Long-term Care Insurance Program Research Articles

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.”

Fruit and Vegetable Intake and Risk of Disabling Dementia: Japan Public Health Center Disabling Dementia Study

BackgroundFruits and vegetables contain abundant amounts of antioxidant vitamins such as vitamin C, α-carotene, and β-carotene. Few prospective observational studies have investigated the effects of fruit and vegetable intake on the risk of dementia, and the results are inconsistent. ObjectivesOur aim was to examine associations between fruit and vegetable intake and the risk of disabling dementia. MethodsWe conducted a follow-up survey within the Japan Public Health Center-based Prospective Study involving 42,643 individuals aged 50–79 y at baseline (2000–2003). Dietary fruit and vegetable intakes and related antioxidant vitamin intakes (i.e., α-carotene, β-carotene, and vitamin C) were determined using a food frequency questionnaire. The diagnosis of disabling dementia was made based on the daily living disability status related to dementia under the Japanese long-term care insurance program from 2006 to 2016. Hazard ratios and 95% confidence intervals for disabling dementia were estimated using area-stratified Cox proportional hazard models adjusted for potential confounding factors. ResultsA total of 4994 cases of disabling dementia were recorded. We observed an inverse association between total fruit and vegetable intake and the risk of dementia among males and females: the multivariate hazard ratios (95% confidence intervals) for the highest compared with lowest quartiles of intake were 0.87 (0.76, 0.99) (P- trend = 0.05) among males and 0.85 (0.76, 0.94) (P- trend = 0.006) among females. Among antioxidant vitamins, vitamin C intake was inversely associated with the risk of dementia among males and females: the multivariate hazard ratios (95% confidence intervals) for the highest compared with lowest quartiles of intake were 0.71 (0.61, 0.84) (P- trend < 0.0001) among males, and 0.76 (0.67, 0.86) (P- trend < 0.0001) among females. ConclusionsFruit and vegetable intake and dietary intake of vitamin C may contribute to reducing the risk of disabling dementia among males and females.

Evaluation of China's long-term care insurance policies.

In response to the increasing demand for long-term care services for older people, the Chinese government has launched a pilot program for long-term care insurance (LTCI) since 2016. The objective of this study is to evaluate the performance and effectiveness of this program in China and provide recommendations for the future development and expansion of the LTCI system. We developed a comprehensive evaluation framework to assess these LTCI policies implemented in all 49 pilot cities in China. Based on our evaluation, the average assessment score for the LTCI program across all pilot cities was 71.8 points, with scores ranging from 57.5 to 92.5 points in these cities. Furthermore, most of the pilot cities achieved higher scores in the fact-based assessment compared to the value-based assessment. The results suggested that the overall pilot effect regarding LTCI was favorable, but there were significant regional disparities. Moreover, in most of pilot cities, current LTCI policies were designed to alleviate both the financial burden and the burden of caring for people with disabilities that families faced. However, some challenges still remained, such as the lack of community and home-based care services, the need to expand the coverage of insurance, and the importance of diversifying funding sources.

EAST MEETS WEST: INTERVENTIONS, PRACTICE MODELS, AND POLICIES TO SUPPORT FAMILY CAREGIVERS IN DIVERSE CULTURES

Abstract This East Meets West symposium consists of six studies that examined innovative interventions, practice models and policies designed to support family caregivers of older adults in the U.S., Taiwan, and mainland China. The first two papers both used case management interventions to assist family caregivers with a focus on caregiver depression. The paper from the U.S. found that more difficulties of performing caregiving tasks and less caregiver preparation contributed to higher levels of depression, and the paper from Taiwan found that caregivers who received the case management service reduced depression at four-month and six-month follow-up assessments. The third paper discussed a “time travel” paradigm developed to guide service design and delivery for persons with dementia at different stages. The fourth paper used the state of Michigan as a case to examine service gaps in the current aging service network, and identifies an urgent need for statewide policy renovations to support family caregivers. The fifth and sixth papers both used large secondary data analyses to examine the effects of piloted policy and practice efforts on family caregiver outcomes. One study found that the long-term care insurance programs have resulted in positive caregiver outcomes including reduced caregiving financial cost, time, and physical and psychological burden. The other study found the use of home-based care services reduced adult children caregiver burden and did not affect the relationship between older adults and adult children caregivers. After individual presentations are done, two discussants will summarize shared themes in these papers and provide critical feedback.

