【作者】 贾清显；

【导师】 朱铭来；

【作者基本信息】 南开大学 ， 保险学， 2010， 博士

【副题名】基于老龄化背景下护理风险深度分析

【摘要】 随着人民生活水平的不断提高,医疗卫生条件的持续改善,人类的平均预期寿命在延长,从1950年延长了20年,达到66岁,预计到2050年将再延长10年。而人口政策的实施和生育观念的转变,导致婴儿出生率下降,使得老年人口在整个人口中的比例不断提高,人口结构趋向老龄化、高龄化。到2050年全球60岁以上人口将从6亿增至近20亿,所占总人口比例预计增加一倍,从10%增至21%。联合国对人口老龄化和老年人有关的问题非常关注,1991年联合国大会通过了《联合国老年人原则》,明确规定了照顾原则,即老年人的健康要在既合乎人道又安全可靠的环境中得到保护和康复,指出老年人享有照顾和社会支助的权利；2002年在马德里举行的第二次老龄问题世界大会上,决定通过了《2002年老龄问题国际行动计划》,要求世界各国必须将老龄问题和老年人的关切纳入国家发展框架和消除贫困战略的主流,积极应对21世纪人口老龄化所带来的机会和挑战,将创新方案、募集资金和发展必要的人力资源同时进行,建立起正规和非正规的社会支助制度,加强家庭成员在家庭内照顾老年人的能力,不断提高老龄健康和福祉以及确保有利和支助性的环境。2006年我国老龄办发布《中国人口老龄化发展趋势预测研究报告》,指出21世纪的中国将是一个不可逆转的老龄社会,到2050年,我国老年人口总量将超过4亿,老龄化水平推进到30%以上,同时我国人口老龄化还表现出两个显著特征：一是老年人口抚养比提高。2000年我国劳动年龄人口对老人赡养比为15.6%,预计到2050年上升为48.49%。如果再加上对幼年子女的抚养,劳动年龄人口的总抚养比上升得更为迅速,2050年达到76.8%,人口老龄化将使劳动年龄人口的经济负担日益沉重；二是高龄化趋势明显。到2050年,80岁及以上老年人口将达到9448万,占老年人口的21.78%。中国高龄老年人口增长速度很快,重度老龄化和高龄化问题显得越来越突出,赡养老年人所面临的困难越来越来严重。为应对老龄化给我国经济社会发展带来的不利影响,2006年国家先后出台了《中国老龄事业发展“十一五”规划》和《关于加快发展养老服务业的意见》两个纲要性文件,对加速构建和完善中国特色养老服务体系,破解我国日趋严峻的人口老龄化难题提出重要规划设计。当前,我国家庭结构因社会工业化、都市化和生育率的下降而产生变化,由传统大家庭转变为以经济为主的核心家庭,家庭结构朝向垂直发展,平均子女数量减少,将无法像过去那样集合多数子女的力量,承担起老年人口经济及照顾上的问题。未来老年人口的生活照料问题已无法完全由家庭来承担,且传统以家庭为中心的社会安全网络,已经失去了保障老人的功能。据此,老年人口的护理需求性风险已无法完全由家庭来负担,也非市场所能适当提供,老年人口的长期护理需求正在由个体风险演化为整体性社会风险,亟需政府调配国家资源,凝聚整体社会共识,实施长期护理保障的制度化发展,以此协助传统家庭护理功能的发挥,乃至扩展长期护理服务的供给主体。按照联合国的标准,美国、德国、日本等发达国家较早进入了老龄化社会。