职工医保统筹基金（以下简称统筹基金）的可持续性与对应的财政责任取决于基金收支的大小,同时受参保人数多少、缴费基数大小以及医疗费用增长等多种因素的影响。我国人口老龄化程度加深导致统筹基金的支付压力日益增大,如何调整才能保障统筹基金可持续运行并减轻财政负担?本文运用精算模型发现,在当前统筹模式下,统筹基金开始出现当期赤字的节点为2029年,开始出现累计赤字的节点为2040年,至2050年累计财政责任为106891.31亿元。若门诊共济改革在2023年全面实施,当门诊费用报销比例为50%时,统筹基金于2041年出现当期赤字,出现当期赤字的节点推迟12年,至2050年并未出现累计赤字。提高门诊费用报销比例会导致统筹基金开始出现当期赤字和累计赤字的节点提前。当门诊费用报销比例与住院费用报销比例一致时（75.6%）,统筹基金于2037年开始出现当期赤字,出现当期赤字的节点推迟8年;于2049年开始出现累计赤字,出现累计赤字的节点推迟9年,至2050年累计财政责任为15947.67亿元。由此可知,门诊共济改革有利于统筹基金的中短期平稳运行,减轻财政压力。

The sustainability of the employees' basic medical insurance pooling fund (hereinafter referred to as the pooling fund) and the corresponding financial responsibility depends on the the fund's income and expenditure, and are affected by many factors such as the number of insured people, the contribution base and the growth of medical expenses. The aging of the population in China leads to the increasing payment pressure of the pooling fund. How to ensure the sustainable operation of the pooling fund and reduce the financial burden? In this paper, the actuarial model is used to find that under the current pooling mode, the node where the pooling fund starts to show current deficit is 2029, the node where the cumulative deficit begins is 2040, and the cumulative financial responsibility is 10689.131 billion yuan by 2050. If the outpatient mutual aid reform is fully implemented in 2023, when the reimbursement ratio of outpatient expenses is 50%, the pooling fund will have a current deficit in 2041, and the node with a current deficit will be delayed for 12 years, and there will be no cumulative deficit by 2050. Increasing the reimbursement ratio of outpatient expenses will advance the point at which the fund begins to show current and cumulative deficits. When the reimbursement ratio of outpatient expenses is the same as that of hospitalization expenses (75.6%), the pooling fund will start to show a current deficit in 2037, and the current deficit node will be delayed for 8 years. The cumulative deficit will start to appear in 2049, the cumulative deficit node will be delayed for 9 years, and the cumulative financial responsibility will be 1594.767 billion yuan by 2050. It can be seen that the reform of outpatient mutual aid is conducive to the stable operation of the pooling fund in the short and medium term and reduce the financial pressure.