【作者】 李强；

【导师】 岳书铭；

【作者基本信息】 山东农业大学 ， 农业经济管理， 2015， 博士

【摘要】 加快推进城乡居民长期照护社会保险制度建设,是应对人口老龄化、保障和改善民生的必然要求;是适应传统照护方式转变,满足长期照护需求的必由之路;是缓解就业压力,扩大消费和促进服务业发展的有效途径;是保障经济持续稳定发展,构建社会主义和谐社会的根本要求。本论文在已有研究的基础上,采用多种研究方法,对城乡居民长期照护社会保险制度进行了总体设计,并分别从制度构建的主要内容、长期护照需求评估、费用保障机制和配套措施等方面进行了分类探讨。本文的主要结论有如下几点:(1)随着人口老龄化、高龄化问题日趋严峻,失能、失智老年人长期照护问题日益凸显。但是家庭结构逐步小型化,城市化进程导致人口迁移频率加快,空巢家庭急剧增多;妇女劳动参工率提高和传统家庭养老思想的弱化等诸多原因,导致以家庭成员为主的非正式照护方式将无法独自承担长期照护的责任。鉴于目前政府层面尚未有正式制度安排,政府应尽快构建以长期照护社会保险制度为主体,长期照护商业保险制度为补充的多层次保障体系。(2)无论是以英国为代表的以税收作为主要筹资来源的“法团主义”国家还是以德国为代表的以社会保险作为主要筹资来源的“保守主义”国家,都为我国城乡居民长期照护社会保险制度建设提供重要的借鉴意义,即在尊重我国国情的前提下,按照适度普惠的原则,分步骤构建城乡居民长期照护社会保险制度。形成政府、社会组织、志愿者和家庭的多元供给主体,以城乡居民长期照护需求为导向,构建“养、医、康、护、临终关怀”五位一体的长期照护服务模式。(3)基于山东省城乡失能老年人的调查数据,系统分析了城乡失能老年人长期照护意愿及其影响因素。分析表明:失能老年人对长期照护需求强烈,最偏好的长期照护方式是家庭照护,最亟需的长期照护服务是康复护理类服务。年龄、文化程度、子女数量、独立居住或夫妻同住、可支配收入、视力、慢性疾病数量、基本生活自理能力、工具性活动自理能力和精神慰藉对失能老年人长期照护的需求程度有显著影响。相对于家庭照护,文化程度越高、独立居住或夫妻同住、子女数量越少、可支配收入越高、视力越差、工具性活动自理能力越差、缺乏精神慰藉的失能老年人更倾向于选择居家照护。文化程度越高、独立居住、可支配收入越高、慢性疾病数量越多且日常生活自理能力越差的失能老年人对机构照护持更高的认可度。(4)综合考虑各地区人口老龄化程度、经济发展水平和长期照护资源等因素,城乡居民长期照护保险制度共分为长期照护补贴制度、长期医疗护理保险制度和长期照护社会保险制度。长期照护补贴制度以财政作为主要资金来源,重点保障低收入失能、失智老年群体。长期医疗护理保险采取跟随基本医疗保险的原则,即凡是参加基本医疗保险的参保人都应参加长期医疗护理保险,给付方式是提供医疗和与医疗相关的长期护理服务,重点解决家庭照护中专业性最强且难度最大的医、养分离的问题。长期照护社会保险制度是在长期医疗护理保险制度的基础上,随着国家财力和城乡居民收入水平的提高,逐步将社会照护服务纳入保障范围,最终形成“养、医、康、护、临终关怀”五位一体的涵盖医疗照护和社会照护的连续性照护服务体系。(5)长期照护需求评估是长期照护保险制度得以顺利实施的基础和前提,本文从日常生活自理能力、工具性活动自理能力、认知能力、情绪行为和感知觉能力五个层面构建了失能等级评估指标体系。运用集成层次分析的模糊综合评判法对失能、失智老年人的失能等级进行综合评判。在此基础上,综合考虑失能、失智老年人的健康状况、家庭经济收入、家庭照护资源和生活居住环境等因素,为失能、失智老年人量身定做长期照护服务计划,尽最大能力满足失能、失智老年人不同层次的长期照护服务需求。(6)基于对城乡居民长期照护补贴制度中政府财政支持能力的可行性分析,本文认为:就全国财政的支持能力而言,当前建立城乡居民照护补贴制度的时机已经成熟,工作的重点是建立中央政府和地方政府之间合理的财政分担机制,中央政府加大对中西部和老龄化严重地区的财政支持力度,各级地方政府要根据自身经济条件和长期照护资源,按照“分类实施、逐步推进”的原则,合理选择保障对象的覆盖范围和长期照护服务项目。(7)就城乡居民长期照护社会保险的财务可行性而言,全国目前不具备普遍开展长期照护社会保险的条件。但是个别经济发达地区,如浙江省、江苏省、北京市和上海市等经济条件较好的省市,已经基本具备开展条件。从城乡居民个人经济承受能力来看,在政府承担50%的长期照护社会保险费用时,城乡居民能够承担长期照护保险费用。但是该方案政府的财政负担较重,政府财政补贴占同年财政收入的比例从2011年的0.89%上升到2020年的1.12%;就地方政府的财政支持能力而言,部分欠发达地区的地方财政负担较重,建议选择适宜的地区先行试点,积累经验,然后在逐步扩面。更多还原

