河南师范大学学报(哲学社会科学版)

基本医疗保险是检视城镇职工福利政策执行的重要民生福祉，统筹基本医疗保险基金稳健发展是制度可持续运行的保证。本文以结余较高的基金统筹区E市为例，基于现行筹资、待遇政策，构建职工医保统筹基金收支预测模型，结合职工门诊共济保障改革方向设置无政策干预、实施门诊共济保障改革、2035年取消个人账户并提高待遇水平三种模拟情形，分别预测其2022年至2050年统筹基金收支情况。结果显示，无政策干预下E市职工医保统筹基金将于2022年、2034年分别出现当期、累计结余赤字；门诊共济保障改革实施后当期、累计结余赤字发生时间分别延后20年、8年；若2035年取消个人账户则于2049年出现基金缺口，同步提高普通门诊、门诊慢特病及住院保障水平在2050年以前不会导致累计结余归零。据此，应通过渐进式取消个人账户，实现医保战略性购买，强化多层次医疗保障的效能，增强医保统筹基金可持续性。

Basic medical insurance practitioners examine the implementation of welfare policies and ensure the stable and healthy development of the basic medical insurance fund, which is the guarantee for the sustainable operation of the system. This article takes E City, a fund pooling area with high surplus, as an example. Based on the current financing and treatment policies, a prediction model for the income and expenditure of the employee medical insurance pooling fund is constructed. Three simulation scenarios are set up, including no policy intervention, implementation of outpatient pooling security reform, and cancellation of individual accounts and improvement of treatment levels by 2035, to predict the income and expenditure of the pooling fund from 2022 to 2050. The results show that without policy intervention, the E city employee medical insurance pooling fund will experience current and cumulative surplus deficits in 2022 and 2034, respectively; After the implementation of the outpatient mutual assistance reform, the occurrence time of the current and cumulative surplus deficit was delayed by 20 and 8 years, respectively; If personal accounts are cancelled by 2035, there will be a fund gap in 2049. Simultaneously increasing the level of general outpatient, outpatient chronic diseases, and hospitalization protection will not result in the cumulative balance returning to zero before 2050. Based on this, it is necessary to gradually cancel personal accounts, achieve strategic purchases of medical insurance, strengthen multi-level security effectiveness, and enhance the sustainability of the medical insurance pooling fund.