长期护理保险的再分配与社会投资功能:来自德日韩的经验与启示

文章基于发展型福利理论构建了长期护理保险制度实施效果的分析框架,着重考察其再分配和社会投资效应,并对德国、日本和韩国进行了比较分析。分析结果表明：(1)无论采用何种待遇支付水平和给付方式,长护险实施均能促进老年照护服务市场的发展,但服务质量和从业人员稳定性受到政府监管程度等因素的影响。(2)低水平的待遇给付将难以促进家庭照料者参与劳动力市场;较高的待遇给付水平虽能在一定程度上对家庭照料形成替代作用,但难以完全取代家庭照料者的角色。(3)在待遇给付水平相近的条件下,较高的自付比例和混合给付方式将在一定程度上造成老年人照护服务使用不平等,不利于促进社会公平。     

Family spillovers and long-term care insurance

We examine how long-term care insurance (LTCI) affects informal care use and expectations among the insured individuals and co-residence and labor market outcomes of their adult children. We address the endogeneity of LTCI coverage by instrumenting for LTCI with changes in state tax treatment of LTCI insurance policies. We do not find evidence of reductions in informal care use over a horizon of approximately eight years. However, we find that LTCI coverage reduces parents’ perceptions of the willingness of their children to care for them in the future and that the behavior of adult children changes, with LTCI resulting in lower likelihoods of adult children co-residing and stronger labor market attachment. These findings provide empirical support for the presence of spillovers of LTCI on the economic behaviors of family members.     

Coping strategies, care manager support and mental health outcome among Japanese family caregivers

Coping and social support are regarded as major modifiers of the caregiving stress and negative mental health effects experienced by caregivers. Under Japan's Long-term Care Insurance (LTCI) system, care managers have played a major role in providing psychosocial support for family caregivers while coordinating formal and informal care resources for elderly people. However, since the launch of the LTCI system in 2000, no evaluation has examined the role care managers play in buffering the negative effects of the caregiver burden among family caregivers in Japan. This study examined the direct and buffering effects of stress-coping strategies and care manager support on caregiver burden and depression among Japanese family caregivers (n = 371) caring for community-dwelling persons aged 65 or over who were having difficulties with the activities of daily living. A self-administrated questionnaire survey was conducted between February and March 2005 in a rural suburb in south-western Japan. Hierarchical regression analyses revealed the following. (i) Coping strategies and 'social talk' by care managers had direct effects on caregiver burden and depression. (ii) 'Avoidant' coping and 'social talk' by care managers had buffering effects on the care needs-depression relationship. (iii) 'Information giving' by care managers had no significant direct effect, but it had a negative effect on the care needs-depression relationship. Overall, results concerning 'approaching' coping were in line with those of previous studies, while findings concerning 'avoidant' coping were not consistent with findings in Western countries. The type of care manager support appeared to have a variable influence on caregiver burden and depression.     

Public health nurses' activities after the initiation of long-term care insurance (Part 1). Focus on operations for long-term care insurance

OBJECTIVE: We conducted a nationwide questionnaire survey to elucidate the present status of public health nurses (PHNs) after initiation of the Long-Term Care Insurance (LTCI) system, in order to study the influence of the allocation of PHNs upon the performance of the system. METHODS: In March 2001, a questionnaire was mailed to 1,344 municipalities throughout Japan (all cities and 23 wards in Tokyo; one quarter of towns/villages). RESULTS: Responses to the questionnaire were received from 569 (42.3%). The largest percentage (36.4%) of PHNs was assigned to Elderly Health, 29.8% was assigned to Maternal and Child Health, and 10.2% assigned to the LTCI. Among LTCI operations, follow-up of individuals not certified as requiring care, guidance for the family caregiver, and counseling/grievance procedures were performed with participation of PHNs in more than 80% of municipalities. In urban areas, PHNs participated in training/guidance/advice for care certification investigators/care managers, guidance for service providers, and preparation/coordination for the Certification Committee for Long-Term Care Need in 60-80% municipalities, while those who participated in these activities were only 30-60% in towns/villages. The participation ratios were highest in municipalities where PHNs were allocated to the LTCI department for almost all of the activities except individual counseling. More PHNs from LTCI departments participated in certificating of care need and improving quality of care plans/services than from other departments in offices of municipalities. On the other hand, more PHNs in Welfare or Public Health-Welfare sections than in the LTCI were involved in individual counseling, guidance for both clients and caregivers, or in case management. Training or guidance for service providers was conducted in nearly 50% of municipalities and the performance rates were lower in towns/villages. In open-ended items of the questionnaire, the following problems were mentioned: difficulties in collaboration between sections; large workloads for certification of care need/care management, and difficulties in capturing information about clients. CONCLUSION: The allocation of PHN influences the activities of the LTCI system, especially in relation to quality assurance. Recently, the sections to which PHNs are posted have expanded to include LTCI and Welfare. While improvement in the quality of LTCI services is anticipated, efforts are needed to strengthen collaboration among different departments. In towns/villages, performance rates of activities such as guidance for service providers of LTCI are low, suggesting the support from prefectural health centers in necessary.     

