Long-term Care Coverage Research Articles

A Comparison of Nationwide Dental Utilization and Medicaid Dental Coverage

Background: In 2020, Medicaid provided health and long-term care coverage to 72,995,197 adults aged 18-64 in the United States. While Medicaid broadly covered medical services, dental benefits were limited in many states. This study aims to examine the relationship between state-level differences in adult Medicaid dental coverage and access to oral health care, using oral health metrics from the Centers for Disease Control and Prevention (CDC). Methods: We conducted a retrospective analysis of data from the official Medicaid website, which outlined dental procedures covered in each state. Dental attendance for individuals aged 18 and older, based on income, was obtained from the Behavioural Risk Factor Surveillance System (BRFSS) for the period of January to December 2019. Authors analysed dental visits across three income groups: Group A (<$15,000), Group B ($15,000-$24,000), and Group C (>$50,000). Each dental procedure covered by Medicaid was assigned a value of '1,' resulting in a 'Total Score' for each state (ranging from 0-13). States were then grouped into categories based on their Total Scores: 1-4, 5-8, and 9-12. Scores of '0' and '13' were analysed separately. Authors found that Groups A and B visited the dentist less frequently than Group C, suggesting a correlation between income, dental coverage, and access to care. Result: This study examined the relationship between state-level Medicaid benefits and access to Oral Health care, demonstrating a direct relationship between Medicaid coverage in each state and overall access to dental services in the same state. Conclusion: Expanding Medicaid dental coverage for various procedures will enhance accessibility to dental care and ultimately protect oral health.

The Unseen Shift: How Partnership Long-Term Care Insurance Influences Caregiving Among Older Adults.

While the Partnership Long-Term Care Insurance (PLTC) Program was designed to mitigate the low uptake of long-term care insurance and reduce Medicaid's financial burden, research has predominantly focused on its direct impacts, leaving the effects on informal caregiving unexplored. This study aimed to investigate how the program alters the dynamics of family-provided care, leveraging nationally representative data to unveil the broader consequences on informal caregiving arrangements among older individuals. Data for this study were sourced from the U.S. Health and Retirement Study (1992-2018) and linked with the timing of the PLTC program implementation across states. The analysis compared individuals exposed to the program with those who were not, employing two-way-fixed-effects and dynamic models to assess its impact on long-term care insurance coverage and reliance on informal caregiving. The program positively affected long-term care insurance coverage, increasing insurance uptake among older individuals in the long run. Conversely, a significant negative effect was observed on the receipt of assistance from any helper, indicating a reduced reliance on informal care. This reduction extended specifically to family helpers and children's assistance with activities of daily living. The analysis suggests that the program effectively reduced the necessity for informal caregiving across several domains. These findings highlight the program's potential to reshape caregiving dynamics, suggesting the need for policies that balance promoting private insurance uptake with the implications for family caregiving roles. Policymakers should consider both the economic benefits and the social shifts induced by such programs in the long-term care landscape.

China’s public long-term care insurance and risky asset allocation among elderly households

China’s elderly households are characterized by higher holdings of cash and cash equivalents and lower holdings of stocks and bonds in their financial portfolios. We utilize the public Long-term Care Insurance (LTCI) reform and data from the China Health and Retirement Longitudinal Study (CHARLS) to examine how LTCI coverage affects risky asset holdings among newly insured elderly households. Employing a difference-in-differences methodology, our findings reveal that LTCI significantly increases the share of risky assets in the financial portfolios of older families. The increased preference for risky assets may be a result of a weakening incentive for precautionary savings. Decomposing risky assets into bonds and stocks, we find that the increase in the share of risky assets following the LTCI pilot comes mainly from bond investments rather than stocks, which indicates that LTCI has a limited effect on risk asset holdings among the Chinese elderly. Our study contributes to understanding the economic impacts of China’s public LTCI by showing that LTCI may lead to changes in asset allocation strategies among elderly households.

