key: cord-0807005-b6qab2mk
authors: Chen, Linhong; Zhang, Lu; Xu, Xiaocang
title: Review of evolution of the public long-term care insurance (LTCI) system in different countries: influence and challenge
date: 2020-11-20
journal: BMC Health Serv Res
DOI: 10.1186/s12913-020-05878-z
sha: 30ce17cc7f1aa1c8a463e14b4aee217309d7fe9d
doc_id: 807005
cord_uid: b6qab2mk

BACKGROUND: The growing demand for LTC (Long-term care) services for disabled elderly has become a daunting task for countries worldwide, especially China, where population aging is particularly severe. According to CSY (China Statistical Yearbook,2019), the elderly aged 65 or above has reached 167 million in 2018, and the number of disabled elderly is as high as 54%. Germany and other countries have alleviated the crisis by promoting the public LTCI (Long-Term Care Insurance) system since the 1990s, while China’s public LTCI system formal pilot only started in 2016. Therefore, the development of the public LTCI system has gradually become a hot topic for scholars in various countries, including China. METHODS: This review has been systematically sorted the existing related literature to discuss the development of public LTCI (Long-Term Care Insurance)system form four aspects, namely, the comparison of public LTCI systems in different countries, the influence of public LTCI, challenge of public LTCI, and the relationship between public LTCI and private LTCI. We searched some databases including Web of Science Core Collection, Medline, SCOPUS, EBSCO, EMBASE, ProQuest and PubMed from January 2008 to September 2020. The quality of 38 quantitative and 21 qualitative articles was evaluated using the CASP(Critical Appraisal Skills Programme) critical evaluation checklist. RESULTS: The review systematically examines the development of public LTCI system from four aspects, namely, the comparison of public LTCI systems in different countries, the influence of public LTCI, the challenge of public LTCI, and the relationship between public LTCI and private LTCI. For example, LTCI has a positive effect on the health and life quality of the disabled elderly. However, the role of LTCI in alleviating the financial burden on families with the disabled elderly may be limited. CONCLUSION: Some policy implications on the future development of China’s LTCI system can be obtained. For example, the government should fully consider the constraints such as price rise, the elderly disability rate, and the substantial economic burden. It also can strengthen the effective combination of public LTCI and private LTCI. It does not only help to expand the space for its theoretical research but also to learn the experiences in the practice of the LTCI system in various countries around the world. It will significantly help the smooth development and further promote the in-depth reform of the LTCI system in China.

The aging of the population has become a global problem. According to the World Population Outlook (2019) (WPP2019, United Nations Population Division), the Aging degree (proportion of the population aged 65 and above) of Japan, Italy, South Korea, and China will reach 28.4, 23.3, 15.8, and 12.0% respectively in 2020, while by 2050, the Aging degree of South Korea, Japan, Italy, and Germany will reach 38.1, 37.7, 36.0, and 30.0% respectively, and China will surge to 26.1%, which is equivalent to the average level of developed countries (26.9%). Subsequently, the cost of long-term care for the elderly who have lost their Activities of Daily Living (ADL) will bring a heavy economic burden to their families [1] . Therefore, the Long-term care insurance (LTCI) system came into being [2] .

Long term care insurance (LTCI) system refers to an institutional arrangement to share the nursing expenses incurred by people who cannot take care of themselves due to chronic diseases or physical and psychological disability (WHO) [3] . From the perspective of whether it is compulsory or not, Long term care insurance (LTCI) system includes public-LTCI and private-LTCI. Private-LTCI exists as a supplement to public-LTCI, and its development is seriously insufficient. Therefore, at present, the focus of government and academic discussion is in the field of public-LTCI, which is also the main research object of this paper.

