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Development high-quality geriatric care systems

Author  :  YU JUYUN, ZHU QIANGHU, LIU JIE     Source  :    Chinese Social Sciences Today     2023-04-18

The Report to the 20th National Congress of the Communist Party of China stated “we will pursue a proactive national strategy in response to population aging, develop elderly care programs and services, and provide better services for elderly people who live alone. By doing so, we can ensure that basic elderly care is accessible to the entire elderly population.” Addressing the fundamental care service requirements of disabled elderly individuals is the foremost priority for the elderly care industry. China Aging Problem National Commission predicts that by 2030 and 2050, the number of disabled elderly people in China will reach 61.68 million and 97.5 million, respectively. Between 2020 and 2050, elderly people with mild, moderate, and severe disabilities are expected to grow by 108%, 104%, and 120%, respectively. On average, this group will experience disability for around 11.45 years. It is essential to establish a comprehensive care system that encompasses insurance, assistance, and welfare so as to meet the increasing care demands and tackle the critical issues faced by the aging population.

Status quo

Currently, long-term care insurance is yet in its pilot promotion phase, so it cannot fully respond to the basic care service needs of the disabled elderly. The care service subsidy system offers a safety net for economically disadvantaged disabled seniors. As of 2021, around 903,000 seniors received care subsidies nationwide, while about 5.736 million benefited from pension service subsidies. However, the primary recipients of these subsidies are economically-disadvantaged, disabled elderly individuals, resulting in limited coverage that reaches only 2.48% of the population aged 60 and above.

The current care service subsidy policy lacks an automatic upgrade mechanism, poorly adapted to the new demands of governing relative poverty. As China progresses towards becoming a moderately prosperous society, poverty governance has shifted its focus to relative poverty. Relative poverty among the elderly population is complex, multi-dimensional, and long-lasting. Should the subsidy system fail to accurately identify new seniors in need, it will be unable to provide full coverage, thereby compromising the system’s overall fairness. For low-income, marginally situated elderly groups, the inability to access pension service subsidies despite facing similar challenges creates a “cliff effect” within the system, hence undermining its function as social safety net.

The 20th NCCPC Report highlights that high-quality development is the primary objective in building a comprehensively modern socialist country. A multi-layered elderly care system is the foundational safeguard for the service needs of disabled senior individuals. That is why we must upgrade and optimize the system in alignment with the principles of high-quality development.

Future efforts

The 20th NCCPC report highlighted that high-quality development is the primary task of comprehensively building a socialist modern country. A multi-level elderly care system is the basic guarantee for the service needs of disabled elders, hence must be upgraded and optimized under the concept of high-quality development. First, we must transform and upgrade the care service subsidy system to make the social safety net more effective and the system more inclusive. The 14th Five-Year Plan of China clearly stated that “the welfare of the elderly will be improved, with a sound subsidy system for the disabled elderly with financial difficulties.” Therefore, we need to meet the requirements of the era of high-quality development and live up to the philosophy of the central government by improving the elderly care system and promoting high-quality development of the elderly care service subsidy system.

We also need to expand the subsidy scope and improve its inclusiveness. To achieve full coverage, local governments should gradually expand the coverage based on the existing subsidy targets according to their economic conditions. First, appropriately lower the age limit for economically-disadvantaged seniors, as they have a higher risk of becoming disabled. Second, cover “pre-disabled older adults” and near-subsistence-living senior members with serious illnesses to alleviate the “cliff effect” of the policy. Third, the subsidies also need to cover seniors whose children have disabilities or suffer from major diseases. They are under tremendous physical and mental pressure and thus require temporary assistance. Fourth, the subsidies need to cover those over 80 who live alone, or have lost their only child. These are the groups that have relatively weaker capacity to take care of themselves even if they are not disabled. Fifth, it is also important to cover those over 80 years old who have made special contributions, such as veterans. The first three types of subsidies are assistance-based, while the latter two are welfare-based. The two concepts are different and can be applied-for concurrently.

It is important to standardize disability level assessment criteria. Terminology used for referring to disabled elderly individuals varies across the country. For instance, Fujian Province categorizes disabled elders as “fully self-reliant” “semi-disabled” and “completely disabled.” Most regions classify them as “mild” “moderate” and “severe,” but the disability level assessment standards lack uniformity and consistency. As a result, some eligible disabled seniors are excluded. In the short term, disability assessment standards should align with long-term care insurance. In the long run, a unified national disability level assessment standard should be established based on actual conditions to ensure equitable benefits for disabled elderly individuals.

