Summary:
For a long time, family support and “raising children for old-age support” have been the mainstream model of old-age care in China. However, ageing, sub-replacement fertility and the increasing size of the disabled senior population have posed a great challenge to traditional family support. Therefore, establishing a society with “a sense of security and joy in old age” for the senior population has become one of the major issues in society. To further improve the multi-level social security system for the senior population, provide basic security for the disabled senior population, and reduce the economic and care burden, China has gradually launched the long-term care insurance (LTCI) pilot program in various cities since 2016. Using data from the China Health and Retirement Longitudinal Study (CHARLS) in 2011-2020, this research examines the impact of LTCI on the elderly care patterns of the disabled senior population from the perspectives of financial independence and residential independence through the difference-in-differences method. The empirical results show that LTCI can significantly enhance the financial independence of the disabled senior population while LTCI has no significant effect on their residential independence. Specifically, if LTCI covers the disabled senior population, the probability of being financially dependent on their children decreases by 22.92 percentage points, while the probability of living with their children does not decrease. Second, this research also finds that there are heterogeneous effects of LTCI on elderly care patterns: generous LTCI (covering both the moderate and severely disabled) can significantly reduce the probability of being financially dependent on their children more than normal LTCI (covering only the severely disabled senior population); LTCI with in-cash benefits can significantly increase the probability living with their children. In addition, LTCI significantly increases the financial independence of disabled elderly who are female, cognitively impaired and have fewer children, while LTCI significantly decreases the probability of living with their adult children for the male and low-income group. Finally, this research finds that LTCI reduces net transfer from children to parents and offline contact frequency, weakening the intergenerational support that the senior population receives from their children. With the above findings, we have two policy insights. First, regarding LTCI design, LTCI with in-kind benefits has a weaker and less significant impact on the financial independence of the disabled senior population than LTCI with in-cash benefits. LTCI with in-cash benefits significantly negatively affects the residential independence of the disabled senior population, while most pilot cities currently adopt LTCI with in-kind benefits. In addition, compared with the normal LTCI, the generous LTCI can more effectively increase the financial independence of the disabled senior population, while most pilot cities currently adopt the normal LTCI. Therefore, to ensure the LTCI fund is sustainable and considering that the formal care market is still underdeveloped, encouraging LTCI with in-cash benefits and generous LTCI can better improve the financial independence for the disabled senior population and reduce the care burden for their families as well as increase the contact frequency of the disabled senior population and children. Secondly, even though the LTCI can significantly reduce the financial and informal care burdens of families with the disabled senior population, the involvement of formal care with LTCI reduces the frequency of intergenerational interactions. This alienates the disabled senior population from their children and may aggravate the sense of loneliness of the disabled senior population. Therefore, by improving the LTCI system, family support should be strengthened through the media and other channels to promote emotional and financial support for the senior population. This research has the following two contributions. First, assessing the senior population's care patterns includes both the living arrangements and the financial source of support for old-age people. Therefore, this research investigates the impact of LTCI on the elderly care patterns of the disabled senior population based on the dual perspectives of the financial source and the living arrangement. Second, the existing literature finds that the reimbursement method of LTCI (in-cash benefits or in-kind benefits) and the eligibility criteria (generous LTCI and normal LTCI) significantly affect individuals' willingness to pay for LTCI and other welfare outcomes. Moreover, there are significant differences in the disability risk by individual characteristics such as gender. Therefore, this research investigates the heterogeneous effects of LTCI on elderly care patterns by different LTCI institutional and individual characteristics. Future research can further focus on the causal effect of LTCI on various welfare outcomes, such as the elderly mental health, children's well-being, or social welfare, and provide more empirical evidence for LTCI improvement and establishing the multi-level social security system for the senior population.