Long-term care insurance (LTCI) system originated in European countries. The Netherlands was the first country that introduced a universal mandatory social health insurance scheme for covering a broad range of longterm care (LTC) services provided in a variety of care settings in the 1960s. Germany is the first country to implement public LTCI(Long-term care insurance) in the form of social legislation. In 1995, LTCI law came into effect and became the fifth pillar insurance after endowment insurance, medical insurance, accidental injury insurance, and unemployment insurance. Since then, the United States and other countries have also formally enacted public LTCI.

Japan and South Korea are the first countries to implement public LTCI in Asia. After the implementation of public LTCI system in Japan since 2000, it has gone through five major changes (2000, 2004, 2006, 2009, 2014) , and has a careful design in the funding sources, identification procedures, and service content. According to the Japanese " LTCI law", the insured only pays 10% of the total nursing expenses when receiving long-term care services, and the remaining expenses are borne by 50% of the premium paid by the insured and 50% of the government's public expenses. This way of financing can ensure that the family's economic burden is not too heavy and not cause too much financial pressure, and ensure that the public LTCI system can be carried out persistently and stably. Korea has also implemented public LTCI to maintain and improve the health and wellbeing of the elderly since 2008.

The increasingly aging population has highlighted the urgency of the crisis in health care services for the elderly in China in recent years. According to CSY (China Statistical Yearbook,2019), the elderly aged 65 or above has reached 167 million in 2018, accounting for 11.9% of the total population. The ODR (Old-age dependency ratio) has climbed from 9.9% in 2000 to 16 .8% in 2018. Among them, the number of disabled elderly due to chronic diseases, environmental pollution, accidental injuries, and natural aging is increasing, and the prevalence rate of chronic diseases in the elderly is as high as 54% [4] [5] [6] [7] [8] . Although the LTC (Long-Term Care) services demand for the elderly was snowballing, the provision of LTC (Long-Term Care) services such as policy formulation, operational models, and especially fundraising lag far behind. As a result, the "healthy China strategy" has been proposed in the Report of the 19th National Congress of China. At the same time, Government-mandated public LTCI (Long-Term Care Insurance) was piloted in 15 cities since 2016, including Qingdao of Shandong province, Chengdu of Sichuan province, and Chongqing, which had a profound impact on the people and economies of the pilot areas(as shown in Table 1 ).

Academic research on Long-term care insurance is carried out from two main lines: public LTCI and private LTCI. The research on private LTCI mainly focuses on the design of different types of LTCI insurance and people's willingness to purchase private LTCI [9] . The research on public LTCI mainly focuses on two aspects. One is how to optimize the financing method to ensure the public LTCI can be carried out continuously and stably. The second is to discuss the effect of LTCI implementation on the health or financial burden of people who benefit from LTCI. For example, Choi & Joung used Cox proportional risk regression model to prove that LTCI (Long-Term Care Insurance) services can help reduce health expenditure and protect the health of the elderly aged 65 and above [10] . All the studies show that LTCI has a positive impact on the health of the disabled elderly, and the theoretical research is becoming more and more in-depth, which were conducted from the perspectives of different age groups, nursing time, and health recovery degrees. Etc.

Looking at the historical evolution of the Long-term care insurance system, we can find that although private LTCI is an important aspect of LTCI system, it is essentially only a supplement to public LTCI. Therefore, this paper only takes public LTCI as the research object to discuss the development of public LTCI system form four aspects, namely, the comparison of public LTCI systems in different countries, the influence of public LTCI, challenge of public LTCI, and the relationship between public LTCI and private LTCI.

The review aimed to show the influence and challenge of the public Long-Term Care Insurance (LTCI) System in Different Countries. By the way, we also discussed the development process of public LTCI in major countries (such as Germany, Japan, South Korea, and China) and its relationship with private LTCI.

The following main databases were taken into account: Web of Science Core Collection, Medline, SCOPUS, EBSCO, EMBASE, ProQuest and PubMed. Considering the regional limitations and the disorder of Chinese literature, CNKI(China) was not included in this literature search. The following combinations of terms were practiced with the Boolean phrase "and/or" to maximize the scope and type of material achieved in the search: 'LTCI' OR "Long Term Care Insurance".