THE BENEFITS OF LONG-TERM CARE INSURANCE FOR FAMILY CAREGIVERS: EVIDENCE FROM CHINA

Abstract This paper aims to evaluate the impacts of the long-term care insurance (LTCI) program on family caregivers of older adults with functional limitations in mainland China. The study used data collected from 1,658 LTCI beneficiaries or those in the LTCI application process in 16 pilot Chinese cities in 2021. Descriptive statistics, chi-square tests, and multiple regression analyses were used to analyze the data. The results indicate that LTCI beneficiaries are more likely to receive institutional care than non-beneficiaries (27.8% vs. 16.8%), reducing the responsibilities and potential burden of family caregivers. LTCI beneficiaries are also more likely to receive social care services than non-beneficiaries (35.9% vs. 26.7%). Family caregivers of LTCI beneficiaries spend less time per day on care than non-beneficiaries (15.45 vs.16.59 hours), and they are less likely to delay their work due to caregiving (41.4% vs. 60.7%). Additionally, LTCI has a positive impact on various aspects for family caregivers, with over 40% reducing their caregiving time, 55.0% reducing care service costs, 68.5% feeling that LTCI has reduced their physical burden, and 77.9% indicating that their psychological burden has been lessened. The study concludes that the establishment of long-term care insurance nationwide should be promoted as the pilot sites have seen significant positive effects on family caregivers. LTCI should also consider more direct support to family caregivers.

The Challenging Role of Informal Carers Within the Long-Term Care System in Japan: Focusing on Issues of Japanese Working Carers

Despite the increasing demand for long-term care (LTC) caused by demographic changes and several long-term care insurance (LTCI) program reforms, formal care in Japan is shrinking because of public financial constraints, leading to many problems for informal carers. Because more than half of the informal carers are employed in paying jobs, balancing working and caregiving roles is an important issue in the political agenda. Based on an online survey data of working carers of care recipients eligible for the LTCI program (N=600), this study aims to examine informal carers’ challenging role within the Japanese LTC system, and analyze the work-life balance issues of working carers. The results reveal that most of the respondents are their parents’ carers and more than half co-reside with the care-recipients. With the community promoting comprehensive care, many frail older adults now use a combination of formal and informal care services. Additionally, over three hours of informal caregiving per day, age, marital status, co-residence with the care recipient, self-rated health, and insufficient understanding of the caregiving role in the workplace are significantly related to the psychological well-being of informal carers. Furthermore, most of the aforementioned factors are also associated with turnover intention due to caregiving responsibilities. Informal care is a crucial component of the Japanese LTC system and to alleviate informal working carers’ struggles and decrease unwanted turnover, it is necessary to consider the link between formal and informal care, together with support programs for informal carers.

Long-term Care Insurance and Health and Perceived Satisfaction of Older Chinese: Comparisons Between Urban/Rural Areas, Chronic Conditions, and Their Intersectionality.

Evidence of the impact of long-term care insurance (LTCI) on health and well-being has predominantly come from developed countries. China officially launched its city-level LTCI policy in 2016. Recent evidence in China has shown that having an LTCI program contributes to positive health. However, it is unclear whether such positive policy effects were attributed to policy announcement or implementation effects, and whether the policy effects vary by locality, chronic conditions, and their intersectionality. This study examines whether there are longitudinal health benefits for older Chinese who are participating in LTCI, particularly considering their city location (urban/rural), whether they have chronic conditions, and the intersectionality. Following the Andersen Behavioral Model, health and satisfaction outcomes of 9253 adults aged 60+ years were extracted from the 2015 and 2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). Individual data were linked to census socioeconomic data with city-level characteristics and LTCI policy variable. Multilevel lagged regression models investigated the impact of LTCI policy on health and satisfaction with health services, after controlling for baseline individual- and city-level covariates. Of 125 cities in the dataset, 21 (16.8%) had adopted LTCI. These city inhabitants had significantly better self-rated health and higher satisfaction relative to cities without LTCI policies when environmental- and personal-level characteristics were modeled. Health benefits of LTCI were stronger after policy announcement and were particularly observed among rural older adults and those with chronic conditions. Results also suggest that LTCI's positive effects on satisfaction spill over to middle-aged adults. Expanding coverage and eligibility to LTCI for all older Chinese could improve health and well-being.