Premium Calculations with Long Term Care Insurance using Markov Chain Method for Human Immunodeficiency Virus Inpatients

<strong> </strong>Indonesia has a high prevalence of HIV, which is inversely proportional to its insurance product propolis. Life insurance offers economic protection by providing payment upon the death of the policyholder. Long Term Care (LTC) insurance, a type of health insurance, guarantees care and health insurance for the elderly. This study calculates LTC insurance premiums with annuities as rider benefits using a multi-status model that includes health status, HIV, and death. Using Markov Chain modeling and data from Malang city in 2022, we determine the premium based on transition probabilities. This case study involves a 20-year-old man with 5 years of LTC coverage, a benefit value of IDR100,000,000, and an interest rate of 5%. The premium varies by age and gender: at age 20, male pay Rp 2,719,241 and female Rp 2,701,893, at age 21, male pay Rp. 5,762,095 and female pay Rp.5,746,178. At age 22, male pay at Rp. 6,203,680 and females pay Rp.6,189,454 while at age 23, male pay Rp. 6,640,674 and females pay 6,628,146. And male at 24, pay Rp. 7,066,949 while females pay Rp. 7,012,138 and at age 25, male pay Rp 7,068,616 and females Rp 7,029,781. The results of this calculation show that the more age increases, the greater the net premium and also the male net premium is greater than the female net premium

Estimation of private-use prices of at-home care services in Japan: Data from a survey of housekeeper employment agencies

ABSTRACT This study examined housekeeper referral agencies’ operations in Japan, their services, and fee standards. This promoted an estimation of the standard price of housekeeping services in Japan if insurance coverage was excluded. Questionnaires were distributed to 399 housekeeping agencies whose addresses were available on the website of the Japan Association of Nursing and Welfare Placement Agencies as of October 2022, and 101 agencies responded (response rate: 25.3%). Surveys were completed in February–March 2023. Two-thirds (65%) of the housekeeper placement agencies had a long-term care (LTC) insurance office. Housekeeper referrals were mostly for 1–4 h; the fee varied according to city size and service provider type, which tended to be higher in larger cities. The fees were lower for attached LTC providers than for stand-alone providers. Most managers (60%) of housekeeper referral agencies rated their fees as ‘somewhat low’ or ‘very low’, requesting an increase in users’ burden and housekeepers’ compensation. LTC insurance keeps the prices of services provided by housekeeper referral agencies low. In the future, daily living support services for the lightly insured may be excluded from LTC insurance coverage in Japan, and the demand for housekeeper agencies’ services is expected to increase.

Long-term care insurance coverage and labor force participation of older people: Evidence from China

Many scholars attribute the slowdown of economic growth to population aging and its negative impact on the size of the labor force. Meanwhile, government programs targeting an aging society can generate work disincentives. This paper studies the unintended labor market effects of Long-term Care Insurance (LTCI) among people of older age by exploiting the launch of the LTCI program in China. We find that policy-covered older adults decreased labor market engagement, significantly increasing the probability of exiting the labor market completely or not working full-time. We also document more substantial effects among those with low income, poor health, advanced age, and few children. The forgone wages of older adults account for >0.25% of GDP. These findings have policy implications for countries “growing old before getting rich.”

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

ObjectivesTo 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.DesignRapid scoping review.Data sourcesFour...

Long-term care insurance facilitating integrated care: the "whole-person, full-responsibility" system in Qingdao City of China

Introduction: The ageing of China has brought the burden of long-term care, and some local areas started the piloting of long-term care insurance (LTCI). In response to its rapid ageing situation, Qingdao was the first city in China to establish LTCI, and it became a national pilot city in 2016. Qingdao has explored an integrated LTCI system, featuring "whole-person, full-responsibility", which promotes the integration of health and long-term care service delivery.
 Short description of practice change implemented: LTCI in Qingdao is financed through a variety of channels, including the reallocation of medical insurance funds, government financial subsidies and premiums. The scope of LTCI coverage is centred on people’s needs and facilitate the provision of integrated services, including medical care, nursing care, living care, functional maintenance and spiritual comfort services. It meets the complex care needs of people with long-term disabilities, reduces the use of hospital beds, and promotes the development of the care service market.
 Targeted population and stakeholders: The targeted population is the LTCI participants in Qingdao, especially the severely disabled and dementia population. Stakeholders include medical insurance agencies, medical institutions, long-term and elderly care facilities, families, etc.
 Timeline: Qingdao has been exploring the construction of LTCI since 2012, and in 2018 it introduced the concept of ""whole-person, full-responsibility"" as a new insurance model.
 Highlights: Qingdao has innovatively established a ""whole-person, full-responsibility"" integrated insurance model facilitating the combination of medical, ageing, nursing, rehabilitation and prevention services. The core is a person-centred, integrated approach to care needs, with the same designated care provider taking full responsibility for providing the integrated services.
 The care includes ""special care"", "" institutional care"", ""home care"" and ""ambulatory care"", covering longer-term hospitalization, institutional care and home care.
 People with dementia were also reimbursed for dementia care. In addition, the Dementia Prevention Fund has been established to promote the prevention of dementia.
 Sustainability and transfer-ability: The establishment of LTCI in Qingdao has effectively reduced the use of hospital beds, reduced the burden of medical insurance funds and promoted the development of the service market. It has been scaled up to the whole province of Shandong and became a national model for LCTI with potential of large scale duplication. But the scheme still faces funding pressure as its expansion of benefits.
 Conclusion: LTCI in Qingdao is based on the concept of ""whole-person, full-responsibility"", taking into account the care needs of people in a holistic manner, which addresses the care integration for long-term disabled and dementia population. It also promoted the development and capacity building of providers and reduced the burden of medical system, resulting in a win-win situation for all parties. It provided a model for China to explore the LTCI system and integrated care for the elderly.
 Discussion: To promote the sustainable development of Qingdao's LTCI system as well as the national LTCI system, issues should be considered in the next step including the sustainable fund raising through diversified channels, the supervision of service quality, training of professionals and workforce, and priority given to disability prevention.

