1、关于完善老年服务和长期护理制度的思考与建议李 珍2018-2-27Reflection and Reccommendation for Improving Old-Age Service and LTCLi Zhen2018-2-27Page 31.前言前言2.中国养老服务制度的发展及长期护理筹资制度的探索中国养老服务制度的发展及长期护理筹资制度的探索3.关于完善老年服务和长期护理体系的思考与建议关于完善老年服务和长期护理体系的思考与建议IndexPage 41.Preface2.Development of Old-Age Service in China and Exploration o
2、f Establishing LTC Financing System3.Reflection and Reccommendation for Improving Old-Age Service and LTCIndexPage 51.前言前言养老服务体系早在上世纪90年代开始建设，2006年就关注到老年人长期护理服务递送体系的建设，中国政府是有远见的。经过十几年的建设，以家庭家庭为基础，社区为依托、机构为补充、医养结合为基础，社区为依托、机构为补充、医养结合的多元利体系已经建成。随着人口寿命的延长，长期护理的需求会日益增长，而另一方面，少子化、家庭小型化、医疗护理的专业化等等原因，老年人长期
3、护理需求在家庭内部得不到满足时，这种需求就会外溢为社会需求外溢为社会需求，社会供给养老服务是必然的。就高收入国家和地区的实践而言，第一，筹资模式的选择取决于许多因素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。Page 61.PrefaceChinese OA Service system start
4、s in 1990s,and in 2006 the focus was moved to LTC delivery,which represents far sight of Chinese government.After about 2 decades,China has basically built up a multi-tier LTC system based on home care,supported by community care,with supplement of institutional care and in combiniation with medical
5、 care.As life expectancy extends,LTC needs increase.However,sub-repleacement fertility,small-scale family,and specialization of medical care cannot satisfy LTC demand in family,and the demand therefore becomes a social need outside family,which necessarily requires social OA services provided.Practi
6、ces in high-income countries and regions,tell us:(1)funding model of LTC depends on many factors,among which economic development,family structure,responsibility distribution,role of government are the most important;(2)no matter what the funding model is,services delivered by institutions cost high
7、er than thouse from family.Higher cost cause family to rely on external service,forming a demand to which supply and production must respond to.The expansion of supply can,in turn,drive or drag demand.Page 72.中国养老服务制度的发展及长期护理筹资制度的探索中国养老服务制度的发展及长期护理筹资制度的探索2.1 中国养老服务递送体系政策的演变1994年以前，中国家庭一直是养老服务的唯一提供者，
8、政府只对没有子女且没有经济能力的老年人负责。1994年以后，养老服务递送主体的政策发生了变化，除了家庭，“社会养老保障制度”被引入，这里的“社会”是指社区和机构。自此，中国养老服务递送进入多元化时代。进入21世纪后，养老服务递送主体的政策一直是一直是在调整家庭、社区和机构的不同主体的权重和三者在调整家庭、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。Page 82.Development of Old-Age Service in China and Exploration of Establishing LTC
9、Financing System2.1 Evolution of OA service policy in ChinaBefore 1994,family has been the only provider of OA service,while the government only take responsibility of old people without child and ecocomic support.Since 1994,in addition to family,Social OA Security system was introduced,of which the
10、 word“social“refered to community and instituion.Then OA service in China started to diversify.After 2000,delivery of OA services is characterized by adjustment and balance of roles of family,community and institution,and at the same time,for the issue of fully and partially disabled old people,LTC
11、becomes one of the focuses in policy discussion.Page 92.1 中国养老服务递送体系政策的演变中国养老服务递送体系政策的演变2006年，关于加快发展养老服务业的意见提出“发展养老服务业要按照政策引导、政府扶持、社会兴办、市场推动的原则，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年发布的老龄事业“十二五”规划强调了机构的作用，政策修正为“居家为基础、社区为依托、机构为支撑居家为基础、社区为依托、机构为支撑”；同年，民政部发布社会养老服务体系建设“十二五”规划
12、，首次提出“解决失能、半失能老年群体养老问题”是“加强社会养老服务体系建设，促进社会和谐稳定的当务之急”。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。而养老服务“十三五”规划的政策是要使“居家为基础，社区为依托，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机构为补充，医养结合的养老服务体系更加完善”，这样在服务递送的主体方面，回归到2006年的表述，在服务递送的内容上适应长期护理的需求，提出了医养结合。Page 102.1 Evolution of OA service policy in ChinaIn 2006,the governme
13、nts Opinion on Developing OA Service Industry was made,which set the objective of LTC as to be a system based on home care,supported by community care and supplemented by institutional service with guide of policy,support of government,practice of social participants and promotion by the market.In 2
