Policy recommendations Marcello MORCIANO Sharing long-term care responsibilities: the role of the individuals, their relatives, the market and the State Policy recommendations Marcello MORCIANO Health Economics Group, University of East Anglia (UK) CAPP – Research Centre for the Analysis of Public Policies, University of Modena and Reggio Emilia (IT) Beijing, February 27th 2018

摩德纳·瑞久·艾米利亚大学公共政策研究中心（意大利） 2018年2月27日，北京 分担长期护理责任: 个人、亲属、市场、国家的角色 政策建议 马哲洛·莫嘉诺 东英吉利大学健康经济研究组(英国) 摩德纳·瑞久·艾米利亚大学公共政策研究中心（意大利） 2018年2月27日，北京

Index Part I- Setting the context Full coverage in my two reports: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing. Morciano (2018) Sharing long-term care responsibilities: the role of the individuals, their relatives, the market and the State, EU-China Social Protection Reform Project, Beijing. Part II- The team leader asked to recommend how best to meet the costs of care and support as a partnership among the individuals, their relatives, the market and the State; how people could choose to protect their wealth against the cost of care; how public funding for the care and support system can be best used to meet care costs; policy messages that could be relevant for China, based on the EU experiences.

目录 第一部分- 语境介绍 两份报告： 第二部分- 专家组长要求的建议 如何在个人、亲属、市场和国家之间以最佳方式分担护理成本和伴护扶助; 莫嘉诺 (2017)《欧洲长期护理：最新证据回顾与归纳》, 中欧社会保障改革项目， 北京 莫嘉诺(2018) 《分担长期护理责任: 个人、亲属、市场、国家的角色》,中欧社会保 障改革项目，北京 第二部分- 专家组长要求的建议 如何在个人、亲属、市场和国家之间以最佳方式分担护理成本和伴护扶助; 如何在付出成本的同时保障财富; 如何以最佳方式运用护理和扶助体系的公共筹资解决护理成本问题; 欧盟经验中与中国相关的政策信息.

Setting the context: The number of older people is increasing: 70% of people turning age 65 can expect to use some form of LTC during their lives The risk of becoming dependent on LTC rises steeply from the age of 80: Social care is the key element of LTC state support. EU citizens are –on average- four times richer than 1950; Care costs are uncertain and can be very high 18% 30% 1960 today 2060 10% Percentage of population above 65 years in the EU region 5% 12% 1960 today 2060 1% Percentage of population above 80 years in the EU region

语境介绍: 老龄人口在增长: 80岁以后依赖于长期护理的风险陡增: 社会性护理是国家对长期护理支持的关键元素 70% 转入65岁以上可人口在有生之年可以获得某些形式的长期护理 80岁以后依赖于长期护理的风险陡增: 社会性护理是国家对长期护理支持的关键元素 欧盟公民平均比1950年代富裕4倍; 护理成本尚未确定，但可能很高 18% 30% 1960 today 2060 10% 欧盟地区65岁以上老人比例 5% 12% 1960 today 2060 1% 欧盟地区80岁以上老人比例

Setting the context: What is long-term care (LTC)? Long-term care (LTC) is a range of services required by persons with reduced degree of functional (physical or cognitive) capacity, and who need help to meet their basic personal needs Most LTC is not medical care: it is care for chronic illness/disability instead of treatment of acute illness. Caring for chronic illness lasts as long as the recipient is alive Most LTC is assistance with the basic personal tasks of everyday life: bathing, eating, taking medication, etc. Most LTC is provided informally (whereas acute care is provided by professionals): Informal care may affect caregiver’s labour supply LTC market dominated by for-profit facilities facing excess demand: little incentive to improve quality of care to remain competitive Comprehensive acute care insurance but little private LTC policies Demographic transitions will affect the LTC industry even more than acute care. See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