By September 30, 2020, we have searched for a total of 445 papers. The selection criteria for publications were as follows: (1) In terms of publication time, we limit it from 2008 to September 30, 2020 (the time of revision of this paper). Although the 'Long Term Care Insurance' article first appeared back in 1984 (Meiners&Tave.1984 [11] ; Schechter,1984 [12] ; Meiners&Trapnell,1984 [13] ), but they simply put forward the concept of 'Long Term Care Insurance', and there were few studies on the subject over the next 25 years. It was not until 2008 that Brown & Finkelstein (2008) [14] first discussed the relationship between American public LTCI and private LTCI, and Ariizumi(2008) [15] first discussed the effect of public long-term care insurance on consumption and welfare, that the topic of long term care insurance began to attract the attention of a large number of scholars. Therefore, this paper takes 2008 as the starting point of research time. (2) The following types of documents are not included: Meeting abstract, Editorial Material, Letter, Proceedings paper, and other types such as Opinions or Comments (194 articles in total). In the end, we determined a total of 59 articles, including 38 quantitative research and 21 qualitative research.

All publication information was exported to the Excel database via Endnote, and duplicate sections were removed. The results were initially extracted by one researcher and then cross-checked by another to ensure that all data had been screened and reviewed. If there is a difference of opinion between the two researchers, the third researcher will be invited to express his opinion and finally reach an agreement.

The information extracted from all the included publication was as follows: Author, Publication date, Sample country, Research method, Research objective, and Key findings. All the analysis results are analyzed in the following process (as shown in Fig. 1 ).

We used the Critical Appraisal Skills Programme (CASP) to evaluate all 59 papers that were selected and Table 2 ). The five questions are: (1)Did the paper address a clearly focused question? (2)Do you think all the important, relevant studies were included? (3) Can the results be applied to the local population? (4) Were all important outcomes considered? All the questions were asked to answer one of the following answers: Yes; No; Can't Tell. The evaluation results of all literatures are shown in Table 2 .

Of the 59 papers selected, 38 were quantitative and 21 were qualitative. Among them, quantitative research is mainly carried out from two perspectives. One is empirical research through microscopic investigation data, such as logistic regression analysis. The second is to discuss the long-term sustainable development of public LTCI caused by financing problems by comparing the financing of public LTCI with the macro data of cost demand.

The publication time and sample countries of public LTCI thematic research are closely related to the development experience of public LTCI in each country. Figure 2 shows some information.

As shown in Fig. 2(a) , the research on public LTCI is mainly concentrated in Korea (16) , Japan (14) , and Germany (8) . Germany is the first country in the world to formally legislate public LTCI (1995), while Japan (2000) and South Korea (2008) are the first countries in Asia to formally legislate public LTCI. In recent years, these three countries have been carrying out many reforms to different degrees for public LTCI according to their national conditions. It is worth noting that since China began to pilot public LTCI in 15 cities in 2016, relevant research has begun to emerge. In addition, the research on Thailand's public LTCI began to appear. Although Thailand's public LTCI system has not been formally implemented, it at least shows that Thailand is trying to make relevant efforts. The information is given in Fig. 2(b) is also very interesting. It shows that the research on public LTCI can be divided into three climaxes in terms of time, namely, 2009-2010, 2014-2015, and 2017-2019.