Availability of Child Care in Rural Communities: Implications for Workforce Recruitment and Retention

The objective of this study was to identify differences in child care availability by rural–urban location for all counties in Wisconsin, and describe implications for recruitment and retention of health care workforce. We used data on licensed child care slots for young children (age <5), socio-demographic characteristics, women’s and men’s labor force participation, and household structure for all counties in Wisconsin in 2013 (n = 72). Data came from KIDS COUNT, County Health Rankings, and the American Community Survey. We used t tests to analyze bivariate differences in child care availability and community characteristics by metropolitan, micropolitan, and non-core rural location. We then used ordinary least squares regression to analyze the relationship between geographic location and child care slots, adjusting for labor force participation and household structure. Rural counties had significantly fewer licensed child care slots per child than metropolitan and micropolitan counties. These counties also had, on average, higher rates of poverty and higher unemployment than micropolitan and metropolitan counties. The association between geographic location and child care availability remained, even after adjusting for household structure and labor force participation. The number of hours men worked and the percentage of men not working were both negatively associated with available child care slots, whereas there was not a significant relationship between women’s labor force participation and child care availability. Rural areas face health care workforce shortages. Recruitment strategies to overcome shortages must move beyond individual-level incentives to focus on community context and family support, including availability of child care in rural counties.     

Long-Term Care Insurance in China: Public or Private?

China faces an overwhelming and urgent need for long-term care (LTC). We explored long-term care insurance (LTCI) plans in China and the factors associated with each plan’s contribution rate. A cross-sectional survey of 814 residents (18–59 years) was conducted to assess the expectations of elderly care, public and private LTCI features. Public LTCI may be more popular whether in terms of participation or contribution. The factors associated with public LTCI contribution rate were healthcare costs, household income, and number of daughters; for private LTCI, the factors were the proportion of living expenditures, worry about future care problems, and healthcare costs. Policymakers should develop public LTCI as a solid foundation and improve private LTCI as a substitute to meet the urgent LTC needs in China.     

Long-Term Care Insurance in Japan

In response to an increase in the number of elderly people and increasing medical costs, the Japanese government implemented the Long-Term Care Insurance (LTCI) system for the elderly in April 2000. Three years have passed since the LTCI was initiated. The purpose of this paper is to describe the framework, current situation and issues of this system, and the challenges and roles of the LTCI in the future.The numbers of service agencies, institutions, and LTCI service users have been steadily increasing. The waiting list for institutions has also increased, and only half of the users have reached the upper cost limit. Most users were satisfied with the LTCI services. However, the decisions made by the elderly on the types of services to use within the LTCI system are sometimes influenced by their families. The system has some problems regarding the lack of support that is provided to the elderly with respect to their access, choice and use of the LTCI services. Often, care managers cannot devote enough time to the care management process. As a result, important elements of care management, such as conducting home visits to assess users’ conditions, monitoring the care that is received by users, and meeting with other service providers to discuss adequacy of care, are sometimes lacking. Private companies have promoted the quality and efficiency of the home care and long-term care market. The total amount of yearly medical expenses for elderly people in Japan has decreased following the implementation of the LTCI system, compared with that prior to the initiation of the system. LTCI premiums differ among municipalities. The questionnaire that has been used to assess the care requirements of the elderly was deficient in some areas of health. However, in 2003, some amendments were made to this questionnaire in an attempt to address these deficiencies. Furthermore, the LTCI system should have relieved some of the burden on the elderly patient’s family; however, since the implementation of the LTCI, its impact on the burden on the family has not been addressed sufficiently.Although there have been amendments to the system, several challenges of the LTCI system must be considered: (i) ensuring the future financing of LTCI services is met; (ii) providing countermeasures to promote the use of home-care services and to alleviate the care burden to family caregivers; (iii) providing adequate support and advocacy of rights and decision-making for the elderly; (iv) providing educational activities to disseminate knowledge about LTCI programs; and (v) ensuring the availability of activities to promote health for the elderly and to prevent them from becoming bedridden.     

