Effect of reduced formal care availability on formal/informal care patterns and caregiver health: a quasi-experimental study using the Japanese long-term care insurance reform

Preferences for home-based care services during China's long-term care market transition: evidence from a discrete choice experiment

BACKGROUND

With population aging and the weakening of traditional family caregiving, home-based care services are becoming more important in China. However, little is known about residents' service preferences during the transition from informal to formal care systems in the context of the long-term care insurance system.

OBJECTIVE

This study examines the preferences of Chinese residents aged 25 or above for home-based care services, focusing on the relative importance of key service attributes, willingness to pay, and preference heterogeneity across demographic groups.

METHODS

A discrete choice experiment (DCE) was conducted from September 2024 to January 2025, with 680 valid responses from 21 provinces in China we're included for analysis. Five attributes were identified through literature review, expert consultations, and focus group interviews: nursing program, service attitude of nursing staff, professional competence of nursing staff, type of service organization and monthly cost. A mixed logit model analyzed preference patterns and heterogeneity.

RESULTS

For respondents, the service attitude of nursing staff (relative importance 29.59%), and the nursing program (29.30%) are of almost equal importance, followed by the monthly cost (20.62%). Respondents showed the highest willingness to pay for a good service attitude. Unmarried individuals, those without children, and non-public sector employees had stronger preferences for service quality and brand reputation, reflecting the role of social support networks and welfare systems in shaping formal care preferences.

CONCLUSION

Findings reveal that home-based care preferences in China are shaped by the dynamic interplay between formal care systems and informal support networks. While the availability of informal support influences individuals' reliance on formal services, the design, quality, and institutional credibility of formal care options also play a key role in shaping preferences. Together, these factors jointly shape how people evaluate and choose home-based care services during China's long-term care market transformation. The observed heterogeneity underscores the need for differentiated service models and policy responses tailored to diverse levels of social and institutional support.

The impact of long-term care insurance on household expenditures of the elderly: Evidence from China

This study aims to investigate the impact of China's long-term care insurance (LTCI) pilot on household expenditures of the elderly. Utilizing the China Health and Retirement Longitudinal Study (CHARLS) 2015-2020 three-period longitudinal panel data, we examine the policy effects of LTCI using the Differences-in-Differences (DID) approach. The results indicate that the implementation of LTCI significantly reduces medical (p<0.05) and healthcare expenditures (p<0.05) for elderly households, while substantially increasing non-medical healthcare expenditures (p<0.01) and total expenditures (p<0.01). This effect is more pronounced for older households in rural areas or with lower levels of education. Furthermore, the improvement in household expenditures is strongly associated with the health status of the elderly and intergenerational economic support. These findings provide empirical evidence that LTCI enhances household expenditures and the quality of life for the elderly, which is crucial for the development of LTCI in China and other middle-income developing countries.

Congenital heart defects in the newborn infant and subsequent depression in parents: A nationwide cohort study

PURPOSE

Although congenital heart defects (CHD) are a fatal disease in newborn infants, little is known whether and to what degree they affect mental health of parents.

METHODS

This cohort study includes parents who were free of depression when their children were first diagnosed with CHD between 2016 and 2021 in Japan. Each parent was matched in a 1:1 ratio using age, gender, income, and the birth date of the infant. Pooled logistic regression was applied to estimate the time-varying risks of parents' depression associated with their infants' CHD over 3 years of follow-up.

RESULTS

Among 4520 matched parents, a new onset of depression was observed in 99 individuals (2.2 %). During the follow-up period of three years, the risk difference (RD) for parents' depression between exposed and unexposed groups was at its highest around 12 months but then dwindled afterward (6 months: RD [95 % confidence interval] = +0.66 [0.33, 1.01]; 12 months: RD = +0.81 [0.35, 1.30]; 24 months: RD = +0.25 [-0.47, 0.99]; and 36 months: RD = -0.36 [-1.27, 0.56]). Our negative control outcome analysis showed no difference in the incidence of diabetes diagnosis by exposure status.

CONCLUSION

Newborn infants' CHD event was associated with an elevated risk of depression in parents. Our findings highlight the importance of support for informal caregiving and preventive psychological care for parents whose newborn infants developed CHD.

Who came to the rescue? Sources of informal support to older Europeans before, during and after the COVID-19 pandemic

BACKGROUND/OBJECTIVE

The COVID-19 pandemic disrupted the provision of informal care in major ways. This study documents the prevalences of informal support with (instrumental) activities of daily living (IADL and ADL) before, during and after the pandemic, distinguishing between children, other relatives and friends/neighbours and focusing on individuals 50 years and older across 27 European countries.

