Background
In recent years, the world’s ageing population has grown rapidly. According to the
World Population Prospects (2020 Revision), the number of people aged 60 and over in 2020 reaches 1.05 billion, representing 13.46% of the world’s total population. This number is estimated to reach 1.41 billion (16.46%) in 2030 and over 2 billion (22%) in 2050. Ageing has become a huge worldwide problem [
1,
2]. As the elderly age, their body functions and resistance to environmental stresses diminish, increasing their need for medical and daily care [
3], so middle-aged and older people make up the majority of disabled people. The increase in the number of disabled adults leads to a decline in their quality of life and life satisfaction, and puts pressure on their family members and finances, it also leads to increased burden on social health resources [
4‐
6]. Long-term care insurance (LTCI) was created to meet the demand for long-term care brought about by the increase in the number of disabled people, and Japan, Germany, the United States and other countries with serious ageing have started to implement and explore it.
LTCI is a type of health insurance that provides reimbursement for various expenses incurred by insured persons who are unable to engage in daily activities because of age, illness and disability and who need to receive various daily basic care and rehabilitation services from others at home or in a nursing home for a relatively long period [
7]. Given that more and more countries began to explore LTCI models to adapt to their respective national conditions, research on LTCI has experienced significant growth in the past 20 years, the focus of scholarly research on LTCI has evolved over time and at different times. On the one hand, the focus of scholars has shifted from the financing and market construction and reform of LTCI to the needs and actual effectiveness of the insured, with the research trend gradually shifting from the supply side to the demand side [
8]. On the other hand, many developing countries are also beginning to look into establishing LTCI that suits their national circumstances, and the number of relevant research is increasing. Although these countries started late in exploring LTCI and relevant research is underrepresented in global research networks, they have explored the LTCI suitable for their own countries based on the experience of developed countries, and have shown strong development potential and research prospects in this area [
9].
With one-fifth of the world’s elderly, China faces the greater challenge of population ageing, and the increased form of ageing will be met with more serious problems of increased disability and increased social burdens. Therefore, relevant research is necessary and can provide some reference for other developing countries [
10]. According to the China Development Report 2020: Ageing Population: China’s Development Trend and Policy Options by the China Development Research Foundation, China’s population aged 65 and above is 190.64 million, accounting for 13.50% of the country’s total population. According to short-term projections, China will have entered an aged society by 2022 (based on a proportion of 14% to 20% of the population aged 65 and above) and will enter a super-aged society by 2033 (based on a proportion of 20% or more of the population aged 65 and above) [
11]. ‘Living with illness’ is a common phenomenon among older people, but the current Chinese basic medical insurance covers the average medical needs of residents. It does not specifically consider the characteristics of elderly people regarding healthcare behaviour and medical cost distribution. The design of the medical insurance system rather than health protection has not kept pace with the development trend of ageing and changes in the disease spectrum [
12]. Data from the China Health Insurance Research Association sample in 2017 show that only 17.3% of the population aged 60 and above participate health insurance, but the total expenses reimbursed by these people through basic health insurance account for nearly 50%, with inpatient medical expenses accounting for 53.3%. Pressure on the health insurance fund will become more pronounced as the degree of ageing increases. At the same time, China suffers from a relatively small number of elderly care institutions and a shortage of professional caregivers. The disability of middle-aged and elderly people lead to increased demand for medical and health services, resulting in the higher burden on medical resources. Coupled with the high number of one-child families in China, the traditional model of relying on families to provide informal care is unsustainable [
13]. Therefore, China must take effective measures immediately to prevent ageing before preparation.
Against this backdrop, China has decided to explore LTCI, which can meet the care needs of disabled middle-aged and elderly people and is compatible with the domestic health insurance system. Given China’s enormous size and regional social and economic differences, applying a one-size-fits-all approach is challenging. Therefore, as with many reforms in other policy areas [
14], China has decided to develop LTCI through policy experimentation. Under an experimentation framework, the Chinese central government encourages sub-national governments to undertake pilot projects to solve problems and explore new policy options through trial and error and to gain experience through pilot projects to help the central government find policies that can be applied nationally [
15]. China launched a pilot scheme for LTCI in 15 cities and two key provinces in 2016 rather than immediately starting a national policy pilot scheme, the implementation time, population covered and eligibility of the LTCI pilot programme in each pilot city are shown in Table
1. The higher the degree of disability,the lower the ability to take care of oneself, and the higher the demand for long-term care [
16], so the people in need of long-term care examined in this research are mainly people with severe incapacity. Some pilot cities have also extended coverage to people with moderate disability as well as those with dementia. However, the tools used to assess the degree of disability were not identical across cities, with some pilot cities choosing the Barthel Scale and others choosing a locally developed composite scale. In 2020, more than 18.93 million disabled people will be over 60 in China, accounting for 7.45% of the elderly population over the age of 60. Among them, more than 7.09 million will be moderately or severely disabled, with expenditures of 16.84 billion yuan for the use of LTCI [
17].