Work–Family Spillover and Daily Reports of Work and Family Stress in the Adult Labor Force*

Work–family research employing nationally representative samples and multiple methods of data collection is uncommon. We used data from two affiliated national surveys to examine the distribution of work–family spillover among working adults. The National Study of Daily Experiences (n= 741 ), an 8‐day daily diary study using a subsample of the National Survey of Midlife Development in the United States (MIDUS; N= 2,130 ), allowed work–family spillover to be conceptualized and operationalized in different ways. Analyses testing family life course hypotheses indicated that self‐reported negative and positive spillover between work and family were not randomly distributed within the labor force. Age was found to have a persistent curvilinear effect on negative spillover between work and family. The prevalence of co‐occurring work and family stress reported over 8 days was comparable across nearly all the sociodemographic characteristics.     

The labor market consequences of family illness

BACKGROUND: This study examines the impact of mental illness on the labor market performance of family members of afflicted individuals. Numerous research projects have attempted to measure the impact of mental illness and related disorders on the ill individual, yet have traditionally neglected estimating potential costs accruing to family members of the ill. AIMS OF THE STUDY: Previous research estimating the impact of illness on the time allocation decisions of family caregivers has been limited in scope. I obtain estimates of the impact of mental illness on the probability of labor force participation and hours of work of all family members. The general analysis used in this study will pave the way for more accurate assessments of the costs of all types of illness and the estimates obtained will provide policy makers with a much more complete picture of the costs of mental illness. METHODS: The main empirical work in this study includes a probit estimation of labor force participation and a tobit regression of hours worked (including sample selection correction). The data sample, taken from the 1987 National Medical Expenditure Survey, is also partitioned by gender to clarify effects of family illness on labor supply for both females and males. RESULTS: Adult males are found to increase their probability of labor force participation in the presence of mental illness in the family (all else equal) when the mental illness is accompanied by a chronic physical illness. However, females are surprisingly found to have no significant impact on their probability of being a member of the labor market when a family member is afflicted with mental illness. On the other hand, hours of work are significantly reduced for both females and males when the mentally ill family member is afflicted with additional illnesses (physical and/or mental). DISCUSSION: Previous studies have traditionally not considered the effects of family illness on males because females are typically found to be the primary caregiver when a family member falls ill. The findings in this study indicate that men suffer reductions in their hours of work in an equivalent magnitude to females. Thus, males should not be ignored when estimating the opportunity costs of illness in families. IMPLICATIONS FOR HEALTH POLICIES: Current federal and state policies provide for some of the medical costs and replace some of the lost income of ill individuals, but generally do not support family members who are negatively affected by illness. This research provides evidence supporting the arguments of advocates for policy to ameliorate the financial burden borne by family members of the ill. IMPLICATIONS FOR FUTURE RESEARCH: The estimates obtained in this study show that women and men both need to be studied when determining the effects of family illness on labor supply, and should be studied separately to obtain clear results. Also, future research should include examining particular mental illnesses to see whether there is a higher cost of one over the other (e.g., schizophrenia versus major depression), as this may provide valuable information to policy makers. In addition, comparison of the costs of psychological disorders to chronic physical illnesses (such as cancer and heart disease) should be undertaken.     

Labor supply effects of long‐term care reform in Germany

Many informal caregivers are of working age, facing the double burden of providing care and working. Negative labor supply effects can severely reduce the comparative cost advantage of informal over formal care arrangements. When designing long‐term care (LTC) policies, it is crucial to understand the effects not only on health outcomes but also on labor supply behavior of informal caregivers. We evaluate labor supply reactions to the introduction of the German long‐term care insurance in 1995 using a difference‐in‐differences approach. The long‐term care insurance changes the caregivers' trade‐off between labor supply and care provision. The aim of the reform was to strengthen informal care arrangements. We find a strong negative labor supply effect for men but not for women. We argue that the LTC benefits increased incentives for older men to leave the labor market. The results reveal a trade‐off for policy makers that is important for future reforms—in particular for countries that mainly base their LTC system on informal care.     

