<轉載自2023年2月20日 明報 社評>
武漢市出現數千人示威抗議,表達對醫療保障制度改革的不滿,有關部門才急急忙忙地推出很多解釋及說明,以緩解民眾的焦躁情緒。如果細看國務院2021年4月發布的文件,的確可以澄清很多現時的誤會,但改革措施的草率與粗暴地推出,導致因誤解而不滿,地方政府「不宣傳、不交代、不透明」的做法,難辭其咎,現在亡羊補牢未為晚也,中央政府更應該吸收教訓,在推行其他改革措施時避免犯同樣的錯誤。
個人帳戶進帳突然減少惹不滿 統籌帳戶進帳增加但查證無門
醫療保障影響千家萬戶,任何措施變動都不是小事。目前推行引發爭議的改革措施,對所有在職職工及家屬,以及退休人員的福祉,都有影響,任何人發現個人帳戶上的錢「突然」少了,而且降幅還不小,都有理由大動肝火。甚至質疑是否因為政府在防控疫情上花錢太多,醫保基金會「爆煲」,所以減少醫保個人帳戶的額度。
3年疫情嚴防死守,要求所有人不停做核酸檢測,以及其他各種開支,確實花了以億計的額外經費,而這筆帳地方政府一直從醫保基金支出,直到國家醫療保障局2022年5月發出聲明,核酸檢測等防控開支必須由地方政府負責,不能再從醫保基金開支。然而,醫保基金入不敷支的根本原因不在於疫情,而是人口結構問題,老齡化的特徵就是退休人員的比例逐漸增多,勞動力人口逐漸減少,在醫保基金同樣出現供款人數減少、享受醫保人數增多。這恰恰就是這次醫保改革要解決的問題。
醫保基金的操作細節也有很大影響。全國95%的人都參加醫保,是全球覆蓋率最高的國家之一,每名參保人都有兩個戶口:「個人帳戶」和「統籌帳戶」,小病和購買藥品從個人帳戶支出,大病住院手術等從統籌帳戶支出。在職職工由個人和工作單位分別按工資的百分比供款,退休人士免供款,醫保基金則會劃款到所有參保人的個人帳戶和統籌帳戶。由於年輕人少看病,個人帳戶累積很多錢沒花,退休人士則多看病但錢不夠。現在提出的改革是,減少劃款進個人帳戶,增加劃款到統籌帳戶,而從統籌帳戶支出的用途和報銷比例也增加,包括以前不包的門診,以及更大的住院和手術範圍,而且可以將一個家庭所有成員的統籌帳戶攏在一起,成為「家庭共濟」,老人可以用年輕人的統籌基金支付醫療費用。目標希望將個人帳戶的「閒置基金」用在更有效的地方,以達到「社會共濟」目的,連帶家庭共濟的作用,基金就可以使用效率最大化。
任何改革都會造成利益的轉移,個人帳戶的錢少了,很多年輕人根本不察覺,因為很少人會經常去查一個很少用的戶口,但經常看病的退休人士會密切關注個人帳戶動態,發覺每月的進款少了而沒有被通知原因,當然會大發雷霆。若然解釋清楚,退休人士統籌帳戶的每月進款多了,使用範圍更大,他們應該不是「受害者」,從而不會有不滿情緒。問題出在透明度嚴重不足,官方解釋的統籌帳戶「錢多了」,但增加多少則不會在帳戶餘額中顯示,去查的渠道和手續也十分繁複,導致絕大部分人「蒙在鼓裏」。
地方政府推改革事前不說明 官方資料與政策透明度均低
醫保金帳戶餘額顯示不清晰、不透明,是中央政府設計的缺失,而推行醫療改革的地方政府,事前不宣傳,遇到投訴解釋模糊,實在不能接受。這項牽涉全國範圍的改革,由於各省市的財政狀况不一,人口結構也千差萬別,所以必須由各地方政府執行。廣東經濟發達,人口流入數量全國之冠,流入人口以年輕人為主,不會對廣東的醫保基金構成即時負擔。廣州市在推行這項改革時,也曾遇到質疑甚至反對的聲音,一是由於退休公務員的反對聲音有渠道向上反映,二是廣州市政府有足夠的財政能力增加對醫保的補貼,所以沒有出現大規模的抗議行動。其他地方沒有足夠財政能力增加醫保補貼,引發反對行動,在所難免。
從國務院發布的醫保改革文件看,要求從2021年底起逐步推進,並可設3年過渡期。而一些省份,疫情導致經濟下滑,財政收入還沒有緩過氣來之前,就匆匆推出醫保改革。國務院文件還要求:要創新宣傳方式,豐富宣傳手段,廣泛開展宣傳,準確解讀政策。很多省份都沒有做到,直到出現大規模抗議,才匆匆提供解釋和說明,還要「驚動」國家醫保局發消息,澄清醫保基金財政穩健,去年略有盈餘。
現時很多省份的醫保基金官方網站,都沒有及時公布信息,廣東省醫保局公開的收支信息,最新的是2021年11月。而被告知個人帳戶的統籌基金有所增加,但又無法查證,這些一切都是民眾表達不滿的合理解釋。改革不限於一時一事,醫保改革目前在幾個省份沒做好,希望以後的其他省份,以及在其他改革能夠做好,否則政府的其他政策也難以有效推行。
Healthcare Reforms on
the Mainland
In Wuhan, only after
thousands had expressed displeasure in a protest at healthcare security reforms
did the departments in charge explain hastily and clarify profusely to mitigate
their restlessness.