METHODS

This longitudinal analysis relies on the Survey of Health, Ageing and Retirement in Europe (SHARE)'s Wave 8 (2019), two Corona surveys (2020 and 2021) and Wave 9 (2022). Linear probability models adjusted for individual fixed effects and time-varying confounders were used to estimate prevalences of informal support over time.

RESULTS

During the pandemic, the prevalences of informal support with both IADL and ADL from all three groups of caregivers increased significantly (P < 0.01), to return to their pre-pandemic levels by 2022. For example, the adjusted likelihood of IADL help from children increased from 18.5% (2019) to 36.6% (2020) and 42.5% (2021), then dropped back to 19.7% in 2022. Friends and neighbours played a critical role, with the adjusted likelihood of IADL help going from 8.8% (2019) to 29.7% (2020), then down to 18% (2021) and 8.9% (2022).

CONCLUSIONS

Future emergency and disaster preparedness plans should contemplate the various sources of informal care, including support measures to non-relative caregivers, as those helpers may be able to rapidly respond to unexpected crisis.

The Unseen Shift: How Partnership Long-term Care Insurance Influences Caregiving Among Older Adults

OBJECTIVES

Although the partnership long-term care insurance (PLTC) program was designed to mitigate the low uptake of long-term care insurance (LTCI) and reduce Medicaid's financial burden, research has predominantly focused on its direct impacts, leaving the effects on informal caregiving unexplored. This study aimed to investigate how the program alters the dynamics of family-provided care, leveraging nationally representative data to unveil the broader consequences of informal caregiving arrangements among older individuals.

METHODS

Data for this study were sourced from the U.S. Health and Retirement Study (1992-2018) and linked with the timing of the PLTC program implementation across states. The analysis compared individuals exposed to the program with those who were not, employing 2-way-fixed-effects and dynamic models to assess its impact on LTCI coverage and reliance on informal caregiving.

RESULTS

The program positively affected LTCI coverage, increasing insurance uptake among older individuals in the long run. Conversely, a significant negative effect was observed on the receipt of assistance from any helper, indicating a reduced reliance on informal care. This reduction extended specifically to family helpers and children's assistance with activities of daily living. The analysis suggests that the program effectively reduced the necessity for informal caregiving across several domains.

DISCUSSION

These findings highlight the program's potential to reshape caregiving dynamics, suggesting the need for policies that balance promoting private insurance uptake with the implications for family caregiving roles. Policymakers should consider both the economic benefits and the social shifts induced by such programs in the long-term care landscape.

Burden in caregivers of patients with schizophrenia, depression, dementia, and stroke in Japan: comparative analysis of quality of life, work productivity, and qualitative caregiving burden

BACKGROUND

The main objective of this study was to examine the burden of schizophrenia, depression, Alzheimer's disease/dementia, and stroke on caregivers and non-caregivers in Japan. This study also aimed to provide a comparative landscape on the burden of caregiving for each disorder.

METHODS

The Japan National Health and Wellness Survey database, 2016 and 2018 was used in this study. Health-related quality of life (HRQoL), work productivity, and health care utilization were assessed using a self-administered, Internet-based questionnaire. The burden of caregiving experienced by each group of caregivers was compared with background-matched non-caregivers (controls) as well as with caregivers of patients with each disorder.

RESULTS

Caregivers of patients with schizophrenia, depression, Alzheimer's disease/dementia, or stroke had lower HRQoL, higher healthcare costs and work productivity impairment than non-caregivers. Furthermore, caregivers of patients with psychiatric disorders such as schizophrenia and depression had lower HRQoL and work productivity than caregivers of patients with Alzheimer's disease/dementia and stroke. In addition, according to the Caregiver Reaction Assessment (CRA), caregivers of patients with schizophrenia and depression were more inclined to perceive a loss in physical strength and financial burden to the same extent as their self-esteem.

CONCLUSIONS

This study indicated a substantial caregiving burden among caregivers of patients with psychiatric and neurological diseases in Japan. The caregiver burden of psychiatric disorders (schizophrenia and depression) was greater than that of neurological disorders (Alzheimer's disease/dementia and stroke), suggesting a need to provide support to caregivers of patients with psychiatric disorders to be better able to care for their patients.

TRIAL REGISTRATION

None.

