With the rapid growth of medical expenses and the high level of personal medical expenses, "free medical care" has always been one of the hot topics in the field of people’s livelihood.
Since its establishment more than five years ago, the National Medical Insurance Bureau has repeatedly replied to the proposals and suggestions on free medical care. The National Medical Insurance Bureau believes that under the current social and economic development conditions, the level of medical insurance financing is still not high, the fund support ability is still insufficient, medical insurance still needs to adhere to the basic principles of insurance, it is still necessary for individuals to bear certain medical and health expenditure responsibilities, and the implementation of "free medical care" is not conducive to the long-term stable and sustainable development of China’s medical security system.
The medical insurance experts interviewed by CBN believe that free medical care seems to be a beautiful ideal, but it is difficult to realize it, and it will be restricted by many realistic conditions. China’s financial resources, unbalanced medical resources and other factors determine that China is not suitable for free medical care at present. At present, there are still many pain points and difficulties in China’s basic medical security, which need to be solved by further deepening the universal medical insurance system.
"Free medical care" is not really free.
Free medical care is popularly understood as "seeing a doctor without spending money". Poverty caused by illness or returning to poverty due to illness is a concern of many families. Therefore, realizing free medical care for all is considered as a way to reduce the medical burden of the people.
But "seeing a doctor without spending money" is not the real connotation of free medical care. Free medical care is not free of charge, but "paid" by the government or medical insurance institutions.
Zhang Xiao, director of the Medical Insurance and Social Security Research Center of Southeast University, told CBN that what people generally think of as free medical care means that medical services are free, such as registration, diagnosis and treatment, surgery, hospitalization expenses, etc. In countries that are said to have achieved free medical care, some can be completely free, while others can’t. The representative of free medical care is the National Health Service (NHS) in Britain, but other Commonwealth countries except Britain are not completely free, and the most important reason is the cost.
A study by Jin Weigang, vice president of the Institute of National System of Zhejiang University, shows that according to the relevant information of 170 countries (or regions) collected by scientific research institutions of relevant state departments, the medical security situation of 115 comparable countries (or regions) is compared and analyzed, among which 74 countries (or regions) implement social medical insurance, accounting for 64.3%. At present, only a few countries (or regions) implement "free medical care for all". Therefore, the social medical insurance system has increasingly become the mainstream trend of international medical security development, while "free medical care for all" is not the mainstream model.
Liao Zangyi, an associate professor at the School of Politics and Public Administration of China University of Political Science and Law, said in an interview with CBN that free medical care is not really free for all, but through different financing models, money is paid in advance in the form of taxes and premiums, and then distributed and spent by the government or medical insurance institutions, and finally used by individuals.
From the perspective of foreign countries, there are currently two modes of free medical care. One is that the state runs hospitals, such as planned economy countries such as North Korea. The other is that individual medical treatment is free (free or almost free), and the state raises funds and pays medical expenses. This is common in market economy countries, such as Britain, Canada, Australia, Northern Europe and other countries, which raise medical insurance through high taxes and then provide it to the whole people as social welfare; Germany, Japan and other countries are social insurance models, which are paid by both work units and individuals, subsidized by the government and shared by the whole society; The United States is a pure commercial insurance model, and special people (the old, the disabled and the poor) enjoy free medical security policies.
Zhang Xiao believes that the advantage of "free medical care" for all people is that the concept of this system is to better achieve fairness, and everyone can get basic protection regardless of the economic situation. However, this system needs strong public financial support, and if we want to turn to free medical care, we must increase taxes.
In December, 2021, the National Health and Health Commission’s reply to Proposal No.4768 of the Fourth Session of the 13th National Committee of the Chinese People’s Political Consultative Conference mentioned that public financial funds were taken from the people and used by the people, and the funds needed to implement universal free medical care ultimately came from the people in the form of taxes or social insurance premiums. For a period of time, China did not have all the foundations for implementing universal free medical care.
Some people think that since the new medical reform, China has invested a lot of money in medical and health care, and now the financial investment and other funds are enough to support free medical care, and the cost will not increase after the implementation of free medical care.
In this regard, Zhang Xiao believes that the problem is that a lot of financial investment funds are not really used for the provision of medical services for ordinary people. Public hospitals spend a lot of money on maintenance and construction and large-scale equipment procurement, and it is difficult to change this investment method with the current system in the short term.
"Free medical care" is subject to these conditions.
