From the perspective of practical logic, with the deepening of population aging, diversified health needs of residents, continuous transformation of disease spectrum, deepening of urbanization, and significant acceleration of the pace of promoting common prosperity for all people, the structural shortcomings and institutional contradictions of the current medical security system have gradually become prominent. There is still a gap between the maturity, fairness, sustainability of the system and the demands of the people in the new era for more fair, reliable, and higher-level disease medical security. Optimizing and improving the multi-level national medical insurance system has become an inevitable choice to break through the current bottleneck of medical insurance development, promote institutional fairness, and achieve sustainable development of the system. It can effectively divert the pressure of basic medical insurance protection, fully meet the diverse and multi-level medical security needs of the people, and solve the development dilemma of a single system that lacks basic protection, quality improvement, and bottom line stability. The urgent demand of reality requires the prompt implementation of the statutory goal of improving the multi-level national medical insurance system, and to promote the transformation and upgrading of the medical insurance system from "full coverage" to "high-quality full coverage" and from "basic protection" to "multi-level, precise, and sustainable" with greater efforts and more precise measures.

The construction effectiveness and existing shortcomings of China's multi-level universal medical insurance system

Since the 18th National Congress of the Communist Party of China, China's medical insurance reform has adhered to the principle of gradual progress and coordinated promotion. It has successively completed the integration of new rural cooperative medical care and basic medical insurance for urban and rural residents, established a unified basic medical insurance system for urban and rural residents, improved the medical assistance system, cultivated and developed commercial health insurance and charitable medical care, and gradually built a multi-level national medical insurance system framework, including a legal guarantee layer of "basic medical insurance+major illness insurance+medical assistance", a market promotion layer of commercial health insurance and supplementary medical insurance, and a social assistance layer of charitable medical care and medical mutual assistance. Among them, the uniformity and inclusiveness of the statutory medical insurance system continue to strengthen; The rapid development of commercial health insurance and the comprehensive deployment of various types of inclusive commercial insurance have become important supplements to basic medical insurance; Charitable medical care and employee medical mutual assistance are being carried out in an orderly manner. After continuous promotion since the establishment of the National Medical Insurance Administration in 2018, the overall planning level of basic medical insurance has achieved full coverage at the municipal level, and is deepening towards provincial-level planning. The mutual assistance and mutual aid capabilities of the fund are constantly enhancing; The reform of medical insurance payment methods continues to deepen, with the comprehensive implementation of payment based on disease group and disease score (DRG/DIP), which plays an important role in regulating medical service behavior and controlling unreasonable growth of medical expenses; The nationwide unified medical insurance information platform has been established and put into operation, with significantly improved capabilities in remote medical settlement, intelligent supervision, and convenient services. The anti medical insurance fraud mechanism coordinated by multiple departments is becoming increasingly mature, and the modernization level of medical insurance governance continues to improve, providing institutional and technical support for the efficient operation of the multi-level medical insurance system. At present, the participation rate of basic medical insurance in China has remained stable at over 95%, achieving the institutional goal of universal medical insurance and building the world's largest medical security system. By the end of 2025, the number of people participating in basic medical insurance nationwide will reach 1330693900 (including 388561200 employees' medical insurance and 942132700 residents' medical insurance), of which 76.6647 million will be supported by medical assistance funds. The reimbursement ratio for hospitalization expenses within the scope of employee medical insurance and resident medical insurance policies has remained stable at over 80% and around 70% respectively. Outpatient coordination and direct settlement for medical treatment in other places have been fully popularized. Major illness insurance provides secondary reimbursement for high medical expenses of insured people, and medical assistance accurately covers the payment and medical burden of difficult groups. This effectively alleviates the fundamental problem of "difficult and expensive medical treatment" for the masses, completely reversing the high incidence of poverty caused by illness and returning to poverty due to illness in the past, and provides increasingly solid guarantees for consolidating and expanding the achievements of poverty alleviation and continuously improving people's livelihoods. In the same year, the premium income of commercial health insurance exceeded 1 trillion yuan for the first time, with over 11000 medical insurance products on sale and an insurance payout ratio of about 40%. Charitable healthcare is also developing, with various specialized charitable organizations and online personal assistance for major illnesses represented by Shuidichou continuing to expand, playing a beneficial role in helping patients with difficult major illnesses reduce their burden of medical expenses.

