Seniors receive basic medical care service at Biyuan Community Daycare Center in Shuangqiao District of Chengde City, Hebei Province, Sept. 13, 2023. Photo: CNSphoto

---

With an aging population and an expanding proportion of seniors of advanced age, the number of seniors who are disabled or suffer from cognitive impairments continues to grow in China. It is therefore a vital public health problem that long-term care is provided to the elderly. The “Outline of the Healthy China 2030 Plan,” released in 2016, explicitly described the need to promote healthy aging, maintain health across an entire lifespan, improve long-term care services for seniors living at home, and establish a multi-level long-term care insurance system. It is of practical significance to create a long-term care insurance system that meets the needs of the elderly, accounts for the interests of care providers, and respects the integrity of family functions based on China’s traditional intergenerational care practices and the current landscape for senior care.

Increasing burdens

As population aging accelerates, modernization inevitably shrinks the average family size in China, posing significant challenges to the family-based long-term care system.

According to statistics, as of the end of 2022, approximately 190 million elderly people in China suffered from chronic diseases, with around 44 million in a disabled or semi-disabled state, accounting for 15.7% of the entire elderly population. In real terms, this means one in six older individuals require assistance in their daily lives. As age increases, the proportion of disabled individuals also continues to rise. Among the population aged 80 and above, more than 40% are disabled or semi-disabled, requiring varying degrees of medical and long-term care services. The impact of disability extends beyond the individual to the entire family, making the care of disabled older adults a pressing social issue that requires policy intervention.

At the same time, with insufficient social security for long-term care, family caregivers are caught in a dilemma. Data shows that in developed countries, over 95% of elderly individuals receive care services at home provided by family and community caregivers. However, in China, family members are the main providers of long-term care, with only 2% of the elderly receiving market-based care. As we know, caring for disabled individuals is a daunting “long-term project” that requires not only significant financial investment but also substantial time and energy. 

According to a survey by the Institute of Gerontology at Renmin University of China, family caregivers spend an average of about 15.7 hours per day caring for older adults, much higher than the daily working hours of regular employees. Moreover, nearly 50% home-based disabled older adults are primarily cared for by their spouses, which poses great challenges to spouses who typically are also of an advanced age. The prolonged overload of caregiving responsibilities can lead to physical and psychological issues, social maladjustment, as well as practical difficulties such as unemployment, economic pressure, marital conflicts, and reduced social interactions. In the process of China’s modernization, with continuous changes to family structures, the challenges faced by the caregivers of disabled elderly individuals are intensifying, urgently requiring the advancement of a family-friendly long-term care insurance system and the construction of a social service system.

Insufficient policy support

To address the challenges posed by the disability and caregiving issues for aging citizens, the 13th Five-Year Plan (2016–2020) proposes the establishment of a long-term care insurance system. Since 2016, China has conducted national-level pilot programs, and many regions have experimented with distinctive long-term care insurance systems based on local conditions. Among these systems, the delivery form and standards of benefits are essential components of long-term care insurance—directly impacting the functionality of family long-term care.

Today, the benefit policies in pilot regions exhibit diverse but fragmented characteristics and have not yet coalesced into a mature model. Most of these pilots lack adequate support and structural guarantees for homecare and family caregivers, with inconsistent policy orientations.

Firstly, some pilot programs adopted a single service benefit model, excluding informal caregivers like family members from the umbrella of benefits. In certain areas, disabled older adults receiving care at home can only access subsidies by choosing service benefits. For example, in Jinan City, Shandong Province, disabled elderly individuals who live in their own homes can enjoy home care provided by designated medical institutions or community care centers, with a daily maximum caregiving duration of 4 hours and a monthly maximum of 15 hours. However, many people need nearly 16 hours of daily care. Thus, family caregivers are left contributing a significant amount of labor and caretaking without receiving any subsidized support. The original intention of offering state-sponsored service benefits was to invest in the long-term assisted-living service market—but this overlooked family-members’ role as the primary caregivers and their financial and time burden .

Secondly, although some pilot regions implemented a mixed benefit policy, the benefit systems were often inaccessible or insufficient for family caregivers. The benefit systems in several pilot programs included the option of selecting “family caregivers” to distribute cash benefits to their caretakers. However, on the ground, the implementation process was riddled with problems.

One form of “cash benefits” was essentially the option of purchasing assisted care services from family members. For instance, in Jingmen City, Hubei Province, family members could complete certification and training to become licensed caregivers. To qualify, they needed to complete several strictly supervised observation periods, such as remote electronic monitoring and regular visits by designated personnel from hosting institutions. In addition, they were required to upload caregiving videos for auditing, and the results of these audits were the sole basis for settling caregiving fees. Many family caregivers reported that this process brought additional costs, both in time and in increased psychological stress, particularly for elderly caregivers with inadequate technical skills to navigate the latest video monitoring systems. These formal measures created additional obstacles, adding to the already heavy burden of their daily care work.