Typologies of dependency, household characteristics, and disparity in formal and informal care use: analysis of community-dwelling long-term care insurance claimants in an urban municipality of China

BackgroundA comprehensive understanding of subgroups of community-dwelling older adults and their long-term care (LTC) utilization can help to promote equality in the long-term services and support system. Dependency and household characteristics were found to affect the LTC utilization of homebound older adults. However, few studies considered the typologies of dependency of older populations according to co-occurring limitations, and little is known about differences in LTC use among elderly of typologies of dependency under distinct household conditions.MethodsWe aimed to identify typologies of dependency of older adults living at home and explore the disparities in formal care and informal care use among typologies of dependency by income and living situation. In this cross-sectional study, we used the public long-term care insurance (LTCI) database of Yiwu, Zhejiang Province, China, and included 1675 individuals aged ≥ 60 years living at home. Cluster analysis was conducted to determine typologies of dependency among older adults. A two-step multilevel analysis was used to examine disparities in formal and informal care use related to household income and living status among typologies of dependency.ResultsSeven dependency clusters were identified. Pro-wealthy inequalities in both formal and informal care use were found in the least dependent cluster and the limited-locomotion cluster. Pro-poor inequalities in formal care use were found in the fully dependent cluster without impaired vision and the cluster with intact continence and vision. Living with family members was positively associated with receiving formal care for the fully dependent cluster. Older adults in most clusters were more likely to use informal care when living with family members, except for the least dependent cluster and the limited-locomotion cluster.ConclusionsOur findings suggest that household inequalities in LTC use varied among typologies of dependency of older adults, which may provide insights for researchers and policymakers to develop tailored LTC and targeted LTCI programs for older adults living at home and their family caregivers, considering both typologies of dependency and household characteristics.

Association between the deaths indirectly caused by the Fukushima Daiichi nuclear power plant accident (disaster-related deaths) and pre-disaster long-term care certificate level: A retrospective observational analysis

The health of the vulnerable populations receiving the Long-Term Care (LTC) Insurance Programs was threatened by the direct and indirect effects of disasters. The 2011 Great East Japan Earthquake and Tsunami and the explosion at the Fukushima Daiichi nuclear power plant (FDNPP) forced 164,865 people's evacuation and caused many disaster-related deaths. We examined the relationship between these deaths and LTC certification. Data were collected from 520 people who were living in Minamisoma City during the earthquake and whose deaths were certified as disaster-related by the Minamisoma City Committee for Certification of Disaster-Related Deaths from September 2011 to February 2021; 467 (90.0%) responded to the LTC item on the survey form, of which 200 (38.5%) were not certified and 266 (51.3%) were certified for LTC. People with high levels of LTC certification needs during the acute phase of the earthquake were found to be more likely to die from circulatory and respiratory diseases. The mean time from disaster to death was shorter for those with higher levels of LTC; it was significantly shorter for those with long-term care level 3 and above. This study points out the importance of timely response with regard to disaster-related deaths and long-term care. Further studies are needed to examine how medical resources can be deployed in a timely manner.

Cross-cultural metathemes of Chinese and Japanese university students' perspective on parental care.

Due to declining birthrates and aging populations, parental care is going to place a greater burden on younger generations in the future, especially in East Asia where it is more common for children to provide care regardless of whether there is a national long-term care insurance program. Therefore, it has become important to understand the younger generation's views on parental care. An explorative, metathematic qualitative study design was used. Data collection relied on semi-structured interviews, of which 19 Chinese and 19 Japanese university students were conducted from December 2021 to July 2022 using a snowball sampling method. Metatheme analysis was then used to identify broad cross-cultural metathemes and inter-relationships on parental care. Three parental care metathemes were identified for the perspectives of parental care: distrust of leaving parental care to others, responsibility to care for their parents, and importance of parent-child interactions about parental care. To improve social support for care, both countries must improve long-term care service delivery and healthcare systems and ensure that there is a trusting relationship between healthcare professionals and the public. Governments should also ensure that adult children receive assistance to balance their work, life, and parental care responsibilities. The findings provide several practical suggestions for improving healthcare systems in China and Japan through the younger generations' views.

Effects of the Long-term Care Insurance on Health Among Older Adults: A Panel Data From China.

China's long-term care insurance (LTCI) has been launched since 2016 to ensure that older disabled people obtain affordable care services. However, rigorous evaluations of the health effects of China's LTCI pilots have been limited. This paper aimed to examine the effects of LTCI on health among older adults aged 60 years and above. Drawing from panel data of the China Health and Retirement Longitudinal Study (CHARLS), we used a propensity score matching (PSM) and difference-in-difference (DID) approach to identify the health effects of the LTCI program and reduce the selection bias. Further, heterogeneity of the effects was examined by physical and intellectual function to evaluate whether the effects differed among subgroups of older population. The implementation of LTCI significantly improved self-rated health (β = 0.15, P<.05) and cognitive function (β = 0.59, P<.01) for older adults. The results were robust when keeping only those living in pilot cities (β = 0.31, P<.05 for self-rated health status; β = 0.98, P<.001 for cognitive function) or non-pilot cities (β = 0.14, P<.05 for self-rated health status; β = 0.60, P<.01 for cognitive function) as the control group. The effects of LTCI were especially manifested in older adults with physical disability (β = 0.13, P<.01 for self-rated health; β = 0.76, P<.001 for cognitive function) or intellectual disability (β = 0.16, P<.01 for self-rated health). From a policy perspective, these findings suggested that LTCI in China could benefit the health outcomes of older adults, especially those with physical or cognitive disabilities. Policy-makers can target resources more effectively to improve health outcomes for the most vulnerable populations.