While achieving development results, we must also be aware that China's multi-level universal medical insurance system is still in the stage of "preliminary formation and not yet finalized", and its structural contradictions and institutional shortcomings are still prominent.

The basic medical insurance system is not yet fully mature, and the foundation of the system's main body is not yet stable. The pattern of parallel implementation of employee medical insurance and resident medical insurance has existed for a long time, with significant differences in funding standards, treatment levels, and protection mechanisms between the two systems. The problem of uneven protection between urban and rural areas and occupational groups is prominent, and the uniformity and fairness of the system need to be improved. In particular, the funding mechanism for residents' medical insurance lacks flexibility, and individual contributions have not yet been directly linked to residents' disposable income. The dynamic adjustment mechanism for fiscal subsidies is not perfect, and the matching between funding growth and security demand growth is insufficient. In some areas, residents' medical insurance funds face significant pressure on revenue and expenditure, and sustainable operation is facing challenges. At the same time, the personal accounts of employee medical insurance still exist, and the boundaries and functions of major illness insurance and basic medical insurance are blurred, which weakens the overall guarantee effectiveness of basic medical insurance.

The positioning of various levels of security functions is vague, and there are problems of functional misalignment and imbalance. In the construction of a multi-level national medical insurance system, there is actually a structural imbalance of "emphasizing the basics, neglecting supplements, and weak support". The basic medical insurance excessively undertakes differentiated and high-quality protection functions, and the positioning of "basic protection" has deviated. In some regions, the protection benefits have been excessively increased and the scope of protection has been expanded, which has increased the pressure on fund operation; However, the supplementary functions of commercial health insurance and supplementary medical insurance have not been fully utilized, and most commercial insurance products have serious homogenization and insufficient precision in protection. The supply of characteristic products for major diseases, long-term care, and high-end medical care is insufficient, and the guarantee of universal commercial insurance has fallen into a situation of insufficient sustainability. At the same time, the scale of charitable medical care and medical mutual assistance is relatively small, the coverage is limited, and the operation is scattered. The social assistance force is difficult to effectively connect with the gap of statutory medical insurance, and the hierarchical system has not formed a benign pattern of gradient protection and layer by layer complementarity.

The connection between various levels of systems is not smooth, and the overall collaborative efficiency of the system is insufficient. The core advantage of a multi-level national medical insurance system lies in its collaborative linkage and complementary efficiency, but there are obvious barriers to connection between the current hierarchical systems. There is a lack of information, data sharing, and process connection between basic medical insurance, commercial insurance, and charitable medical care. Patients' medical expense reimbursement and assistance have problems such as duplicate declarations, cumbersome processes, and disjointed breakpoints; The reimbursement settlement connection between basic medical insurance, major illness insurance, and medical assistance is not smooth enough, and the multiple protection effects of disadvantaged groups and major illness patients have not been fully released; The disconnect between commercial health insurance claims and basic medical insurance settlements, as well as the lack of precise coordination mechanisms for charitable medical assistance, have resulted in ineffective overlapping of multiple protections for some people, incomplete resolution of high medical expense burdens, and weakened overall protection effectiveness of the multi-level system.

The governance system and supporting mechanisms are not perfect, and the effectiveness of collaborative governance among the "three medical institutions" urgently needs to be improved. The level of refinement in the supervision of medical insurance funds is insufficient, and the collaborative governance mechanism for medical services, medical insurance payments, and fund supervision is not sound enough. Problems such as excessive medical treatment, false medical treatment, and fund waste still occur, and the efficiency of fund utilization needs to be improved; Lack of multi-level collaborative governance mechanism for medical insurance, unclear division of rights and responsibilities among government, market, and society, and lack of unified planning, standardized standards, and assessment mechanisms; The adaptability of insurance coverage and protection for new forms of workers, flexible employment personnel, floating population and other groups is insufficient, and the inclusiveness of the system needs to be improved; The coordination between medical insurance reform and reforms in medical services, pharmaceutical consumables, public health, and other fields is insufficient, and the supporting support for the construction of a multi-level national medical insurance system is inadequate, making it difficult to meet the high-quality development needs of health security in the new era.