As early as 10 years ago, Campbell et al. (2010) [2] compared the differences between Germany and Japan in the objectives, qualification procedures, scale, and sustainability of the public LTCI system, hoping to learn from the experience and find a suitable LTCI system for the [2] used data from the Netherlands and Germany, two countries with general public LTCI, and found that although the overall use rate of LTC was similar in the two countries, the use of formal care was more common in the Netherlands and the use of informal care was more common in Germany. Courbage et al. (2020) [2] also performed similar comparative studies on Italy and Spain through cross-sectional data from the European Health, Ageing, and Retirement Survey (SHARE) database. Rhee et al. (2015) [2] compared the public LTCI systems of Korea, Japan, and Germany from the perspective of financing, and believed that in order to achieve the sustainable development of LTCI, the financing of LTCI should be planned in advance in terms of income generation, welfare design, and qualification. A more meaningful study was conducted by Chandoevwit&Wasi (2020) [2] , who discussed the feasibility and benefits of introducing public LTCI to middle-income countries such as Thailand through discrete Choice experiment (DCEs). To sum up, the comparison of public LTCI system in different countries is mainly carried out from the three aspects of structure design, fund raising and policy effect of public LTCI system (as shown in Table 3 ).

The social and economic impact of public LTCI on population aging is enormous, and many scholars have analyzed its influence from different angles (as shown in Table 4 ). Firstly, the impact of public LTCI on the health of beneficiaries. As the first country with formal legislation and public LTCI, Germany has made remarkable achievements in LTCI reform. The physical health of the beneficiaries of the public LTCI has improved significantly for the most part, especially those receiving good home care (Buscher, et al. 2010 ). The changes in Japan Secondly, the impact of LTCI on the economic burden of beneficiary families, which is an inevitable problem that must be solved in the process of sustainable development of public LTCI. For instance, after the implementation of public LTCI, German people's perception of financial security also increases with the increase of income (Zuchandke et al. 2010 ), but there is a gender and age difference. When the age is older, women spend more than men of the same age (Schwarzkopf, et al. 2012 Thirdly, the impact of public LTCI on long-term care providers, i.e., the labor market. German scholars Geyer designed a structural model of labor supply and family caregiver welfare choices and found that benefits in kind had a small positive effect on labor supply Finally, the influence of LTC system design, including nursing style, is discussed. The influence of public LTCI on the choice of long-term care methods in various countries, such as home care, community care, and institutional care, is restricted by income level, family environment, and other factors ( 

As a new type of insurance coexisting with endowment insurance and medical insurance, LTCI system has experienced different degrees of difficulties and challenges in the development process of different countries, which will affect the long-term sustainability and stability of LTCI system development (as shown in Table 5 ).

Firstly, the challenges from the sustainability of LTCI financing, which is a core issue for LTCI's long-term development. For instance, the success of the Netherlands LTCI reform depends to a large extent on the accuracy of the LTCI needs assessment and the proper budgeting of LTC costs (Schut& van den Berg,2010). Germany's public LTCI has undergone several reforms, as has Japan Secondly, the challenges from design flaw of LTCI system, including certification. For instance, publicly provided health-based LTC crowds out the medical spending among low health individuals in USA (Ariizumi, 2008),while future policy experimentation on LTCI reform in China needs to address the some policy issues such as expanding the coverage of LTCI and narrowing rural-urban disparities in access (Zhu& Osterle, 2019). The lack of coordination between the health sector and the long-term care sector is a weak point in the development of Korea's public LTCI (Kang et al.2012; Chon, 2013 Chon, ,2014 . It explored differences between Germany and Japan in program goals, eligibility process, scope, size, and sustainability for possible applications in the United States.

Public spending on long-term care in the United States is actually higher than in Germany, and is only slightly lower than in Japan.

Meijer& Van Doorslaer (2015) [46] HEALTH ECONOMICS

Quantitative research

Using comparable data from two countries with universal public LTC insurance, the Netherlands and Germany, we examine how institutional differences relate to differences in the choice for informal and formal LTC.

System features such as eligibility rules and coverage generosity and, indirectly, social preferences can influence the choice between formal and informal care. Less comprehensive coverage also has equity implications: for the poor, access to formal LTC is more difficult in Germany than in the Netherlands. This paper examined the financing systems of long-term care insurance (LTCI) in South Korea, Japan, and Germany.and draw lessons regarding revenue generation, benefits design, and eligibility.