14、011,the 12th F-Y-Plan on OA service emphasized the role of institutions,for which the 2006 objective was changed to be that of being“backed by institutional services“.In the same year,MOCA issued its 12th F-Y-Plan on Social OA Service,which proposed to solve the problem derived from fully or partial
15、ly disabled old people,viewing it as the urgent issue for the harmony of Chinese society.Capital entered the OA service market rapidly at the same time,for which the government gave substantial subsidies to OA institutions,resulting in oversupply of OA services.In the 13th F-Y-Plan,the objecive of L
16、TC was changed to be that of to improve the system based on home care,supported by community care,supplemented with institutional services and in combination of medical services,which is a return to the 2006 policy,with the combination with medical services as the addition.Page 112.2 城乡养老服务及长期护理体系的现
17、状城乡养老服务及长期护理体系的现状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。Page 122.2 OA Service and LTC in Urban and Rural ChinaFamily is the main supplier of LTC services.OA services supported by communit care is developin
18、g rapidly,especially those provided to disabled old people,very-old people,and low-income old people without child.Digital Community OA sercive platform is generally established across China.Beds for OA services in institutions increase rapidly,and policy makers pay more attention to services for LT
19、C,rehabilitation and hospice care.Page 13老龄委“四调”：需要护理服务的城乡老年人中，91%的老人实际获得了照料护理服务，城镇为93.46%，高于农村的89.43%。只有约10%的老年人不能获得所需要的照料护理服务。在照料护理服务的主要提供者中，仍然以家庭成员为主：配偶（43.48%）、儿子（28.64%）、儿媳（10.08%）、女儿（10.35%）这四个主要提供者就占到了约93%。2016年底，注册登记的养老服务机构2.9万个，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）。根据青连斌2014年底和2
20、015年对421家养老机构的调查，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。Page 14According to the4th survey by Chinas Aging Committee,91%of old people in need of care service got the services.93.46%of urban old people in need receive the services,while 89.43%of thouse from
21、 rural area got the services.Only 10%of old people couldnt receive cares they needed.Families were still the major supplier of service:spouse(43.48%),son(28.64%),sons wife(10.08%),daughter(10.35%),totally accounting for 93%of all the service suppliers.As of the end of 2016,there were 29,000 OA insti
22、tutions registered,7.3 million beds provided(31.6 beds per 1000 old people,including beds in community services and daytime centers).According to Qing Lianbins report on 421 OA institutions in the ends of 2014&2015,84.6%of the instituions had beds for disabled old persons,with averagely 9 beds in ea
23、ch,accounting for 42%of all the beds.In 61.8%of the institutions,there were multi-functional beds for care,with averagely 53 in each.Page 15 2.3 老年人长期照护服务体系发展的主要问题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。性错配的问题。居家养老来看，有几个问题需要关注：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
24、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。Page 16 2.3 Major problems in developing LTCProblems of LTC and its service delivery system are resulted f
25、rom both the relation between total supply and demand and the structure of supply.For home care,problems include:(1),rural old persons are weaker than those urban in terms of health and income.Controdiction between supply and demand in rural area is much obvious than that in urban area.Public policy
26、 covers more for urban people,which enlarge the U&R imbalance(affecting the first generation of migrant peasant-workers)(2),Todays policy has paid attention to LTC needs of and services for very-old people,no-child old people,low-income old people.Some families composed of several generations would
