中国人民大学 李 珍 LI Zhen, Renmin University of China 关于完善老年服务和长期护理制度的思考与建议 Thoughts and suggestions on how to improve the elderly care services and the LTC system in China 中国人民大学 李 珍 LI Zhen, Renmin University of China

来自国际比较的几点总结 Some conclusion from internatonal comparison 第一，筹资模式的选择取决于许多因素，经济发展水平和家庭制度、长期护理的责任归属、人们对政府作用的认识是几个非常重要的因素； 第二，无论筹资制度如何，越依赖机构递送服务花费就越高，家庭的作用越大则总体费用越小。花费越高则家庭对外部的依赖程度也越高。即需求产生供给，供给的扩张反过来推动或拉动需求。 第三，福利国家曾经将长期照顾看作是国家的责任，目前价值观发生变化，认为长期照顾责任应该是个人的。 1.Financing model depends on: economy, household, LTC responsibility, expectation on government; 2. Institutional services cost more, while family costs less. Higher cost is higher dependency on external resources. Demands result in supplies, and expanded supplies drive demands. 3. For a long period, welfare states have considered LTC responsibility of the state. It is changing：people start to consider it individual‘s responsibility.

1.内容提要 Summary 2.中国养老服务制度的发展及长期护理筹资制度的探索 Retirement Service in China & LTC Financing 3. 关于完善老年服务和长期护理体系的思考与建议 Thoughts and suggestions on how to improve the Senior Services and the LTC system in China

1. 内容提要 Summary 以家庭为基础，社区为依托、机构为补充、医养结合的多元福利体系已经建成。 与医疗有关的长期护理应纳入基本医疗保险，与生活有关的长期照料属私人事务，个人家庭是第一责任人。 现阶段，政府应建立长期照护津贴制度，对服务和经济能力不足的对象进行精准资助。 财政支出政策应由“补供方”为主转向以“补需方”为主。 完善健康养老、积极养老政策降低失能概率。 构建“支持和维护家庭”的养老和长期照护政策体系。 In China the pluralistic welfare system that is based on family, supported by community, supplemented by institutions, and combined with health care and elderly care has been established. Medical-related LTC should be included in the Basic Medical Insurance scheme, while private LTC should rely on individual. Government should provide subsidies to those who cannot afford to LTC services. The fiscal expenditure policy therefore should trans form from targeting the “supply-side” to confusing on the “demand-side”. The research suggests that policies regarding healthy ageing and active ageing should be improved to reduce probabilities of disability “family supporting and maintaining” policies should be built up in the elderly care and long-term care system. 

2.中国养老服务制度的发展及长期护理筹资制度的探索 Senior Service & LTC Financing in China 2.1 中国养老服务递送体系政策的演变 Evolution of Senior Service Policies 1994年以前，家庭一直是养老服务的唯一提供者，政府只对没有子女且没有经济能力的老年人负责。 1994年后，中国养老服务递送进入多元化时代。 21世纪后，养老服务递送主体的政策一直是在调整家庭、社区和机构的不同主体的权重和三者之的协同关系，同时失能、半失能老年人的养老问题被提出，长期护理体系的建设受到重视。 Before 1994, family was the only source for senior services, while government were only responsible for elderly without child. After 1994, senior services diversify in China. In the 21st Century, main policies on senior services have tried to coordinate and readujust the roles of family, community and institution. At the same time, disabled and semi-disabled elderly, and LTC become the focuses.