1. Early financing ensures that the service delivery system has time to adapt because most middle-income countries lack the infrastructure for providing long-term care services. 2.One approach is to start with a limited benefit package and strict eligibility rules and expanded the program as the country develops sufficient experience and more providers became available. Exercise and drinking habits were significantly less common in support-or care-level elderly than in specified or uncertified elderly. The prevalence of taking antihypertensive, antihyperlipidemic, antidepressant or sleeping medications was significantly higher in the support-or care-level elderly than in uncertified or specified elderly people. Supportor care-level elderly also had a significantly higher prevalence of past medical histories of stroke, bone fractures, osteoarthropathy, heart disease and cancer than uncertified or specified elderly people. There were significant differences in cognitive function, behavioral symptoms, and physical function at baseline between individuals receiving the three LTCI service type (HC, IC, CC) and overall improvements in those outcomes over 2 years in the three groups. A lower age of caregivers, a more advanced need classification level, and more satisfaction with the services were independently associated with a reduction of the care burden. In Japanese LTCI, the overall satisfaction of the caregivers appears to be relatively high and is associated with the reduction of the care burden. The LTCI introduction has significant and positive spillover effects on family caregivers' labor force participation and the effects vary by gender and age. In contrast, the LTCI amendment is found to have generally negative spillover effects on their labor force participation. This article uses a methodology of personal in-depth and focus group triangulation, by which the views of three groups of stakeholders are explored and compared: persons with AD, relatives, and professionals.

The presence of stigmatic selfimages among persons with AD or other types of dementia and the absence of such images in relatives' and professionals' views of them and of LTCI. However, treatment stigma was found to be primarily associated with eligibility determination procedures. The study concludes that LTCI, even when mandated and almost universal, may also generate welfare stigma due to the ways in which it is Thirdly, challenges from traditional social concepts or family relationships. For example, Whether in Europe (Costa-Font, 2010) or Israel (Ayalon, 2018) , family relationships or family culture are correlated with the benefit coverage of LTCI. This is especially true in South Korea, which is heavily influenced by traditional East Asian culture. Many Korean studies found that the state has difficulty in regulating the market and costs, and deeply embedded familialism seems difficult to overcome (Chon, 2012 ; Kim& Choi2013; Ha et al.2017 ).

Finally, how to balance fairness and efficiency is also a big challenge for the future development of public LTCI. For example, Dutch using prior utilization and expenditure as risk adjusters reduces incentives for efficiency, creating a trade-off between equity and efficiency (Bakx et al.2015) .Long-term care reforms in Korea should continue to concentrate on expanding insurance coverage and reducing the inequities reflected in disparities in consumer cost sharing and associated patterns of utilization across plans (Park, 2015) . There remain sizable disparities in financial burden among insurance participants, despite an emphasis on ensuring equitable access to care in China (Yang et al.2020 ) and Japan (Saito et al.2018) .

As shown in Table 6 , Brown&Finkelstein (2008) 's study published in AMERICAN ECONOMIC REVIEW in 2008 was the first classic paper in the world to discuss the relationship between PUBLIC LTCI and private LTCI. Two years later, the difference between public nursing institutions and private nursing institutions in the Long term care effect of disabled elderly after the formal launch of public LTCI system in Japan since 2000 was compared (Yoshioka et al., 2010) . Their study found that private LTCI plays an important role in promoting the use of care services, but the quality of care may be problematic. In the following years, some scholars conducted in-depth discussions on the crowding out effect of public LTCI and private LTCI (Cremer&Pestieau,2014; Costa-Font&Courbage,2015), cooperation mode (Schmitz& Giese,2019) and other aspects.

In addition, Before China officially launched the pilot system of public LTCI in 2016, some Chinese scholars discussed what roles public LTCI and private LTCI should play in response to China's huge long-term care needs. For instance, Shen& Li (2014) conducted a crosssectional survey of 814 residents (ages 18-59) and found that public LTCI was likely to be more popular in terms of participation and contribution. Factors associated with public LTCI demand are medical costs, household income, and for private LTCI, these factors include the proportion of living expenses, concerns about future care, and medical costs. Therefore, policy makers should develop public LTCI as a solid foundation and perfect private LTCI as an alternative.