Discovering "out of
the blue" that their personal account has less money — and not just a
little less — can outrage anyone. They may even question whether the Healthcare
Security Fund has run out of money because of government overspending on pandemic
control and if that has led to a cut in the individual insured amount in
healthcare security.
The three-year
watertight defence against the pandemic required everyone to take endless
nucleic acid (PCR) tests. Together with all sorts of expenses, this indeed translated
into an extra expenditure of hundreds of millions of Chinese yuan. Local
governments had been paying these bills with the Healthcare Security Fund until
May 2022, when the National Healthcare Security Administration stated that
expenses incurred in pandemic prevention and control, such as those of nucleic
acid (PCR) tests, must be shouldered by local governments and could no longer
be covered by the Fund.
However, the reason that
the Healthcare Security Fund is unable to balance its books is not the
pandemic, but the population structure. An ageing population is characterised
by a gradual increase in the proportion of retirees and a gradual decrease in
the labour population. Similarly for the Healthcare Security Fund, the number
of people making contributions has decreased, while those enjoying the
healthcare protection have increased. This is precisely the problem the current
healthcare reforms are trying to solve.
The operating details of
the Healthcare Security Fund also have a great impact. Each participant has two
accounts: a "personal" and a "collective account". The
personal account covers expenditures on minor illnesses and medication, while
the collective account pays for those of serious illnesses, hospital care, surgery,
etc. Employees and their employers make contributions by a percentage of their
wages, while retirees are exempt. The Healthcare Security Fund transfers the
money to the personal and collective accounts of all participants.
As young people need not
see the doctor very often, their personal accounts have accumulated a lot of
money, while retirees see the doctor often but do not have enough money. The
reforms proposed now are to reduce money transfers to personal accounts and
increase transfers to collective accounts. Furthermore, it will allow more
reimbursement purposes and higher reimbursement proportions from collective
accounts, including outpatient clinic services and a broader range of hospital
care and surgery uncovered before the reforms. Besides, a family will be able
to pool the money in the collective accounts of all its members to serve as
"family mutual aid", so the elderly can use the funds from the
collective accounts of the young to pay for their medical expenses. The goal is
to put the "idle funds" of personal accounts into more effective use
to achieve "social mutual aid". Together with family mutual aid, it
maximises the efficiency of the Fund.
Despite the official
explanation that "there is more money" in collective accounts, the
difference does not show in the account balance. The way and procedures to
check it are complicated, leaving many "in the dark". The central
government is at fault for designing the unclear and opaque healthcare fund
account balance. It is also unacceptable for local governments to launch no
publicity before implementing the healthcare reforms and offer ambiguous
explanations upon complaints.
Reforms are not a
one-off matter. The healthcare security reforms have not been done well in
several provinces. It is hoped that a good job will be done in other provinces
and for other future reforms. Otherwise, the government will find it difficult
to implement other policies effectively.
內地醫保改革本意好 粗暴推行引誤解抗議
武漢市出現數千人示威抗議,表達對醫療保障制度改革的不滿,有關部門才急急忙忙地推出很多解釋及說明,以緩解民眾的焦躁情緒。
任何人發現個人帳戶上的錢「突然」少了,而且降幅還不小,都有理由大動肝火。甚至質疑是否因為政府在防控疫情上花錢太多,醫保基金會「爆煲」,所以減少醫保個人帳戶的額度。
3年疫情嚴防死守,要求所有人不停做核酸檢測,以及其他各種開支,確實花了以億計的額外經費,而這筆帳地方政府一直從醫保基金支出,直到國家醫療保障局2022年5月發出聲明,核酸檢測等防控開支必須由地方政府負責,不能再從醫保基金開支。
然而,醫保基金入不敷支的根本原因不在於疫情,而是人口結構問題,老齡化的特徵就是退休人員的比例逐漸增多,勞動力人口逐漸減少,在醫保基金同樣出現供款人數減少、享受醫保人數增多。這恰恰就是這次醫保改革要解決的問題。
醫保基金的操作細節也有很大影響。每名參保人都有兩個戶口:「個人帳戶」和「統籌帳戶」,小病和購買藥品從個人帳戶支出,大病住院手術等從統籌帳戶支出。在職職工由個人和工作單位分別按工資的百分比供款,退休人士免供款,醫保基金則會劃款到所有參保人的個人帳戶和統籌帳戶。
由於年輕人少看病,個人帳戶累積很多錢沒花,退休人士則多看病但錢不夠。現在提出的改革是,減少劃款進個人帳戶,增加劃款到統籌帳戶,而從統籌帳戶支出的用途和報銷比例也增加,包括以前不包的門診,以及更大的住院和手術範圍,而且可以將一個家庭所有成員的統籌帳戶攏在一起,成為「家庭共濟」,老人可以用年輕人的統籌基金支付醫療費用。目標希望將個人帳戶的「閒置基金」用在更有效的地方,以達到「社會共濟」目的,連帶家庭共濟的作用,基金就可以使用效率最大化。
官方解釋的統籌帳戶「錢多了」,但增加多少則不會在帳戶餘額中顯示,去查的渠道和手續也十分繁複,導致絕大部分人「蒙在鼓裏」。醫保金帳戶餘額顯示不清晰、不透明,是中央政府設計的缺失,而推行醫療改革的地方政府,事前不宣傳,遇到投訴解釋模糊,實在不能接受。
改革不限於一時一事,醫保改革目前在幾個省份沒做好,希望以後的其他省份,以及在其他改革能夠做好,否則政府的其他政策也難以有效推行。