政府补助、保险支付与老年临终照料成本——基于2002-2014年CLHLS死亡人口追踪数据的分析

为应对日益增大的老年人照料压力，我国各地试点通过政府补助或社会保险支付的方式满足老人的照料需求。基于2002-2014年CLHLS死亡人口追踪数据，文章用两部分模型、Heckman选择模型和结构方程模型，分析了政府补助、保险支付对老年临终照料直接成本和总成本的影响及其中介机制。研究发现，老年临终照料服务由保险支付的直接成本和总成本都比家庭支付明显更高，政府补助的直接成本比家庭支付更高，保险支付的直接成本比政府补助更高。保险支付和政府补助对照料成本影响的机制存在差异，保险支付主要通过收入效应对照料成本产生显著影响，但替代效应也发挥了中介作用，政府补助则主要通过替代效应对照料成本产生显著影响。文章的研究结论具有重要的政策含义。我国发展长期护理保险，应合理界定政府、市场、社会和家庭对老年人的照料责任，并明确长期护理保险的有限责任，尽量降低可能的收入效应和替代效应对照料成本的影响。

Government Subsidies,Social Insurance Support and Care Cost of the Elderly at the End of Life: Evidence from the Deceased Older Adults Data of 2002-2014 Waves of Chinese Longitudinal Healthy Longevity Survey

In response to the increasing pressure of care for the elderly, pilot programs have been conducted in China to meet the care needs of the elderly by means of government subsidies or social insurance support. This paper explored thoroughly the effects of government subsidies and social insurance support on the direct and total care costs at the end of life and their mediation mechanisms using Two-Part Model, Heckman Sample Selection Model and Structural Equation Model based on the deceased older adults' data of 2002-2014 waves of Chinese Longitudinal Healthy Longevity Survey. The main conclusions are as follows:1) The care cost of the elderly at the end of life in China is relatively high. 2) Government subsidies and social insurance have a significant impact on the direct and total care costs. Compared with payment by the family, the direct and total costs by way of social insurance support were significantly higher by 62.74% and 43.91%, respectively. The direct costs by way of government subsidies were significantly higher by 15.84%. And the direct costs by way of social insurance support were significantly higher than government subsidies by 40.47%. 3) The income effect and substitution effect played the mediating roles between social insurance support and care costs. 4) The substitution effect played the mediating role between government subsidies and care costs.The differenceof impact mechanism between government subsidies and social insurance support on the care costs may be related to their payment systems. Government subsidies generally provide targeted formal support services based on the assessment of the elderly's self-care ability, care needs and family care ability, to alleviate the family care pressure. Such limited service support avoids possible income effects. Social insurance support is usually based on the expenses of care services and reimburse the care costs in a certain proportion, mainly to reduce the out of pocket care costs. When the out of pocket care cost is relatively low, it may lead to the excess demand of the elderly for care services. If there is no perfect assessment and supervision of care needs, it may be a greater income effect and lead to moral hazard and the excess utilization of care services.Although both social insurance support and government subsidies have substitution effect on the utilization of care services for the aged and lead to the increase of direct and total care costs, it has certain rationality. Because it is conducive to reducing thefamily care pressure, and to improve the possibility to obtain professional care services for the elderly. However, this may also weaken the family's care responsibilities and may be detrimental to the mental health of the elderly. Moreover, social insurance support also has an income effect on the utilization of care services for the elderly, which may also lead to excessive inflation of care costs.These findings have important implications for public support care policy for the elderly in China. To minimize the impact of possible income effects and substitution effects on the cost of care, it is necessary to define the responsibility of the government, the market, the society and the family for the care of the elderly, and clarify the limited liability of long-term care insurance.