Effect of long-term care insurance policy on depression in non-disabled people: evidence from China

BACKGROUND

Policy effect might be multidimensional and spill over to non-recipients. It is unclear how the implementation of Long-Term Care Insurance (LTCI) policy affects depression in non-disabled people and how this effect differs in different non-disabled groups.

METHODS

Using time-varying differences-in-differences method and nationally representative health survey data in wave 2011, wave 2013, wave 2015 and wave 2018 from the China Health and Retirement Longitudinal Study, we assessed the effect of LTCI policy on depression in non-disabled people aged 45 years and older, and discussed the heterogeneity of effect across different population characteristics: retirement, financial support and social participation status.

RESULTS

We found LTCI policy statistically significant reduced depression by 0.76 units in non-disabled people compared to non-pilot cities. Depression in non-disabled people who unretired, with financial support and without social participation was reduced by 0.8267, 0.7079 and 1.2161 units, respectively.

CONCLUSIONS

Depression in non-disabled people was statistically significant reduced because of LTCI policy in China, and non-disabled people who unretired, with financial support and without social participation benefited more from LTCI policy. Our findings highlight the depression-reducing effect of LTCI policy in non-recipients and suggest that non-disabled people who unretired, with financial support and without social participation should be concerned during LTCI policy progress.

Health effects of long-term care insurance on spouses of disabled people: a quasi-experimental study

BACKGROUND

It is still uncertain whether and how formal long-term care (LTC) systems affect the health status of family members. This paper examines the health effects of long-term care insurance (LTCI) on spouses of disabled people in China.

METHODS

The data is from China Health and Retirement Longitudinal Survey (CHARLS), a longitudinal survey of a nationally representative sample of Chinese residents aged 45 or older and their spouses, and China City Statistical Yearbook. Exploiting the regional variation in the implementation of LTCI in the first round of pilot cities in China, a difference-in-difference (DID) strategy is applied to identify the causal effects of LTCI on the health status of spouses of disabled people. We carefully identify the causal effects by controlling for city-level covariates, testing common trends between the treatment and control groups, combining propensity score matching (PSM) with DID, selecting the second round of pilot cities as the control group, controlling for city fixed effects (FE) instead of individual FE, and evaluating selection bias from omitted observable and unobservable factors.

RESULTS

The introduction of LTCI in China reduces the number of painful body parts and the self-reported health score significantly, indicating that spouses of disabled people get physical health benefits from LTCI coverage. However, the impact of LTCI on the depression index remains ambiguous and needs to be analyzed further. LTCI improves the physical health status of spouses of disabled individuals mainly through the time reallocation channel, while the impact of the consumption promotion channel has not been verified. Furthermore, the beneficial effects of LTCI on physical health are stronger for spouse caregivers and spouses with lower-level education and lower household income.

CONCLUSION

These findings demonstrate that LTCI not only improves the health status of family caregivers by reducing their caregiving burden but also has beneficial health effects on non-caregiver family members. Policy designs of LTCI should emphasize the orientation of home and community-based care services (HCBS), which can not only satisfy the care preferences of disabled individuals, reduce the care burden on family caregivers, promote the health of all family members, but also prevent a large number of disabled individuals from choosing high-cost institutional care and reduce the financial burden of the LTCI Fund.

Health spillover studies of long-term care insurance in China: evidence from spousal caregivers from disabled families

BACKGROUND

To alleviate the shortage of caregivers associated with disabled persons, China has implemented a pilot policy for long-term care insurance. This policy has the characteristics of "familialization" and "de-familialization" policy orientation, and it is indeed essential to clarify whether the policy has a positive spillover effect on the health of family caregivers, which is of great value to the pilot from local practice to national institutional arrangement.

METHODS

Based on the China Health and Retirement Longitudinal Study microdata and time-varying DID method, our study used the implementation of the pilot policy as a "quasi-natural experiment" to assess the health spillover effects of the pilot policy on family spousal caregivers.

RESULTS

This policy significantly improved the health of spousal caregivers, increasing self-rated health and life satisfaction, and reducing depression; Compared with female, urban and central-western spousal caregivers, male, rural and eastern spousal caregivers were "beneficiaries" in more dimensional health.

CONCLUSIONS

Our research indicated that spousal caregivers of disabled people, particularly male, rural and eastern spousal caregivers, experienced positive health spillovers after implementing long-term care insurance. These results suggest that the imbalance between supply and demand of nursing staff could be solved in terms of de-familialization and familialization, spousal caregivers should be promoted to equally enjoy the policy benefits on gender, urban-rural and regions.

