China’s Long-Term Care Insurance Eases Physical Pain for Family Caregivers, but Not Their Minds

China is ageing at a pace few societies have ever matched. The number of people aged 65 and over has climbed sharply since 2000 and is projected to approach 400 million by 2050, with roughly 66 million people aged 60 and older expected to need substantial care. Traditionally, that care has fallen almost entirely on families, on spouses who lift, bathe and feed their partners, and on adult children who juggle parental care with jobs and their own households. As family sizes shrink and the old-age dependency ratio worsens, the Chinese government has begun shifting part of this burden onto the state through a long-term care insurance scheme, and a new study now offers one of the most detailed pictures yet of who actually reaps the health rewards.

The research, published in SSM – Population Health by economists Yichen Qiu and Asako Ohinata, examines how China’s long-term care insurance (LTCI) policy affects the physical and mental well-being of the informal caregivers themselves, not just the frail older people it was designed to help. Using nearly a decade of nationally representative panel data, the authors find a striking asymmetry: the policy significantly reduces physical pain among both spousal and adult-child caregivers, but it does remarkably little for their mental health. The finding challenges a common assumption in the international literature that relieving care burdens automatically lifts caregivers’ moods, and it carries important lessons for other middle-income countries facing similar demographic pressures.

China’s LTCI scheme emerged from a 2016 pilot programme that initially covered 15 cities and 2 provinces, expanding to 49 cities by September 2020, although some cities such as Qingdao and Changchun had begun earlier. The insurance is funded largely through the existing public medical insurance system, drawing roughly 70 percent of its financing from medical insurance reserves in most pilot cities, with recipients contributing the remaining 30 percent. Eligibility is strict: applicants must generally suffer from severe disability, assessed with the Barthel Index of Activities of Daily Living or similar tools, expected to last at least six months. A few cities, including Shanghai, Suzhou and Nantong, have broadened coverage to moderate or even mild disability.

The benefits are delivered mainly as in-kind services, covering home-based care, institutional care and hospital care, including help with daily activities such as feeding and bathing as well as basic nursing. The financial stakes are considerable: home or community-based care typically costs between 50 and 80 RMB per hour, or 2,500 to 17,000 RMB per month, equivalent to roughly 44 to 300 percent of the average monthly wage. By the end of March 2022, 1.72 million people with disabilities had received benefits, with average annual payments of about 16,000 RMB per person. For families who would otherwise shoulder these costs alone, the scheme represents a substantial transfer of both money and physical labour away from the household.

To measure the policy’s effects on caregivers, Qiu and Ohinata combined all five available waves of the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative survey covering around 20,000 respondents aged 45 and older across 28 provinces, with waves in 2011, 2013, 2015, 2018 and 2020. They identified spousal caregivers as people whose partners reported difficulties with daily activities before the policy arrived, and adult-child caregivers as those with at least one living parent nearby, a group that had been almost entirely overlooked in earlier research despite providing care to roughly half of China’s older dependents. The final sample comprised 17,897 adult-child caregivers and 13,312 spousal caregivers across 21 treatment cities and 103 control cities.

The identification strategy was a staggered difference-in-differences design with two-way fixed effects, exploiting the fact that different cities adopted the policy at different times. Because this popular estimator can produce biased estimates when treatment effects vary over time, the authors also applied the correction proposed by De Chaisemartin and d’Haultfoeuille, and the results were reassuringly consistent. Event-study tests found no significant pre-policy differences in pain or depression between treatment and control cities, supporting the parallel trends assumption on which the causal interpretation rests. Standard errors were clustered at the city level, the level at which the policy was actually implemented.

The headline result is a clear and persistent reduction in physical pain. Spousal caregivers saw the number of painful body areas fall by 0.517 on average, while adult-child caregivers experienced a reduction of 0.405, both statistically significant. Disaggregating pain across fifteen body sites revealed that the largest improvements occurred in the limbs and back, precisely the regions strained by lifting and physically assisting a dependent person. This spatial pattern is mechanistically telling: it suggests the policy works by substituting formal hands-on care for the most physically punishing tasks that family members perform, rather than through some diffuse improvement in general health.

The mental health story is far more muted. Depression, measured with the CESD-10 scale on which scores above 10 indicate depressive conditions, barely moved. Only adult-child caregivers showed a marginally significant improvement, and spousal caregivers showed none at all. Supplementary analyses of smoking, drinking and social engagement likewise found no significant changes, consistent with the absence of a mental health effect. The authors point to several plausible explanations rooted in the Chinese context: administrative hurdles in accessing benefits, concerns about the quality of formal services, and, most distinctively, the enduring strength of filial norms, under which delegating a parent’s or spouse’s care to outsiders can generate guilt and moral conflict that offset the relief of reduced workload.

The heterogeneity analysis adds considerable nuance. Physical health gains were stronger among older spousal caregivers, whose partners are more likely to meet the age and disability criteria for eligibility, and among male spousal caregivers, who shoulder more of the care within marriages. Among adult-child caregivers, whose caregiving duties are split more evenly between men and women, gender differences were small. Less educated caregivers, who have fewer private resources to buy care on the market, benefited more than highly educated ones, and caregivers with more living children also gained more, possibly because larger family networks help navigate the application process and coordinate care arrangements. Notably, caregivers looking after spouses with moderate or severe disabilities saw significant physical improvements, but mental health gains appeared only for those caring for moderately disabled partners, suggesting that the emotional strain of severe disability persists even when formal help arrives.

Policy design details mattered as well. Results were robust when the three cities with broader eligibility were excluded, and effects were stronger in cities offering only in-kind services than in the handful that also provided cash allowances, perhaps because cash payments may simply compensate informal caregivers rather than finance genuine substitution from family care to formal services. Taken together, the findings suggest that long-term care insurance can meaningfully protect the bodies of those who care for China’s frail elderly, but that physical relief alone does not heal the mind. The authors argue that if policymakers want to support caregivers comprehensively, formal care expansion must be accompanied by targeted psychological support, respite services and other assistance aimed squarely at the informal caregivers themselves, with design choices calibrated to the very different circumstances of spouses and adult children.

Subject of Research: Health effects of China's long-term care insurance policy on spousal and adult-child informal caregivers

Article Title: Who benefits from long-term care insurance? Heterogeneous effects among spousal and adult-child caregivers in China

Article References: Qiu, Y., & Ohinata, A. (2026). Who benefits from long-term care insurance? Heterogeneous effects among spousal and adult-child caregivers in China. SSM – Population Health, Article 101976. https://doi.org/10.1016/j.ssmph.2026.101976

Image Credits: AI Generated

DOI: 10.1016/j.ssmph.2026.101976

Keywords: long-term care insurance, China, informal caregivers, spousal caregivers, adult-child caregivers, physical health, mental health, depression, CHARLS, difference-in-differences, ageing population, health policy