The operation concept of long-term care insurance system and its enlightenment to China

In 1974, a report by the German Foundation for the Care of the Elderly on the long-term care insurance system drew attention to the long-term care needs of the elderly, but it was not until 1994 that the Long-term Care Act (Pflege-Versicherungsgesetz) was introduced. A universal, non-means-tested, co-contribution-paid long-term care insurance system was established, effective 1 January 1995.

At this time, the reform of Germany's welfare system has changed from the period of welfare expansion to the period of welfare contraction and transformation: Chancellor Helmut Kohl (1930-2017) advocated a full return to the idea of a social market economy, reducing state intervention in economic life, placing greater emphasis on the role of the family and the market in welfare provision, and introducing liberal elements such as "markets" and "competition" into his reforms in the field of social policy.

What, then, led to the establishment of long-term care insurance at a time of austerity in the German welfare state? What are the implications for the development of long-term care insurance system in China? This is the question that this article tries to answer.

I. The institutional logic of long-term care insurance in Germany

(I) The direct cause of the establishment: long-term care risks overflow from the family to the society

long term care, also known as long-term care, means that a person needs regular, frequent, or long-term care for at least six months due to physical or mental illness or disability. To help them complete "activities of daily life" (ADL) and "instrumental activities of daily life" (IADL).

The demand for long-term care has the characteristics of long-term and persistent, which means that families should have both the ability to supply care services and the corresponding ability to pay. As a typical "conservative/combinationist" welfare state, Germany has traditionally identified long-term care as a family risk that should be provided by female members of the family. Social policy has a clear "auxiliary" feature, and the state will intervene only when the family is unable to provide services and security for its members.

Since 1962, the support for long-term care provided by German law can be divided into two levels: the first level is to provide medical services through statutory medical insurance for more serious diseases, but does not provide daily care type of monitoring; The second level incorporates long-term care services into the social assistance system, funded by state taxes and providing means-tested benefits to seniors who cannot afford care. Non-profit charities provide services and have priority in service delivery - only when the charity cannot provide services. Municipal governments can start their own service organizations or purchase the services of for-profit organizations.

At this time, the support for long-term care policy is more inclined to the characteristics of the liberal welfare system: the asset-based social assistance is dominated, the institutional payment is based on demand selective payment rather than universal, people who do not need social assistance are more dependent on the family and the market, and social policy only plays a supporting function.

But as the population ages and female employment rates rise, and fertility rates continue to decline, the demand for long-term care is increasing, and the basis for providing care to women is eroding. In this situation, the long-term care responsibility, which is traditionally regarded as the family responsibility, continues to overflow into the social assistance system, and the demand for long-term care is gradually unbalanced with the institutional supply.

On the one hand, Germany is the country with the highest degree of aging in Europe. In the 1960s, the proportion of the elderly population over the age of 65 in Germany was 11.6%, and it has increased to 14.9% in 1990, while the care risk increases with the increase of age: The proportion of elderly people with care needs between 75 and 85 years old is 14.1%, between 85 and 90 years old is 39.7%, and over 90 years old is as high as 66.1%. On the other hand, due to the increasing participation rate of women in the Labour market, the ability to rely on female members of the family to provide care services is constantly reduced. Once the family is unable to provide services and support, the elderly have to choose nursing institutions, which are generally more expensive than personal pensions. More and more elderly people have to submit to a means test and give up their possessions to apply for social assistance. From 1963 to 1994, the number of people eligible for care allowance increased from 16,500 to 563,452, accounting for 43.1% of the total number of social assistance, and the total expenditure accounted for 35.6% of the total social assistance expenditure, and the expenditure of long-term care has become an unbearable burden for the social assistance system.

In the face of the increasing needs of the elderly for long-term care, the existing system cannot be sustained. Under such circumstances, after nearly two decades of discussion and negotiation, the final long-term care insurance Act was passed by the Bundestag and the Bundesrat in 1994, and the mandatory change of the system was realized in the form of law. Compared with other European countries, Germany has a strong family culture, and long-term care has long been regarded as the responsibility of the family. With the deepening of the aging of the population and the increase of the employment rate of women, the demand for long-term care continues to flow from the family to the society and promote the rising cost of social assistance in the medium and long term care. The social assistance system is increasingly deviating from its original goal, but the right to survival of the elderly is still not effectively guaranteed, which is the direct reason for promoting the establishment of long-term care in Germany. (Although "social hospitalization" due to long-term care theoretically exists in Germany, it is not covered in this article because the disease foundation treats "illness" separately from "custodian care" and only provides treatment for disease, and it is difficult to find valid data to prove the erosion of long-term care on health insurance funds.