| Background and ObjectiveChina currently has entered into a period of accelerated population aging,facing severe challenges like a rapid growth of the number of the elderly who are older in empty nest,and with chronic disease.With the changing family structure and the weakening support function,the traditional family endowment cannot meet the needs of elderly care.The long-term care(LTC)of the disabled elderly brings heavy economic burden in the caring of the elderly with their families.This has become a common risk being faced by society,and also a great challenge in China's social security system.However,China is currently in the pilot stage of LTC insurance and has not yet formed a unified insurance system.At the same time,most of the related studies are still in the primary stage of foreign reference and policy analysis,mainly qualitative research,and lack of empirical analysis and prediction research of LTC insurance from the perspective of supply and demand.There are key issues which need to be urgently resolved by researchers and policy makers,for example,building an LTC cost compensation mechanism to reduce the burden of family care,meeting the growing demand for old-age and medical services,creating a health care combined with old-age care service model,improving the quality of LTC services,and promoting the formulation and improvement of LTC insurance system.Research ContentsFirstly,this study systematically reviewed the research progress of domestic and foreign scholars,compared to the LTC insurance systems of typical countries,in order to provide an institutional analysis framework for the formulation of localized LTC insurance.Secondly,we used macro and microdata to know the supply and demand for LTC of the elderly in China and further analyzing its influencing factors.Thirdly,the policy simulation model was used to predict the disability scale and financial needs of LTC insurance in China from 2020 to 2050.Fourthly,based on the theory of supply and demand equilibrium,this study predicted the changeable trend of LTC insurance rate in China.Also formulating the insurance financial system to further exploring the mode of combining medical care with old-age care services in the country,and improving the evaluation standard of old-age care service quality.Lastly,the paper brought forth some policy suggestions on how to build a localized public LTC insurance system in China.Data and MethodsThe research data mainly comes from the authoritative national open data and self-designed survey data.They comprise the latest database of Chinese Longitudinal Healthy Longevity Survey(CLHLS)from 1998 to 2014,the Statistical Yearbook of China in 2014,the Health Statistics Yearbook of China in 2014,the National Economic and Social Development Bulletin in 2017,the Statistical Bulletin of Civil Affairs Development in 2017,the data of the Sixth National Population Census in 2010,the self-designed survey data of community elderly in Xiamen in 2016,and the survey data of all LTC institutions in Xiamen in 2016,etc.Quantitative research methods,such as data envelopment analysis and comprehensive evaluation,were used to analyze the efficiency and quality of China's LTC institutions.Multiple Logistic regression models,Orderly Probit model,and Tobit regression model were used to analyze the influencing factors of LTC service demand and supply.In addition,based on the Population Administration Decision Information System(PADIS),this paper further explored the financial supply and demand balance of the LTC insurance system for disabled elderly in China by applying actuarial techniques such as population prediction technology,overall policy simulation model,Manchester united method and ILO financing model.Results and Conclusions1.China should adopt the "multi-level and social" LTC insurance model.The social insurance model has a strong superiority,compared systematically to three LTC insurance models of typical countries and regions,which include tax model,commercial model and social model,considering the fairness,efficiency and financial sustainability.Social assistance mode should be primarily implemented in the short term,while in the long run,priority should be given to social insurance mode,as well as to actively encourage the development of complementary commercial insurance mode.Meanwhile,Chinese LTC insurance system should cover demand assessment,insurance finance,service mode,and quality supervision.2.LTC needs of the elderly are increasing rapidly,with significant differences between urban and rural areas.LTC needs of the elderly in China showed a rapid rise from 2008 to 2014.The proportion of LTC needs reached up to 41.67%,among which the demand for bathing(35.2%)and toileting(23.9%)was relatively higher in 2014.The oldest old in rural areas have the highest demand(54%),followed by the oldest old in urban areas(36.91%)and the young-old in rural areas(13.78%),while the young-old in urban areas have the lowest demand(8.8%).The old-age models and old-age services for the elderly with different characteristics(urban and rural,age)are affected by many factors including the factors of predisposing(marital,educational level),enabling(economic and income level),and demanding(subjective and objective health).3.The contradiction between the supply and demand for LTC of the elderly is prominent,and the current situation is not optimistic.In this study,82.01%of the elderly still prefer to receive family care,which will remain the mainstream care for a long time.However,home-based care for the elderly are provided with limited nursing care,spiritual comfort and housekeeping services by caregivers at present.The content is relatively simple and lack of supporting policies obviously,leading to the structural imbalance between supply and demand.The function of community daycare is not clearly defined,the supply is not enough,and the function is similar to the elderly activity center.The average occupancy rate of pension institutions is low(60.22%),and the occupancy rate in rural areas is generally lower than 50%.Professional talents such as psychological consultants(0.46%)and rehabilitation physiotherapists(1.15%)are scarce.The quality of service is uneven,for example,the quality of service in public institutions is higher than that that of private institutions,and the quality of service in urban institutions is higher than that in rural institutions.In terms of service efficiency,LTC institutions need to further improve the scale resource utilization and service personnel quality.4.The number of disabled elderly and financial needs for LTC are both growing rapidly.This study predicts that the total disabled population in China will reach 43.75 million in 2020,among which are the disabled elderly in urban and rural areas,accounting for 54.52%and 45.47%respectively.The