In order to deal with the aging population and its longterm nursing costs, the research on LTCI has become the international academic frontier and hot topic. Judging from the current development of global LTCI system, the development of private LTCI is still in its infancy. Countries including Germany, the United States, Japan, South Korea and China all focus on the construction and sustainable development of public LTCI system. In practice, although the LTCI system originated in the Netherlands, Germany (1995) and Japan (2000) are the first countries in the world and Asia to legislate public Higher likelihoods of institutionalization were found in individuals living with a non-family member compared to individuals living with their spouses. Individuals without a caregiver or with a paid caregiver were also more likely to experience institutionalization than individuals with a spouse primary caregiver. This paper discusses what should be the focus of the second reform of German public LTCI system. the focus of the second reform of German public LTCI system should concentrated on quality improvements, care management and careful adjustments of benefits. Financing issues are of particular concern such as increasing in the contribution rate. GERONTOLOGIST Germany Qualitative research

The study reviews legislative and programmatic changes of LTCI, using program data, as well as legislative documents and program reports.

1.The program is widely accepted among citizens and has achieved many of its original goals: ensuring access to long term services and supports and reducing reliance on the locally-funded safety-net social assistance program, which can be used to cover nursing home costs. 2.Recent reforms has addressed financing issues by increasing premiums, introducing subsidies for the purchase of private insurance, and creating a "demographic reserve fund." 3.the program provides evidence for the financial viability of a social insurance model, although longer-term challenges may yet arise.. Lessons from Japan's long-term care insurance policy

There has been an increase in families' access to formal care at lower cost, but results for the wellbeing of caregivers have been mixed. The system's successful challenges include dissatisfaction with home care, the provision of necessary support to home caregivers, and financial sustainability.

5 Kato(2018) [59] JAPAN AND THE WORLD ECONOMY Japan Quantitative research This paper explores the impact of population aging on the Japanese public long-term care insurance (LTCI) within a numerical dynamic general equilibrium model with multiple overlapping generations.

In order to reduce future burdens in the LTCI, an increase in co-payments is most preferable, rather than an earlier starting age of contribution in the longer duration with lower annual burdens, or a shift of the cost to the public sector with a very high consumption tax. 2. the per capita financial demands of care in urban and rural areas in 2050 will be approximately six times and 11 times higher than in 2020, respectively. 3.the overall contribution rate of LTCI in China will increase sharply from 1.46% in 2020 to 5.14% in 2050, an increase of about 3.5 times. By comparison, the contribution rate in 2020 will be close to 1.33% in Japan in 2015 and 1.40% in Germany in 2010. This paper discussed LTCI's eligibility qualifications and the certification process based on functional disability, benefits and coverage of community-based and institutional care in Korea.

The lack of coordination between the health and long-term care sectors, limited consideration of physicians' assessments in the certification process, inadequate provision of health services in long-term care facilities, and overlapping and inefficient use of care resources act as barriers to providing comprehensive healthcare for older beneficiaries. The Aday-Andersen model was used as a conceptual model to examine the extent to which equity in the use of long-term care has been achieved in Korea.

