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

At the time of its creation, the SLTCI was a national rather than a regional scheme, with contribution rates determined by the Bundestag, entitlements regulated at the national level, and all regional entitlements disbursed from a pool of funds. It has no administrative body of its own and is managed by the existing statutory Medical Insurance Fund Association, and there is no competition between the different foundations. Therefore, compared with the German social medical insurance system, the system design of SLTCI reflects a more obvious centralized feature of "state intervention". Between 1986 and 1994, before the SLTCI was officially launched, the social assistance medium and long-term care expenditure increased from €7.595 billion to €17.723 billion, in stark contrast to the three years after the SLTCI was officially launched. The expenditure of social assistance medium - and long-term care insurance decreased from 17.473 billion euros in 1995 to 3.01 billion euros in 1998, a decrease of 82.8%. At the same time, SLTCI expenses began to increase rapidly (see Figure 1), which realized the transfer of long-term care expenses from the social assistance system to the social insurance system.

However, the governance of long-term care still retains the characteristics of decentralized governance: local governments still bear the responsibility of social assistance, and social assistance still provides support for nursing expenses for those who need to meet the conditions. The formal establishment of SLTCI has made a significant qualitative change in the proportion of the social insurance system interfered by the federal government and the local government's tax support for nursing costs. However, because SLTCI adopts the design concept of payment according to budget, those who cannot get enough payment from SLTCI and cannot afford their own out-of-pocket expenses. Eventually they had to turn to the social assistance system. It can also be clearly seen from Figure 1 that although the medium - and long-term care costs of the social assistance system increased slowly after 1998, they still showed an upward trend on the whole. In 2015, the medium - and long-term care costs of the social assistance system accounted for 13.47% of the total social assistance expenditures. Social assistance accounts for 7 to 8 percent of the total cost of long-term care, and more than a third of people who choose institutional care still apply for social assistance.

It can be said that the transfer of long-term care authority has greatly reduced the financial burden of local governments. But this upward shift of authority is neither complete nor permanent, and the tax-funded social assistance system still acts as a backstop.

(2) System coverage: the principle of universality based on the assessment of nursing needs

Similar to the medical insurance system, Germany's long-term care insurance system also implements a "dual-track system" : members of the Sickness fund association are automatically enrolled in SLTCI, and spouses and children are automatically covered by the system; Private health insurance enrollees must purchase Private long-term care Insurance (PLTCI) and can also voluntarily enroll in SLTCI; Others who voluntarily join the social health insurance system are automatically enrolled in SLTCI. Therefore, in terms of the coverage of the system, the German SLTCI covers all residents as much as possible, especially those who are enrolled in high income private medical insurance. In the statutory health insurance system, people with incomes above a certain limit must participate in the private health insurance system, while in the setting of the nursing insurance system, people with high incomes can choose to participate in either the social long-term care insurance system or the private health insurance system. This practice expands the financial resources of the social long-term care insurance system, and also reflects the particularity of long-term care risks from the side.

When the system was established in 1995, the enrollment rate of SLTCI reached 88.03%, of which 29.19% entered the long-term care insurance system through family insurance (see Table 1). Since then, the participation rate has fluctuated around 85%. The benefits of the system are only related to the nursing needs of the insured, and the insured with different levels of nursing needs have different benefits, independent of the age and income of the insured. Therefore, compared with the long-term care services provided by the previous "filling-in" social assistance, the new SLTCI has a clear principle of universality.