Labor market work and home care's unpaid caregivers: a systematic review of labor force participation rates, predictors of labor market withdrawal, and hours of work

As people continue to age and receive complex health care services at home, concern has arisen about the availability of family caregivers and their ability to combine employment with caregiving. This article evaluates the international research on unpaid caregivers and their labor market choices, highlighting three conclusions: first, caregivers in general are equally as likely to be in the labor force as noncaregivers; second, caregivers are more likely to work fewer hours in the labor market than noncaregivers, particularly if their caring commitments are heavy; and finally, only those heavily involved in caregiving are significantly more likely to withdraw from the labor market than noncaregivers. Policy recommendations are targeting greater access to formal care for "intensive" caregivers and developing workplace policies for employed caregivers.     

Health insurance and female labor supply in Taiwan

We examine whether the availability of subsidized health insurance to the non-working population in Taiwan affected the labor force participation of married women. Our empirical identification exploits the fact that such insurance was first made available to wives of government employees, before being made universally available in Taiwan in 1995. We find that the availability of insurance for non-workers was associated with a 4 percentage point decline in labor force participation among married women, with larger declines among women from low income households. Countries considering universal health insurance as in Taiwan should anticipate similar declines in labor force participation.     

Spousal labor market effects from government health insurance: Evidence from a veterans affairs expansion

Measuring the total impact of health insurance receipt on household labor supply is important in an era of increased access to publicly provided and subsidized insurance. Although government expansion of health insurance to older workers leads to direct labor supply reductions for recipients, there may be spillover effects on the labor supply of uncovered spouses. While the most basic model predicts a decrease in overall household work hours, financial incentives such as credit constraints, target income levels, and the need for own health insurance suggest that spousal labor supply might increase. In contrast, complementarities of spousal leisure would predict a decrease in labor supply for both spouses. Utilizing a mid-1990s expansion of health insurance for U.S. veterans, we provide evidence on the effects of public insurance availability on the labor supply of spouses. Using data from the Current Population Survey and Health and Retirement Study, we employ a difference-in-differences strategy to compare the labor market behavior of the wives of older male veterans and non-veterans before and after the VA health benefits expansion. Although husbands’ labor supply decreases, wives’ labor supply increases, suggesting that financial incentives dominate complementarities of spousal leisure. This effect is strongest for wives with lower education levels and lower levels of household wealth and those who were not previously employed full-time. These findings have implications for government programs such as Medicare and Social Security and the Affordable Care Act.     

退休老年群体劳动参与行为对医疗服务利用的影响研究

目的：探究退休老年群体劳动参与行为对其医疗服务利用的影响,为渐进式延迟退休政策的推出提供建议。方法：使用2020年CFPS数据,采用Logit回归模型和倾向得分匹配进行分析,通过三步回归法与KHB分解法检验变量间的中介效应。结果：Logit模型显示退休后参与劳动对医疗服务利用存在负向影响(P<0.05);PSM检验显示,退休后参与劳动对门诊服务利用、住院服务利用平均处理效应分别为-0.059、-0.074,对男性老年人和退休收入低的老年人在医疗服务利用方面的作用更明显;自评健康对门诊服务利用和住院服务利用的中介效应分别占总效应的68.25%和39.07%。结论：退休后的劳动参与行为可一定程度缓解医疗资源压力,应鼓励老年人退休后参加劳动,并根据不同人群弹性调整退休政策。     

Public long-term care insurance and consumption of elderly households: Evidence from China

This study investigates the impact of long-term care insurance (LTCI) on the non-health consumption of elderly households. By exploiting a quasi-experiment on the public LTCI pilot program in China, we identify the effect of LTCI using a triple-difference approach. Using longitudinal data from the China Health and Retirement Longitudinal Study, we find that LTCI has led to an increase in the non-health consumption of elderly households by 15.7%, mostly observed in households having no older members with need for long-term care (LTC). Further evidence suggests that the effects are stronger for households with higher expected LTC risks, less wealth or family insurance, and covered by more generous schemes. Finally, LTCI increases the expectation of using formal LTC when disabled and subjective longevity expectations for older adults having no need for LTC. Overall, these findings offer empirical support for the role of LTCI in mitigating precautionary savings against LTC risks.     

Heterogeneous Impact of Taiwan's National Health Insurance on Labor Force Participation of Married Women by Income and Family Structures

In this study, I investigate how the impact of the National Health Insurance (NHI) introduction in Taiwan in 1995 on the labor force participation (LFP) decisions of married women varies with income and family structures. Employing the difference-in-differences (DID) approach, I find that the NHI introduction reduced LFP of married women in the twenty-fifth to fiftieth percentiles of the income distribution between 17.8 and 21.7 percentage points (33%–40%). The difference-in-differences-in-differences (DIDID) results suggest that married women in different family structures (the presence of children under 3 or less healthy elderly household members) did not respond differently to the NHI introduction.     