The impact of long-term care insurance system on family care: Evidence from China

AIMS

The inconsistent findings on the impact of the long-term care insurance (LTCI) system on family care require us to extend our study horizon to more countries with LTCI system designs or market practices. China has explored the LTCI system through pilot programs, which provide a quasi-natural experimental environment. This paper aims to examine how the LTCI system affects family care in China.

METHODS

We primarily employ the time-varying difference-in-differences method to perform regression analyses based on the panel data from the China Health and Retirement Longitudinal Study.

RESULTS

We discover a 7.2% rise in family care under the LTCI system. Specifically, the LTCI system is more likely to promote family care as the relatively primary care for disabled women, disabled people aged 60-74, and those who cannot fully take care of themselves. In addition, the formal care support policy of LTCI will crowd in both formal care and family care, and the crowding-in-effect on formal care may even obscure the crowding-in-effect on family care. The family care support policy of LTCI may encourage the policy-covered groups to take family care as their relatively primary care. It may also lengthen family care for those groups.

CONCLUSIONS

The LTCI system has a crowding-in effect on family care. It can increase family care through cash payments or linking formal and informal care resources by providing formal community and home care.

Associations between long-term care-service use and service- or care-need level progression: a nationwide cohort study using the Japanese Long-Term Care Insurance Claims database

BACKGROUND

The effectiveness of the long-term care service in Japan has been unclear, and most of the relevant studies of this service have been limited to a single region and relatively small samples, necessitating large-scale studies. We examined the associations between long-term care service use and the service/care-need level progression at the national scale in Japan.

METHODS

We conducted a nationwide retrospective cohort study using data from the Japanese Long-Term Care Insurance Claims database. Individuals aged ≥ 65 years and newly certified as being at the support-need level 1 or 2 or the care-need level 1 between April 2012 and March 2013 were included. We first conducted 1:1 propensity score matching and then examined the associations between service use and the progression in support-need or care-need levels by using Kaplan-Meier survival curves and log-rank tests.

RESULTS

The final sample consisted of 332,766 individuals. We observed that service use was associated with a faster decline in the support/care-need level, although the differences in the subjects' survival rate diminished; the log-rank test showed significance (p < 0.001). When stratified for urban-rural classifications or regions of Japan, the results were similar to the primary analysis in all of the stratified groups, and no clear regional variations were observed.

CONCLUSION

We did not observe a clear beneficial effect of receiving long-term care in Japan. Our results suggest that Japan's current long-term care service may not be effective for the recipients of these services. Considering that the system is becoming a financial burden, a re-examination of the service to provide more cost-effective care may be advisable.

Differences in spatial patterns of long-term care depending on severity in Hokkaido, Japan

The increasing demand for long-term care (LTC) among the ageing population is a serious problem worldwide, which has greatly increased also in Japan since the introduction of the LTC insurance system there. Since there is a difference between insurers with respect to the proportion of people needing LTC, this study aimed at clarifying the spatial patterns of LTC. Insurer (n=156) LTC data for the period 2012-2019 were obtained from Ministry of Health, Labour, and Welfare and those needing LTC were classified into three classes: total, mild and severe with ageand sex-adjusted proportions needing LTC. Global and local Moran’s I statistics were calculated for each 2-year period to clarify the trends of global and local spatial clusters. From 2012 to 2019, the mean proportion of mild class cases increased (10.6% to 11.6%), whereas that of severe class cases decreased slightly (5.9% to 5.7%). The spatial pattern of the proportion of each class revealed positive spatial autocorrelation. Based on analysis by local Moran’s I, differences in spatial patterns were emphasised between the mild and severe classes. In Hokkaido, High-High clusters of mild cases were identified in the central and southern parts and severe ones in the northern and southern parts. Spatial patterns differed depending on the LTC class. Some insurers had distinctly higher or lower certification rates than those of their neighbourhoods.

Family caregiving and changes in mental health status in Japan during the COVID-19 pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a widespread significant impact on mental health. However, the effect of providing care to family members (informal caregiving) on changes in mental health status during the pandemic remains unclear.

Methods

Using cross-sectional data from a large internet survey conducted between August and September 2020, we investigated the association of informal caregiving status with the incidence of mental health deterioration (increased loneliness, self-reported deterioration in mental health, and new suicidal ideation) in Japan during the COVID-19 pandemic.

