This year's Government Work Report proposed to "accelerate the development of commercial health insurance, promote the high-quality development of innovative drugs and medical devices, and better meet the people's diverse needs for medical treatment and medication." This marks the first time the Government Work Report has specifically emphasized commercial health insurance.
What is the background behind including "accelerate the development of commercial health insurance" in the Government Work Report? How has commercial health insurance developed in recent years? Where does its development potential and main direction lie? Industry insiders were interviewed on these topics.
The structure of the trillion-yuan health insurance market is undergoing transformation. Commercial health insurance has been held in high expectation for many years. Regulators had previously set specific targets for it. In January 2020, the former China Banking and Insurance Regulatory Commission, jointly with other departments, issued an opinion aiming for the commercial health insurance market scale to exceed 2 trillion yuan by 2025. In 2020 itself, health insurance premiums reached 817.3 billion yuan.
Data shows that the reality over the subsequent five years remained far from this target. In 2025, the combined premium income from health insurance operations of life insurance companies and property insurance companies was 997.3 billion yuan, only half of the "2 trillion yuan target."
However, structural changes occurred as commercial health insurance approached the trillion-yuan mark. From a sub-sector perspective, life insurance companies were previously the main operators of health insurance business. Driven by government business and various internet-based operations, property insurance companies contributed the vast majority of the growth in health insurance. During the "14th Five-Year Plan" period, health insurance premiums from life insurers grew from 705.9 billion yuan to 769.9 billion yuan, an increase of only 9%; whereas health insurance premiums from property insurers grew from 111.4 billion yuan to 227.4 billion yuan, an increase of 104%.
In terms of insurance types, among the four categories—disease insurance, medical insurance, nursing insurance, and income loss insurance due to disability—the driving force for health insurance growth has recently shifted from critical illness insurance to medical insurance. In recent years, new critical illness policy growth has consistently been in the single-digit percentage range, hampered by weak growth and worsening disease incidence rates, leading to a "gear-shifting period" for critical illness insurance. In contrast, the medical insurance market has been quite active. In 2016, million-yuan medical insurance became the first popular category, quickly surpassing 100 million policyholders; around 2018, specific drug insurance was launched; in 2020, inclusive commercial health insurance (Hui Min Bao) sparked a new wave; and in the last two years, mid-range medical insurance has formed another market trend.
This shift in focus from critical illness insurance to medical insurance has its logic. A 2024 research report on health and pension insurance security indices analyzed several reasons: Firstly, critical illness insurance has stronger life insurance attributes and weaker synergy with the pharmaceutical industry compared to medical insurance; its "lump-sum payment" nature is not necessarily linked to the growth of drug and healthcare service consumption expenditures. Secondly, under policy guidance, the broader environment prioritizes innovative drugs and devices, empowered by healthcare insurance data and settlement systems, opening more potential and smoother growth paths for medical insurance and inclusive commercial insurance, continuously challenging the former dominance of critical illness insurance. Thirdly, the sales force in the commercial insurance industry has bottomed out, and下调预定利率 has led to increased premiums for long-term health insurance, suggesting the high-growth model for critical illness insurance may not return.
The development is moving from "operating independently" to integrating into the "triple coordination" of healthcare delivery, medical insurance, and medicine. A senior executive from a large insurance company stated that health insurance development over the past 20 years has gone through stages of specialized operation, elevated positioning, and new requirements for high-quality development. The 2019 revised "Administrative Measures for Health Insurance"首次提出 health insurance is an important part of the national multi-level healthcare security system. In September 2024, the National Healthcare Security Administration proposed the concept of a "1+3+N" multi-level healthcare security system, wherein commercial health insurance should play a role. In September 2025, the National Financial Regulatory Authority's "Guiding Opinions on Promoting the High-Quality Development of Health Insurance" clarified that "by 2030, the important role of health insurance in the national health security system will be further enhanced."
"Recently, the value of commercial health insurance within the national healthcare security system has been more fully reflected and has gained broad social recognition," said Wang Guojun, Assistant Dean and Professor at the School of Insurance, University of International Business and Economics.
Traditional commercial medical insurance primarily covered expenses within the basic medical insurance scheme, providing supplemental reimbursement after basic医保报销. Recently, based on customer demand, many products now include coverage for out-of-pocket expenses and innovative drugs, such as specific drug insurance, million-yuan medical insurance, Hui Min Bao, and mid-to-high-end medical insurance, playing a significant compensatory role for patients' high medical costs.
Simultaneously, as payment reforms based on Diagnosis-Related Groups (DRG) and Big Data Diagnosis-Intervention Packet (DIP) are implemented, healthcare security departments also expect commercial health insurance to play a greater role. In December 2025, the National Healthcare Security Administration released the first edition of the "Commercial Health Insurance Innovative Drug Directory" (hereinafter "Commercial Insurance Innovative Drug Directory"). The National Healthcare Security Work Conference held in the same month proposed supporting the development of commercial health insurance and improving the multi-level healthcare security system. It advocated for complementarity and differentiated development between commercial health insurance and basic medical insurance. It also emphasized actively implementing the Commercial Insurance Innovative Drug Directory and encouraging commercial health insurance to include more reasonable medical expenses outside the basic medical insurance catalog.
