news

한어Русский языкEnglishFrançaisIndonesianSanskrit日本語DeutschPortuguêsΕλληνικάespañolItalianoSuomalainenLatina

author: jia yongmin

academic advisor, institute of balance

special researcher, interdisciplinary center, zhejiang university

recently, the national healthcare security administration, together with the ministry of finance and the state administration of taxation, issued the "notice on doing a good job in basic medical insurance for urban and rural residents in 2024", which clearly stated that the fiscal subsidies and personal payment standards for basic medical insurance for urban and rural residents in 2024 will increase by 30 yuan and 20 yuan respectively compared with the previous year, that is, no less than 670 yuan and 400 yuan per person per year respectively.

although this is the first time since 2016 that the new individual contribution standard is lower than the new fiscal subsidy standard, compared with 20 years ago when rural residents only had to pay 10 yuan per year for medical insurance, the increase is already 40 times.

against this background, a video by peking university professor li ling attracted widespread attention.

li ling suggested in the video that a health tax should be levied. she believes that this is more reasonable and scientific, and can benefit more people, especially because capable people should help the weak and incapable.

the "health tax" that li ling mentioned mainly refers to the fact that the individual payment model of residents' medical insurance should be reformed to pay fees according to personal income level, and on this basis, change from voluntary payment to compulsory payment.

li ling said that now about one billion people in china pay for residents' medical insurance, and complete egalitarianism is implemented in terms of financial subsidies and personal contributions.egalitarianism is not equal to fairness. compared with high-income people, this payment method is unfair to low-income people. one of the main goals of medical insurance is fairness. she said that in the future, whether urban or rural residents or employees or non-employees, a certain proportion of health tax or health fee can be levied completely according to personal income. this is a fair system and can truly narrow the so-called urban-rural gap in medical insurance benefits.

this statement won a lot of applause.

so, is the introduction of a health tax really beneficial to low- and middle-income people? can it really bring about fairness in medical insurance?

in the name of fairness, the burden on the middle-income group has increased

as we all know, china's current basic medical insurance system is roughly divided into two parts: employee medical insurance and resident medical insurance. the former covers employees and retirees of urban enterprises and institutions, while the latter is mainly for urban and rural residents, most of whom are rural residents. the number of people covered by resident medical insurance far exceeds the number of people covered by employee medical insurance.

according to the "statistical bulletin on the development of national medical insurance in 2023" released by the national healthcare security administration, as of the end of 2023, 133,389 million people were covered by basic medical insurance nationwide, including 37,095 million people covered by employee medical insurance and 96,294 million people covered by resident medical insurance.

it is worth noting that the number of residents covered by insurance decreased by 20.55 million compared with the previous year, and this downward trend has continued for many years.

li ling said that this is due to the unfair financing method of "personal payment + fiscal subsidy" currently adopted by the residents' medical insurance, which is completely egalitarian. because there is a large gap in the economic income levels of residents in different regions, for families with less economic conditions, the annual residents' medical insurance payment of 2,000 to 3,000 yuan is a huge expense, which will reduce their enthusiasm for payment.

however, li ling herself fell into the trap of "egalitarianism" here. she did not take into account that every family has a structure. the decline in the number of residents participating in medical insurance is largely a result of adverse selection.

teenagers and the elderly are more susceptible to injuries and illnesses, and their medical expenses are relatively high. for economic reasons, some families may decide to purchase medical insurance only for children and the elderly who have no income, while young people with a certain income will choose not to participate.

for the sake of illustration, let's assume that there is a typical rural family with low income, with a total of 6 people: a couple, their two parents, and their two children. according to the current resident medical insurance payment standard, the annual insurance fee for 6 people is about 2,400 yuan.

what would happen if we followed li ling’s suggestion and imposed a health tax on parents with income, while children and the elderly without income did not have to pay?

according to the relevant figures of the national bureau of statistics, the per capita disposable income of rural residents will be 21,691 yuan in 2023. since the average will cover up many problems, let's look at the median disposable income of rural residents, which will be 18,748 yuan in 2023. according to this calculation, the income of this rural family with 6 members is about 110,000 yuan. since we assumed that this family has "low income" before, let's give it a 50% discount, that is, assume that the family's annual income is 55,000 yuan.

in this case, how much health tax does this family need to pay? li ling suggested that "resident medical insurance and employee medical insurance should be integrated" and collected in the form of health tax. currently, the individual and unit payment ratios for employee medical insurance are 2% and 10% of personal wages respectively, and the medical insurance payment ratio for flexible employment personnel in urban areas is generally 8% to 11%.

it is easy to calculate that the health tax this family needs to pay should be around 6,000 yuan per year, and generally speaking it will not be less than 5,000 yuan.

it can be seen that the introduction of a health tax will more than double the medical insurance burden of this family compared to the current level. the assumptions in this example may not be entirely reasonable, and the calculation process may also have many loopholes, but it can at least provide some inspiration.

li ling also said in the video that now even elderly people over 80 years old with no income must pay to enjoy medical insurance benefits, which is too unfair! however, this problem has been basically solved under the current institutional framework, because local governments have introduced policies to provide classified subsidies for the personal payment part of the residents' medical insurance for the needy. for example, in shandong province, in 2023, medical assistance subsidized 1.888 million needy people to participate in residents' medical insurance.

in fact, a little analysis shows that the health tax is largely aimed at the more than 200 million "flexible employment workers".

formal employees have already paid a percentage of their salary (about 10% for the individual plus the company), so they are basically unaffected and cannot raise more funds. flexible employment workers can participate in urban and rural medical insurance, and only need to pay a few hundred yuan a year. however, if they pay the "health tax", they will have to pay at least a few hundred yuan a month based on a certain percentage of their income (because there is no company to pay for them).

