1.33 Billion People Insured, $3.4 Trillion in Fund Expenditure: A Look at the 2025 Medical Insurance Bill

On March 16, 2026, the "2025 Statistical Express on the Development of Medical Security Undertakings" (hereinafter referred to as the "Express") released by the National Healthcare Security Administration showed that, as of the end of 2025, the number of participants in basic medical insurance was approximately 1.331 billion, with a stable participation rate of 95%; about 389 million people were enrolled in employee medical insurance, and about 942 million in resident medical insurance, reflecting a more optimized enrollment structure.

Zhang Chenguang, Deputy Director of the Department of Regulations and Finance of the National Healthcare Security Administration, introduced that the number of participants in the resident medical insurance decreased by 5.01 million, while the number of participants in the employee medical insurance increased by 9.08 million. This "one rise and one fall" is not only the result of structural adjustment but also reflects the trust of the majority of insured people in the basic medical insurance system. It also confirms, from a certain perspective, the good momentum of China's economy maintaining continuous, stable, and healthy development.

In terms of pharmaceuticals, payment, and industrial innovation, the medical insurance reform has shown many highlights. 114 new drugs have been included in the medical insurance catalog, the first edition of the commercial insurance innovative drug catalog has been released, the coverage of direct medical insurance settlement has been expanded, the payment cycle for centralized procurement drugs has been shortened to 30 days, and the China Drug Price Registration System has been launched, providing support for Chinese-produced drugs to "go global."

So, how has the medical insurance fund pool changed? The data shows that it has become larger and more stable. In 2025, the total revenue of China's basic medical insurance fund reached 3,587.311 billion yuan, with total expenditures at 3,000.938 billion yuan, increasing by 2.7% and 0.8% respectively. This marks the first time in many years that the growth rate of income has reversed the previous trend of being lower than expenditure growth. The majority of coordinated regions in China have surplus funds.

What other noteworthy information does the express report reflect besides this?

By the end of 2025, the number of participants in China's basic medical insurance will reach 1.331 billion, with the participation rate stabilized at 95%. Among them, the number of employees covered by medical insurance will be 389 million, and the number of urban and rural residents covered by medical insurance will be 942 million. The participation structure has been further optimized, reflecting a trend towards more comprehensive system coverage and a more reasonable participant demographic.

In terms of fund operation, the total income of the basic medical insurance fund (including maternity insurance) was 3.59 trillion yuan, with a total expenditure of 3.00 trillion yuan. The income of the employee medical insurance fund was 2.46 trillion yuan, and the expenditure was 1.94 trillion yuan. The income of the urban and rural residents' medical insurance fund was 1.12 trillion yuan, with an expenditure of 1.07 trillion yuan. Overall, the operation was stable, ensuring the orderly development of medical security services.

In terms of medical insurance benefits, in 2025, the number of outpatient visits covered by medical insurance in China reached 7.215 billion, increasing by 25.51% over the previous year. Among them, there were 3.849 billion outpatient visits for employees, a year-on-year increase of 30.28%, and 3.366 billion outpatient visits for residents, a year-on-year increase of 20.47%. This reflects the strong support of medical insurance for daily medical needs. Meanwhile, the number of inpatient treatments nationwide was 278 million, a year-on-year decrease of 3.40%.

The reform of payment methods has directly changed medical practices at the hospital level. By the end of 2025, the 2.0 version of Diagnosis-Related Groups (DRG) / Diagnosis-Intervention Packet (DIP) will be fully implemented across China.

Over 95% of short-term inpatient cases are reimbursed by diagnosis-related groups (DRGs), with the inpatient pooled fund covering more than 80% of cases through DRG-based payments. All pooled regions have established five supporting mechanisms: special case reviews, advance payments, feedback collection, negotiation and consultation, and data working groups, which also help control unreasonable increases in medical costs.

In 2025, the number of hospitalizations and hospitalization costs for employees increased. The average cost per hospitalization was 8,509 yuan, with 11,153 yuan for employees and 7,338 yuan for residents.

In the field of price governance, reforms have also entered uncharted waters. In 2025, the 11th batch of national drug procurement and the 6th batch of high-value medical consumables procurement arrived as scheduled. From commonly used chronic disease medications to high-end urological interventional devices, further reductions in pricing margins have been achieved.

More crucially, the online procurement order amount of the national provincial pharmaceutical centralized procurement platforms will reach 969.8 billion yuan in 2025, with drugs in the medical insurance catalog accounting for as high as 93%. This means that the vast majority of clinical drugs have entered transparent and standardized public procurement channels.

How to properly regulate this huge sum of money is also the top priority for medical insurance work in 2025.

