Resident Medical Insurance Contribution Schemes and Fiscal Burden in China: An Actuarial Projection Under Demographic Dynamics

Deepening population aging is increasing the long-term financing pressure on China’s resident medical insurance fund. This paper constructs an actuarial model for the medical insurance fund that accounts for dynamic population structure changes by integrating the BayesTFR model and the cohort-component method. Based on this model, the paper projects changes in fiscal subsidy demand and fiscal burden across 12 sample provinces over 2023–2050 under two contribution schemes: fixed-amount contribution and income-linked proportional contribution. The results indicate that under the fixed-amount financing schemes, medical expenditure growth driven by population aging will translate into rising fiscal subsidy demand. By 2050, the average share of fiscal subsidies in total fund revenue across sample provinces will climb to 73.66%. The income-linked proportional contribution scheme strengthens the income elasticity of individual contributions and reduces the fund’s reliance on fiscal subsidies, yet its effects exhibit significant regional disparities. Northeast China faces stronger constraints from population aging, while western China is more limited by economic carrying capacity. These results provide scenario-based evidence for the design of differentiated financing arrangements for resident medical insurance.