Table 1
Timing of implementation, coverage and eligibility for the first LTCI pilot areas
Chengde | Nov. 2016 | √ | | | √ | | | |
Changchun | May 2015 | √ | √ | | √ | | | |
Jilin | Nov. 2016 | √ | √ | | √ | | | |
Qiqihaer | Oct. 2017 | √ | | | √ | | | |
Shanghai | Jan. 2017 | √ | √and ages 60 + | √and ages 60 + | √ | √ | | |
Nantong | Jan. 2016 | √ | √ | √ | √ | √ | | √ |
Suzhou | June 2017 | √ | √ | √ | √ | √ | | |
Ningbo | Dec. 2017 | √ | | | √ | | | |
Anqing | Jan. 2017 | √ | | | √ | | | |
Shangrao | Nov. 2016 | √ | | | √ | | | √ |
Jinan | Jan. 2016 | √ | | | √ | √ | | |
Qingdao | July 2012 | √ | √ | √ | √ | √ | | √ |
Weifang | Jan. 2015 | √ | | | √ | | | |
Liaocheng | Oct. 2017 | √ | | | √ | | | |
Binzhou | Jan. 2018 | √ | | | √ | √ | | |
Jingmen | Nov. 2016 | √ | √ | √ | √ | | | |
Guangzhou | Aug. 2017 | √ | | | √ | √ | | √ |
Chongqing | Dec. 2017 | √ | | | √ | | | |
Chengdu | July 2017 | √ | | | √ | | | |
Shihezi | Jan. 2017 | √ | √ | √ | √ | | | |
From the first day of implementation, the performance of these pilot cities has received increasing attention from scholars and policymakers in various countries. Relevant studies have addressed cost issues, including financial efficiency and expenditure forecasting [
18,
19]. In addition to the supply-side concerns of balancing budgets, meeting the care needs of individuals and reducing non-essential health service utilization and costs are also key features of successful LTCI. Scholars such as Xueqin Deng and Jin Feng have assessed the policy effects in a pilot city [
20,
21], and found that LTCI can effectively reduce the burden on families and healthcare. Some of the studies used publicly available databases to assess the effectiveness of LTCI, but did not accurately correspond to the provisions for the disabled population in each pilot city [
22], or did not include the non-covered population in the pilot city in the control group [
23]. Therefore, this paper focuses on the effect of LTCI on healthcare utilzation among disabled middle-aged and elderly people, selects appropriate data and methods for accurate analysis and substantive discussion, and explores the heterogeneity of LTCI’s policy effects across regions and different disabled populations from a health equity perspective. On the one hand, it aims to assess the effectiveness of China’s LTCI pilot construction scientifically and quantitatively and provide data support and decision-making reference for the direction and future trend of China’s work to improve LTCI in line with national conditions. On the other hand, it aims to explore the establishment of representative models of LTCI in developing countries and provide a reference for research trends in the field of LTCI.
Discussion and suggestion
Effect of LTCI on health service utilization of middle-aged and elderly people
Similar to previous studies [
28,
29], the results of this study also suggest that LTCI effectively reduces hospitalization health service utilization among middle-aged and elderly adults. Unlike the study by Chao Ma et al., this study found that the effect of LTCI on outpatient health service utilization was not significant, possibly because of the difference in the chosen study sites. Chao Ma et al. studied the effectiveness of policy implementation of LTCI in Qingdao, which was the first the LTCI pilot city to explore implementation programmes in 2012, three to five years earlier than other cities. Over the past few years, a series of complementary policies have been introduced to develop care services that cover a wide range of population groups in various forms, providing timely, continuous and integrated long-term care services for insured persons. Some policies also direct the people at risk of mild disability to preventive care, improves the health of insured persons and makes them less in need of outpatient medical services [
30]. In addition, considering that during the same period China was implementing a reform to integrate the NCMS and the URBMI into the urban–rural health insurance. We conducted a relevant literature search, and most of the studies exploring the impact of urban–rural health insurance integration showed that the policy increased the utilization of healthcare services for rural residents and had a less significant impact for urban residents [
31,
32]. Combined with the results of the analyses in this study, it somewhat reinforces the idea that LTCI is effective in reducing inpatient healthcare service utilization among middle-aged and older adults.
