report notes significant differences in the surplus rates of resident medical insurance across 31 provincial-level units, with 17 showing positive rates and 14 negative [2] 4. Fund Operation Overview - From January to May 2025, the medical insurance fund's operation is reported to be stable, with income of 1.2295 trillion yuan (up 5.9%) and expenditure of 944.3 billion yuan (up 1.2%) [69]

Group 1 - The core viewpoint of the report indicates that the Chinese medical security system continues to improve, with enhanced benefits for the public, stable fund operations, and improved management services [1] Group 2 - As of the end of last year, approximately 1.327 billion people were covered by basic medical insurance, maintaining a coverage rate of over 95%. The total income of the basic medical insurance fund was 3.491337 trillion yuan, while total expenditures were 2.976403 trillion yuan [2] - The number of insured employees reached 37.94834 million, while the number of insured urban and rural residents was 94.71373 million. The average hospitalization cost for insured employees was 11,707 yuan, with a fund payment ratio of 84.8% [2] - The medical expenses for insured residents amounted to 2.031216 trillion yuan, reflecting a year-on-year growth of 3.7%. The number of treatment instances for insured residents was 3.035 billion, increasing by 14.9% [2] Group 3 - Over 90% of discharged patients were covered under the disease-based payment system, with approximately 80% of the fund expenditures for eligible inpatient medical insurance being allocated to this system [3] - Since the establishment of the National Medical Insurance Administration, the cumulative expenditure of the medical insurance fund has reached 16.48 trillion yuan, with an average annual growth rate of 11% [3] - From 2018 to 2024, the sales revenue of newly negotiated drugs during the agreement period exceeded 540 billion yuan, with medical insurance fund expenditures surpassing 370 billion yuan [3] Group 4 - Approximately 253 million people participated in maternity insurance, with fund expenditures reaching 140.293 billion yuan, a year-on-year increase of 19.2% [4] - The long-term care insurance pilot program is progressing steadily, with 18.78634 million participants in 49 pilot cities and 146,250 individuals receiving benefits [4] Group 5 - Last year, there were 397 million instances of outpatient and inpatient care, with medical expenses totaling 786.774 billion yuan. The medical insurance system recovered 27.5 billion yuan through intelligent supervision, saving 3.1 billion yuan in losses [5] - The National Medical Insurance Administration conducted 64 inspection groups, checking 506 designated medical institutions, and awarded 754 individuals for reporting, totaling 1.866 million yuan in rewards [5]

Core Viewpoint - The National Healthcare Security Administration (NHSA) has released the "2024 National Medical Security Development Statistical Bulletin," indicating a stable growth in basic medical insurance coverage and a focus on improving service quality and fund management [2][4]. Group 1: Basic Medical Insurance Coverage - As of the end of 2024, approximately 1.327 billion people are enrolled in basic medical insurance in China, maintaining a coverage rate of 95% [4][5]. - The number of employees covered by medical insurance has increased to 379 million, reflecting a 2.3% growth compared to the previous year [5]. Group 2: Fund Revenue and Expenditure - The total revenue and expenditure of the national basic medical insurance fund (including maternity insurance) for 2024 are projected to be approximately CNY 3.49 trillion and CNY 2.98 trillion, respectively [4]. - The employee medical insurance fund revenue is estimated at CNY 2.373 trillion, a 3.5% increase year-on-year, while expenditures are expected to reach CNY 1.910 trillion, marking a 7.6% increase [7][11]. Group 3: Medical Treatment and Benefits - The number of treatment beneficiaries under employee medical insurance is projected to reach 5.308 billion in 2024, a 9.9% increase from the previous year [13]. - The average hospitalization cost for employee medical insurance participants is estimated at CNY 11,707, with varying costs across different levels of medical institutions [15][18]. Group 4: Resident Medical Insurance - By the end of 2024, the number of participants in urban and rural resident medical insurance is expected to reach approximately 947 million [20]. - The revenue for resident medical insurance is projected to be CNY 1.118 trillion, with expenditures of CNY 1.066 trillion, resulting in a cumulative balance of CNY 818.3 billion [21]. Group 5: Maternity Insurance - The number of participants in maternity insurance is expected to reach 25.3 million in 2024, with a 30.2% increase in the number of beneficiaries enjoying maternity benefits [32]. - Maternity insurance fund expenditures are projected to be CNY 140.293 billion, reflecting a 19.2% increase from the previous year [32]. Group 6: Medical Assistance - In 2024, medical assistance expenditures are expected to reach CNY 79.232 billion, providing support to approximately 79.16 million people participating in basic medical insurance [34]. - The average assistance for hospitalization and outpatient services is projected to be CNY 1,254 and CNY 92, respectively [34]. Group 7: Drug and Medical Supply Management - The 2024 National Basic Medical Insurance Drug List includes 3,159 drugs, with 91 new additions this year [38]. - The implementation of centralized procurement for drugs and high-value medical consumables continues, with 62 drugs included in the latest round of procurement [43]. Group 8: Cross-Region Medical Services - In 2024, the total number of cross-region medical visits is expected to reach 397 million, with associated costs of CNY 786.774 billion [44]. - Employee medical insurance accounts for 262 million of these visits, while resident medical insurance accounts for 134 million [44].

Core Viewpoint - The document outlines the Chinese government's new policy aimed at enhancing social welfare and addressing the urgent needs of the population, with a focus on improving social security, public services, and overall quality of life for citizens [1] Group 1: Social Insurance Expansion - The policy emphasizes the need to increase the coverage and effectiveness of social insurance, particularly for urban employment, flexible employment, and migrant workers, by removing household registration restrictions and improving incentive mechanisms [2][3] - It aims to link medical insurance contributions to residents' disposable income and enhance benefits for low-income families, including setting minimum living and wage standards [2][3] Group 2: Public Service Equity - The document highlights the disparities in public services between urban and rural areas, and among different population groups, calling for improved equity in basic public services and better resource allocation [3][4] - It proposes a mechanism for the coordinated use of existing public service facilities and the inclusion of new service items into national standards based on economic and social development levels [3] Group 3: Education and Healthcare Development - The policy outlines a five-year plan to standardize compulsory education facilities and improve the quality of high schools, while also supporting the establishment of new research universities and enhancing vocational education [4] - In healthcare, it aims to strengthen basic medical services by decentralizing resources to county hospitals and grassroots healthcare, and establishing a remote medical service network [4] Group 4: Diverse and Accessible Social Services - The document stresses the importance of diversifying social service offerings to meet public demand and making these services more accessible and convenient [5] - It sets clear policy directions for inclusive development targeting vulnerable groups such as children, youth, and the elderly, with a focus on enhancing community services [5]