Professor Wang Guojun believes that while basic medical insurance achieves broad coverage, it struggles to fully meet public demand for higher-level health security needs like specialized medical care, high-end devices, and innovative drugs. The development of commercial health insurance can, on one hand, help share the pressure on basic医保基金 through market mechanisms, and on the other hand, drive supply-side reforms in medical services and promote the R&D of innovative drugs and medical devices. Essentially, it builds a "multi-level, diversified" healthcare security system on the foundation of "basic coverage," allowing different income groups to find suitable health security solutions.
However, industry insiders admit that commercial health insurance has not yet fully realized its role as a multi-level payer for medical expenses. There is a long way to go for commercial health insurance to evolve from primarily raising funds to significantly increasing claim payments and fully functioning as a payer for medical services.
"High-quality development of health insurance cannot be achieved by insurance companies working behind closed doors; it must actively integrate into the broader reform and development of the triple coordination, starting from deep integration with pharmaceuticals, healthcare, and the health industry," the aforementioned insurance executive said. The operation of health insurance needs to shift from independent action to ecological synergy, transforming from a passive payer into a resource integrator and ecosystem enabler.
Senior insurance scholar Zhu Junsheng stated that, considering the first Commercial Insurance Innovative Drug Directory and the Government Work Report requirements, the next steps for commercial health insurance regarding innovative drug coverage should focus on key areas such as accessibility, tiered coverage, payment coordination, and institutional-market integration.
A relevant负责人 from Zhonghui Mutual Insurance mentioned that the implementation of the Commercial Insurance Innovative Drug Directory is driving a restructuring of insurance product systems: firstly, developing specific drug insurance products to complement existing medical insurance and attract high-net-worth individuals; secondly, refining coverage details for innovative drugs, clarifying reimbursement ratios and limits, upgrading from "vague promises" to "clear terms"; thirdly, promoting tiered product design to meet the differentiated needs of people with varying consumption capacities.
These developments pose new capability requirements for insurance companies. Against this backdrop, what are the key focuses for the development of commercial health insurance, and how can they be implemented concretely?
"Products are the most direct载体 of insurance services, the bridge connecting companies and customers; therefore, product innovation must be driven first," the large insurance company executive said. It is necessary to provide a rich variety of comprehensive health and medical products covering the entire lifecycle, tailored to various health risks and medical scenarios people face. "The potential for multi-level, multi-dimensional medical insurance is vast." Simultaneously, the commercial nursing care insurance market also holds potential during the "16th Five-Year Plan" period.
The second key development area mentioned by the executive is expanding the insured population, moving from covering the "healthy" to including those with "pre-existing conditions," and shifting focus from "insuring healthy people" to "insuring people's health." The third focus is on the entire cycle around disease occurrence, providing full-cycle health solutions encompassing pre-disease prevention, during-disease control, and post-disease rehabilitation. Disease insurance should upgrade from simple赔付 to comprehensive health solutions throughout the cycle.
However, product innovation, insurance for individuals with pre-existing conditions, and health solutions all present new challenges to insurers' capabilities.
Regarding product innovation, insurers need to enhance precise pricing capabilities. The executive mentioned that actuarial science's crucial role is managing future uncertainties. Insurers must increase data collaboration with medical institutions,医保 platforms, health management organizations, pharmaceutical companies, and external institutions. While ensuring security and compliance, they should strive to build integrations based on medical big data, health behavior data, and claims data to accurately identify risks and predict future changes.
As for insurance for individuals with pre-existing conditions, Ding Junfeng, Vice President of Taikang Online, previously stated that operating such insurance has high barriers to entry and cannot be managed solely relying on traditional core insurance competencies. She analyzed that traditional insurance product pricing relies on the law of large numbers, with pricing key being disease incidence rates across age groups—more of a statistical problem. However, venturing into insurance for those with pre-existing conditions deeply involves medical issues. The onset, progression, and the associated pharmaceuticals, treatments, and health interventions for each disease affect both disease incidence and medical costs, thereby impacting insurance product pricing. Therefore, this business requires close collaboration between insurers and medical service networks, pharmaceutical companies, drug distribution industries, and health service/management sectors. It necessitates disease management capabilities and industry integration skills.
"Operating health insurance business requires breaking down industry barriers, actively integrating into the domestic circulation of medical care, health insurance, and pharmaceuticals, and building a symbiotic and integrated health ecosystem," the large company executive stated. This involves several levels. At the business level, synergy with the medical industry must be achieved, innovative insurance products developed, while also addressing the high cost of innovative drugs to aid pharmaceutical innovation. At the capital level, it involves acting as patient long-term capital, deeply engaging in the "insurance + health and elderly care" ecosystem through diverse investment methods like direct investment,控股, and参股.
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