Liu Zhe, Shi Ruolin, Jiang Lexue, Tang Fengwen, Qiu Zenghui, Yao Lan
School of Medicine and Health Management, Tongji Medical College, Hugzhong University of Science and Technology, Wuhan, China.
School of Foreign Languages, Huazhong University of Science and Technology, Wuhan, China.
Front Public Health. 2025 Jul 15;13:1616761. doi: 10.3389/fpubh.2025.1616761. eCollection 2025.
China's rapidly aging population has intensified the demand for long-term care (LTC), resulting in higher out-of-pocket expenditure (OOPE) ratios and financial strain among older adults. To mitigate these burdens, Long-Term Care Insurance (LTCI) has been piloted across selected cities. However, its effectiveness in reducing financial burden-particularly OOPE ratios-remains insufficiently evaluated. This study assesses the causal impact of LTCI on OOPE ratios and explores subgroup heterogeneity.
We used panel data from the China Health and Retirement Longitudinal Study (CHARLS, 2015-2020), applying difference-in-differences (DID), dynamic DID, and propensity score matching DID (PSM-DID) approaches. The treatment group consisted of older adults living in 12 LTCI pilot cities, while controls were drawn from non-pilot areas. We adjusted for socio-demographic and health covariates and conducted robustness and parallel trend tests.
DID results show that LTCI significantly reduced OOPE ratios ( = -0.035, < 0.01), with dynamic DID confirming a 5.6% reduction in the post-treatment period. PSM-DID estimates remained consistent ( = -0.019, < 0.05). Subgroup analysis revealed stronger effects among relatively younger individuals within the older adult population (70-79), rural residents, and individuals with lower education or chronic conditions. In contrast, minimal impact was observed among those aged ≥80 and highly educated individuals. Notably, OOPE ratios continued to increase over time, indicating that inflation and systemic cost pressures may offset policy gains.
While LTCI has demonstrable short-term benefits in reducing OOPE ratios and improving equity, long-term sustainability remains at risk due to persistent cost escalation. Targeted policy design and enhanced integration with broader health financing mechanisms are needed to strengthen its long-term impact.
中国人口老龄化迅速加剧了长期护理（LTC）需求，导致老年人自付费用（OOPE）比例上升和经济负担加重。为减轻这些负担，长期护理保险（LTCI）已在部分城市开展试点。然而，其在减轻经济负担，特别是自付费用比例方面的效果仍未得到充分评估。本研究评估了长期护理保险对自付费用比例的因果影响，并探讨了亚组异质性。
我们使用了中国健康与养老追踪调查（CHARLS，2015 - 2020）的面板数据，应用双重差分（DID）、动态DID和倾向得分匹配DID（PSM - DID）方法。治疗组由居住在12个长期护理保险试点城市的老年人组成，对照组则来自非试点地区。我们对社会人口统计学和健康协变量进行了调整，并进行了稳健性和平行趋势检验。
双重差分结果表明，长期护理保险显著降低了自付费用比例（β = -0.035，p < 0.01），动态双重差分证实治疗期后降低了5.6%。倾向得分匹配双重差分估计结果一致（β = -0.019，p < 0.05）。亚组分析显示，在老年人群中相对年轻的个体（70 - 79岁）、农村居民以及教育程度较低或患有慢性病的个体中效果更强。相比之下，80岁及以上老年人和高学历个体的影响最小。值得注意的是，自付费用比例随时间持续上升，表明通货膨胀和系统性成本压力可能抵消政策收益。
虽然长期护理保险在降低自付费用比例和改善公平性方面具有明显的短期效益，但由于成本持续上升，长期可持续性仍面临风险。需要有针对性的政策设计，并加强与更广泛的健康融资机制的整合，以增强其长期影响。