长期护理(LTC) 是为（生理、认知）功能降低人员为满足其基本个人需求而提供的系列服务 大多数长期护理并非医疗: 它是对慢性疾病/失能的护理，而不是急性病的治疗。慢性疾病的护理伴随被护理人的一生。 大多数长期护理都是对个人日常生活基本任务的扶助: 沐浴、饮食、服药等。 大多数长期护理都是以非正式方式提供的（急性病治疗则是以专业方式提供的）：非正式护理影响到护理人员的劳动力供给 长期护理市场由供不应求的盈利性设施（机构）主导: 基本没有鼓励措施帮助护理质量提升、保持竞争优势 有综合性急性病护理保险，但很少有民营的长期护理保险（保单） 人口转型会对长期护理产业造成影响，甚于急性病护理 见：莫嘉诺 (2017)《欧洲长期护理：最新证据回顾与归纳》, 中欧社会保障改革项目，北京

In EU, there is no a single LTC system. Typology of LTC systems in the EU28 Formal-care (FC) oriented provision; generous, accessible and affordable Financed from general revenue allocations to LA High public and low private spending on FC Low Informal care (IC) use, high IC support Modest cash-benefits. 莫嘉诺 (2017)《欧洲长期护理：最新 证据回顾与归纳》, 中欧社会保障改 革项目，北 See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

欧盟没有同意的长期护理制度 欧盟28国长期护理分类 正式护理 (FC) 导向型; 福利慷慨、易得、价格合适 有全国总体收入筹资，划拨LA 公共支出高，私人支出低 非正式护理（IC）享用度低，扶持度高 现金福利属中等 See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

Typology of LTC systems in the EU28 Formal-care (FC) oriented provision; generous, accessible and affordable Financed from general revenue allocations to LA High public and low private spending on FC Low Informal care (IC) use, high IC support Modest cash-benefits. FC of medium accessibility; some IC orientation in provision Obligatory social insurance financed from contributions Medium public and low private FC spending High IC use, high IC support Modest cash-benefits. See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

欧盟28国长期护理分类 正式护理可及性属中等; 福利慷慨、易得、价格合适 正式护理(FC) 型; 制度规定中有部分非正式护理导向 有全国总体收入筹资，划拨LA 公共支出高，私人支出低 非正式护理（IC）享用度低，扶持度高 现金福利属中等 正式护理可及性属中等; 制度规定中有部分非正式护理导向 通过缴费实现义务社会保险筹资 非正式护理公共支出属中等；私人支出低 非正式护理享用度高；扶持度高； 现金福利属中等。 See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

Typology of LTC systems in the EU28 Formal-care (FC) oriented provision; generous, accessible and affordable Financed from general revenue allocations to LA High public and low private spending on FC Low Informal care (IC) use, high IC support Modest cash-benefits. FC of medium accessibility; some IC orientation in provision Obligatory social insurance financed from contributions Medium public and low private FC spending High IC use, high IC support Modest cash-benefits. FC of medium accessibility; medium IC orientation in provision Medium coverage financed from contributions\general revenue Medium public and private FC spending High IC use, high IC support High cash-benefits. See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

欧盟28国长期护理分类 正式护理可及性属中等; 福利慷慨、易得、价格合适 正式护理(FC) 型; 制度规定中有部分非正式护理导向 有全国总体收入筹资，划拨LA 公共支出高，私人支出低 非正式护理（IC）享用度低，扶持度高 现金福利属中等 正式护理可及性属中等; 制度规定中有部分非正式护理导向 通过缴费实现义务社会保险筹资 非正式护理公共支出属中等；私人支出低 非正式护理享用度高；扶持度高； 现金福利属中等。 正式护理可及性属中等; 制度规定有中等非正式护理导向 缴费/全国总体收入筹资居半 费正式护理公共支出和私人支出居半 非正式护理享用度高；扶持度高； 现金福利高 Source: European Commission, “Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability”, October 2016.

