本文利用GM（1,1）模型预测2024—2030年全国职工医保基金和居民医保基金收支状况,在考虑辅助生殖技术纳入医保报销范围的现实背景下,构建精算模型测算其分别对职工医保基金和居民医保基金运行状况的影响。研究发现：第一,测算期内职工医保基金总体运行状况良好,至2030年累计结存为120245.28亿元,但居民医保基金2030年开始出现穿底风险,赤字额为803.26亿元;第二,即使职工参保群体的渗透率较高,但辅助生殖技术纳入医保报销范围对居民参保群体需求释放更为明显,即参加居民医保的育龄夫妇接受辅助生殖治疗的增量更高。第三,当辅助生殖技术渗透率不变时,测算期内因辅助生殖技术带来的新生儿总量为299.52万人。提高渗透率会使新生儿数量显著增加,渗透率低、中、高增长方案下测算期内新生儿总量分别增加63.24万人、110.17万人、157.10万人,可见辅助生殖技术纳入医保报销范围有利于缓解我国生育率下降的局面。第四,同渗透率增长方案下,居民医保基金在辅助生殖技术的支出高于职工医保基金,且辅助生殖技术给居民医保基金带来的支出压力远高于职工医保基金。渗透率高增长方案下,2030年因辅助生殖技术带来的职工医保基金支出仅占基金支出的0.24%,但居民医保基金该占比达0.72%,约是职工医保基金支出压力的3倍。第五,若不对居民医保制度进行政策干预以维持基金精算平衡,辅助生殖技术纳入医保报销范围给居民医保基金带来的支出最终会转嫁为财政负担。以渗透率高增长方案为例,2030年财政弥补居民医保基金赤字的负担从803.26亿元上升至1502.68亿元。针对以上结论,本文从如何减少不孕不育患者、提高辅助生殖技术的渗透率和成功率、促进居民医保基金可持续以及防范辅助生殖技术纳入医保报销范围可能产生的道德风险等角度提出相关建议,以更好地为完善辅助生殖技术纳入医保报销的相关措施提供参考,有助于平衡社会效益与医保基金的可持续发展。

In this paper, the GM (1,1) model was used to predict the income and expenditure of national employees’ medical insurance fund and residents’ medical insurance fund from 2024 to 2030. Under the realistic background of considering the inclusion of assisted reproductive technology in the reimbursement of medical insurance, an actuarial model was constructed to measure its impact on the operation of employees’ medical insurance fund and residents’ medical insurance fund, respectively. The study found that, first, during the calculation period, the employees' medical insurance fund was in good overall performance, with a cumulative balance of 12024.528 billion yuan by 2030. However, the residents' medical insurance fund began to face the risk of imbalance in 2030, with a deficit of 80.326 billion yuan. Second, even though the penetration rate of the employees’ medical insurance group is high, the inclusion of assisted reproductive technology in the medical insurance reimbursement will release the demand of the residents’ medical insurance group more obviously, that is, the increment of assisted reproductive treatment for the couples of childbearing age who participate in the residents’ medical insurance is higher. Third, when the penetration rate of assisted reproductive technology remained unchanged, the total number of newborns caused by assisted reproductive technology during the calculation period would be 2.9952 million. Increasing the penetration rate will significantly increase the number of newborns. Under the low, medium and high penetration rate growth plan, the total number of newborns will increase by 0.6324 million, 1.1017 million and 1.5710 million during the calculation period, respectively. It is clear that the inclusion of assisted reproductive technology in medical insurance reimbursement is conducive to alleviating the situation of fertility rate decline in China. Fourth, under the same penetration rate growth plan, the expenditure of the residents’ medical insurance fund on assisted reproductive technology is higher than that of the employees’ medical insurance fund, and the expenditure pressure brought by assisted reproductive technology to the residents’ medical insurance fund is much higher than that of the employees’ medical insurance fund. For example, under the plan of high penetration rate growth, the expenditure of employees’ medical insurance fund due to assisted reproductive technology would only account for 0.24% of the fund expenditure in 2030, but the proportion of residents’ medical insurance fund would reach 0.72%, which was about three times the expenditure pressure of employees’ medical insurance fund. Fifth, if there is no policy intervention in the residents’ medical insurance system to maintain the actuarial balance of the fund, the expenditure brought by the inclusion of assisted reproductive technology in the reimbursement of medical insurance will eventually be transferred to the financial burden of the residents’ medical insurance fund. Taking the high penetration rate growth plan as an example, the financial burden of making up the deficit of the residents’ medical insurance fund will rise from 80.326 billion yuan to 150.268 billion yuan in 2030. In view of the above conclusions, this paper puts forward relevant suggestions from the perspectives of how to reduce the number of infertile patients, improve the penetration rate and success rate of assisted reproductive technology, promote the sustainability of residents' medical insurance fund, and prevent the possible moral risks caused by the inclusion of assisted reproductive technology in medical insurance reimbursement, so as to provide references for improving the relevant measures of the inclusion of assisted reproductive technology in medical insurance reimbursement, which is helpful to balance the social benefits and the sustainable development of medical insurance fund.