number of disabled people is increasing year by year.By 2050,the total number of disabled people will rise to 91.4 million,including 63.74 million in urban areas and 27.66 million in rural areas,significantly 2.09 times more than in 2020 and 3.23 times more than in 2014.Similarly,the total financial demand for long-term care insurance in China shows an increasing trend,especially in the period of 2030 to 2050.The total demand will rise from 538 billion yuan in 2020 to 8530.8 billion yuan in 2050,an increase of about 16 times.Moreover,the total demand and growth rate of urban areas will increase from 427.7 billion yuan in 2020 and up to 6843.7 billion yuan in 2050,with an increase of almost 15 times,which is higher than that of rural areas.5.The total contribution rate of LTC insurance is linearly growing,with social insurance financial system being the first choice.The results of this study show that the overall contribution rate of LTC insurance in China will increase linearly from 2020 to 2050.The total contribution rate will be 1.46%in 2020 and rise to 5.14%in 2050,an increase of about 3.5 times.By systematically comparing the financial systems of LTC insurance in typical countries,the establishment of social LTC insurance with multiple financial providers can ensure the stability and sustainable development of financial resources.This will serve as a key to the establishment of a localized public LTC insurance system in the future.Specifically,the system planning should be carried out from the financial model,the insured object and the payment of benefits.6.The integrated medical care and old-age care service system is as a carrier for the realization of the LTC insurance system.Through systematically combing the domestic and foreign medical combination of pension service system,China should combine its own reality,based on "give priority to care,the medical auxiliary" service concept,from six aspects,including pension mode,service object,service content,service carrier,service team and supervision unit to build a multi-level old-age service system,and boost the establishment and perfection of LTC insurance system.7.Assessment of the quality of pension services is the guarantee for the sustainable development of the LTC insurance system.Based on the three-dimensional theory of quality evaluation,this study built LTC quality evaluation index system,with the authority of experts(0.83),familiarity(0.96),the judgment coefficient(0.71),the opinion coordination degree(P<0.001).SARE scale with high reliability and validity(general Cronbach's alpha=0.940,good structure validity,and content validity),demonstrates that the index system is scientific and reliable.Through literature study and interviews,it is concluded that the grading management system of service quality in LTC institutions should specifically cover such aspects as evaluation principles,principal and responsible units,evaluation subjects,evaluation personnel,evaluation objects,evaluation methods,review procedures,grading,reward and punishment mechanism,and information disclosure,etc.Policy Recommendations1.Constructing sustainable financing mechanisms for multiple financial providersBased on our national conditions,we should set up a LTC income distribution adjustment mechanism,establish a mixed and pluralistic sustainable financing system covering the government,employers and employees,encourage the development of commercial LTC insurance as a supplement,make full use of public welfare and charitable mechanisms to ensure the sustainability of LTC financial resources,and ultimately give legislative protection.2.Establishing a differentiated coverage mechanism of LTC insuranceIn the process of implementing LTC insurance,the country should fully consider the differences between urban and rural areas and regions to formulate a differential coverage mechanism of LTC insurance in stages and steps.The choice of service content and coverage should follow the actual situation.3.Speeding up the construction of social insurance financial system from the perspective of supply and demand balancePay-as-you-go system should be the preferred financial model in the Chinese LTC insurance system.The insured population,defined as urban and rural people under 18-64 of age,are engaged in economic activities and with regular wage.At the initial stage of system design,BADL was taken as the standard to measure disability.After the system was mature,IADL and cognitive impairment could be included in the evaluation standard.A mixed payment system is adopted,which combines payment in kind with payment in cash.4.Specifying the division of labor and responsibilities of medical and nursing care to promote the integration of medical and nursing careThe medical service system focuses on emergency and treatment,while the nursing care system is mainly for prevention,rapid division and the treatment of chronic diseases.We will refine and clarify the policy and regulatory responsibilities in the combination of medical and nursing care,simplifying the approval process for setting up medical facilities in LTC institutions,at the same time,lowering the standards appropriately.The development plan,financial subsidy policy and facilities construction plan for the multi-level medical and nursing care system will be promulgated as soon as possible in China.5.Building a multi-level integrated medical and nursing care systemThe service content of the combination of medical care and nursing care shall be clarified,like standardizing the classification standard of service objects,the service personnel access,proportion of service personnel and performance appraisal,this could lead to the sustainable service system,with the combination of medical care and nursing,to be formed with a progressive relationship of "basic care services-nursing-medical care".6.Improving the talent training mechanism and strengthening education and supportMedical colleges,especially higher ones,are encouraged to set up nursing programs for the aged,so as to cultivate nursing professionals in meeting the long-term needs of the nursing industry.We will establish and improve access,training,evaluation and incentive mechanisms for elderly care workers to raise their salaries and social security benefits,and complete their career planning and development.7.Establishing uniform service quality standards and hierarchical management systemA unified evaluation standard system for service quality of pension service institutions should be established,as well as a normalized and mandatory hierarchical management system for LTC institutions.In addition,the expert pool of pension industry evaluation should be made as soon as possible,and the third-party evaluation mechanism should be formulated and improved. |
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