Assessing the Sustainability of Long-Term Care Insurance Systems Based on a Policy-Population-Economy Complex System: The Case Study of China

Recent innovations in long-term care coverage and financing: a rapid scoping review

OBJECTIVES

To identify, chart and analyse the literature on recent initiatives to improve long-term care (LTC) coverage, financial protection and financial sustainability for persons aged 60 and older.

DESIGN

Rapid scoping review.

DATA SOURCES

Four databases and four sources of grey literature were searched for reports published between 2017 and 2022. After using a supervised machine learning tool to rank titles and abstracts, two reviewers independently screened sources against inclusion criteria.

ELIGIBILITY CRITERIA

Studies published from 2017-2022 in any language that captured recent LTC initiatives for people aged 60 and older, involved evaluation and directly addressed financing were included.

DATA EXTRACTION AND ANALYSIS

Data were extracted using a form designed to answer the review questions and analysed using descriptive qualitative content analysis, with data categorised according to a prespecified framework to capture the outcomes of interest.

RESULTS

Of 24 reports, 22 were published in peer-reviewed journals, and two were grey literature sources. Study designs included quasi-experimental study, policy analysis or comparison, qualitative description, comparative case study, cross-sectional study, systematic literature review, economic evaluation and survey. Studies addressed coverage based on the level of disability, income, rural/urban residence, employment and citizenship. Studies also addressed financial protection, including out-of-pocket (OOP) expenditures, copayments and risk of poverty related to costs of care. The reports addressed challenges to financial sustainability such as lack of service coordination and system integration, insufficient economic development and inadequate funding models.

CONCLUSIONS

Initiatives where LTC insurance is mandatory and accompanied by commensurate funding are situated to facilitate ageing in place. Efforts to expand population coverage are common across the initiatives, with the potential for wider economic benefits. Initiatives that enable older people to access the services needed while avoiding OOP-induced poverty contribute to improved health and well-being. Preserving health in older people longer may alleviate downstream costs and contribute to financial sustainability.

Influences of long-term care insurance on pulmonary and urinary tract infections among older people with disability

BACKGROUND

Pulmonary infection (PI) and urinary tract infection (UTI) have been the most common cause of hospitalization and most frequent infection respectively in older people with disability (OPWD). Long-term care insurance (LTCI) policy, intending to provide services to reduce the disease burden of OPWD, it remains unclear whether LTCI could reduce PI-, and UTI-related hospitalizations. This quasi-experimental study aimed to assess the influences of LTCI on all-cause, especially PI- and UTI-related hospitalizations among OPWD and the variation across sociodemographic characteristics.

METHODS

32,120 participants in the Chengdu Long-term Care Insurance cohort were considered the intervention group, and 2,704 not covered by the LTCI were in the control group. A total of 3,134,160 hospitalization records were collected between January 2014 and June 2021. A doubly robust difference-in-differences (DID) method was used to estimate the average treatment effect on the treated (ATT), indicating the average effect of LTCI on intervention group.

RESULTS

The average monthly all-cause, PI-, and UTI-related hospitalization rates were 16.3%, 4.0% and 0.5% in the intervention group, respectively, and were 19.3%, 3.9% and 0.5% in the control group, respectively. Under LTCI, all-cause (ATT [95% CI]: 7.15% [6.41%, 7.88%]), PI- (3.25% [2.76%, 3.74%]), and UTI-related hospitalizations (0.46% [0.28%, 0.64%]) were decreased. The influences of LTCI became significant after 5 months since the LTCI implementation and remained stable over time. The impact was more pronounced among those with longer coverage. The overall reduction was stronger in those who were not married, lived alone, and resided in institutions.

CONCLUSIONS

LTCI may reduce the occurrence of all-cause, PI-, and UTI-related hospitalizations in OPWD, with stronger influences observed over an extended period of implementation. The implementation of LTCI can play a role in reducing the burden of infectious diseases in OPWD and the care burden of families and society.

Growing old in China in socioeconomic and epidemiological context: systematic review of social care policy for older people

BACKGROUND

From 2020 to 2050, China's population aged ≥65 years old is estimated to more than double from 172 million (12·0%) to 366 million (26·0%). Some 10 million have Alzheimer's disease and related dementias, to approach 40 million by 2050. Critically, the population is ageing fast while China is still a middle-income country.