2006年，逐步建立和完善以“居家养老为基础、社区服务为依托、机构养老为补充”的服务体系。 2006: a senior service system based on family, supported by community, supplemented by institutions 2011: a senior service system based on family, supported by community, supplemented by institutions ; solving problems for disabled and semi-disabled elderlies; capital from social forces entered the market; government provided large subsidies, resulting in excessive institutions; 2016: 2006: a senior service system based on family, supported by community, supplemented by institutions, with combination of medical and health cares for elderly people. 2006年，逐步建立和完善以“居家养老为基础、社区服务为依托、机构养老为补充”的服务体系。 2011年，“居家为基础、社区为依托、机构为支撑”；同年，提出“解决失能、半失能老年群体养老问题”；社会资本快速进入养老服务市场，政府也给予养老机构大量补贴，导致养老机构过剩。 2016年，“居家为基础，社区为依托，机构为补充，医养结合的养老服务体系更加完善”，提出了医养结合。

2.中国养老服务制度的发展及长期护理筹资制度的探索 Senior Service & LTC Financing in China 2.2 城乡养老服务及长期护理体系的现状 current senior service and LTC in urban & rural areas. 家庭是长期护理服务的主要提供者。 社区为依托的养老服务递送尤其是针对失能半失能老年人、高龄老年人、低收入空巢老年等特殊群体的服务递送体系得到了快速发展。 信息化服务系统为依托的社区居家养老服务平台基本健全。 机构养老床位数快速增长，长期护理、康复、临终关怀等等服务受到重视。 Family is the main provider of LTC. Great progress is seen in the senior service supported by commuity, especially services is for semi-disabled, older,low-income single elderly. Digitalized services are established for home and community services. Number of beds in institutions increase rapidly; more attention have been paid to LTC, rehabilitation and hospice care.

2016年底，各类养老床位合计730.2万张，（每千名老年人拥有养老床位31.6张，包括社区留宿和日间照料床位）。 老龄委“四调”（寸草春晖）：91%的老人实际获得了照料护理服务，城镇为93.46%，农村的89.43%。只有约10%的老年人不能获得所需要的照料护理服务。服务提供：配偶（43.48%）、儿子（28.64%）、儿媳（10.08%）、女儿（10.35%）。 2016年底，各类养老床位合计730.2万张，（每千名老年人拥有养老床位31.6张，包括社区留宿和日间照料床位）。 青连斌（2014年-2015年）：84.6% 的养老机构设置了失能老人床位，平均每家设置失能老人床位91张，占平均床位数的42%，61.8%的养老机构设置了多功能护理床，平均每家机构设置多功能床位53张。 According to the 4th Servey by Aging Committee (Cuncao Chunhui)： 91% of elderly received care de facto, (93.46% urban and 89.43% rural). Only 10% of elderly couldn‘t receive services they need. Provider: partner (43.48%)，son(28.64%), son‘s wife (10.08%) & daughter(10.35%). In the end of 2016, bed for senior care: 73.02 million (31.6/1000 elderly, included beds in communicy domitory and day-care center) According to Qing Lianbin (2014-2015) 84.6% of institutions had beds for disabled elderly： 91 beds / institution, accounting for 42% of all beds; 61.8% of the institutions had multi-functional beds: 53 beds/ institution.

2.3 老年人长期照护服务体系发展的主要问题 长期护理服务及递送体系的问题既有供求关系总量也有供求结构性错配的问题。Mis-match of supply and demand in both quantity and structure. 居家养老来看，有几个问题需要关注：for home care: 第一，农村老年人在健康状态、收入状态等方面较城镇老年人更弱势，长期护理服务供求矛盾比城镇更突出，而公共政策对城镇老年人关照更多，加剧了这种不平衡。（第一代农民工） 第二，现有的政策已经关注到高龄老人、空巢老人、低收入老人的养老服务和长期护理需求问题，一些多代同居的家庭可能是既没有能力提供长期护理服务也没有能力购买服务的，“两代老人”家庭（老人与老老父母同居）长期护理能力也是有限的。 第三，城镇家庭医疗护理需求可及性不强。 第四，老年人利用互联网能力不足。 Rural elderly are more vulnerable than urban elderly in terms of health and income, resulting bigger problem of LTC than in cities; policies prefer urban elderly, increasing the unbalance (1st generation of migrant peasant workers) Some policies pay attention to services and LTC for older, no-child, and low-income elderly. But family with more generations would not afford to the services; families with 2 generations of elderly have bigger problem. accessibility of urban family madicare is not strong elderly’s capability of using internet is not strong.