Can long-term care partnership programmes increase insurance coverage and reduce Medicaid costs?

ABSTRACT Although long-term care is a substantial financial risk for elderly Americans, only about 10% purchase insurance, with many of the remainder relying on Medicaid. Faced with rising Medicaid expenditure on long-term care, states introduced long-term care partnership programmes in the hope of reducing Medicaid spending by encouraging the purchase of private insurance. Using numerical optimization techniques, we show theoretically that partnership programmes will only modestly increase long-term care insurance coverage. Most of the benefits will go to those who would have purchased non-partnership policies. Thus, the potential costs to Medicaid will exceed the savings.

Effective service coverage of long-term care among older persons in South Korea.

Global population aging, and the accelerated increase in the number of oldest-old adults, over 80years, has implied a heightened need for long-term care (LTC). We aimed to provide a theoretical care cascade of LTC services to assess publicly funded LTC (Analysis 1) and to investigate the association between the use of LTC insurance (LTCI) and unmet care needs among older people (Analysis 2) in South Korea. Analysis 1 used data from the eighth wave (2020) of the Korean Longitudinal Study of Aging (KLoSA), the 2020 National Health Insurance Service LTCI Statistical YearBook and the 2020 National Awareness Survey of LTCI. The care cascade consisted of the target population, service contacts, coverage and outcomes. Analysis 2 used the fifth to eighth waves of KLoSA, and LTCI analysis was based on three groups: not aware, aware but do not use and aware and use. Unmet care needs were defined as the absence of help among older people with care needs. Among 8,489,208 people aged 65 or older in 2020, 1,368,148 (16.1%) were estimated to want care. Of these, 62.7% (N = 857,984) had LTCI service contact and 807,067 (94.1%) of those had used LTCI services in the past year (Analysis 1). Older people who were aware and used LTCI were less likely to report unmet activities of daily living (ADL) (prevalence ratio (PR): 0.34, 95% confidence interval (CI): 0.18-0.66) or unmet instrumental ADL (IADL) needs (PR: 0.27, 95% CI: 0.17-0.43) than those who were not aware (Analysis 2). This article provides a theoretical cascade to assess LTC provision in South Korea and a preliminary model for other countries. Korea's LTCI is associated with reduced unmet ADL and IADL needs.

Why is care use declining? Changes in residential long-term care between 1999 and 2018 in Finland

Abstract Background Residential long-term care (LTC) coverage has declined in many countries over the past decade. However, it is unclear to what extent the decline is attributable to a smaller proportion of older people entering or shorter time spent in LTC, and if the change has been similar across sociodemographic groups. This study analysed changes in life expectancy in LTC at age 65, the proportion ever entering, and years spent in LTC among those who entered, and quantified the contributions of changing rates of admission, mortality and exit to the change in life expectancy in LTC. Methods We analysed linked population register data that covered all Finnish residents aged 65+ between 1999 and 2018 (n = 2,016,987) on dates of entries to and exits from LTC, dates of death, and sociodemographic characteristics. We estimated transition rates between home, LTC and death, and calculated multistate life tables by sex, marital status and education across four periods 1999-2003, 2004-2008, 2009-2013 and 2014-2018. Results Life expectancy in LTC increased from 0.75 to 0.89 years among men and from 1.61 to 1.83 years among women between 1999-2003 and 2003-2008. The increase was mainly attributable to declining rates of exit from LTC, and thereby longer time spent in LTC for those who entered. Life expectancy in LTC started declining in 2009-2013 and reached 0.80 years among men and 1.51 years among women in 2014-2018. The decline mainly related to an increasing death rate in LTC. In all periods, declining mortality in the community contributed to an increase in life expectancy in LTC, but this was offset by steady declines in admission rates. Life expectancy in LTC changed similarly across marital status and education groups. Conclusions Recent declines in LTC use - driven by lower rates of entry and higher mortality in LTC when entered - imply that across sociodemographic strata it is has become more difficult to find LTC placement and older people enter LTC in ever worse health. Key messages • Overall LTC use increased in early 2000s despite declining admission rates. The increase was mainly due to declining exit rate from LTC indicating longer time spent in LTC for those who entered. • The recent shortening of life expectancy in LTC derives from entering LTC at a later stage and closer to death, indicating greater level of disability and worse health at the time of entry.

