1. Health Insurance Reforms in China
YAN, FEI Prof., Chair, Dept. of Social Medicine School of Public Health, Fudan University

2. Outlines General introduction Development of Health Insurance Schemes
Challenges & Strategies

3. General introduction
The goal of the health reform is to establish a primary health care and insurance system to assure that every citizen has equal access to affordable basic health care.

4. Health Insurance Reform
URBMI
The Urban Resident-based Basic Medical Health Insurance
(starting since 2007)
UEBMI
The Urban Employee-based Basic Medical Health Insurance
(launched in Dec. of 1998)
NRCMS
The New Rural Cooperative Medical Scheme
(starting since 2003)
MAF
Medical Assistant Funds for vulnerable people
(introduced between 2003 and 2007)
Supplementary and commercial health insurance plans
Public Welfare Health Insurance
Public agencies
Labour Health Insurance
Enterprises
Cooperative Medical Scheme
Rural residents

5. Health Insurance Schemes
Name
Eligibilities
Management
Service package
Source of fund
UEBMI
Urban employed, pensioners,
& Self-employed workers
Municipal Department of Human Resources and Social Security
Outpatient and inpatient services
The premium is collected in the form of a payroll tax, , 6% of which is provided by employers and 2% is contributed by employees. About 2000yuan in total.
For self-employed, individual premiums.
URBMI
Children, students, elderly,
disabled, other non-working
urban residents
The same as above
inpatient services
and catastrophic illness, outpatient services in some areas
Premiums are pooled at the municipal or prefectural level, and contributed by individual premium and subsidy of government, government subsidies make up over 70 percent of the total fund.

6. Health Insurance Schemes
Name
Eligibilities
Management
Service package
Source of fund
NRCMS
Rural registered residents
County NCMS office
Outpatient and inpatient services
The premium is from individual premium and subsidy of government including local and central government, government subsidies make up over 80 percent of the total fund. The premium for poor is by government.
Medical Assistant
Vulnerable people
Civil Affairs Department
Outpatient and inpatient services. additional reimbursement after general insurance.
The fund is from special budget by government

7. Development of NRCMS History
The RCMS was initiated in the late 1950s in China.
RCMS was developing significantly in the 1960s and 1970s, covering around 90% of Chinese villages by end of 1970s, which were jointly funded by individual contributions and the co-operative economy.

8. Unfortunately, RCMS collapsed in most places of China in the mid 1980s when China’s agriculture sector was privatized. Only about 5-10% of the Chinese rural population, mostly in the richer eastern coastal areas, were still covered by RCMS during the 1990s.

9. Development situation
In 2002 the Central government sponsored a national conference on rural health development in which a document “Decision on further strengthening rural health development”.
The Decision proposed the establishment of new RCMS with financial support from the central government to reduce the number of people living in poverty that is caused by serious illnesses and the payment of expensive medical care.
The NRCMS was launched in July 2003 in over 300 counties.

10. Enrolment
For expanding population coverage, a number of strategies have been implemented, including:
To increase government subsidies.
To increase awareness of the families about benefits of the schemes.
- To change the individual-based to family-based enrolment policy.
- To simplify procedures of enrolment and reimbursements.
- To change timing for premium collection.
- To extend scope of services and benefit package to attract people.

11. Enrollment rate (%) (%)
Data from: China health statistics yearbook 2008,2014,2015

12. Management of NRCMS
Implementing a finance mechanism of a combination of government financial assistance, rural residents enrollment premium, and collective economy support
Transferring payment by the public finance to the middle and western China
Aiding the poor rural residents to join in the NRCMS and get additional subsidy from the Ministry of Civil Affairs
Taking the county as a pooled unit to enhance the risk pooling ability

13. Embodied the main function of the government in the development of the NRCMS
The State Council established a joint-ministry meeting system
Guaranteeing the structure of the NRCMS organization and leadership, and a sound running mechanism.

14. Benefit Package of the NRCMS
(by the end of 2008)
Pooling fund offers to inpatient care for all enrollees, with family medical savings accounts for outpatient care (58.3%)
Overall pooling fund offers to both inpatient and outpatient care for all enrollees. (32.2%)
Overall pooling fund offers to inpatient care (9.4%)
now
Outpatient pooling fund extended
Reimbursement proportion 50% outpatient care, 75% inpatient care

15. The catastrophic diseases covered by NRCMS in most areas
2011
Congenital heart disease of children
Acute leukemia of children
Breast cancer
Cervical cancer
Severe mental illness
End-stage renal disease
Multidrug-resistant tuberculosis
Opportunistic infection of AIDS
2012
Congenital heart disease of children
Acute leukemia of children
Breast cancer
Cervical cancer
Severe mental illness
End-stage renal disease
Multidrug-resistant tuberculosis
Opportunistic infection of AIDS
Lung cancer
Esophageal cancer
Gastric cancer
Colon cancer
Colorectal cancer
Chronic myelogenous leukemia
Acute myocardial infarction
Cerebral infarction
Hemophilia
Type Ⅰ diabetes
hyperthyroidism
Cleft lip and palate
2010
Congenital heart disease of children
Acute leukemia of children

16. Increasing of premium level of NRCMS
Yuan
Increasing of premium level of NRCMS 16

17. million person-times
Reimbursement proportion 50% outpatient care, 75% inpatient care
Data from: China health statistics yearbook 2008,2014 17

18. Financing and expenditure of NRCMS
a hundred million
Financing and expenditure of NRCMS
Data from: website of the National Bureau of Statistics

19. Progress of UEBMI Million people 19
Data from: China health statistics yearbook 2008,2014,2015 19

20. Progress of URBMI Million people 20
Data from: China health statistics yearbook 2008,2014,2015 20

21. （million person-times)
Progress of MFA
（million person-times)
Data from: China health statistics yearbook 2008,2009,2014,2015 21

22. Health care untilisation
2003
2013
rural
urban
Outpatients visit rate（%）
13.9
11.8
12.8
13.3
Un-visit rate (%)
45.8
57.0
22.0
32.9
Hospitalization rate during last year (%)
3.4
4.2
9.0
9.1
Un-hospitalization rate (%)
30.3
27.8
16.7
17.6
Data from: China National health household survey

23. Challenges
Disparities in fund and benefit packages between the schemes.
Lack of mobility for the rural migrants.
Inefficiency in operation of the schemes.
Limited capacity for financial protection.
Cost escalation (providers & users).
Poor quality of medical care.

24. Policy options To unify the three health insurance schemes.
To use cross-region settlement
To raise fund pooling level to increase financial protection. (prefectural, provincial level)
To adjust the contribution between government and individuals.

25. Policy options
To strengthen capacity of management and administration of the schemes.
To use provider payment systems to enhance efficiency performance and quality of care of the schemes.
Cost containment (monitoring, payment methods)

26. Thanks for your attentions!