1.those who rated his or her health to be fair, good, and very good, had no limited activities, were disabled, and had insurance coverage were more likely to use long-term care services, respectively. 2.the introduction of a national long term care insurance program did not yield a fully equitable distribution of services. 3. Long-term care reforms in Korea should continue to concentrate on LTCI, and have been carrying out many reforms and improvements for more than 20 years. Since 2016, China, as the country with the largest aging population in the world, began to pilot public LTCI, which has a great impact on people's daily life and academic circles. This paper attempts to systematically sort out the relevant research literature on public LTCI, and to explore the continuous reform and improvement of LTCI system in Germany, Japan and South Korea, so as to seek experience and promote the further sustainable development of China's public LTCI. This is also a further thinking to cope with the impact of covid-19 and other similar public health events on subsequent LTC services. Firstly, a preliminary review of relevant literature was done. Of the 59 papers selected, 38 were quantitative and 21 were qualitative. Among them, quantitative research is mainly carried out from two perspectives. One is empirical research through microscopic investigation data, such as logistic regression analysis. The second is to discuss the long-term sustainable development of public LTCI caused by financing problems by comparing the financing of public LTCI with the macro data of cost demand. With the passage of time, there are more and more researches on public LTCI, which shows that the development of public LTCI is paid more and more attention by governments and academic circles. The research on public LTCI is mainly concentrated in Korea, Secondly, from the comparison of public LTCI systems in different countries, By comparing the development of public LTCI in the Netherlands, Germany, South Korea and Japan, we find that the structural design of public LTCI, including fund-raising and qualification procedures, has different characteristics in different countries (Campbell et Thirdly, the social and economic impact of public LTCI on population aging is enormous. Firstly, The physical health of the beneficiaries of the public LTCI has improved significantly, especially those receiving (Feng et al. 2020 ). Finally, LTCI system has experienced different degrees of difficulties and challenges in the development process of different countries, which will affect the long-term The literature review of this paper gives us some policy implications. First of all, learning from the practical experience of LTCI system in the world, such as structural design and financing mode, will contribute to the in-depth development of China's public LTCI system. However, the literature review also makes us realize that, restricted by different factors in different countries, the long-term care system is a long-term process, which needs continuous reform ;Chandoev-wit&Wasi,2020) in order to truly meet the growing and changing long-term care needs, especially in China, which has the largest elderly population in the world. Secondly, it is always the core of the stable and sustainable development of public LTCI to solve the financing problem of public LTCI. However, the breakthrough of traditional social concept and family concept, the balance of fairness and efficiency, are very important factors that affect the sustainable development of public LTCI, especially Japan, South Korea, and China, which are deeply influenced by traditional culture (Costa-Font, 2010; Chon, 2012; Kim& Choi,2013; Ayalon, 2018). Perhaps, while steadily promoting public LTCI, it is wise to actively develop private LTCI market (Schmitz& Giese,2019).

In general, Germany, Japan, and other countries have their characteristics in the specific implementation policies of public LTCI, such as fundraising. For example, German LTCI law emphasizes two essential principles, namely, "in the home care priority" and "prevention and rehabilitation priority." All medical insurance policyholders, as long as is an adult, regardless of men and women's health and age, must attend the LTCI. On fundraising, the difference according to individual income level presses different proportions to execute personal pay costs. Spending on Long-term care services accounted for about 1% of GDP in 2018. Overall, there are two types of public LTCI (Long-Term Care Insurance) systems in different countries at present. The first is the Nordic "welfare state" model of the comprehensive general welfare, which is not suitable for China's specific social conditions. The second is the "corporatist-welfare" mode of universal coverage, which emphasizes the combination of comprehensive coverage and mutual benefit, which is meet China's current "peer-to-peer" rights and obligations of social insurance concept consistent, but there are some risks such as the cost burden. Therefore, China's future public LTCI development should choose a unique path suitable for its social conditions. 

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We thank Professor Timothy Kyng 

All authors have read and agree to the published version of the manuscript. Conceptualization, X.X.; methodology, L.C.; writing-original draft preparation, L.C.; writing-review and editing, L.Z.; visualization, X.X.; project administration, L.C.

This research is the stage research result of the National Social Science Fund of China: Research on the blocking mechanism of the critical poor households returning to poverty due to illness (NO:20BJY057).

The original data that If the reader has a personal request, I will provide it to him.Ethics approval and consent to participate Not applicable. Ethical approval is not necessary as this study does not involve human or animal studies.

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The authors declare that they have no competing interests.