Health effects of long-term care insurance on spouses of disabled people: a quasi-experimental study

BackgroundIt is still uncertain whether and how formal long-term care (LTC) systems affect the health status of family members. This paper examines the health effects of long-term care insurance (LTCI) on spouses of disabled people in China.MethodsThe data is from China Health and Retirement Longitudinal Survey (CHARLS), a longitudinal survey of a nationally representative sample of Chinese residents aged 45 or older and their spouses, and China City Statistical Yearbook. Exploiting the regional variation in the implementation of LTCI in the first round of pilot cities in China, a difference-in-difference (DID) strategy is applied to identify the causal effects of LTCI on the health status of spouses of disabled people. We carefully identify the causal effects by controlling for city-level covariates, testing common trends between the treatment and control groups, combining propensity score matching (PSM) with DID, selecting the second round of pilot cities as the control group, controlling for city fixed effects (FE) instead of individual FE, and evaluating selection bias from omitted observable and unobservable factors.ResultsThe introduction of LTCI in China reduces the number of painful body parts and the self-reported health score significantly, indicating that spouses of disabled people get physical health benefits from LTCI coverage. However, the impact of LTCI on the depression index remains ambiguous and needs to be analyzed further. LTCI improves the physical health status of spouses of disabled individuals mainly through the time reallocation channel, while the impact of the consumption promotion channel has not been verified. Furthermore, the beneficial effects of LTCI on physical health are stronger for spouse caregivers and spouses with lower-level education and lower household income.ConclusionThese findings demonstrate that LTCI not only improves the health status of family caregivers by reducing their caregiving burden but also has beneficial health effects on non-caregiver family members. Policy designs of LTCI should emphasize the orientation of home and community-based care services (HCBS), which can not only satisfy the care preferences of disabled individuals, reduce the care burden on family caregivers, promote the health of all family members, but also prevent a large number of disabled individuals from choosing high-cost institutional care and reduce the financial burden of the LTCI Fund.

The impact of a long-term care information campaign on insurance coverage

I estimate the impact of an information campaign on long-term care planning behaviors. I identify this effect using the staggered timing of the federal-state “Own Your Future” campaign, which urged individuals to plan ahead for long-term care needs and reached 26 states over five years. I find the campaign increased long-term care insurance coverage for individuals in the top quintile of the asset distribution by four percentage points, or seventeen percent. A back-of-the-envelope calculation indicates Medicaid savings of $483 million in present value.

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.

On potential information asymmetries in long-term care insurance: A simulation study using data from Switzerland

The long-term care insurance (LTCI) market in Switzerland is still in a very early development stage. In this work, we make use of a representative sample of the Swiss population to simulate the likely effects of previously discovered information asymmetries in the LTCI market. By resorting to LTCI preferences of potential customers, and using Monte Carlo simulations, we provide estimations of the expected probability and duration of dependence indicators. Thereby, we compare the frequency and severity of the sub-population that has shown interest in LTCI with the rest in different mortality scenarios. While in the Swiss demographic context, individuals have a high probability to experience loss of autonomy in their lifetime, we do not find evidence to believe that those interested in LTCI coverage are so based on privileged information about them being at greater risk. In fact, we discover that most people are not aware of their own risk to lose autonomy, which makes potential adverse selection in the LTCI market rather difficult.

Private Long-Term Care Insurance Ownership in a Simple Choice Environment: Does Financial Literacy Matter?

ABSTRACT We present new evidence on financial literacy and private long-term care insurance (LTCI) ownership in Singapore, where policy intervention has resulted in a highly standardized marketplace with fixed benefit terms and premiums schedules. Using data from the 2018 Singapore Life Panel (N = 6,151), we document that almost half of the adults aged 50 and above in our large community-based sample have private LTCI coverage. We find that that financial literacy significantly increases LTCI demand, notwithstanding a simple choice environment where consumers cannot customize their policies. Furthermore, the importance of financial literacy was borne out through the knowledge aspect rather than financial skills/experience aspects; specifically, each financial knowledge question answered correctly increased the probability of LTCI ownership by 4.4% points on average. Tests for endogeneity between literacy and LTCI ownership reveal no endogeneity bias in the non-instrumented estimates. Overall, these findings underscore these importance of promoting financial education and literacy among consumers in LTCI markets, especially since financial knowledge is expected to play an even more salient role in markets with little or no product standardization.