Practice path for optimizing and improving the multi-level national medical insurance system

To optimize and improve the multi-level universal medical insurance system, we must build a Chinese path to modernization overall situation with the essential feature of common prosperity and build a healthy China on schedule, adhere to the essential attribute of social security, follow the development law of the medical insurance system, adhere to the system concept, problem orientation, and goal orientation, and truly build a modern medical insurance system with clear responsibilities, clear division of labor, smooth connection, and efficient coordination.

Optimize the basic medical insurance system arrangement and consolidate the foundation of the legal medical insurance subject. One is to strengthen overall coordination, actively promote the integration and optimization of the two basic medical insurance systems for employees and residents, gradually narrow the gap in group protection, and achieve a higher level of fairness and unity in the basic medical insurance for all. The second is to optimize the mechanism of medical insurance financing and benefit adjustment. In particular, we must implement the principle of responsibility based on capacity, focus on promoting the linkage between individual contributions to residents' medical insurance and their disposable income, and eradicate the negative correlation between residents' payment burden and income level, as well as the reverse adjustment of medical insurance benefits; Establish a dynamic growth mechanism for fiscal subsidies, scientifically adjust funding standards based on residents' income levels, medical expense growth, and fund revenue and expenditure, and strengthen the financial responsibility for providing a guarantee for residents' medical insurance and medical assistance; Reform the payment mechanism for benefits, explore the implementation of a personal self funded expense cap system, replace the single fund payment cap, and effectively reduce the high burden on seriously ill patients; Implement insurance and payment reduction policies for special groups such as infants and young children, elderly people, and severely disabled people, to enhance the inclusiveness and benefit of the system. Thirdly, we will actively promote provincial-level coordination of basic medical insurance and strengthen the mutual assistance capacity of funds. Fully implement the "15th Five Year Plan for National Medical Security" and basically achieve the goal of provincial-level coordination of basic medical insurance by 2029, unify fund management, revenue and expenditure accounting, and establish a national medical insurance fund adjustment or special subsidy system to ensure that people in underdeveloped areas enjoy basic medical services universally; Standardize the operation of the major illness insurance system, promote the integrated management and settlement of major illness insurance and basic medical insurance, simplify the reimbursement process, improve the accuracy of protection, and build a solid defense line against major disease risks. The fourth is to precisely strengthen the bottom line effectiveness of medical assistance. Establish a hierarchical and classified medical assistance mechanism, distinguish between different groups such as extremely poor, low-income, low-income, and those who have returned to poverty, implement differentiated assistance standards, and accurately implement insurance payment subsidies and hospitalization expense support; Improve the dynamic monitoring and precise assistance mechanism for poverty caused by illness, achieve full coverage and rescue of medical security for disadvantaged groups, and firmly hold the bottom line of not returning to poverty on a large scale due to illness.

Activate the vitality of market entities and social forces, and fill the gaps in the development of multi-level systems. One is to standardize the development of commercial health insurance and strengthen market-oriented medical security. We should actively guide insurance companies to optimize the supply of health insurance products, abandon homogeneous low-end competition, focus on key areas such as major diseases, chronic diseases, long-term care, high-end medical care, and remote medical treatment, and develop exclusive health insurance products that are precisely adapted, cost-effective, and provide strong protection; Continuously optimizing the development model of inclusive commercial health insurance, improving product iteration, risk management, and sustainable operation mechanisms, connecting the guarantee channels between basic medical insurance and commercial insurance, and effectively meeting the higher-level medical and health security needs of the people. The second is to standardize the development of supplementary medical insurance and improve the level of protection for occupational groups. Encourage enterprises, government agencies, and public institutions to standardize the implementation of supplementary medical insurance, based on the actual situation of the unit, reasonably determine the scope and standards of protection, focus on compensating for the self funded burden of employee medical insurance, and promote the standardized, orderly, and precise improvement of supplementary medical insurance. Thirdly, actively support charitable medical care and medical mutual assistance, and activate social assistance forces. Improve the policy system for charitable medical assistance, facilitate social donation channels, support the development of professional charitable medical institutions, and focus on special areas such as rare diseases, severe chronic diseases, and extremely poor families to provide special assistance; Standardize the operation of employee medical mutual assistance and community medical mutual assistance, expand the coverage of mutual assistance, and make up for the blind spots and shortcomings of legal and market guarantees.