under the current economic situation, how can we bear to sharpen our knives against this group?

it is easy to talk about big principles, but policy making cannot be taken for granted

li ling said that one of the goals of the medical insurance system is fairness. fairness should not be egalitarianism, but people with ability should help people with low incomes, healthy people should help sick people, and young people should help old people. the model of paying according to personal income is just like collecting taxes, which can achieve relative fairness in income and the same proportion of medical insurance reimbursement for each person in terms of expenditure. this is the real equalization.

such truths seem to be very convincing.

however, under current social conditions, can the imposition of a health tax really narrow the gap in urban and rural medical insurance benefits and promote fairness?

this involves the problem of reverse subsidy of medical insurance. fundamentally speaking, medical insurance is still a mutual aid and mutual assistance institutional arrangement to a large extent. most people pay for medical insurance that they don’t need for the time being, but it can help a very small number of people with serious diseases through this channel. this kind of mutual aid insurance is naturally difficult to avoid adverse selection and reverse subsidy.adverse selection is easy to understand, that is, healthy people tend not to take out insurance, while people with more serious illnesses are more willing to take out insurance.

reverse subsidies refer to subsidies provided by people with lower incomes and less access to medical services to people with higher incomes and more access to medical services.let's take a simple example. suppose a poor person and a rich person have the same serious disease, which costs one million yuan to cure, and the reimbursement rate is 80%. then the poor person may decide not to get treatment because he cannot afford the 200,000 yuan that he needs to pay out of pocket. in this case, only the rich person can enjoy the benefits of medical insurance reimbursement, and part of the money reimbursed to the rich person is paid by the poor person.

reverse subsidies can also occur between regions. when all places within the medical insurance pooling area are required to implement a unified reimbursement ratio, the actual reimbursement and treatment levels that regions with abundant medical resources can receive may be much higher than those in regions with scarce medical resources. in addition, regions with scarce medical resources are also regions with low medical insurance fund income, resulting in regions with low medical insurance fund income and few medical resources providing reverse subsidies to regions with high medical insurance fund income and abundant medical resources.

if we look at the health tax from the perspective of reverse subsidy, we will find that it may be difficult for it to fulfill its promise to reduce the urban-rural medical insurance gap and promote fairness.

the above analysis has actually shown that the essence of levying a health tax is, to a large extent, to force more than 200 million "flexible employment personnel" to pay more for medical insurance, thereby increasing the income of the medical insurance fund on the one hand, and helping local governments to unload (at least part of) the financial burden of subsidizing medical insurance on the other hand.

more importantly, given the current income gap between urban and rural residents and the uneven distribution of regional medical resources, the introduction of a health tax is likely to lead to the following consequences:more than 200 million "flexible employment workers" are asked to pay to improve the medical insurance benefits of higher-income groups in cities, while the medical insurance benefits of vulnerable groups such as the elderly in rural areas may decrease in relative terms, thus causing greater unfairness.

the mechanism here is not difficult to understand: rural elderly people have much fewer opportunities to receive medical services than urban residents (especially retired or resigned urban residents) due to their low income, insufficient medical resources in their area, and the inconvenience of seeing a doctor (such as long distances and "not even being able to find their way around the city"). therefore, the medical insurance benefits they can actually enjoy are relatively much less than those of urban residents.

in fact, this means that, to a certain extent, the health tax paid by young people who move from rural areas to cities for "flexible employment" will be spent more on urban residents rather than their elderly parents.for example, the extra medical insurance fees paid by the couple will be used to improve the medical insurance benefits of urban residents (especially retired or resigned urban residents) rather than to improve the medical insurance benefits of their parents and children. it seems difficult to say that this promotes fairness.

although it is not possible to find direct evidence from existing statistical data for the time being, indirect evidence is not difficult to find.

the "statistical bulletin on the development of national medical insurance in 2023" shows that in 2023, the number of employees insured will enjoy benefits reached 2.53 billion, and the number of residents insured will enjoy benefits reached 2.61 billion.

in addition, the comparison of hospitalization rate and hospitalization cost also provides indirect evidence. in 2023, the hospitalization rate of employees covered by the employee medical insurance was 21.86%, of which the hospitalization rate of employed employees was 11.93% and the hospitalization rate of retired employees was 49.02%. the average hospitalization cost per visit was 12,175 yuan, and the average hospitalization bed day per visit was 9.8 days. in contrast, the hospitalization rate of residents covered by the resident medical insurance was 20.7%, the average hospitalization cost per visit was 7,674 yuan, and the average hospitalization bed day per visit was 8.8 days.

it is noted that the number of people covered by residents' medical insurance is almost three times that of employees' medical insurance. at the same time, rural residents account for the majority of the people covered by residents' medical insurance. the above figures can undoubtedly explain many problems.

moreover, this substantial unfairness may be further exacerbated by medical insurance cost control. for example, an important aspect of medical insurance cost control is the centralized procurement of drugs and medical equipment. one consequence of centralized procurement is that many highly effective drugs are no longer included in medical insurance or are only available in large hospitals in some large cities. rural residents may face an even more unfair situation.

finally, let me mention two more points.

first, changing voluntary medical insurance premiums into compulsory taxes must be done with extreme caution, because it means a significant reduction in personal choice rights, and the reduction in personal choice rights cannot be without other consequences.

secondlythe term “health tax” itself may also be inappropriate because in the fields of economic theory and public policy, the term health tax has always had a clear meaning, referring to consumption taxes on products that may harm health, such as tobacco, alcohol, and sugary drinks.

when discussing whether to raise medical insurance funds through taxation, it may be more appropriate to use "medical insurance tax" rather than "health tax". however, perhaps health tax is more eye-catching.

this article is an original article specially commissioned by the phoenix news commentary department and only represents the author's views.

editor: liu jun