Top-level design is needed for the formulation of subsidy standards. Current policies regulate that local governments can broaden the scope of subsidies and raise subsidy standards based on local economic conditions, price fluctuations, and fiscal conditions. But local standards are neither sufficiently scientific nor standardized, and lack automatic adjustment mechanisms. So national-level top-down design is needed to propose minimum standards and adjustment parameters, taking into account the rising cost of care and enhancing the system’s automatic adjustment capability. Subsidy standards can be categorized into social assistance-based and social welfare-based subsidies, the former providing a safety net and reflecting the right to subsistence, requiring higher standards.

Furthermore, we need to study the linkage mechanism between the care service subsidy system and long-term care insurance, while enhancing the multi-layered basic elderly care system. Long-term care insurance serves as the fundamental insurance system for addressing the risk of elderly disability. Since its pilot program in 2016, this insurance has covered 49 cities and 145 million people, alleviating the care burden for the disabled and semi-disabled elderly individuals. According to national plans, a long-term care insurance system framework with Chinese characteristics will be established during the 14th FYP period. As long-term care insurance is progressively promoted and implemented, it is crucial to prepare for the integration of basic systems.

The foremost task is to define the functional roles and responsibility boundaries of the system. Long-term care insurance adheres to the social insurance mechanism, offering benefits to insured individuals. The elderly subsidy system follows the social assistance and welfare mechanism, providing a safety net guarantee and social welfare functions. The two systems fall under different departments and cater to distinct target populations. Their benefit conditions and content vary, but there is an overlap between the two.

While ensuring the integrity of the system, it is essential to clarify the graded relation between treatments across systems. We need to establish a payment list for the care service subsidy system to prevent omissions, overlaps, and conflicts with long-term care insurance. For instance, if a severely impoverished elders qualifies for benefits from both systems, they should not receive benefits from both simultaneously. Since the care service subsidy system serves as a safety net for disabled individuals, if those requiring care receive basic benefits from long-term care insurance, they should not receive additional benefits. However, to ensure that the insured’s benefits are not compromised, the insured should be granted the right to choose. Welfare-based elderly care service subsidies are provided by the subsidy service system, allowing seniors to choose from a basic service item list according to their needs, thereby improving supply-demand compatibility.

More room for improvement

In addition, we must integrate and coordinate governance between systems, and enhance the financial guarantee for basic care services. The elderly are usually at risk of poverty, illness, and disability, which are addressed by the multi-level pension guarantee system, medical security system, and care system, respectively, providing risk-sharing mechanisms. The responsibility boundaries between systems should be clearly defined while enhancing the connection, integration, and collaborative governance between them.

However, the current functional roles of some systems remain unclear, the linkage between systems is not smooth, and systematic design is insufficient. This reduces the efficiency of resource allocation in the field of aging security. A case in point occurred in 2022, when Jiangxi Province increased its pension by over 5 billion yuan, 10% of which (about 500 million yuan) specifically targeting seniors. Based on current subsidy targets, i.e. 86,000 recipients, the average service subsidy per person per year will increase by about 6,000 yuan. This marks a much larger marginal contribution than the above adjusted portion. If we adjust the structure of fiscal expenditure and care service subsidies, it will increase the efficiency and value of fiscal funds and help alleviate the pressure of pension adjustment.

Furthermore, it is suggested to exempt urban and rural elderly residents from medical insurance fees to enhance their ability to purchase or exchange elderly care services. The medical insurance fees paid by elderly residents account for one fourth of the basic pension, while retired employees not only do not need to pay medical insurance fees, but their pensions are also about 20 times that of residents’ pensions.

Lastly, we need to coordinate service subsidy systems and family care support policies, as a way of promoting an organic combination of formal and informal care. Research indicates that long-term care insurance has a crowding-out effect on inter-generational economic support but is beneficial in increasing the care-giving time and emotional comfort provided by offspring. If the elderly have sufficient pension resources, they can exchange them for more family care. This not only helps strengthen family care functions and foster inter-generational harmony, but also reduces the risk of senior disability, thereby decreasing care subsidy expenditures.

Thus, we must advocate the concept of self-reliance in old age and support personal pension asset allocation to cope with longevity risks. This includes increasing the basic pension for residents, encouraging residents to participate in occupational pensions and raising the contribution levels, supporting financial institutions to launch affordable pension financial products, and exempting urban and rural elderly residents from medical insurance fees. Meanwhile, we must improve support policies for family caregivers and enhance their care capabilities. This requires encouraging enterprises to provide flexible working hours, paid care, and other measures for employees with disabled elderly care needs. It will also require multi-generational cohabitation, increasing the individual tax deduction for the cost of children’s disabled care, focusing on the rigid service needs of the elderly such as short-term care and respite services, and developing community-embedded elderly care services.

 

The authors are from the School of Finance and Public Administration at Jiangxi University of Finance and Economics.

Editor: Yu Hui

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