Liao Zangyi believes that free medical care in Britain and Northern Europe costs all taxpayers’ money. The key to realizing free medical care is to pay taxes, but free medical care only meets the minimum requirements of individuals. There is no free lunch in the world, and free medical care will not be the best.
Cai Haiqing, a master tutor at Jiangxi University of Traditional Chinese Medicine, wrote that in order to alleviate the unbearable problem of government finance caused by the rapid growth of medical expenses, some "free medical care" countries can only find ways to reduce the supply of medical services, and the number of drugs and medical consumables included in the free range and the number of beds in hospitals are strictly restricted or even reduced. In India, for example, public hospitals not only have poor facilities, but also have a serious shortage of beds. There are only 348 kinds of free medicines.
Zhang Xiao believes that the implementation of free medical care requires five conditions, the first is to have very ample financial support, the second is a balanced medical service system, the third is a sound medical security system, the fourth is to have a reasonable allocation of medical resources, and the fifth is legal and policy incentives, such as the reform of doctors’ salary system and legal protection.
Judging from the situation in our country, at present, public hospitals are the mainstay in our country, and the construction of medical facilities, the training and salary of medical personnel, and the recruitment of medicines all need financial support. If free medical care is to be implemented, these should be classified as financial payment, which is a burden for finance.
According to the Statistical Bulletin on the Development of China’s Health Care in 2021, the total national health expenditure in 2021 is estimated to be 7,559.36 billion yuan, and the total health expenditure accounts for 6.5% of GDP. From the international comparison, the proportion of China’s total health expenditure to GDP is far lower than that of developed countries, accounting for only half of that of Britain.
"Financial pressure is the first obstacle to free medical care, especially for developing countries, the pressure of medical investment is very great. The insufficient and unbalanced development of medical resources in China also determines that it is difficult to implement free medical care for all. If free medical care is implemented, from a fair point of view, all good medical institutions should treat patients all over the country equally, and good hospitals will be overcrowded, so it is difficult to guarantee patients’ right to fair medical treatment. Therefore, to achieve free medical care, medical resources must be rationally allocated, and it is difficult to realize the reconfiguration of medical resources now. " Zhang Xiao said.
Liao Zangyi believes that China’s medical supply is still insufficient in general, especially high-quality medical resources. Free medical care will cause a run on resources to a certain extent, which will aggravate the problem of difficulty in seeing a doctor. Many people understand that there is no threshold for free medical care, and everyone can enjoy medical services equally and freely, but as we all know, no threshold is the highest threshold, and high-quality medical resources and top-level expert teams have always been scarce resources in society. Even to some extent, free medical care will aggravate the severity of "difficulty in seeing a doctor", and there may be patients all crowding into provincial medical institutions, and the result that everyone wants to be satisfied is that everyone is not satisfied.
Do what you can to improve the level of security
Liao Zangyi pointed out that an important reason why China is not suitable for free medical care at present is that the policy of raising medical insurance is basically divided into two ways: employee medical insurance and resident medical insurance. These two methods are part of the personal burden and part of the unit burden, and then the government makes unified financial subsidies, which determines that our medical insurance fund itself is tight. It is our long-term direction and policy for medical insurance departments to solve how to spend every cent of medical insurance money and do their best to do what they can.
CBN combed the responses of the National Medical Insurance Bureau to the proposal of free medical care since 2019, and found that there are two main voices for free medical care. One is to propose free medical care for all people, and the other is to suggest free medical care for specific groups, such as the elderly over 60 years old in rural areas, the elderly over 80 years old, children or people with specific diseases.
Zhang Xiao said that the implementation of "free medical care" for all people is not suitable for China’s national conditions, but it is possible to improve the level of medical security for specific groups within the framework of the medical security system. Every country has such a policy. For example, Japan, South Korea and other aging countries also have special medical insurance policies for the elderly over 85 years old. The key is to do what you can. The amount of funds in the medical insurance fund is limited every year and it is impossible to meet the needs of everyone.
On July 20th, the National Health Insurance Bureau issued the "Reply to Recommendation No.1437 of the First Session of the 14th National People’s Congress", saying that the medical insurance department should speed up the establishment of a multi-level medical insurance system with basic medical insurance as the main body and medical assistance as the backing, supplemented by medical insurance, commercial insurance, charitable donations and medical mutual assistance, continuously improve the service level of medical insurance, and make overall plans to reduce the medical expenses burden of the insured people, including seriously ill patients in rural areas.