社区和机构养老总体情况是供给与需求的错配 Mismatch of supply and demand of community and institutional services. 社区长期护理服务供给与需求的错配： Mismatch of community LTC 一是社区养老床位的供给与需求的错配， 二是政府通过社区递送的服务与多样化需求的错配。 1. Mismatch between supply and demand of care beds for elderly 2. Mismatch between services by government and diverse demands. 养老机构供给与需求的错配的主要表现是: Mismatch of institutional services 一是机构养老床位总供给在数量上与总需求错配。 二是养老机构供给与需求存在空间上的错配。 三是财政补供方使得资源错配。 1. Mismatch between total quantities of supply and demand of institutional beds; 2. mismatch between supplied and demanded rooms in institutions 3. mismatch of resources resulted from government‘s subsidy to supply-side.

图1 2006-2016年养老机构床位数及入住人数增长情况 Beds(B) and Service Recipients (R) in Institutions, 2006-2016

图2 2006—2016年养老机构与床位增长情况 Institutions(I) and Beds(B), 2006-2016

2.4 长期护理筹资体制的探索 The way of Financing for LTC 2.中国养老服务制度的发展及长期护理筹资制度的探索 Senior Service & LTC Financing in China 2.4 长期护理筹资体制的探索 The way of Financing for LTC 一是政府供给的补残模式； 二是社会保险模式； 三是相互保险模式。 1. Government‘s Subsity to Insufficient Parts; 2. Social Insurance 3. Mutual Insurance

2016年8月，全国26个省（区、市）出台了高龄津贴补贴政策，20个省（区、市）出台了养老服务补贴政策，17个省（区、市）出台了长期护理补贴政策。享受高龄补贴的老年人2355.4万人，比上年增长9.3 %；享受护理补贴的老年人40.5万人，比上年增长52.8%；享受养老服务补贴的老年人282.9万人，比上年增长9.7%。 2016年７月，人力资源社会保障部办公厅出台《关于开展长期护理保险制度试点的指导意见》，选择15个城市试点，先行先试，探索长期护理社会保险的模式。 In Aug 2016, 26 provinces issued subsidy polices for older elderly; 20 provinces issued subsidy policies for senior services; 17 issued subsidy policies for LTC. 23.5 million elderly received subsidy for older elderly, increasing by 9.3%; 405,000 elderly received LTC susbdies, increasing by 52.8%； and 2.8 million received subsidies for elderly services, increasing by 9.7%. In Jul 2016, General Office of MOHRSS issued Guideline for LTC Pilot Sites, which selected 15 cities for experimenting LTC social insurance.

3. 关于完善老年服务和长期护理体系的思考与建议 Thoughts and suggestions on how to improve the Senior Services and the LTC system in China 3.1 政府在长期护理领域的首要责任是“兜底线，织密网” 3.1 The primary responsibility of the government is providing basic and strong safety net 3.1.1 老年人长期生活照料是私人事务，个人和家庭是第一责任人； 3.1.2 现阶段长期护理社会保险不适应中国国情； 3.1.3 政府要“兜底线，织密网”，精准资助需要帮助的人群 3.1.1 Care of daily life for elderly is the responsibility of individual and family; 3.1.2 LTC insurance is not suitable to China‘s reality 3.1.3 Government should provide basic and strong safety net with targeted assistance to people in need 转至3.2 to 3.2

3.1.1 护理内容：Contents of Care 医疗护理：基本医疗保险（日本、荷兰2015年重入医保） 生活照料：私人事务，应该由私人来决定供给 《老年人权益保障法》、《婚姻法》 中国没有遗产制度 Medicare: Basic Medical Insurance (JP, Netherland re-included it into the Medical Insurance in 2015) Life care： private affaris and responsiblity Law on Protecting Elderly Rights Marriage Law No Private Inheritance System in China

