| 引用本文：邹嘉诚,李绍华.基于多情景模拟的A省职工医保统筹基金可持续性研究[J].中国卫生政策研究,2025,18(11):39-47 |
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| 基于多情景模拟的A省职工医保统筹基金可持续性研究 |
| 投稿时间：2025-11-02 修订日期：2025-11-17 PDF全文浏览 HTML全文浏览 |
| 邹嘉诚1,2，李绍华2,3 |
| 1.东南大学公共卫生学院 江苏南京 210009;2.安徽医科大学卫生管理学院 安徽合肥 230032;3.安徽省医疗保障研究院 安徽合肥 230032 |
| 摘要:目的 系统评估职工医保统筹基金的运行规律与可持续性，为政策优化提供参考。方法 以A省为例，基于收支平衡原理构建动态精算模型，设计7种政策模拟情景，对2024—2050年基金运行趋势进行预测与比较。结果 在无进一步政策干预条件下，基金中长期失衡风险较高；激励生育与放松迁入对短期改善效果有限，仅表现为赤字时点的适度推迟；筹资分担机制改革显著改善基金收入质量；医保支付方式改革有效抑制非人口因素费用增速；渐进式延迟退休通过延长缴费期与推迟支出期增强基金稳健性；异地就医即时结算基金支出压力最为突出；综合改革情景实现统筹基金的最优平衡与可持续运行。结论 未来改革应以延迟退休与医保支付方式改革为主线，协同推进筹资扩基、人口结构优化与异地就医监管，形成多元政策协同治理格局，以实现职工医保基金的中长期可持续运行。 |
| 关键词:职工医保 统筹基金 精算模型 多情景模拟 |
| 基金项目:2020年度安徽高校人文社会科学研究重大项目（SK2020ZD14） |
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| A study on the sustainability of employee medical insurance pooling fund： Multi-scenario simulation evidence from A Province |
| ZOU Jia-cheng1,2, LI Shao-hua2,3 |
| 1.School of Public Health， Southeast University， Nanjing Jiangsu 210009， China;2.School of Health Services Management， Anhui Medical University， Hefei Anhui 230032， China;3.Anhui Provincial Academy of Medical Security Research， Hefei Anhui 230032， China |
| Abstract:Objective To systematically assess the operating dynamics and sustainability of the employees' basic medical insurance pooling fund and provide evidence for policy optimization.Methods Using Province A as a case study， a dynamic actuarial model grounded in the revenue-expenditure balance framework was constructed. Seven policy simulation scenarios were designed to forecast and compare fund trajectories from 2024 to 2050.Results Without further policy intervention， the pooling fund faces a high risk of medium-to long-term imbalance. Fertility incentives and relaxed migration policies have limited short-term effects， serving primarily to slightly delay the emergence of deficits. Financing-sharing reforms significantly improve revenue quality， while provider-payment reforms effectively curb non-demographic cost growth. Gradual postponement of retirement strengthens fund sustainability by extending contribution periods and delaying benefit outflows. Cross-provincial instant settlement exerts the greatest pressure on fund expenditure. A comprehensive reform package delivers the most favorable and sustainable balance across revenue， expenditure， and accumulation.Conclusion Future reforms should center on delayed retirement and provider-payment restructuring， coordinated with contribution-base expansion， demographic optimization， and strengthened oversight of cross-regional medical services， thereby forming a multi-policy collaborative governance framework to ensure the long-term sustainability of the pooling fund. |
| Key words:Employee medical insurance Pooling fund Actuarial models Multi-scenario simulition |
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