【Abstract】 To accelerate the construction of urban and rural residents in long-term care social insurance system, is the inevitable requirement to cope with population aging, protect and improve people’s livelihood; is the only way to change the traditional mode of care and meet the needs of long-term care services; is the effective way to ease the employment pressure, expansion of consumption and promote the development of service industry; is the basic requirement to ensure sustained and stable economic development and constructing harmonious society.This study is based on existing research scholars, using a variety of methods, for urban and rural residents in long-term care insurance system for the overall design, classification of the main content of the construction of the system, the needs assessment of long-term care, passport fee protection mechanism and supporting measures of. The main conclusions of this paper are as follows:With an aging population increasingly serious, the long-term care for the elderly with disability, dementia has become increasingly prominent. But the family structure gradually miniaturization and city urbanization leads population migration move faster and the sharp increase in empty nest families; the increasing of the women’s labor participation rate and the weakening of the traditional family pension ideas and other reasons, the informal care, which is the main member of family members, will not be responsible for the long-term care alone. In view of the current government has a not yet relevant institutional arrangement, so the government should be constructed as soon as possible from the long term care insurance as the main social safety net, the elderly long-term care commercial insurance supplement.Whether it is represented by the United Kingdom to tax as a major source of funding for the "corporatism" countries or in Germany as the representative of the social insurance as a major source of funding for the "conservative", as a long-term urban and rural residents in long-term care of social insurance system provides an important reference, namely in the premise of respecting our national conditions, in accordance with the principle of moderate Pratt & Whitney, staged in the construction of urban and rural residents in long-term care insurance system. The formation of government, social organizations, volunteers and family pluralistic as the theme of the multiple suppliers, with the demand of urban and rural residents long-term care as the guidance, construction one of five long-term care service model of “culture, medicine, nursing, hospice care”.Based on the survey data of the disabled elderly in rural areas of Shandong Province, the paper analyzes systematically long-term care willingness and its influencing factors of rural disabled elderly. Analysis shows that: The rural disabled elderly have strong demand for long-term care, the most preferable pattern of long-term care is family care, the most needed of long-term care services are rehabilitation nursing services. The influencing factors which affect long-term care willingness significantly are age, educational level, number of children, independent living or living with spouse, disposable income, visual acuity, number of chronic diseases, activities of daily life, instrumental activities of daily life and spiritual solace. With respect to family care, higher educational level, independent living or spouse, children, and the less the amount of disposable income is higher, eyesight worse, instrumental activity of self-care ability is worse, the lack of spiritual comfort in rural disabled elderly are more likely to choose home care. The higher level of education, independent living, disposable income is higher, number of chronic diseases and daily life self-care ability is poor rural disability elderly of institutions according to symbolically more high degree of recognition.Considering the degree of population aging, the region’s economic development level and the long-term care resources and other factors, the long-term care insurance system of urban and rural residents is divided into long-term care subsidy system, long-term medical care insurance system and long-term care social insurance system. Long-term care subsidy system to finance as the main financing source, focus on the protection of low-income disabled elderly and Alzheimer’s disease patients. Long- term care insurance taken to follow the pork stomach of the basic medical insurance principle, those who participate in the basic medical insurance of people in long-term care insurance payment is to provide medical and medical related long-term care services, the key to solve the disabled elderly pain most professional and most difficult medicine, raise problems in the separation of family care. The long-term care social insurance system is based on the long-term medical care insurance system, with the national financial resources and the improvement of people’s life gradually, long-term social care services included in the scope of protection, and ultimately the formation of "culture, medicine, health, nursing and hospice care" one of five covering health care and social care continuity of care service system.Long term care needs assessment is the basis and prerequisite for the smooth implementation of long-term care insurance system. This paper constructs an assessment index system from five levels of daily life, instrumental activity, cognitive ability, emotional behavior and sense perception ability. For the disabled, elderly dementia disability grade comprehensive evaluation using fuzzy comprehensive evaluation method integrated AHP. Based, comprehensive consideration of disability, the health status of elderly people with dementia, family income, home care resources and life living environment etc. factor, as a disability, elderly people with dementia tailored long-term care service plan, to maximize its ability to meet disability, elderly people with dementia diversity and different levels of long-term care service needs.The feasibility of government financial support capacity subsidy system for urban and rural residents in long-term care analysis, This paper shows that national financial support, the establishment of urban and rural residents care subsidy system of the time is ripe, the focus of the work is established between the central government and local government finance rational sharing mechanism, The central government increased financial support for the central and western regions and the aging of the serious areas, local governments at all levels should according to their own economic conditions and long-term care resources, According to the principle of “implementation of the classification and gradually advancing”, reasonable choice of the coverage and long-term care service projects of the object.The financial viability of long-term care for urban and rural residents, the country is not generally carried out long-term care social insurance conditions. But the developed areas of the individual economy, such as Zhejiang Province, Jiangsu Province, Beijing city and Shanghai City, and other economic conditions, have already carried out the basic conditions. From the personal economic affordability of urban and rural residents, in the government to take 50% of long-term care social insurance costs, the urban and rural residents can take long-term care insurance costs. But the fiscal burden of the program is heavier, the proportion of government financial subsidies increased from 0.89% in 2011 to 1.12% in 2020; the local financial burden of local governments is heavier than the local financial burden. It is suggested that the appropriate areas should be chosen to accumulate experience and then expand the area gradually.更多还原