27、be those without capacity to provide LTC and without purchase power for buying the services.In families with two generations of parents,the capacity of LTC is also limited.(3),accessibility of urban family medical care is weak.(4),Old peoples capacity of accessing to internet is insufficient for get
28、ting the services.Page 172.3 老年人长期照护服务体系发展的主要问题老年人长期照护服务体系发展的主要问题 社区和机构养老总体情况是供给与需求的错配供给与需求的错配社区长期护理服务供给与需求的错配：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。养老机构供给与需求的错配的主要表现是: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。Page 182.3 Major problems in developing LTCFor community and institutiona
29、l cares,the general problem is the mis-match between supply and demand:In communities,the problems are:1,mis-match of beds in community services2,mis-match bewteen types of community services provided by the government and diversified demand of old peopleIn institutions,the problems are:1,mis-match
30、of beds 2,mis-match of space3.mis-match of subsidies provided by public financePage 19beds(10,000)being cared(10,000 persons)beds(10,000)being cared(10,000 persons)Page 20institutions(100)beds(10,000)Page 212.4 长期护理筹资体制的探索长期护理筹资体制的探索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。Page 222.4 Exploring establishment of
31、 LTC funding system1,Government Subsidy Model 2,Social Insurance Model3,Mutual Insurance ModelPage 232016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
32、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。Page 24In August 2016,26 provinces made subsidy polices for very-old persons allowance;20 provinces made subsidy policy for OA services provision;17 provinces made subsidy policy for LTC services.Compared with the previous year,beneficiaries of very-old persons allowan
33、ces were 23.55 million,increased by 9.3%;those of LTC subsidy were 405 thousand,increased by 52.8%;and those of OA service subsidy were 2.82 million,increased by 9.7%。In July 2016,General Office of MOHRSS issued the Guidelin for Piloting LTC Insurance and chose 15 cities as pilot sites.Page 253.关于完善
34、老年服务和长期护理体系的思考与建议关于完善老年服务和长期护理体系的思考与建议3.1 政府在长期护理领域的首要责任是“兜底线，织密网”3.1.1 老年人长期生活照料是私人事务，个人个人和家庭是第一责任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不适应中国国情情；3.1.3 在长期照料领域政府的首要责任是“兜兜底线，织密网底线，织密网”Page 263.Reflection and recommendation on improving OA service and LTC system3.1 The principal responsibility of governme
35、nt in the field of LTC should be“guaranteeing the minimum livelihood and strengthening the safety net for the people“.3.1.1 LTC for old peoples life is private affair,for which individual and familty should be primarily responsible.3.1.2 In the current stage,the LTC insurance is not suitable in Chin
36、ese context.3.1.3 The principal responsibility of government in the field of LTC is“guaranteeing the minimum livelihood and strengthening the safety net for the people“.Page 273.1.1老年人长期护理包含两个内容，一是与医疗护理有关的筹资与服务，一是与日常生活照料有关的筹资与服务。与医疗有关的服务应该是基本医疗保险基金来购买，而不是另建一个险种来解决老年人的医疗费用问题；从经济理论和社会伦理的角度看，与日常生活照料有关的
37、服务属于私人事务，就像婴幼儿和其他家庭成员的生活照料是私人事务一样，应该由私人来供给，私人可以自由决策是自己提供服务或者是购买服务，购买老年人长期生活照料服务的费用，可以自付也可以通过保险的方式来转移，但决定权力在私人。正因为赡养和照料家庭成员的私人事务，所以中国的老年人权益保障法和婚姻法都规定了夫妻之间、父母子女之间经济上和生活上相互照料的权力与义务。中国没有遗产制度，老年人的财富下传，从社会伦理的角度子女理应赡养父母。从个人和家庭的经济能力看，除了退休金外，多半个人和家庭是有一定经济能力的。中国学者主张建立长期护理社会保险制度的理由之一是老年人长期住院浪费了医疗资源，并以日本、荷兰等国为学
38、习对象。其实日本的案例并没有证明设立长期护理保险能有效解决“社会性住院”问题，荷兰2015年的改革将与医疗有关的护理重新纳入医疗保险。Page 283.1.1 LTC includes two elements:1,funding and service related to medical care;2,funding and services related to daily life.Medical-related LTC service should be purchased with funds of the Basic Medical Insurance,but not with