Typology of LTC systems in the EU28 Formal-care (FC) oriented provision; generous, accessible and affordable Financed from general revenue allocations to LA High public and low private spending on FC Low Informal care (IC) use, high IC support Modest cash-benefits. FC of medium accessibility; some IC orientation in provision Obligatory social insurance financed from contributions Medium public and low private FC spending High IC use, high IC support Modest cash-benefits. FC of medium accessibility; medium IC orientation in provision Medium coverage financed from contributions\general revenue Medium public and private FC spending High IC use, high IC support High cash-benefits. Low FC accessibility; strong IC orientation in provision Modest social insurance against LTC risks Low public and high private FC financing High IC use, low IC support High cash-benefits. See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

欧盟28国长期护理分类 正式护理可及性属中等; 正式护理可及性低； 福利慷慨、易得、价格合适 制度规定非正式护理导向强 正式护理(FC) 型; 福利慷慨、易得、价格合适 有全国总体收入筹资，划拨LA 公共支出高，私人支出低 非正式护理（IC）享用度低，扶持度高 现金福利属中等 正式护理可及性属中等; 制度规定中有部分非正式护理导向 通过缴费实现义务社会保险筹资 非正式护理公共支出属中等；私人支出低 非正式护理享用度高；扶持度高； 现金福利属中等。 正式护理可及性属中等; 制度规定有中等非正式护理导向 缴费/全国总体收入筹资居半 费正式护理公共支出和私人支出居半 非正式护理享用度高；扶持度高； 现金福利高 正式护理可及性低； 制度规定非正式护理导向强 以中等社会保险应对长期护理风险 正式护理公共开支低，私人开始高 非正式护理享用度高；扶持度低 现金福利高 Source: European Commission, “Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability”, October 2016.

Typology of LTC systems in the EU28 Formal-care (FC) oriented provision; generous, accessible and affordable Financed from general revenue allocations to LA High public and low private spending on FC Low Informal care (IC) use, high IC support Modest cash-benefits. FC of medium accessibility; some IC orientation in provision Obligatory social insurance financed from contributions Medium public and low private FC spending High IC use, high IC support Modest cash-benefits. FC of medium accessibility; medium IC orientation in provision Medium coverage financed from contributions\general revenue Medium public and private FC spending High IC use, high IC support High cash-benefits. Very low FC accessibility; (almost) exclusive IC orientation Little social insurance against LTC risks Very low public FC spending Very high IC use, little to no IC support Modest/low cash-benefits. Low FC accessibility; strong IC orientation in provision Modest social insurance against LTC risks Low public and high private FC financing High IC use, low IC support High cash-benefits. See: Morciano (2017) Long-term care in Europe A review and synthesis of the most recent evidence, EU-China Social Protection Reform Project, Beijing.

欧盟28国长期护理分类 正式护理可及性属中等; 正式护理可及性低； 福利慷慨、易得、价格合适 制度规定非正式护理导向强 正式护理(FC) 型; 福利慷慨、易得、价格合适 有全国总体收入筹资，划拨LA 公共支出高，私人支出低 非正式护理（IC）享用度低，扶持度高 现金福利属中等 正式护理可及性属中等; 制度规定中有部分非正式护理导向 通过缴费实现义务社会保险筹资 非正式护理公共支出属中等；私人支出低 非正式护理享用度高；扶持度高； 现金福利属中等。 正式护理可及性属中等; 制度规定有中等非正式护理导向 缴费/全国总体收入筹资居半 费正式护理公共支出和私人支出居半 非正式护理享用度高；扶持度高； 现金福利高 正式护理可及性极低; (几乎) 纯非正式护理导向 以较少社会保险应对长期护理风险 正式护理公共开支极低 非正式护理享用度极高，几乎或很少有扶持 中等/低等现金福利 正式护理可及性低； 制度规定非正式护理导向强 以中等社会保险应对长期护理风险 正式护理公共开支低，私人开始高 非正式护理享用度高；扶持度低 现金福利高 来源:欧盟委员会，《医疗护理、长期护理、财税可持续性联合报告》, 2016.年10月

How different systems cope with current/future pressures Universal public LTC policies: Problem: it could encourage over-use of care and erode the important role of informal care with significant consequences for taxpayers. Solutions: increase co-payments and user contribution towards the cost of care (Tax-based models). Increase mandatory premiums, deductibles, introducing elimination periods or even capped benefit periods (Public LTC insurance models). Boost private insurance as asset protection & choice enhancement. Means-tested safety net schemes Problems: People above the threshold for state support face high costs in the current system. Some people can lose most of their assets. Solutions: Extending State support at the intensive and extensive margins. Private Insurance-based systems: Problems: intra- inter- generational myopia, moral hazard, adverse selection, sub-optimal risk pooling. Solutions: Employer-sponsored insurance policies, with the State that often incentivises the developement of the LTC market.