Insuring longevity risk and long-term care: Bequest, housing and liquidity

We study the impact of housing wealth and individual preferences on demand for annuities and long-term care insurance (LTCI). We build a multi-state lifecycle model that includes longevity risk and health shocks. The preference is represented by a recursive utility function that separates risk aversion and elasticity of intertemporal substitution (EIS). When health shocks are considered, a higher level of risk aversion lowers the annuity demand, while a lower level of the EIS has the opposite effect. The impact diminishes with a weaker bequest motive, more liquid wealth, or access to LTCI, all of which increase the demand for annuities. The presence of home equity can enhance annuity demand, but the enhancement is marginal when LTCI is available. The presence of home equity has a crowding-out effect on LTCI demand, and the effect is strengthened by a lack of bequest motives or a lower degree of risk aversion. The cash poor but asset rich may demand more LTCI coverage than their renter counterparts to preserve bequests. When both life annuities and LTCI are available, we find that the product demand is robust to changes in risk aversion and the EIS, providing insights into product designs that bundle annuities and LTCI.

노인 자살률은 왜 감소하고 있는가?

The elderly suicide rate in South Korea has declined sharply over the past decade. This study inferred that the decrease in the elderly suicide rate is due to the achievement of expanding the coverage of major social security systems rather than demographic changes. Therefore, we analyzed whether the expansion of the service guarantee and income security system had an impact on the elderly suicide rate. The research method is a panel fixed-effects analysis with the dependent variable of the elderly suicide rate from 2011 to 2020 at the county level and the independent variables of the long-term care for the elderly, the national pension (old-age pension), and the basic pension. The results show that all but 12 of the nation's 228 cities and counties experienced a decrease in the elderly suicide rate, and that the expansion of the elderly long-term care coverage over the past decade has contributed significantly to the decrease in the elderly suicide rate. In the model with social security coverage, a one percentage point increase in long-term care coverage was associated with a 2.26 percentage point decrease in the suicide rate, and a one percentage point increase in old-age pension coverage was associated with a 1.35 percentage point decrease in the suicide rate. In the model that included the amount of benefits, the additional amount of old-age pension was statistically significant, with a 1.5 percentage point decrease in the suicide rate for every 100,000 won per capita increase. The results suggest that the challenge of responding to elderly suicides is to strengthen the security of the social security system rather than individual welfare programs in the city and county, and that the main way to do so is to expand the entitlement of the universal social insurance system.

Long-term care insurance, mental health of the elderly and its spillovers.

The paper studies the effects of the long-term care insurance (LTCI) program in China on the mental health of older adults and the wellbeing of their families. We employ the staggered difference-in-differences approach based on the LTCI pilots from 2015 to 2017. First, we find the LTCI program improves older adults' happiness and reduces depression symptoms significantly. The effects on the improvement in memory and cognition are associated with the elderly with activities of daily living-related need for care. Second, the effects of LTCI are partially mediated through providing community services, relieving care burdens, and reducing the incidence of diseases. More importantly, LTCI coverage improves caregivers' physical health and social activities, reflecting its welfare spillover effects. Furthermore, the relationship between LTCI and mental health differs due to the difference in LTCI designs and older adults' demographic characteristics. This presents a need to consider mental health in the services and evaluation criteria of LTCI.

Long-term care insurance and multidimensional poverty of middle-aged and elderly: Evidence from China.

This paper examined the impact of public long-term care insurance (LTCI) pilots in China on the multidimensional poverty status of middle-aged and older adults. Using panel data from the China Health and Retirement Longitudinal Survey, we utilized LTCI pilots conducted in different cities from 2012 to 2018 and assessed the impact of LTCI using a difference-in-differences strategy. We found that the implementation of LTCI reduces the multidimensional poverty of middle-aged and older adults and their likelihood of future multidimensional poverty. LTCI coverage was also associated with a reduction in the likelihood that middle-aged and older adults in need of care fall into income poverty, living consumption poverty, health poverty, and social participation poverty. From a policy perspective, the findings of this paper suggest that the establishment of an LTCI system can improve the poverty of middle-aged and older adults in several ways, which has important implications for the development of LTCI systems in China and other developing countries.