Do Home- and Community-Based Services Delay Frailty Onset in Older Adults With Low Care Needs?

ObjectivesTo assess whether using adult day services or personal assistance services can delay the onset of frailty among older adults with low care needs during a 5-year follow-up study. DesignThis prospective cohort study was conducted using long-term care and health insurance claims data. Setting and ParticipantsThis was a population-based study of 3 municipalities in Osaka, Japan. Initially, 655 nonfrail or prefrail individuals were included from a cohort of 790 population-based adults aged ≥65 years, who were newly certified as being on a support level of the long-term care insurance program from September 2012 to March 2013. MethodsUsing long-term care and health insurance claims data from the Southern Osaka Health and Aging Study, conducted between April 2012 and March 2017, monthly usage of adult day and personal assistance services was measured. Data were analyzed from December 2021 to January 2022. ResultsOf the 655 individuals (median age at baseline: 79 years), 436 (66.6%) were female, 388 (59.2%) were nonfrail, and 267 (40.8%) were prefrail, according to the Veterans Affairs Frailty Index. During the 5-year follow-up period, 222 individuals (33.9%) experienced the onset of frailty. The time-dependent Cox regression models showed that using adult day services lowered the risk of frailty when compared with not using such services [hazard ratio (HR) 0.60, 95% CI 0.42-0.86; P = .006], although personal assistance services usage was not associated with the onset of frailty (HR 0.70, 95% CI 0.48-1.03, P = .07). Conclusions and ImplicationsUsing adult day services lowered the risk of frailty in older adults with low care needs over the 5-year follow-up period. The findings support the value of providing adult day services to prevent frailty for those in need of long-term care.

Dynamic Effects of Long-Term Care Insurance on Healthcare Expenditures: Evidence from South Korea

Long-term care expenses pose a large financial risk to the elderly. In 2008, South Korea introduced a public long-term care insurance (LTCI) program for individuals older than 65. We study the dynamic effects of the LTCI on various healthcare expenditures. We find that after the implementation of the LTCI, average prescription drug and outpatient expenditures of the elderly increased. Dynamically, we observe that the growth in these expenditures moderates. We also find suggestive evidence that after the introduction of the LTCI, the elderly may utilize LTC hospitals instead of inpatient hospital services. These findings underscore the importance of understanding the long-term effects of LTCI on health and healthcare expenditures of the elderly and the need to account for interactions between LTC and other types of healthcare services in policy design.

Controlling Spending For Health Care And Long-Term Care: Japan's Experience With A Rapidly Aging Society.

As the Japanese population has aged rapidly, Japan's experience has implications for other high-income countries, including the United States. The aging of Japan's population, coupled with the government's decision to implement a public long-term care insurance program in 2000, has increased the nation's expenditures. In acute care, costs have been relatively contained by biennially revising the fee schedule for all physician and hospital services and by lowering pharmaceutical prices. The fee schedule not only sets prices but also controls volume by setting the conditions of billing for each item. This fee schedule is applied to all social health insurance plans (which enroll all permanent residents of Japan) and to virtually all providers. In contrast, despite the use of a similar fee schedule, spending in long-term care insurance has increased more than spending in health care. This is both because long-term care became an entitlement and because aging has had a greater impact on long-term care insurance spending than on health insurance spending. In this article we analyze Japanese expenditure data to provide essential information to the US as the percentage of its population ages sixty-five and older continues to rise. A key lesson that the US can learn from Japan's experience is that as its population ages, the need for long-term care will increase, necessitating better control of acute care spending.

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.

DOES TRUST IN SOCIAL SECURITY INHIBIT ACCEPTANCE OF ASSISTIVE TECHNOLOGY FOR ADL HELP?