39、funds from a new insurance.Economically and ethnically,LTC service for daily life should is private issue.Therefore,family and members should provide it to old people,just like family members provide cares to babies or other members.An individual can also decide freely that who should be the provide
40、r or what sort of service should be purchased.For purchasing LTC services,funds can be provided through insurance,but this should be decided by the person that needs the services.Since support to and care for family members are private affairs,the PRCs Law on Protecting Old Peoples Rights and Marria
41、ge Law regulates that parents and children have the right to receive mutual supports from each other and under the obligation of providing supports to each other.There is no(western)heritage system in China.Assets of old people would be inherited by their next generation.Therefore,ethnically,childre
42、n should support their old parents.From the perspective of personal and family economy,in addition to pension income,most individuals and families have more economic resources to support old members.The reason why Chinese scholars propose to establish social LTC insurance is that long-term medical c
43、ure for old people in hospital would waste medical resources and therefore China should learn from Japan and Netherlands.However,in Japan case,there is no evidence that LTC insurance can effectively solve the problem of“social hospital stay”.The Netherlands have,on the contrary,re-included medical-r
44、elated LTC into medical insurance.Page 293.1.2中国的家庭制度是社会保护制度中的正式制度安排中国的社会保障制度定位于“保基本”，“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，甚至不是纯粹风险中国人均GDP仍然处于中等偏上水平，且中国的人均可支配收入呈偏态分布，通常收入水平较高者对保险资金的利用率较高，而收入水平较低者利用率较低，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中国经济结构和就业结构呈明显二元化状态，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
45、口供给侧改革，政府要求降低企业税费Page 303.1.2Chinese family is a formalized system for social protection.Chinese SP is for protecting the minimum livelihood,which means providing basic insurance and basic protection.Costs for LTC are not basic risk,and even not pure risk.Chinas GDP per capita ranked at the middle a
46、nd slightly upper level in the world,and the disposable income per capita is abnormally distributed.Usually,higher income receiver uses insurance funds more efficiently,while lower income receiver does not.Thus,in terms of benefits ownership,social insurance functions reversely in income redistribut
47、ion.This is a common problem in the Insurance for Disastrous Disease and Housing Credit.In China,the economic and employment structure is characterized by the urban-rural dualism.In 2016,only 41%people possessed the urban Hukou,while the working people were 800 million,of which only 290 million part
48、icipated in the Medical Insurance for Employees.In China,the government is conducting the supply-side reform and reducing tax and fees for enterprises.Page 31Page 32strong family supportweak family supportpoorrichDibaoLow income,weak supportLow income,strong supportHigh income,Weak supportHigh incom
49、e,strong supportClassification of disabled old people and policy targetPage 33四调：有效样本：215577个失能定义：吃饭、穿衣、上厕所、室内走动、上下床、洗澡，ADLS六项只要一项做不了则为完全失能，有困难和不费力为自理，1-2项做不了为轻度失能，3-4项做不了为中度失能，5-6项做不了为重度失能四调：4.2%为失能老人（2.2亿老年人口，失能924万）轻度：2.3%中度：0.5%重度：1.3%Page 34The 4th Survey：Effective samples:215577Definition of d
50、isability：eating,dressing,toileting,moving in house,moving in and off bed,bathing(ADLS)disabled in these 6 points=full disabilityhaving problem but managing to overcome it:OKdisabled in 1-2 points:light disability;disabled in 3-4 points:medium disabilitydisabled in 5-6 points:serious disabilityThe 4