Another form of “cash benefit” was that older adults in need of caretaking could also receive care from relatives without having family caregivers undertake excessive audits. In this situation, the audit results were separate from the payment of caregiving subsidies. Nonetheless, this type of family caregiving had smaller subsidies, ranging from 240 yuan/month to 450 yuan/month. This low level of payment was more symbolic, rather than a substantial incentive or financial relief for family caregivers, making it challenging for caretakers to obtain effective support. Moreover, while cash benefits do acknowledge that informal caregiving has a monetary value, relying solely on this meager cash subsidy could not effectively alleviate the caregiving burden placed on family caregivers, rendering the effect negligible.

Overall, within the proposed benefit designs, either family caregivers were not taken into account, or mixed benefit options were set only at the institutional level, making it impossible to flexibly meet the comprehensive needs of disabled older adults and their family caregivers. In reality, informal family caregiving has always been an essential part of any long-term care system. If, after the establishment of long-term care insurance, the efforts of family caregivers are still not adequately recognized, it may worsen the situation in family caregiving, potentially leading to a decline in family caregiving and slowing the construction of a multi-level long-term care system.

Multi-level long-term care system

The 49 national-level long-term care insurance pilots in China have had strong initial results, relieving some of the economic and logistical burdens faced by the disabled older adults and their families. Non-pilot regions have also proposed the establishment of long-term care insurance, indicating the imminent need to establish a formal long-term care insurance system at the national level. 

In the future, as policymakers expand the pilot program and promote it nationwide, it is crucial to focus on integrating lessons learned from these experiences. A unified orientation adapted to China’s national conditions should be formed, with a focus on key aspects such as protection goals and benefit systems, to provide comprehensive support for disabled older adults and family caregivers. This will help establish a multi-level long-term care service system with collaboration from families, institutions, and society.

On one hand, it is essential to cultivate the long-term care market, establish a sound socialized long-term care service system, and convert financial support into caregiving service support for disabled individuals. Efforts should be made to expand the market supply of long-term care services, making the burden of family caregiving reasonably “socialized.” 

On the other hand, incorporating a family perspective to construct a family-friendly long-term care insurance system is equally important. Institutional care cannot completely replace family caregivers, while family caregiving can be an effective supplement to institutional care. When developing a market-oriented social care system, it is important to encourage and support family members to provide a portion of care services.

A timely rollout of a mixed-benefit model should be encouraged, as it will enhance the diversity of benefit payments. Flexible and diverse mixed benefit models, based on international experience in long-term care, are the most popular choices. These models are conducive to promoting the joint development of formal and informal caregiving. Therefore, based on a mixed benefit model, beneficiaries should be given three “self-determined” options in benefit attainment, ensuring that beneficiaries and their family caregivers can obtain the most appropriate service solutions that align with their caregiving preferences and their family realities. 

First, disabled older adults living at home can choose between institutional assisted living services and family caregiving based on their own willingness and condition. Second, beneficiaries can choose home based care services between designated service institutions and other institutions, with payment settled by long-term care insurance. Third, when the time is right, beneficiaries should have the option to simultaneously enjoy the combination of two or more types of benefits and flexibly determine the proportion of each from in-kind benefits, service benefits, and cash benefits based on their actual needs.

At the same time, we should enrich the support content of long-term care insurance, allocating a certain percentage of long-term care funds to provide comprehensive and systematic support for family caregivers. We can draw from Germany’s diverse design of long-term care insurance benefits to provide a range of benefit options for family caregivers in addition to cash subsidies, appropriately including assisted living services, rental and purchase of caregiving aids, and a residential environment retrofitted with assisted living services—all within the scope of long-term care insurance payments. The welfare benefits offered to family caregivers must be enhanced, providing them with caregiving allowances, interest-free loans, personal accident insurance, unemployment insurance for caregivers of working age, free caregiving training courses and psychological support services. 

There should also be relatively complete 24-hour respite services for family caregivers, including a few days of dedicated 24-hour home care or short-term institutional care services. This will provide temporary relief for family caregivers, giving them a break from healthcare burdens to handle personal matters while still ensuring the health and safety of disabled older adults. 

We should encourage the use of information technology, and applications such as smart devices or intelligent platforms, including caregiving robots, safety alarms, and electronic assistants, to enhance the convenience of home care.

Tang Dan is a professor from the Population Development Studies Center and Hu Qing is from the Institute of Gerontology, both at Renmin University of China.

 Edited by YANG XUE