Abstract In 2000, Japan introduced a mandatory long-term care insurance program to facilitate aging-in-place of older care recipients; there has been a great demand for assistive technologies such as AI (artificial intelligence) and robots in care settings to reduce the burden of caregivers and long-term care costs in society. This study examined the relationship between the trust in social security and acceptance of assistive technology for ADL help and discussed the challenges in introducing technology in a well-developed social security system. An online survey was conducted in August 2020 among community-dwelling individuals aged between 40 and 89 across Japan to find out their acceptance of help provided via AI or robotics technology in five dimensions of ADL. In addition, a 5-point Likert scale was used to assess the trust in social security.A total of 4,047 respondents were analyzed in this study. The respondents’ mean age was 60.6 (SD=11.3), and 53.2% of them were female. Of those, 13.2% preferred help from humans in ADL, while for 86.8%, the use of some assistive technology was acceptable. Logistic regression revealed that the female and younger respondents and those who had better health and had completed higher education were more likely to accept AI or robotics technology in all/some ADL if they needed assistance; those with higher trust in social security, however, were less likely to accept technology (OR=.894; p=.011).The challenges in introducing assistive technology under a well-developed social security system will be discussed.

The Effect of a Long-Term Care Insurance Program on Subjective Well-Being of Older Adults with a Disability: Quasi-Experimental Evidence from China.

China launched its long-term care insurance (LTCI) program for older adults in 2016. Although the scheme has shown some promising outcomes, little is known about whether it improves subjective well-being. This study explored this topic among older persons with a disability and identified the underlying mechanisms associated with the channel of this effect using data from a national survey. The LTCI program was shown to improve the subjective well-being among older persons with a disability and this effect increased over time. The LTCI program has great positive effect among women and those who lived alone compared to their counterparts. Mechanism analysis revealed that the main channel by which the LTCI program has positive effect occurred through the satisfaction of long-term care needs and improved self-reported health. This study suggests promising benefits of the LTCI program for older Chinese adults.

The Economic and Health Effects of Long-Term Care Insurance: New Evidence from Korea

With a rapidly aging global population, Long Term Care Insurance (LTCI) for older people is a pressing policy issue. While long-term care services are designed to assist people with limited functional ability, the breadth of coverage considerably varies from country to country. There is a debate on the costs of such programs and the adequacy of benefits. Understanding the impacts of LTCI programs is central to informing LTCI policies as few countries have embraced them. In 2008, the Korean government initiated a national public contributory LTCI program to help older people lead more independent and secure lives and support family caregivers. We use the Korean Welfare Panel Study (KOWEPS) and a difference-in-differences model combined with propensity score matching to assess the effect of the program on self-rated health, healthcare utilization, household expenditures, and savings. While older adults in beneficiary households tend to have better self-rated health and receive fewer regular health check-ups, those with inpatient visits tend to stay longer in the hospital compared to those in non-beneficiary households. We find that LTCI beneficiary households have lower savings and higher out-of-pocket healthcare expenses compared to non-beneficiary households. Overall, results suggest a positive effect of LTCI on self-rated health but detrimental effects on household out-of-pocket healthcare expenses and savings for those with less comprehensive health insurance coverage, the near-poor, and older singles. LTCI requires further research and policy attention in Korea and beyond.

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

ObjectiveThis 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.MethodAn 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.ResultsMore 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%.ConclusionsOur 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.

Soy product intake and risk of incident disabling dementia: the JPHC Disabling Dementia Study

PurposeWe evaluated the association between total soy, soy product (natto, miso and tofu) and isoflavone intake and incident disabling dementia in a Japanese population.MethodsWe conducted a population-based prospective study in 18,991 men and 22,456 women. Intake of soy products and isoflavone was calculated using a validated food frequency questionnaire when participants were 45–74 years old (1995 and 1998). Incident disabling dementia was defined by the daily living disability status related to dementia in the long-term care insurance program of Japan from 2006 to 2016. Multivariate hazard ratios (HRs) and 95% confidence intervals (CIs) of disabling dementia were calculated by quintiles of total soy, individual soy product and isoflavone intake, using Cox proportional hazard regression models.ResultsTotal soy product intake was not associated with disabling dementia risk in both men and women. By individual soy products, natto intake was marginally inversely associated with disabling dementia in women (trend P = 0.050). When we stratified by age, this inverse association was clearer in women aged under 60 years (multivariate HR for the highest versus lowest quintile was 0.78, 95% CI 0.59–1.04, trend P = 0.020 for those aged under 60 years and 0.90, 95% CI 0.77–1.05, trend P = 0.23 for those aged 60 years and older, respectively). Any soy product or isoflavone intake was not associated with disabling dementia risk in men.ConclusionsAlthough total soy product intake was not associated with disabling dementia risk, natto intake may contribute to reducing the risk of disabling dementia in women, especially in those aged under 60 years.