Smooth the linkage mechanism of various levels of systems and enhance the collaborative guarantee efficiency of the system. One is to build an integrated information sharing platform. Under the condition of protecting personal privacy in accordance with the law, relying on the national unified medical insurance information platform, we will break down the data barriers of basic medical insurance, major illness insurance, medical assistance, commercial health insurance, and charitable medical care, realize the interconnection and intercommunication of insured information, diagnosis and treatment information, expense information, and reimbursement information, and provide data support for institutional linkage, precise settlement, and precise assistance. The second is to improve the one-stop settlement linkage mechanism. Fully implement the one-stop settlement of "basic medical insurance+major illness insurance+medical assistance+commercial insurance", simplify the process of handling affairs for the people, and achieve effective connection and synergy of multiple guarantees; Establish a precise docking mechanism for charitable medical care, rely on medical insurance big data screening to identify difficult major illness patients, actively carry out assistance and relief, and transform patients' passive applications into platform active matching. The third is to establish a cross level collaborative linkage mechanism. Clarify the division of responsibilities among the government, insurance institutions, charitable organizations, and medical institutions, establish a normalized collaborative consultation, business docking, and problem resolution mechanism, coordinate and solve the bottlenecks and difficulties in the connection of different levels of systems, and maximize the comprehensive protection efficiency of the multi-level national medical insurance system.

Improve the comprehensive governance of the multi-level national medical insurance system and establish a solid guarantee for the sustainable operation of the system. One is to deepen the comprehensive reform in the field of medical insurance. Continuously promote the reform of medical insurance payment methods, improve the normalized operation mechanism of DRG/DIP payments, perfect the outpatient mutual assistance guarantee mechanism, and optimize the revenue and expenditure structure of medical insurance funds; Strengthen the coordinated reform of medical insurance, healthcare, and pharmaceuticals, standardize medical service behavior, strictly control unreasonable growth of medical expenses, and reduce the pressure on medical insurance funds and the burden of medical treatment on the public from the source by improving the efficiency of medical resource allocation. The second is to establish a sound long-term mechanism for the supervision of medical insurance funds. Building a comprehensive regulatory system that combines intelligent supervision, comprehensive supervision, and social supervision, relying on technologies such as big data and artificial intelligence to achieve dynamic supervision of the entire process of medical insurance funds, cracking down on fraud, excessive medical treatment, and other behaviors, and continuously improving the accuracy and efficiency of fund use. The third is to optimize the medical insurance handling services. Establish a sound dynamic monitoring mechanism for nationwide insurance coverage, with a focus on solving the difficulties faced by new industry workers, flexible employment personnel, and migrant populations in participating in insurance. Improve policies for flexible insurance coverage, remote insurance coverage, and transfer and continuation, and achieve full coverage of insurance coverage and no blind spots in protection; Continuously optimize services such as remote medical settlement, online reimbursement, and convenient inquiry, and improve the equalization and convenience level of medical insurance public services. The fourth is to improve the multi-level medical insurance coordination and promotion mechanism. Promptly introduce a top-level design plan, clarify the development positioning, promotion pace, and assessment standards of each level of system, regulate the business behavior of market entities, guide social forces to participate in an orderly manner, and build a new pattern of modern medical insurance governance led by the government, actively participated by market entities and social forces, and jointly built and shared by the whole people.(Outlook New Era)

Author: Zheng Gongcheng (Professor at Renmin University of China and President of the Chinese Social Security Society)