Statistical Express shows that, in 2025, the national medical insurance system in China recovered a total of 34.2 billion yuan of medical insurance funds. Among them, 27.8 billion yuan was recovered through the review and verification of medical insurance handling, 1,626 institutions were found to have defrauded medical insurance, 1,678 cases were transferred to judicial authorities, 19,000 cases were transferred to disciplinary inspection and supervision authorities, and 59,000 cases were transferred to administrative departments such as health authorities. Jointly with public security organs, 3,776 medical insurance cases were investigated, and 10,357 criminal suspects were arrested.

In 2025, using drug traceability codes to conduct full-chain precision strikes against the resale of "re-imported drugs," verifying more than 240,000 suspicious leads, inspecting 124,700 designated medical institutions, and handling 39,100 institutions for violations and illegal activities.

In the 2025 medical insurance billing, a set of data is particularly eye-catching: nationwide, 3.2397 million people received treatment under assisted reproductive medical insurance programs, benefiting 1.6018 million individuals.

Procedures like egg retrieval and artificial insemination, which used to cost tens of thousands of yuan, are now reimbursable.

Starting from January 1, 2025, all provinces in China have included appropriate assisted reproductive procedures in the scope of medical insurance payments, such as oocyte retrieval, embryo culture, sperm retrieval, and artificial insemination. Thirty provinces have included labor pain relief in the scope of medical insurance payments.

This is just a microcosm of how medical insurance helps reduce childbirth costs. By the end of 2025, the number of participants in maternity insurance reached 259.6574 million, increasing by 6.6623 million year-on-year.

A total of 35,344,900 people enjoyed maternity benefits, including 3,996,400 female employees, 195,600 spouses of male employees, 24,266,500 people who received prenatal examinations, 3,871,300 people who underwent inpatient deliveries, and 4,806,400 people who received allowances.

More groundbreaking is that all coordinating regions in China have basically realized the direct issuance of maternity allowances to individuals. In the past, these allowances required companies to distribute them through cumbersome processes, but now they are directly deposited into personal accounts.

Warmth Extends to the Disabled Elderly. By 2025, the number of participants in long-term care insurance will exceed 300 million, with 1.8813 million people benefiting. For these elderly individuals and their families, long-term care insurance not only provides financial subsidies but also introduces professional nursing services.

If security and regulation are one of the bottom lines of medical insurance, then supporting innovation and empowering the industry are another high line demonstrated by the 2025 medical insurance.

Medical insurance is no longer just a payer; it is transforming into a driving force for industrial innovation.

The release of the 2025 "Several Measures to Support the High-Quality Development of Innovative Drugs" established a medical insurance access and negotiation renewal mechanism centered on new drugs. The time from market launch to inclusion in medical insurance for innovative drugs has been significantly shortened, with a group of globally leading Class 1 new drugs entering the medical insurance catalog just months after approval.

Of the 114 drugs newly added to the catalog in 2025, the vast majority possess extremely high clinical innovation value. Among them, 50 are Class 1 innovative drugs, while 29 drugs that were either unavailable clinically or could be better replaced by other medications have been removed.

After the adjustment, the total number of drugs in the catalog increased to 3,253, including 1,857 Western medicines and 1,396 traditional Chinese medicines. The level of coverage for key areas such as cancer, chronic diseases, mental illnesses, rare diseases, and pediatric medications has significantly improved.

The first edition of the Commercial Insurance Innovative Drug List includes 19 drugs that are highly innovative, have significant clinical value, and provide notable benefits to patients but fall outside the coverage of basic medical insurance. Among these, there are nine Class 1 new drugs.

10 drugs are imported innovative medicines, of which 4 were introduced by Chinese companies, including Hutchmed, Nanjing Luye, BeiGene, and SciClone Pharmaceuticals. The remaining 9 Chinese-produced drugs are mostly anti-tumor medications, including 5 high-cost CAR-T tumor innovative drugs.

The settlement speed has also invigorated the industry. By 2025, the medical insurance departments will gradually expand direct settlement coverage for pharmaceutical enterprises, reducing the average payment cycle for centrally procured medicines and consumables to around 30 days. This not only significantly eases the cash flow pressure on enterprises but also helps to reverse the long-standing issue of difficult repayment in the pharmaceuticals sector.

A landmark event occurred in December 2025 when China's Drug Price Registration System officially went online. This platform, initiated by the National Healthcare Security Administration, is designed with an international perspective. By early 2026, the system had issued drug price certificates for 15 enterprises, marking the first breakthrough for China’s pharmaceutical "price identity card" in overseas markets. In coordination with the development of regional pharmaceutical trading platforms in Guangxi, Xinjiang, Tianjin, and other areas, China's healthcare security system is firmly supporting domestically produced pharmaceutical companies to "go global" and participate in global competition.