Results

Among 25,482 participants (mean age 48.8 [standard deviation 17.3]; 50.3% women), 2,500 (9.8%) were providing informal care during the pandemic. After adjusting for potential confounders, informal caregivers were more likely than non-caregivers to experience increased loneliness (adjusted odds ratio [aOR] 2.16; 95% confidence interval [CI] 1.70–2.76), self-reported deterioration in mental health (aOR 1.54; 95% CI 1.14–2.08), and new incidence of suicidal ideation (aOR 3.65; 95% CI 1.92–6.92). The degree of mental health deterioration depended on the intensity of care. For example, the incidence rates of new suicidal ideation were 15.0%, 5.2%, and 3.6% for individuals who provided high-intensity caregiving, those who provided low-intensity caregiving, and non-caregivers, respectively (p-for-trend<0.001). The stratified analysis by gender showed that informal caregiving was associated with self-reported deterioration in mental health status among women (aOR 2.19; 95% CI 1.49–3.21) but not men (aOR 1.08; 95% CI 0.75–1.56).

Conclusion

Informal caregivers were more likely to experience mental health deterioration than non-caregivers during the COVID-19 pandemic.

Formal home care use and spousal health outcomes

This study explores the relationship between formal home care provided by paid professionals and spousal health outcomes. We use data from the Survey of Health, Ageing, and Retirement in Europe, a panel of older adults living in several European countries. We match new formal home care users to non-users to eliminate baseline (t-1) differences between couples who decide to seek formal home care in t and those who do not. After considering several potentially confounding changes between baseline and t, and looking closer at specific subgroups, we conclude that in the short run, use of formal home care is unlikely to affect spousal physical or mental health.

Factors associated with psychological distress in family caregivers: Findings from nationwide data in Japan

AIM

Family caregivers can experience psychological distress, resulting in physical and mental health problems, and discontinuation of caregiving. This study's objective was to examine factors associated with caregiver psychological distress.

METHODS

We analyzed data from the Comprehensive Survey of Living Conditions in 2007, 2010, 2013 and 2016, which included 12 504 pairs of caregivers and care recipients sharing a household in Japan. Kessler's Psychological Distress Scale (K6) was used to measure caregiver psychological distress. Multivariable logistic regression analyses identified factors associated with caregiver psychological distress (K6 score ≥5).

RESULTS

Caregivers' median K6 score was 3 (interquartile range 0-7), and 38.6% had a K6 score ≥5. K6 scores ≥5 were positively associated with female sex (adjusted odds ratio 1.35, 95% CI 1.21-1.51), poor caregiver health status (compared with "very good," 9.48, 95% CI 7.91-11.37 for "not very good/poor"), longer care time (compared with "help only when needed," 1.40, 95% CI 1.25-1.58 for "almost all day") and dementia (1.16, 95% CI 1.05-1.28), lower respiratory tract disease (1.25, 95% CI 1.06-1.49) and diabetes (1.16, 95% CI 1.00-1.33) in care recipients. K6 scores ≥5 were negatively associated with older caregiver age (compared with 20-54 years, 0.65, 95%CI 0.58-0.74 for 55-64 years, 0.54, 95%CI 0.46-0.63 for 65-74 years and 0.50, 95% CI 0.40-0.62 for ≥75 years), employment (0.88, 95% CI 0.80-0.97) and being a care recipient's child-in-law (compared with spouse 0.75, 95% CI 0.61-0.92).

CONCLUSIONS

The findings identified several factors associated with caregiver psychological distress, showing that particular attention might need to be paid to caregivers with these risk factors. Geriatr Gerontol Int 2021; 21: 855-864.

Impact of Economic Accessibility on Realized Utilization of Home-Based Healthcare Services for the Older Adults in China

Home-based healthcare service has gradually become the most important model to cope with aging in China. However, the contradiction between oversupply and insufficient demand of healthcare services is becoming increasingly serious. How to effectively improve the realized utilization of healthcare resources has become a key issue in the development of healthcare services. Based on the social background of “getting old before getting rich”, this article explores the relationship between economic accessibility and realized utilization, and finds that the impact of economic accessibility on realized utilization is inverted U-shaped, not a linear positive effect. In addition, considering the moderating role of family support, it is found that family support can strengthen the inverted U-shaped effect of economic accessibility on realized utilization. Therefore, exerting the role of family and improving economic accessibility can effectively solve the dilemma of low utilization of healthcare services.