医疗保障制度是国家治理体系的重要组成部分,是实现“健康中国”战略与共同富裕目标的基础性制度安排。本研究系统梳理了中国特色医疗保障参保模式从“自动加入”到精准治理的演进历程,并尝试构建中国特色医疗保险参保模式理论框架。基于2024年全国参保数据的实证分析表明,我国医保工作在高覆盖率基础上正向更高质量、更可持续的方向发展。但当前参保扩面仍面临一些挑战和不足,需要着力优化参保结构、完善筹资机制、加强数据共享、提升基层服务效能,并推动制度设计与人口流动、新就业形态等新发展要求更好地适应。本文在总结地方参保治理探索经验,借鉴东南亚与金砖国家“立法强制+财政兜底+数据驱动”参保经验的基础上,基于中国式现代化及共同富裕目标下的医保参保要求,提出构建家庭参保、探索“费改税”、建立平台经济自动参保机制、实施“一老一小”免缴等改革建议。

The healthcare security system serves as a crucial component of the national governance framework and constitutes a foundational institutional arrangement for advancing the Healthy China strategy and the goal of common prosperity. This study systematically reviews the evolution of China's healthcare security enrollment model, tracing its development from "automatic inclusion" to the current phase of precision governance, and attempts to construct a theoretical framework for this distinctively Chinese approach. Empirical analysis based on national enrollment data from 2024 indicates that China's medical insurance efforts, building upon a foundation of high coverage rates, are progressing toward higher quality and greater sustainability. While challenges persist in further expanding enrollment, the focus must be on optimizing the enrollment structure, refining financing mechanisms, enhancing data sharing, improving grassroots service delivery, and ensuring that the institutional design better accommodates new developmental realities such as population mobility and emerging forms of employment. Drawing upon insights from local governance innovations and examining experience from Southeast Asian and BRICS countries regarding "legislative mandates, fiscal support, and data-driven approaches", and in consideration of the requirements for medical insurance enrollment within the context of Chinese modernization and common prosperity, this paper proposes several reform recommendations. These include establishing a family-based enrollment system, exploring a potential transition from insurance premiums to a tax-based model, creating automatic enrollment mechanisms tailored for the platform economy, and implementing exemption policies for the very young and the elderly.