[1]乐章,2012,《依赖与独立:新农保试行条件下的农民养老问题》,《中国农村经济》第11期,第88～96页。 [2]李海舰、李文杰和李然,2020,《中国未来养老模式研究——基于时间银行的拓展路径》,《管理世界》第3期,第76～90页。 [3]刘宏、高松和王俊,2011,《养老模式对健康的影响》,《经济研究》第4期,第80～93页。 [4]刘二鹏和张奇林,2018,《失能老人子女照料的变动趋势与照料效果分析》,《经济学动态》第6期,第92～105页。 [5]马超、俞沁雯、宋泽和陈昊,2019,《长期护理保险、医疗费用控制与价值医疗》,《中国工业经济》第12期,第42～59页。 [6]王贞和封进,2021,《长期护理保险对医疗费用的替代效应及不同补偿模式的比较》,《经济学(季刊)》第2期,第557～576页。 [7]余央央和封进,2018,《家庭照料对老年人医疗服务利用的影响》,《经济学(季刊)》第3期,第923～948页。 [8]张川川和陈斌开,2014,《“社会养老”能否替代“家庭养老”？——来自中国新型农村社会养老保险的证据》,《经济研究》第11期,第102～115页。 [9]张文娟和付敏,2020,《长期护理保险制度中老年人的失能风险和照料时间——基于Barthel指数的分析》,《保险研究》第5期,第80～93页。 [10]郑成功和申曙光,2020,《医疗保障蓝皮书:中国医疗保障发展报告》,中国社会保障学会。 [11]朱铭来和何敏,2021,《长期护理保险会挤出家庭照护吗？——基于2011—2018年CHARLS数据的实证分析》,《保险研究》第12期,第21～38页。 [12]Ai, J., Brockett, P L., Golden, L L., and Zhu, W., 2017, “Health State Transitions and Longevity Effects on Retirees' Optimal Annuitization”, Journal of Risk and Insurance, 84(S1), pp. 319～343. [13]Altonji, J G., Hayashi, F., and Kotlikoff, L J., 1997, “Parental Altruism and Inter Vivos Transfers: Theory and Evidence”, Journal of Political Economy, 105(6), pp. 1121～1166. [14]Bakx, P., Meijer, C de., Schut, F., and Doorslaer, E van., 2015, “Going Formal or Informal, Who Cares？ The Influence of Public Long-Term Care Insurance”, Health Economics, 24(6), pp. 631～643. [15]Bonsang, E., 2009, “Does Informal Care From Children to Their Elderly Parents Substitute for Formal Care in Europe？”, Journal of Health Economics, 28(1), pp. 143～154. [16]Brown, J R., and Finkelstein, A., 2008, “The Interaction of Public and Private Insurance: Medicaid and the Long-Term Care Insurance Market”, American Economic Review, 98(3), pp. 1083～1102. [17]Callaway, B., and Sant’Anna, P H., 2021, “Difference-in-Differences with Multiple Time Periods”, Journal of Econometrics, 225(2), pp. 200～230. [18]Cheng, L., Liu, H., Zhang, Y., and Zhao, Z., 2018, “The Heterogeneous Impact of Pension Income on Elderly Living Arrangements: Evidence from China's New Rural Pension Scheme”, Journal of Population Economics, 31(1), pp. 155～192. [19]Costa-Font, J., Jiménez-Martín, S., and Vilaplana-Prieto, C., 2022, “Do Public Caregiving Subsidies and Supports affect the Provision of Care and Transfers？”, Journal of Health Economics, 84, 102639. [20]Courbage, C., and Eeckhoudt, L., 2012, “On Insuring and Caring for Parents' Long-term Care Needs”, Journal of Health Economics, 31(6), pp. 842～850. [21]Courbage, C., Montoliu-Montes, G., and Wagner, J., 2020, “The Effect of Long-term Care Public Benefits and Insurance on Informal Care From Outside the Household: Empirical Evidence From Ltaly and Spain”, The European journal of health economics, 21(8), pp. 1131～1147. [22]Courbage, C., and Zweifel, P., 2011, “Two-sided Intergenerational Moral Hazard, Long-term Care Insurance, and Nursing Home Use”, Journal of Risk and Uncertainty, 43(1), pp. 65～80. [23]de Bresser, J., Knoef, M., and Van Ooijen, R., 2022, “Preferences For In-kind and In-cash Home Care Insurance”, Journal of Health Economics, 84, 102626. [24]Engelhardt, G V., Gruber, J., and Perry, C D., 2005, “Social Security and Elderly Living Arrangements Evidence from the Social Security Notch”, Journal of Human Resources, XL(2), pp. 354～372. [25]Fan, Y., Fang, S., and Yang, Z., 2018, “Living Arrangements of the Elderly: A New Perspective From Choice Constraints in China”, China Economic Review, 50, pp. 101～116. [26]Feng, J., Wang, Z., and Yu, Y., 2020, “Does Long-Term Care Insurance Reduce Hospital Utilization and Medical Expenditures？ Evidence from China”, Social Science & Medicine, 258, pp. 113081. [27]Fu, R., Noguchi, H., Kawamura, A., Takahashi, H., and Tamiya, N., 2017, “Spillover Effect of Japanese Long-term Care Insurance as an Employment Promotion Policy for Family Caregivers”, Journal of Health Economics, 56, pp. 103～112. [28]Gentili, E., Masiero, G., and Mazzonna, F., 2017, “The Role of Culture in Long-term Care Arrangement Decisions”, Journal of Economic Behavior & Organization, 143, pp. 186～200. [29]Geyer, J., and Korfhage, T., 2015, “Long-term Care Insurance and Carers' Labor Supply - A Structural Model”, Health Economics, 24(9), pp. 1178～1191. [30]Goda, G S., Golberstein, E., and Grabowski, D C., 2011, “Income and the Utilization of Long-term Care Services: Evidence From the Social Security Benefit Notch”, Journal of Health Economics, 30(4), pp. 719～729. [31]Goda, G S., Manchester, C F., and Sojourner, A J. (2014) “What Will my Account Really be Worth？ Experimental Evidence on How Retirement Income Projections Affect Saving”, Journal of Public Economics, 119, pp. 80～92. [32]Jia, H., and Lubetkin, E. I., 2020, “Life Expectancy and Active life Expectancy by Disability Status in Older US Adults”, PloS one, 15(9), e0238890. [33]Johar, M., and Maruyama, S., 2014, “Does Coresidence Improve an Elderly Parent's Health？”, Journal of Applied Econometrics, 29(6), pp. 965～983. [34]Kim, H B., and Lim, W., 2015, “Long-term Care Insurance, Informal Care, and Medical Expenditures”, Journal of Public Economics, 125, pp. 128～142. [35]Lei, X., Strauss, J., Tian, M., and Zhao, Y., 2015, “Living Arrangements of the Elderly in China: Evidence From the CHARLS National Baseline”, China Economic Journal, 8(3), pp. 191～214. [36]Liu, H., Ma, J., and Zhao, L., 2023, “Public Long-term Care Insurance and Consumption of Elderly Households: Evidence From China”, Journal of Health Economics, 90, 102759. [37]Luo, Y., Su, B., and Zheng, X., 2021, “Trends and Challenges for Population and Health During Population Aging-China, 2015-2050”, China CDC Weekly, 3(28), pp. 593～598. [38]Meng, D., Xu, G., He, L., Zhang, M., and Lin, D., 2017, “What Determines the Preference for Future Living Arrangements of Middle-Aged and Older People in Urban China？”, Plos One, 12(7): e0180764. [39]Orsini, C., 2010, “Changing the Way the Elderly Live: Evidence From the Home Health Care Market in the United States”, Journal of Public Economics, 94(1), pp. 142～152. [40]Teerawichitchainan, B., Pothisiri, W., and Long, G T., 2015, “How do Living Arrangements and Intergenerational Support Matter for Psychological Health of Elderly parents？ Evidence From Myanmar, Vietnam, and Thailand”, Social Science & Medicine, 136-137, pp. 106～116. [41]Wang, J., Guan, J., and Wang, G., 2023, “Impact of Long-term Care Insurance on the Health Status of Middle-aged and Older Adults”, Health Economics, 32(3), pp. 558～573. [42]Wattmo, C., Londos, E., and Minthon, L., 2014, “Risk factors that Affect Life Expectancy in Alzheimer's Disease: a 15-year Follow-up”, Dementia and Geriatric Cognitive Disorders, 38(5-6), pp. 286～299.
