Governance of the risk of operating deficits in basic medical insurance funds in China: based on the data from City H for the period 2021-2025.

backgroundThe levels and coverage of the Basic Medical Insurance Fund (BMIF) continue to expand, and its financial position is transitioning from a high-surplus phase to one with increasing deficit risks. Accordingly, research on the governance of deficit risks in the BMIF has become increasingly urgent.

methodDescriptive statistical analyses were conducted on the number of BMIF participants, the income and spending level of BMIF, the spending structure, the distribution of the fund’s settlement hospitals, and the main types of diseases paid (the top 20). This study investigated the correlations between the operating surplus rate of BMIF and the population aging rate, as well as the surplus rate of the critical illness assistance fund. Simultaneously, the Autoregressive Integrated Moving Average (ARIMA (p, d, q)) model was employed to forecast the operational risks of BMIF.

resultsThe number of employees enrolled in the Urban Employee Basic Medical Insurance (UEBMI) scheme shows positive growth, while the number of residents enrolled in the Urban and Rural Residents Basic Medical Insurance (URBMI) shows negative growth. There is a good and increasing trend in the current balance of the Social Pooling Fund (SPF), but a decreasing trend for Individual Medical Savings Accounts (MSAs), and a deficit in Critical Illness Medical Insurance (CIMI); The number of patients seeking medical treatment in allopatry is ever-increasing yearly, and the top ten medical institutions receiving the most medical visits are all high-quality hospitals in the province or top hospitals in China. Furthermore, a phenomenon of palliative chemotherapy in hospital treatments is observed, along with the disorderly outflow of patients for routine post-operative examinations. The surplus rate of the UEBMI is negatively correlated with the population aging rate (r = −0.0185), positively correlated with the surplus rate of the CIMI (r = 0.285), and positively correlated with COVID-19 (r = 0.621). In contrast, the surplus rate of the URBMI is negatively correlated with COVID-19 (r = −0.775). The BMIF operational risk prediction model indicates that the UEBMI in City H is operating stably, whereas the URBMI presents potential risks, with certain regions approaching or falling below the safety threshold.

conclusionThe BMIF in City H is generally operating stably. However, it also indicates that deficit risks are evolving from “periodic fluctuations” to “structural pressures.” The rigid growth in expenditures driven by population aging and the expansion of major illness protection spending (including MSAs and CIMI) jointly constitute the core drivers of deficit risk. Additionally, structural imbalances in cross-regional medical services and public health emergencies also contribute to the deficit risk of the medical insurance fund. Optimizing the population age structure, promoting public health and the quality of life, containing the prevalence of chronic diseases, and establishing a cooperation mechanism between local medical institutions and those in allopatry have become a recipe for avoiding the risk of deficits in the operation of medical insurance funds.