Heterogeneous impact of Taiwan's national health insurance on labor force participation of married women by income and family structures

In this study, I investigate how the impact of the National Health Insurance (NHI) introduction in Taiwan in 1995 on the labor force participation (LFP) decisions of married women varies with income and family structures. Employing the difference-in-differences (DID) approach, I find that the NHI introduction reduced LFP of married women in the twenty-fifth to fiftieth percentiles of the income distribution between 17.8 and 21.7 percentage points (33%-40%). The difference-in-differences-in-differences (DIDID) results suggest that married women in different family structures (the presence of children under 3 or less healthy elderly household members) did not respond differently to the NHI introduction.     

Demografie und Fachkräftemangel

For demographic reasons, the German labor force will decrease dramatically and it will be much older on average. However, labor demand, especially for qualified workers, is expected to remain high. This paper focuses on the possibilities of expanding the labor force by increasing the participation rates of women and older persons. Herein, the change in the labor force is decomposed with respect to population and labor participation and, moreover, the effects of higher participation rates are simulated. The decomposition and simulation scenarios are based on data published by the Institute for Employment Research. The analysis clearly reveals that the effect of a considerably higher labor participation of women and older workers will disappear over time when the working-age population shrinks more and more. In addition, individuals who are currently unemployed or out of the labor force are not skilled enough. Since it seems difficult to get more qualified workers in the short and even in the medium term, improving the conditions for women and older people to take up jobs should be tackled soon. This includes investments in education and health care.     

Acceptance of multiple injectable vaccines in a single immunization visit in The Gambia pre and post introduction of inactivated polio vaccine

BackgroundAs the World Health Organization (WHO) currently recommends that children be protected against 11 different pathogens, it is becoming increasingly necessary to administer multiple injectable vaccines during a single immunization visit. In this study we assess Gambian healthcare providers’ and infant caregivers’ attitudes and practices related to the administration of multiple injectable vaccines to a child at a single immunization visit before and after the 2015 introduction of inactivated polio vaccine (IPV). IPV introduction increased the number of injectable vaccines recommended for the 4-month immunization visit from two to three in The Gambia.MethodsWe conducted a cross-sectional questionnaire-based survey before and after the introduction of IPV at 4 months of age in a representative sample of all health facilities providing immunizations in The Gambia. Healthcare providers who administer vaccines at the selected health facilities and caregivers who brought infants for their 4 month immunization visit were surveyed.FindingsPrior to IPV introduction, 9.9% of healthcare providers and 35.7% of infant caregivers expressed concern about a child receiving more than 2 injections in a single visit. Nevertheless, 98.8% and 90.9% of infants received all required vaccinations for the visit before and after IPV introduction, respectively. The only reason why vaccines were not received was vaccine stock-outs. Infant caregivers generally agreed that vaccinators could be trusted to provide accurate information regarding the number of vaccines that a child needed.ConclusionHealthcare providers and infant caregivers in this resource limited setting accepted an increase in the number of injectable vaccines administered at a single visit even though some expressed concerns about the increase.     

Home-based care provision within the German welfare mix

With the introduction of long-term care insurance (LTCI) in 1995/96, Germany established a universal long-term care scheme within a cost containment framework to provide public support in defined situations of care dependency. The scheme aimed to promote ageing in place with an emphasis on public support for family care provision as a precondition. A further aim was the expansion of market-oriented professional care services to offer users a choice between family and professional care provision and care providers. The focus of this study is on the interplay of formal and informal family care provision within the institutional framework of LTCI, as well as the organisation, regulations and mix of different types of formal care services. In a first step, an examination of the interplay of formal and informal care provision shows the largely family-oriented care strategy, the burdened situation of informal carers, the mix of rationalities of service use and their interrelationship with socioeconomic inequality. In a second step, an analysis of the organisation of different types of formal services reveals paid care provision that emerges in the interplay of politicians' strategies to develop professional care services within the framework of LTCI, bottom-up strategies of users to increase the range of services outside the framework of LTCI and efforts of politicians to regulate the latter. Basic orientations of care provision underlying the development process such as user orientation, quality and comprehensiveness guided the process and are used to analyse the development. Finally, the discussion of the situation of care workers reveals a contradictory picture with increasing employment opportunities, a comparably well-qualified workforce and worsening employment conditions. Empirically, the research is based on an institutional analysis of LTCI combined with a literature review and representative statistics.