Analysing the regression results obtained in this study, the possible reason is that the care system provided by LTCI and the corresponding entitlement payments have effectively guided the disabled middle-aged and elderly people to accept the long-term care service programme, thus reducing some of the original demand for hospitalisation. The pilot areas will provide home care services and enable disabled patients to stay in professional or elderly care institutions with medical qualifications to build a ‘medical, nursing, care and recreation’ system that relies on families and communities. The medical expenses incurred will be reimbursed proportionally, while the fees for nursing services will be settled by social security institutions and nursing care institutions on a fixed lump-sum basis [
33], leading to the direct transfer of many disabled elderly people who have been hospitalised. Some pilot cities have also specified that participants are not entitled to medical insurance treatment for hospitalization while receiving reimbursement for LTCI to reduce the excessive utilization of medical resources and encourage some patients who need care or rehabilitation through hospitalization to turn to home care [
34,
35], thus effectively alleviating the problem of ‘social hospitalization’ and reducing medical costs. The non-significant effect of LTCI on outpatient service utilization may be because of the following reasons. On the one hand, the relatively low average cost of outpatient care imposes a low financial burden on patients; when faced with the need for outpatient services, patients and their families may trust the services the hospital provides more than a new system of care because of its authority. On the other hand, implementing LTCI focuses on addressing the long-term care needs of the severely disabled. Most of the pilot areas are compensated for disabled people who need long-term care after more than six months of treatment [
36], and they have less demand for outpatient care and more demand for daily living care. Thus, the utilization of outpatient services for the middle-aged and elderly has little difference before and after the implementation of LTCI.
Based on the previous description of the population covered in the pilot cities and the results of the statistical analyses, this study makes some recommendations. Firstly, a scientific rating standard and assessment system for a disability should be developed, and a reasonable catalogue and reimbursement contents should be designed to meet the local economic level. The policy documents of the first pilot cities of LTCI in China did not explicitly provide for a unified disability rating standard, and the pilot cities mainly adopted the Barthel Scale and the locally-developed comprehensive scale as the tools for assessing the degree of incapacity. To emphasise the differences in local LTCI, the pilot cities tend to ignore the universal rules of the social insurance system, and the path dependency resulting from long-term trial and error will increase the cost of policy unification. Therefore, the results of each pilot project should be evaluated immediately, summarizing universal standards and experiences to provide referable principle-based standards for the further development of more pilot LTCI programmes in China. At the same time, each pilot region should reasonably choose a long-term care service model according to the different local economic and characteristics of the disabled, improve service facilities and service conditions and increase the reserve of care resources, so that a nationwide LTCI system can eventually be established. Secondly, LTCI should be integrated into the multi-layered, multi-pillar social security system. Life care and primary medical care should be combined, and the provision that participants can enjoy LTCI treatment and outpatient coordination treatment paid by the medical insurance fund should be improved, so as to adapt to the context of the establishment of a multi-level medical insurance system. Resources for long-term care services should be increased to alleviate the delayed discharge of disabled persons, pressurised patients and medical care instead of nursing to improve the health of people with disabilities and reduce their outpatient and inpatient care burden. Finally, the pilot coverage should be further expanded in due course, and the conditions for LTCIs should be gradually relaxed. At present, LTCI in the pilot areas mainly covers people with severe disabilities who participate in urban employees’ medical insurance and can be appropriately expanded to cover all people with mild, moderate and severe disability and people with dementia among urban employees’ medical insurance and urban and rural medical insurance participants. The successful pilot experience of LTCI in the first batch of pilot cities should also be extended to more cities as soon as possible to alleviate the worsening level of disability among the middle-aged and elderly to meet the care needs arising from an ageing population and save LTCI funds and medical insurance fund expenditures effectively.
Regional, educational level and assistance in care heterogeneity in the effect of LTCI on health care utilization among middle-aged and older adults
The results of the heterogeneity analysis show that the effect of LTCI on the utilization of residential services for middle-aged and elderly people in the eastern pilot areas is more pronounced in terms of geographical distribution, which differs from the results of Yanzhe Zhang and Xiao Yu’s study in which residents in central and western inland cities were more accepting of LTCI than those in eastern coastal cities [
37], probably because the subjective satisfaction with LTCI is higher in the central and western regions with a high net outflow of population and a higher proportion of elderly people living alone with empty nesters have more urgent care needs.
