Harmonization of Health Insurance Schemes in China

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1 Harmonization of Health Insurance Schemes in China Hai Fang Professor of Health Economics China Center for Health Development Studies Peking University China Presentation at the First National Conference on Thai Universal Health Coverage November 16,

2 Outline Background information about China. China s health insurance system. Some pilot experiences of harmonizing China s health insurance system. Major issues and future directions in China.

3 China s Population and Economy Population in 2014: 1.37 billion GDP in 2014: USD trillion GDP per capita in 2014: USD 7575

4 China s Health Expenditures Health expenditures in 2014: USD 573 billion (5.55% of GDP) Health expenditures per capita in 2014: USD % is from governments, 38% is from social health expenditures (mainly health insurance), and 32% is from individual out-of-pocket.

5 China Health Insurance System China has a social health insurance system mainly sponsored by governments. Commercial health insurance market share is only about 10% in Social health insurance covered more than 95% of Chinese population in 2014.

6 China s Social Health Insurance Schemes Urban employee-based basic health insurance scheme (UEBMI, launched in 1998), for employed population in urban areas (283 million). Rural new cooperative medical scheme (NCMS, launched in 2003), for rural population (736 million). Urban resident-based basic health insurance scheme (URBMI, launched in 2007), for non-employed population in urban areas (314 million).

7 Financing of Health Insurance Schemes Payroll taxes are the main fund source for UEBMI. Government subsidies are the major revenue sources for NCMS and URBMI (80% of fund is from governments). The per-capita fund for UEBMI is about 7 times higher than that for the URBMI and NCMS.

8 Administration of Health Insurance Schemes The three health insurance schemes are separately administered and operated at national and local levels. NCMS is administered by the National Health and Family Planning Commission (formally the Ministry of Health). URBMI and UEBMI are administered by the Ministry of Human Resources and Social Security.

9 Health Risk Pooling NCMS is pooled at the county level (2,852 rural counties in 2012). URBMI and UEBMI are pooled at the municipal (prefecture) level (333 municipals and prefectures in 2012). There are roughly 2,852 NCMS schemes, 333 UEBMI schemes and 333 URBMI schemes.

10 Benefits of Health Insurance Schemes Universal health coverage in China is only at the insurance coverage level. The benefit packages and financial protection are not equalized within and across the schemes, which is critical barrier for achieving full universal health coverage (UHC). Rural population have more restricted access to health care than urban residents and carry a higher financial burden.

11 Disparities among Health Insurance Schemes Access to health care for the 245 million migrants is also affected by fragmentation of the health insurance schemes. Within the rural region, NCMS offers much higher benefit packages in rich rural counties than those in poor counties as a result of gaps in economic development.

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13 Harmonization of Health Insurance Schemes To establish a consolidated health insurance system by 2020 is one of the main goals in China s current health system reform agenda. Achievement of UHC needs both vertical consolidation (NCMS pool from county level and URBMI and UEBMI pool from municipal level to higher level) and horizontal consolidation (merging the fund pools of the three schemes). Some pilot consolidations have been done in selected areas.

14 Some Pilot Consolidations By the middle of 2014, seven provinces, including Chongqing, Guangdong, Ningxia, Shandong, Qinghai, Zhejiang, and Tianjin, were in the process of consolidating their social health insurance schemes. The practice of consolidating the schemes was also found in some municipal cities (prefectures) outside the provinces noted above.

15 Consolidation of NCMS and URBMI Consolidation of the schemes is usually initiated between NCMS and URBMI because of their similarities in funding sources and levels. Merging NCMS and URBMI administrative offices and staff, creating uniformity of information systems, integrating funding collection and pooling, and unifying benefit packages and provider payment systems are the major elements in the consolidation.

16 Experiences of Dongying, Shandong Province Dongying is a municipal city consisting of three rural counties and two urban districts in Shandong Province. From November of 2012, the municipal government started consolidating NCMS and URBMI in two phases. Phase 1: Consolidation of administrative resources. Phase 2: Consolidation of financing and benefit packages.

17 Phase 1 of Dongying s Consolidation NCMS administration was transferred from the Dongying Department of Health to the Department of Human Resources and Social Security. The NCMS management office and URBMI management office were merged together. Some NCMS staff joined the management office and others were reallocated to other sectors to reduce human resource costs. Information systems were merged.

18 Phase 2 of Dongying s Consolidation Fund pooling and management of NCMS were moved up from the county level to municipal level, integrating with URBMI. An integrated funding collection system was applied to all counties and districts in Dongying. Rural and urban residents were covered by the same benefits package, including reimbursement policies and health care services.

19 Dongying s Changes from the Consolidation Rural residents received a benefits package equivalent to that of urban residents. Drugs in the NCMS list were extended from 523 at village clinics and 785 at township health centers to 2387 (URBMI list). The integration of NCMS and URBMI saved government subsidies 4.4 million US Dollar in 2013 as a result of reduced overlapping enrollments of NCMS and URBMI

20 Consolidating All Three Schemes Some areas also piloted the primary consolidation of NCMS and URBMI with UEBMI, in various forms, including a simplified procedure for the transfer of insurance types and the free selection of different benefit packages under a consolidated health insurance system. However, to our best knowledge, some selected areas tried to merge three schemes in terms of their administrative organizations, but they had not really merged the fund pool with universal benefit packages.

21 Major Challenges of Consolidation A lack of institutional design and guidelines from the national government constitutes one of the most critical constraints. Operation of the consolidated schemes requires higher capacity in administration and information system, and this requisite is not sufficiently met at present. Funding sources are still limited, particularly for NCMS and URBMI.

22 Keys for Consolidating Insurance Schemes Dimensions of fund level. Standards of service provisions. Cost sharing methods. Payment systems.

23 What Shall We Do in the Future Develop a national guideline and action plan. Encourage innovative consolidation pilots. Strengthen political leadership and financial support. Build capacities of the scheme administration.

24 Develop A National Guideline and Action Plan Develop a long-term plan for a national universal health insurance scheme. Risk pool of NCMS can be raised from county level to a much larger risk pool at municipal (prefecture) level. Consolidation of NCMS and URBMI are more feasible than consolidation of all three schemes for their similarities in funding level and benefit packages.

25 Encourage Innovative Consolidation Pilots Before a national or provincial universal health insurance scheme is achieved, a risk adjustment mechanism could be established at provincial and national level based on economic and population characteristics to redistribute risks. Another possible way is to use a family-based mechanism to consolidate the URBMI and UEBMI, in which the fund from URBMI and UEBMI can be pooled and shared by the family members without changing the current premium collection and government subsidies.

26 Strengthen Political Leadership and Financial Support A national guideline for the importance and approaches of scheme consolidation is extremely needed. Consolidation of the schemes must be a part of the government social development agenda as a critical strategy for a justice society. The level of consolidation and responsibility of different levels of government are important issues.

27 Build Capacities of the Scheme Administration The current national authorities in charge of the three schemes have their own advantages. Social Security authorities have rich experiences in administering urban social insurance programs, while health authorities have a better understanding of health care practices and richer experiences in administering health providers. In the long run, an independent authority could be created to specifically administer the insurance system.

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