为解决老年人口的护理需求问题,帮助老年人筹集足额的护理购买资金,避免家庭及个人因支付护理费用而背上沉重的经济精神负担,切实保障老年人能够幸福地安度晚年,并在很大程度上力求缓解国民对公共福利需求的压力,降低政府对长期护理成本的财政支出,这些国家纷纷采取措施加以应对。到20世纪中期,长期护理保险(Long-term Care Insurance,简称LTCI)制度作为解决老年人口护理问题的有效措施应运而生,该制度利用保险原理筹集护理资金,加快了护理产业的专业化发展,化解了老年人口长期护理难题。德国、日本采用社会保险运作模式,由保险费作为长期护理的资金来源。其中,德国强制全民进行保险,保费由保险对象和雇主共同分摊；日本保障四十岁以上的民众,保费由政府、雇主及保险对象共同分摊。美国的长期护理服务由Medicare、Medicaid、美国老年人法方案及商业性长期护理保险等多个体系加以供给,而Medicare、Medicaid、美国老年人法方案属于公共福利政策,政府负担全部费用,但其保障未能涵盖全体国民；因而于19世纪80年代商业性长期护理保险兴起,目的在于保护个人免于庞大的长期护理支出而产生的生活危机以及满足民众多样化的护理需求,其费用完全按照保险原理运作。比较而言,我国老年人口规模巨大,老龄化速度快于发达国家,而经济发展水平较低,其老龄化的显著特点是未富先老,人均收入刚过1000美元,而农村老年人在经济上可谓两手空空,同时我国农村老年人口的比重又大,因此此种经济、人口形势与日益加重的护理费用形成强烈反差,极易构成个人及其家庭的沉重经济和精神负担,对整体社会、经济、政治结构产生重大而长远的影响。因而我国必须对老年人口长期护理服务所引发的财务问题,及早因应和规划,构建起适合我国国情的长期护理保险制度体系,在保障老年人生活质量的同时,确保我国经济持续发展和国家的和谐稳定。本文首先介绍长期护理的概念、长期护理保险的基本理论及保障内容,分析了长期护理保险与健康保险、养老保险及残疾收入保险的区别和联系,阐明长期护理保险是专为分摊老年人口护理风险而设置的保险计划；其次,本文根据经济学基本原理,从效用最大化的视角出发,借鉴保险需求的理论模型,通过对影响长期护理保险需求的多因素分析,构建出长期护理保险需求理论模型—三世代模型；第三,分析美国、德国和日本等发达国家发展长期护理保险的实践经验,对其实施背景、运营模式、保障内容、监管政策、税收优惠以及发展前景进行了比较分析,寻找各国策略的优点和不足,从而为我国长期护理保险的发展提供有益的借鉴；第四,利用人口统计学、卫生经济学、精算学等理论,从宏观角度分析了我国老年长期护理服务的需求趋势,并按照2004年我国国家统计局专门针对老年人的生活自理能力进行的抽样调查数据和美国、德国、日本的老年长期护理体系标准,通过建立人口模型、数理模型来预测我国老年长期护理服务的需求趋势及总体费用支出,指出我国应基于老年人口多、经济实力相对薄弱的基本国情,探索出适合我国国情的老年长期护理发展模式；最后,本文在国际实践经验的基础上,结合我国经济欠发达,地区之间发展不平衡的现实,并考虑我国不同发展阶段的政府财政实力,主张国家应积极借助保险的方式来筹集护理资金,采用社会保险和商业保险并行的模式,有社会保险提供最基本的、必要的长期护理服务或其费用支出,并对这种长期护理进行全民强制保险,而商业性护理保险用于满足民众对护理的多样化和多层次需求。更多还原