LTCI’s significant impact on the utilization of hospitalizations for middle-aged and elderly adults in the eastern region is analysed as follows. Firstly, given that China has entered an ageing society, regional inequalities in population ageing have become increasingly prominent in recent years [
38], with the eastern region having a more serious ageing population and a relatively high level of economic and social development, where residents are well-educated in insurance culture and choose health insurance to transfer risks when encountering health risks and are therefore more receptive to the new concept of LTCI and the combination of medical and health care [
39]. Secondly, the economic level of the central and western regions is lower, people’s purchasing power is weaker, and the pressure on the medical insurance fund is greater, whereas the eastern region is economically developed and have high financial levels. Therefore, the coverage and services provided by LTCI policies in the central and western regions and the eastern regions have a large gap [
40], the eastern regions offer a wider range of coverage, more professional medical, more nursing and elderly care institutions and residents’ higher ability to pay. Thus, middle-aged and older people in the east benefit more from LTCI.
The heterogeneity analysis also found that LTCI has a non-significant effect on hospitalizations utilization among low-education and unattended middle-aged and older people but reduced the number and cost of annual hospitalizations among other middle-aged and older adults. Analysing the reasons, most middle-aged and elderly people are influenced by the traditional Chinese filial culture and choose home-based care for the aged, relying heavily on informal care from family members [
41], whereas LTCI treatment is mainly based on reimbursement for institutional care and home care services provided by them. Middle-aged and elderly people with a high level of education and their caregivers may choose formal care services to reduce the double financial burden of the cost of elderly care and their family’s financial situation and obtain more working hours [
42], thus reducing hospitalizations. The lower-educated and unattended middle-aged and elderly adults, usually in poorer financial and health conditions, still have more health needs after joining LTCI, have more difficulty distinguishing between care needs and medical needs, and tend to choose hospitalization for treatment when they have health needs.
Based on the above findings, the following recommendations are made in this study. Firstly, the LTCI system should be improved according to local conditions on the basis of summing up the pilot experiences of each region. Influenced by the scope of the pilot, the level of financial support and the balance between supply and demand, the effects of LTCI have regional differences, being more pronounced in the eastern region compared to the central and western regions. Policies should be formulated and implemented to avoid the inequitable provision of protection and care services with a focus on the central and western regions. Policies should improve the intensity of LTCI compensation and the quality of care services, combine transfer payment methods to ensure fairness and equity between different regions and make differentiated designs in terms of the characterization of the system, funding methods and treatment methods, considering the level of regional economic development. Secondly, the referral interface between medical and skilled nursing facilities must be improved and the capacity of skilled nursing facilities must be strengthened to promote LTCI and health literacy content. Influenced by the culture of filial piety, many middle-aged and elderly people choose home-based care for the aged. Some of them are not always accompanied by someone to care for them, and their education level is not high enough to understand the knowledge and usage of new things like LTCI, so they still prefer hospitals for treatment when they encounter health problems. Thus, a referral mechanism must be established between medical institutions and skilled nursing facilities for those involved in LTCI disabilities, and policy advocacy and health literacy among family caregivers and skilled nursing staff in medical care facilities should be enhanced for this group of middle-aged and elderly adults.
Limitation
This study has two limitations. First, the study period covered only two waves due to the limitations of the publicly available database. The short study period may not reflect the long-term impact of long-term care insurance on health care use. The follow-up research team will continue the study after the release of the new wave of survey data. Second, given the limitations of the sample size, further validation is needed. The research team will subsequently build on this study to find more partners to obtain data on LTCI coverage and use cost–benefit analyses to provide a clearer picture of the overall benefits.
Conclusions
This study has two main contributions. Firstly, after exploring the effect of LTCI on the utilization of health care services for middle-aged and elderly adults in the pilot cities, LTCI is found to reduce the utilization of hospitalisations but did not significantly affect the utilization of outpatient services. Moreover, policymakers need to improve the treatment plans of LTCI further and increase the supply of resources for long-term care services. Secondly, a heterogeneity analysis revealed that the effect of LTCI on the utilization of hospitalizations by middle-aged and elderly adults in the pilot cities differed in terms of regional distribution and educational level and care assistance with health service utilization by middle-aged and elderly adults in the central and western regions and those with low educational levels or unattended care insignificantly affected by LTCI. Policymakers should develop locally tailored long-term care service models to facilitate the use of long-term care resources by different disabled middle-aged and elderly people in different regions, based on the actual situation of the economy, medical resources and health service needs of middle-aged and elderly adults in different regions. Our findings are informative for the literature on ageing societies, social sector reform and policy evaluation. Moreover, China’s experience could provide useful lessons for other developing countries considering similar LTCI to strengthen their response to population ageing.
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