METHODS

Using official and population-level statistics, we summarise China's demographic and epidemiological trends relevant to ageing and health from 1970 to present, before examining key determinants of China's improving population health in a socioecological framework. We then explore how China is responding to the care needs of its older population by carrying out a systematic review to answer the question: 'what are the key policy challenges to China achieving an equitable nationwide long-term care system for older people?'. Databases were screened for records published between 1st June 2020 and 1st June 2022 in Mandarin Chinese or English, reflecting our focus on evidence published since introduction of China's second long-term care insurance pilot phase in 2020.

RESULTS

Rapid economic development and improved access to education has led to widescale internal migration. Changing fertility policies and household structures also pose considerable challenges to the traditional family care model. To deal with increasing need, China has piloted 49 alternative long-term care insurance systems. Our findings from 42 studies (n = 16 in Mandarin) highlight significant challenges in the provision of quality and quantity of care which suits the preference of users, varying eligibility for long-term care insurance and an inequitable distribution of cost burden. Key recommendations include increasing salaries to attract and retain staff, introduction of mandatory financial contributions from employees and a unified standard of disability with regular assessment. Strengthening support for family caregivers and improving smart old age care capacity can also support preferences to age at home.

CONCLUSIONS

China has yet to establish a sustainable funding mechanism, standardised eligibility criteria and a high-quality service delivery system. Its long-term care insurance pilot studies provide useful lessons for other middle-income countries facing similar challenges in terms of meeting the long-term care needs of their rapidly growing older populations.

The Impact of Long-Term Care Insurance on Medical Utilization and Expenditures: Evidence from Jingmen, China

The purpose of this study was to evaluate the impact of long-term care insurance (LTCI) on medical utilization and expenditures in Jingmen, a pilot city of China. The propensity score matching-difference in difference (PSM-DID) approach was employed to examine the expenses and frequency of inpatient and outpatient services before and after the implementation of the LTCI based on the 2015-2018 panel data from the China Health and Retirement Longitudinal Study (CHARLS). The results showed that the annual expenditure and frequency of the inpatient services of Jingmen residents were reduced by 1923 Yuan (287.0 USD) and 0.24 times, respectively. The impact of the LTCI varied between urban and rural areas. The annual expenditure and frequency of inpatient services in rural areas were reduced by 1600 Yuan (238.8 USD) and 0.30 times, which were lower than those (3400 Yuan (507.5 USD) and 0.20 times) in urban areas. The monthly outpatient expenses and frequency in rural areas were reduced by 300 Yuan (44.8 USD) and 0.14 times, but increased by 555 Yuan (82.8 USD) and 0.07 times in urban area. The findings indicated that the implementation of the LTCI can reduce the medical utilization and expenses, and it had a greater effect in rural areas than in urban areas. It is suggested to promote the LTCI nationwide, and more policy preference should be given to the development of the LTCI in rural areas.

Public trust in the long-term care insurance pilot program in China: An analysis of mediating effects

Objective

This study aimed to evaluate the implementation of the long-term care insurance (LTCI) pilot program in China through an examination of public trust in the system and its associated factors of insurance awareness and satisfaction with the LTCI policy.

Method

An online survey was used to collect data from 786 participants in the city of Guangzhou, one of the pilot sites of the LTCI. Ordinal logistic regression models were used to investigate the related factors of public trust in the LTCI. Structural equation modeling (SEM) was conducted to test the mediating effect of satisfaction with LTCI policy on the relationship between insurance awareness and public trust.

Results

More than 60% of participants gave a positive evaluation of the LTCI pilot program. More than 70% of the participants recognized the important role of the program. Both an understanding of insurance and satisfaction with LTCI policies were associated with public trust. The proportion of the indirect effect with regard to the total effect of satisfaction on trust was 70.133%, greater than the direct effect of 29.867%.

Conclusions

Our findings supported the hypothesis that satisfaction with the LTCI policy plays a mediating role between insurance awareness and public trust. Optimalization of the LTCI policy was recommended to improve public trust in the LTCI program.