【Abstract】 With economic development and technological progress, the people’s living standards and health conditions continue to be improved, human health awareness and the level of immunity to the disease are increasing, resulting in human average expectancy, from 1950 to extend for 20 years, reached 66-year-old, it is expected that will be extended for a period of 10 years by the 2050. While the implementation of population policy and concept change in the fertility, the baby birth rate is declining and the proportion of elderly population to entire population is rising. By 2050, The world’s population aged 60 and above will be from 6 million to 20 million, the proportion of population is expected to double, from 10% to 21%. The United Nations are very concerned about the problem of population ageing. In 1991, the United Nations General Assembly adopted the "United Nations principles for older people", Specified care principles, namely, Health of the elderly in both humane, safe and reliable environment is protected and rehabilitation, pointed out that the elderly have care and social support; In 2002, Madrid held the Second World Assembly on Aging, decided to adopt the "2002 International Plan of Action on Aging,"demanded that the world must be concerns of older persons into national development frameworks and poverty eradication strategies, dealt with the challenge of population ageing in the 21st century,established formal and informal social support system, strengthen family-based care capacities of older people, ensured a favourable and supportive environment.In 2006, Aging Office in China issued "China’s aging population trend forecasting report", pointed out that the 21st century China will be an irreversible aging society. By 2050, China’s elderly population will exceed 400 million, aging level to more than 30%. Meanwhile, China’s aging population also demonstrated two salient features:First, the elderly dependency ratio increased. In 2000, it was 15.6%, by 2050 rose to 48.49%. If we add to the custody of young children, the total dependency ratio rose even more rapidly, by 2050 rose to 76.8%, population aging will make the working-age population increasingly heavy financial burden; Second, Aging phenomenon was obvious. By 2050,80-year-old and above population will reach 9448 million, accounted for 21.78% of the elderly population. Chinese elderly aged grow quickly, severe problems of aging has become increasingly prominent. As a response to the aging, in 2006, China have promulgated the "development of China’s Undertakings for the Aged, "Eleventh Five-Year"plan" and the"accelerating the development of old-age service" two framework documents, to improve the old-age service system and crack China’s increasingly serious problem of population aging.In population aging society, the elderly population often accompanied with physical function declined and the increased possibility of suffering from chronic diseases, is the main demanders for long-term care. In future, long-term care demand and supply will become a pressing issue. Due to the community of industrialization, urbanization and the decline in fertility, The family structure become to be nuclear family from traditional extended family. The family that has fewer children on average will not be able to take care of the elderly population, and the traditional family-oriented social security network has lost the functionality of the elderly. Accordingly, the risk of the elderly care have not fully borne by the family, but non-market can also provide an appropriate long-term care needs, it evolves as a whole social risk from an individual risk, requiring Government allocation of national resources, the implementation of long-term care insurance and the institutionalization of development, so assisted traditional home care functions, and even extended long-term care provider. In accordance with United Nations standards, United States, Germany, Japan and other developed countries were the early aging society. To address the care needs of the elderly, help the elderly to raise funds to purchase care in full, and largely sought to ease the national pressure of demand on the public welfare and reduced the cost of the Government’s long-term care expenditures, these countries have taken measures to deal with. Into the mid-20th century, Long-term Care Insurance system is a solution to the problem of the aged care, using the insurance principle to raise money, to speed up the nursing industry professional development, to resolve long-term care of the elderly.long-term care insurance system is a social insurance model in Germany and Japan. German forces nationwide for insurance, premiums by insurance and employer. Japan protects people aged over 40, premiums by the Government, employers and the insurance co-share target. America’s long-term care can get from Medicare, Medicaid, Older Americans Act programs and commercial insurance, while the Medicare, Medicaid, Older Americans Act programs is the public welfare policy, the Government has to pay the full cost, but its protection does not cover the entire population; Thus in 1980, Private long-term care insurance has been introduced, intended to protect individuals from the huge long-term care expenditures and meet the diverse care needs of the people.In contrast, China’s elderly population is huge, aging faster than developed countries, while the lower level of economic development, per capita income of just over＄1000. while the rural elderly in the economic can be described as empty-handed. At the same time, the proportion of elderly population in China’s rural areas are big, so that the economic and demographic situation and the ever increasing cost of care will be in sharp contrast, individuals and their families can be easily constituted a heavy financial and emotional burden, the overall social, economic, political structure have a significant and long-term impact. So our country must deal with the financial issues from long-term care services, build up the appropriate long-term care insurance system, ensure China’s continued economic development, national harmony and stability. This article first describes the concept of long-term care, long-term care insurance basic theory and protection, analysis of differences and connections between long-term care insurance and health insurance, pension and disability income insurance, clarify long-term care insurance is specifically designed for the allocation of risk; Secondly, this article according to the basic principles of economics, from the utility maximization perspective, drawing on life insurance demand theoretical models, build a LTCI theoretical model-three generations model; Third, the analysis of the experience of long-term care insurance development in he United States, Germany and Japan, Including its operational context, operational mode, protected content, regulatory policies, as well as the prospect, looking for the benefits of national policy, so it can provide useful reference for China’s long-term care insurance; Fourth, the use of demographic, health economics, actuarial science and other theories, from a macroscopic point of analyzing the trend in long-term care service needs. In accordance with the sample survey data of China’s National Bureau of Statistics in 2004 and the United States, Germany, Japan’s long-term care system standards, by population model, mathematical models, we predict the long-term care services demand trends and overall expenditure, pointed out that China should be based on the elderly population and economic realities to explore appropriate development models of long-term care; Finally, based on international experience, combined with our economic underdevelopment, uneven development between regions, considered Government financial strength in China’s different development stages, maintains that China should actively help to fund the care insurance funds by social insurance and commercial insurance, social insurance provide the most basic and necessary long-term care services or their costs, and as a universal compulsory insurance, while Private long-term care insurance are designed to meet the people in nursing diversity and multi-level needs.更多还原