不同制度如何应对当前/未来压力 全民覆盖型公共长期护理政策: 问题: 会因对纳税人的影响而导致护理过度使用、渐渐消磨非正式护理的角色 解决方案: 增加护理成本共担份额和被护理人分担份额 (税收型)。增加法定缴费、税优额度，设定免费期或最高福利期 (公共长期护理保险型)。促进民营保险发展，成为财产保护和已选利益增厚的办法。 家计调查型安全网制度 问题: 收入超过国家所定门槛的人员在当前制度下面临高额成本。一些人会因此丧失大部分财产。 解决方案: 扩大国家支助的内延和外延。 民营保险型制度: 问题: 代内、代际短视，道德风险，负向选择，欠优风险汇集. 解决方案: 建立雇主发起的保险制度，由国家提供激励措施促进长期护理市场的发展。

Policy recommendations: The fundamental problem in the LTC sector is the unpredictability of (long-term) risks related to: Demography Epidemiology Economy By removing the fear and uncertainty in LTC risks, people are encouraged to make sensible preparations for the future. There is consensus that an “optimal” system should: be flexible: funding has not kept up with demand avoid private catastrophic LTC-related costs (cap the cost of care) provide support for those not able to afford the cost of care limit perverse incentives; “nudge” and stimulate saving for old-age sharing the risks among different institutions.

通过消除长期护理风险所带来的恐慌和不确定性, 鼓励人们为未来做出有意义的准备. 政策建议: 长期护理行业的基本问题就是（长期）风险的不可预测性，这些风险与下列相关: 人口 疾病 经济 通过消除长期护理风险所带来的恐慌和不确定性, 鼓励人们为未来做出有意义的准备. 人们一致认为，“优良”制度应当： 具有灵活性：筹资还跟不上需求 避免出现巨额的民营长期护理费用（设定护理成本最高限额） 为无法支付护理费用的人员提供支助 限制随意激励政策；只需“轻推”，刺激养老储蓄 在不同的制度间分担风险。

A possible solution: Capping the cost of care The State steps in and takes responsibility for the area of greatest unpredictable risk. Individuals would need to take responsibility for their own costs up to a certain point but, after this, the state would pay. Provides public coverage (via social insurance mechanism) for catastrophic LTC costs only. The state steps in and takes responsibility only when costs exceed a certain threshold. Great role for private insurance as asset protection & choice enhancement. A minority of people would reach the level at which the state steps in (these would be those with the highest care needs over the course of their lifetime). However, everyone would benefit from knowing that, if they ended up having to face these costs, they would be covered.

可能的解决方案: 设定护理费用最高限额 国家介入承担不可测风险最大方面的责任 个人须为其一定额度内的费用负责，而后由国家负责 Provides public coverage (via social insurance mechanism) for catastrophic LTC costs only. The state steps in and takes responsibility only when costs exceed a certain threshold. Great role for private insurance as asset protection & choice enhancement. 少部分人费用会达到国家介入的水平 (他们可能是在人生中护理需求最多的人). 但是, 知晓此事，人人都会受益, 当其临终时需要支付这些费用，就可以获得国家支助.

A possible solution: capping the cost of care The state steps in and takes responsibility only when costs exceed a certain threshold Individuals would need to take responsibility for their own costs up to a certain point but, after this, the state would pay. Capping people’s costs should free up people to spend some of their resources earlier (e.g. on home adaptation) Incentivise innovation in care delivery models to develop extra care housing markets Big space for the financial insurance services sector to help people in meeting their contribution, protecting wealth It is a public catastrophic LTC insurance system equivalent to a type of social insurance policy, with a significant ‘excess’ that people will need to cover themselves

