| With the aging of the population and the increase in life expectancy,the size of the disabled population in China is expanding,and the demand for long-term care is increasing.At present,the traditional nursing model based on home care has been unable to meet the continuously expanding nursing needs of the elderly.It is urgent to establish a comprehensive and systematic long-term care insurance(LTCI)system to ensure the effective supply of long-term care resources.China has launched an LTCI pilot system since 2016.Different from the multi-channel financing model of foreign systems,the financing of LTCI in China’s pilot system mainly comes from the medical insurance fund,which is prone to impose a heavy burden on medical insurance fund expenditures.It is important to clarify the mechanism of LTCI system’s impact on medical insurance fund expenditures,construct a reasonable financing system,and determine reasonable funding sources and funding levels,in order to establish a sustainable LTCI system in China in the future.Based on the theory of family intergenerational support,life cycle theory,overlapping generation model and health demand model,this paper summarizes the theoretical framework of LTCI system design,and analyzes the current situation of China’s LTCI pilot system,through comparison of domestic and foreign systems and empirical research.Then the short-term and long-term development paths of financing mechanism of LTCI,suitable for China’s national conditions,are proposed.Firstly,this paper sorts out the theoretical framework of LTCI system design from three perspectives.(1)Based on the family intergenerational support theory,the government should establish an LTCI system,reasonably divide the responsibility scope of social care and home care,and jointly undertake long-term care responsibilities with families.(2)Based on the life cycle theory and generation overlapping model,the LTCI system should reasonably determine the level of financing and payment,in order to achieve macro social insurance fund balance,steady economic development and social welfare effect maximization.(3)Based on the health demand model,the paper sorted out the main factors affecting the demand for long-term care,and focused on the mechanism of the impact of LTCI on the expenditure of the basic medical insurance fund.This mechanism can be summarized as scale effect and structure effect,in which,scale effect leads to increase of basic medical insurance fund expenditure,while structure effect leads to decrease of basic medical insurance fund expenditure,which jointly determine the effect of LTCI on basic medical insurance fund expenditure.Secondly,this paper analyzes the current situation and existing problems of the pilot system of LTCI in China through the comparison of domestic and foreign systems and empirical research.(1)Different from the multi-channel financing mode of the German or Japanese system,the financing of LTCI in China’s pilot system mainly comes from the medical insurance fund’s social pooling account,which is a part of the expenditure of the medical insurance fund.(2)The panel data of 64 cities in China were used to construct a DID model for empirical study.It was found that the implementation of LTCI system would expand the expenditure of medical insurance fund for urban employees,and the scale effect of LTCI on the expenditure of medical insurance fund for urban employees was greater than the structure effect.This deviates from the original intention of China’s LTCI system,which is to control the excessive growth of medical insurance fund expenditure by optimizing the expenditure structure of medical insurance fund for urban employees.Therefore,the LTCI system attached to the current medical insurance fund is faced with financing risks under the reality that China’s medical insurance fund itself bears huge payment pressure.It is urgent to design a more perfect financing mechanism to ensure the stable and sustainable development of LTCI system.Thirdly,this paper constructs the population prediction model,the income and expenditure model of urban employees’ medical insurance social pooling fund and the international labor organization financing model,and puts forward the short-term and long-term development paths of China’s LTCI financing mechanism by using the actuarial results of the above models.In the short term,considering that Chinese enterprises have already borne relatively heavy payment responsibilities for social insurance,in the current pilot promotion stage,the LTCI system attached to the medical insurance fund is mainly financed from the medical insurance fund,which is the most realistic and feasible financing path because of no additional enterprise payment obligations.Therefore,maintaining the balance of medical insurance fund has become the primary condition to ensure the smooth operation of the current LTCI system.Based on the actuarial prediction of the financial income and expenditure of medical insurance fund for urban employees from 2021 to 2050,it is found that increasing the individual out-of-pocket payment ratio of LTCI and implementing the outpatient mutual-aid guarantee mechanism can effectively enhance the balance of income and expenditure of the medical insurance fund for urban employees in a short term.However,even if the above two policies are implemented simultaneously,the medical insurance fund for urban employees still cannot maintain the balance in the long term,and will be in deficit before 2050,leading to the financial risk and unsustainable of the LTCI system.In the long run,China should separate the LTCI from the medical insurance fund and construct an independent financing mechanism to ensure the stability and sustainability of the LTCI system.By simulating the implementation of the financing mechanism in Germany,Japan and China,the optimal financing level is calculated under China’s current national conditions,and the LTCI financing mechanism that enterprises and individuals bear the financing responsibility in accordance with their respective proportions is constructed:In the case of taking all urban employees and retirees as fund-raising objects,the proportion of LTCI contributions from enterprises and individuals from 2021 to 2050 are calculated.The contribution rate in 2021 is the same as the initial contribution in Germany and Japan and falls within a reasonable range that enterprises and individuals can bear.Finally,this paper proposes the following four policy recommendations.(1)While deeply promoting the pilot work of LTCI system attached to the medical insurance fund,select some cities to carry out the pilot work of independent LTCI system,and gradually transition to an LTCI financing mechanism that enterprises and individuals bear the financing responsibility in accordance with their respective proportions.(2)We will gradually establish a unified national LTCI system,which will gradually expand the coverage from urban employees to urban and rural residents.The financing mechanism should be independent of the medical insurance fund,the financing responsibility and rate structure is clear and reasonable,and the service system and payment mechanism focus on home and community.(3)We should pay attention to the construction of coordinated support systems,encourage the development of commercial LTCI,accelerate the legalization of LTCI,and establish and improve sopport systems such as nursing personnel and information platforms.(4)We will fully implement the Healthy China strategy,and guide and promote the development of the concept of active aging.The main innovations of this paper include:(1)This paper summarizes the theoretical framework of LTCI system design,including the theory of family intergenerational support,life cycle theory,overlapping generation model and health demand model,and sorts out the mechanism of the impact of LTCI on medical insurance fund expenditures for the system attached to the medical insurance fund implemented in China on a pilot basis.(2)A DID model is constructed using panel data of 64 cities in China,and found that the implementation of LTCI system would expand the expenditure of medical insurance fund for urban employees,which provides a more in-depth and comprehensive review of the policy effects of China’s LTCI system.(3)When building a population model based on the cohort element method to forecast the number of participants of medical insurance fund for urban employees from 2021 to 2050,the total fertility rate is revised,demographic characteristics and policy parameters such as delaying retirement age and two-child policy are added,and dynamic simulations and reforecasts are conducted based on the 2020 participation data to improve the forecast accuracy.(4)It is clarified that when the LTCI system is mainly financed from the medical insurance fund,increasing the individual out-of-pocket payment ratio of LTCI and implementing the outpatient mutual-aid guarantee mechanism can effectively enhance the balance of income and expenditure of the medical insurance fund for urban employees in a short term and guarantee the smooth operation of the current LTCI pilot system. |
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