3.1.2 中国的家庭制度是社会保护制度中的正式制度安排； “保基本”含义是保障基本风险和基本保障水平，长期照料费用不是基本风险，甚至不是纯粹风险； 从福利归属看，社会保险具有逆向再分配的作用，这一问题在大病医保和公积金制度中都存在； 2016年户籍城镇化率仅为41%，8亿多劳动力，参加职工医疗保险的只有2.9亿人口； 供给侧改革，政府要求降低企业税费。 Household is formal arrangement in the social protection system of China; Basic safety net means protection of basic risks with basic benefits; LTC costs is not basic risk, and even not pur risk; Social insurance benefit can be reversed redistribution of income, a problem also seen in the Insurance for Distastrous Desease and Housing Credit Scheme; In 2016, only 41% Chinese citizen had urban Hukou, and only 290 million were covered by Medical Insurnace for Employees For the supply-side reform, government makes effort on reducing enterprise‘s fiscal burden.

Needs of Disabled Elderly and Targeting of Policies 3.1.3 Strong support from family Low-income/ support from family High-income/support from family Week support from family Low-income/week support from family High-income/week support from family poor Dibao line rich Needs of Disabled Elderly and Targeting of Policies

3.2 建议财政支出政策由“补供方” 为主转向以“补需方” 为主 3. 关于完善老年服务和长期护理体系的思考与建议 Thoughts and suggestions on how to improve the Senior Services and the LTC system in China 3.2 建议财政支出政策由“补供方” 为主转向以“补需方” 为主 Fiscal subsidies should turn from supply side to demand side 3.2.1 老年人长期照料以补需方为主 3.2.2 改政府直接购买服务为服务券补贴 3.2.1 For LTC, subsidize the demand side 3.2.2 Change service purchase into service coupon

3. 关于完善老年服务和长期护理体系的思考与建议 Thoughts and suggestions on how to improve the Senior Services and the LTC system in China 3.3 构建“支持和维护家庭”的政策体系 Family-supporting Policies 3.3.1 Support elderly to get access to internet; 3.3.2 Promote General Practitioner 3.3.3 Hosing Adaptation for Elderly 3.3.4 Tax Deduction for LTC family caregivers 3.3.5 Repite Service or Subsidies for LTC family caregivers 3.3.6 City design adapted to population ageing and nuclear family, which accommodate different generations with independent spaces; 3.3.7 policy facilitating children to live in one-soup distance from elderly parents 3.3.1 利用现有电视网络或者其他资源联通老年人家庭的互联网；社区养老服务机构可以为老年人及其家庭成员提供相关培训，使互联网的便利惠及老年人、特别是社会性失能老年人； 3.3.2 推进家庭医生签约并将长期护理内容纳入家庭医生服务内容； 3.3.3 支持适老住房改造。城镇多数人老年人的住房为上世纪80年代建造； 3.3.4 对提供长期护理服务的家庭成员进行所得税减免； 3.3.5 对提供长期护理服务的家庭成员提供喘息服务或者津贴； 3.3.6 未来的城市住房设计应该将人口老龄化与家庭小型化考虑在内，使代际既有独立空间又能相互照顾； 3.3.7 通过税惠政策鼓励子女居住在老年父母的“一碗汤”距离内。

3. 关于完善老年服务和长期护理体系的思考与建议 Thoughts and suggestions on how to improve the Senior Services and the LTC system in China 3.4 完善健康养老、积极养老政策降低失能概率 3.4 The research suggests that policies regarding healthy ageing and active ageing should be improved to reduce probabilities of disability 3.4.1 Spread concepts of active ageing and healthy ageing 3.4.2 take action so to reduce probability of disablity 3.4.3 reinforce rehabilitation 3.5 Space for family and community senior services in the city and community design 3.6 open the market and change pre-facto approval into during and post-facto supervision adapted to local economy 3.4.1 普及积极养老、健康养老的理念； 3.4.2 采取积极措施，降低失能概率； 3.4.3 加强康复训练减轻失能程度。 3.5 城市和社区规划中为家庭养老和社区养老留有空间。 3.6 开放机构养老市场，变前置审批为事中和事后监督，监管的标准一定要与当地经济发展水平相一致。

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