可能的解决方案: 设定护理费用最高限额 为护理费用设定限额，可以让人们尽早花费一些资源（如，进 行房屋改造） 当费用超过一定门槛时，国家介入负担。 个人 在一定额度内要负责个人费用，而后由国家负担。 为护理费用设定限额，可以让人们尽早花费一些资源（如，进 行房屋改造） 对护理提供模式创新实施激励，发展额外护理住房市场 金融保险服务部门有很大的发展空间，为人们提供服务，帮助 其支付缴费、保障财务。 是一套公共性长期护理巨额费用保险制度 相当于一类社会保险, 为民众支付“超额部分”

A possible solutions: capping the cost of care The contribution individuals are expected to make in meeting the cost of care will be capped. To start with, people would be expected to meet their own needs as best they can. Once their accumulated needs have reached the level of the cap, they would be eligible for a care package funded by state. Those who cannot afford fully to make their contribution would continue to receive (current or extended) means-tested support. Those in residential care could be expected to make a contribution to their general living costs, just as they would be expected to meet the costs of living in their home.

可能的解决方案: 设定护理费用最高限额 个人所要支付的缴费要设定最高限额 一开始，人们希望尽可能满足其自身需求；一旦需求累积达 到最高限，则有资格获得国家资助的护理服务包。 无法完全缴费者，可以继续接收（当前或额外的）家计调查 型支助。 接受住院护理的人员应为其基本生活费用进行缴费，与其在 家支付基本生活费用一样。

Capping the cost of care: key parameter At the core of the proposal is the new capped cost element, which sets a limit on the amount individuals are expected to contribute towards their care over their lifetime. After individuals have spent a certain amount, they would become eligible for state-funded care. Careful consideration to the level at which the cap should be set. If too high, it would: be Sustainable for the State: low financial burden; Be Unfair: protect only wealthy people; Create little incentive for the development of a private insurance market. If too low, it would: be similar to the German System but under possible financial stress in the future; Be fair: with an almost universal coverage; Create little incentive for the development of a private insurance market and for the individuals/family.

可能的解决方案:关键参数 本提议的核心新元素就是“限额成本”, 即对个人终身护理缴费进行额度限制。在个人花费一定额度后，可以获得国家资助的护理。 对限额设定，要慎重考虑： 如果过高，则: 可保持国家预算可持续性：财政负担就低； 会对百姓不公平：制度仅能保障富人 不会为民营保险市场发展形成激励。 如果过低，则: 会与德国制度类似，但未来会有一定财政压力； 具有公平性：几乎全民覆盖； 不会对民营保险市场发展或个人/家庭形成激励。

Capping the cost of care: Flexibility in other arrangement dimensions The financing mode: The LTC system could be constructed either as a Social insurance model (contributions levied on a narrower tax base than general revenue, tax distortions on employment) or a Tax-based model (funds levied on a bigger tax base that is ageing). Or a mixed financing model? The definition of needs: Assessment of LTC needs based on an objective assessment scale; a national eligibility threshold; Portable assessment Note also that all other dimensions are not strictly dictated by the reform: The public/private mix The mix between cash-benefits and services* The freedom to choose the LTC providers The balance between public and private providers The quality assurance The level of integration and coordination of care among different LTC institutions (*) Everyone could be entitled to universal disability benefits (which will also support people in addressing lower care and support needs). By varying them, the State gains more flexibility in the long-run (alternative option of re-setting the cap).

筹资模式: 或通过税收模式（在高额税收基础上筹集针对老龄问题的基金）进行筹 资。或者考虑混合模式进行筹资？ 可能的解决方案:其他灵活安排 筹资模式: 或通过税收模式（在高额税收基础上筹集针对老龄问题的基金）进行筹 资。或者考虑混合模式进行筹资？ 需求界定: 根据客观量表对长期护理需求进行测量；设定全国通用的护理收益资格 标准；施行“可携带式”的测量。 也要注意改革中没有严格讨论的其他维度： 公/私混合模式 现金/服务混合模式* 自由选择长期护理供应单位 公私护理供应单位平衡 质量保障 不同长期护理机构所提供的护理之整合与统筹 (*) 人人均可获得全民残障福利(该制度也支助民众的低端护理和需求)。通过改造这些福利，国家可以在长期施行灵活政策（重新设定最高限额）

Thank you for your attention 谢谢聆听 E-mail: m.morciano@uea.ac.uk