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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Long-Term Care Insurance in China: Public or Private? a
a
Suyan Shen PhD , Fang Li PhD & John Kipkorir Tanui PhD
b
a
College of Public Administration, Nanjing Agricultural University, Nanjing, China b
Department of Agricultural Economics, Moi University, Nairobi, Kenya Published online: 18 Aug 2014.
To cite this article: Suyan Shen PhD, Fang Li PhD & John Kipkorir Tanui PhD (2014) Long-Term Care Insurance in China: Public or Private?, Social Work in Health Care, 53:7, 679-692, DOI: 10.1080/00981389.2014.925999 To link to this article: http://dx.doi.org/10.1080/00981389.2014.925999
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Social Work in Health Care, 53:679–692, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2014.925999
Long-Term Care Insurance in China: Public or Private? SUYAN SHEN, PhD and FANG LI, PhD College of Public Administration, Nanjing Agricultural University, Nanjing, China
Downloaded by [University of Connecticut] at 00:09 09 October 2014
JOHN KIPKORIR TANUI, PhD Department of Agricultural Economics, Moi University, Nairobi, Kenya
China faces an overwhelming and urgent need for long-term care (LTC). We explored long-term care insurance (LTCI) plans in China and the factors associated with each plan’s contribution rate. A cross-sectional survey of 814 residents (18–59 years) was conducted to assess the expectations of elderly care, public and private LTCI features. Public LTCI may be more popular whether in terms of participation or contribution. The factors associated with public LTCI contribution rate were healthcare costs, household income, and number of daughters; for private LTCI, the factors were the proportion of living expenditures, worry about future care problems, and healthcare costs. Policymakers should develop public LTCI as a solid foundation and improve private LTCI as a substitute to meet the urgent LTC needs in China. KEYWORDS long-term care, care insurance, private care, public care, China
INTRODUCTION The aging population is a growing phenomenon across developed countries and some developing countries (Uhlenberg, 1992). In 1999, the aging population was identified as a significant challenge for China (Zhong, 2011). Today, China has more than 180 million people over 60 years and the elderly
Received April 25, 2014; accepted May 14, 2014. Address correspondence to Suyan Shen, College of Public Administration, Nanjing Agricultural University, Nanjing, China. E-mail: [email protected] 679
Downloaded by [University of Connecticut] at 00:09 09 October 2014
680
S. Shen et al.
population is expected to increase each year from 5 to 8 million (Xiang, 2012). As people age, their health declines from chronic diseases and disabilities that increase the likelihood of them requiring assistance with daily living (Bernard, Lampley-Dallas, & Smith, 1997), especially the oldest group of elders. This trend will lead to a marked rise in the future for health care (Schulz, 2010). In 2010, the Chinese National Urban and Rural Disabled Elderly Status Report estimated that there were approximately 33 million elderly partially or completely disabled, which accounted for 19% of all elders. By 2015, this figure may rise to 40 million, and approximately 70% of elders may need long-term care (LTC; Wu, 2011). In China, family members have traditionally cared for elders in their homes. However, more recently, the social situation has changed. The number of young people serving as caregivers has decreased because of the one-child policy (Rowland, 2009). The labor market has caused migration from different areas, which has weakened a typical family’s capacity to provide care (Arnsberger, Fox, Zhang, & Gui, 2000) and the costs of private nursing care services continually rise (Smith & Tang, 2004). Apparently, the need for LTC is overwhelming, affecting millions of families and demanding our attention in the long run. Some developed countries facing the aging problem have been forced to take action (Grupp, Richter, & Wolfsdorf, 1992). Germany, the United States, Japan, the United Kingdom, the Netherlands, and other countries have public and private long-term care insurance (LTCI) programs. The government and society have played a fundamental role in establishing public programs in Germany and Japan (Oura et al., 2007; Schneider, 1999). Private plans primarily depend on the private sector to provide insurance for LTC expenditures (Brown & Finkelstein, 2009). Although public and private plans have different operating mechanisms, their mission is to reduce uncertainty about potential LTC expenditures for the very old. In September 2013, the State Council of China issued a document outlining the rapid development of a network of home-care services (Zhu, 2013). Jiangsu province has explored the implementation of LTCI since the beginning of 2013 (Xiang, 2013). Fundamental questions must be answered to establish a viable LTCI system in China. The purpose of this study was to (1) explore the fit of LTCI plans in this context, (2) assess people’s preferences for different plans, and (3) examine factors that influence individuals’ contribution rates to LTCI plans.
LITERATURE REVIEW The advantages and disadvantages of the two types of LTC plans have been extensively examined. Referred to as later-life needs, LTC needs are often
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Long-Term Care Insurance in China
681
huge and unmet for some elderly people (Holdenrieder, 2006; Williams, Lyons, & Rowland, 1997). As people age, they are likely to need LTC, particularly women approximately 80 years or older who have demonstrated significantly higher care needs (Pfaff, 2010). In response to demographic trends and the inadequacy of existing programs, LTCI was created and enacted to ease the burden of care on the elderly and their families (Morginstin, 1987). The macro-environment (social, political, economic, and technical) and micro-environment (individual characteristics) affect the need for LTCI and its coverage (Stum, 2001). On the macro side, low fertility and mortality, longer life expectancy, changes in family and social values (Yong & Saito, 2012), an increase in nursing home population, quality of service providers, and average income (Doerpinghaus & Gustavson, 2002), have been identified as factors influencing the choice of, and contributions to, a LTCI plan. The factors influencing the micro-dimension are age, gender, health condition, household size, living arrangements, personal income and assets, and health care expenditures (Chung et al., 2009; Gupta & Li, 2004; Kuzuya et al., 2006; Sato, Hashimoto, Tamiya, & Yano, 2006; Schulz, 2010). Considered a more efficient approach, private market-sector insurance is a form of risk pooling that uses an individual’s income and capital to fund LTC (Sutherland, 1999). In Germany, prior to the comprehensive federal approach to LTCI, the market was minimally effective in developing attractive and affordable insurance plans (Schneider, 1999). During that time, underinsurance in Germany’s market setting, and an underdeveloped private market for LTC in the United States, left much of the LTC expenditure risk uninsured (Brown & Finkelstein, 2009). Explanations regarding market failure can be explored from the demand and supply sides. The supply-side factors may limit demand, including transaction costs, imperfect competition, asymmetric information, and dynamic contracting problems (Norton, 2000). The demand-side factors include underestimating the probability of needing care, family as a source of unpaid care or informal insurance, or public substitute offered by the LTCI program (Brown & Finkelstein, 2007). These factors may reduce demand by increasing the price of insurance, which explains the limited size of the private market. Private insurance programs have played a limited role in LTCI, prompting supporters of state-led approaches to initiate social insurance solutions to share the burden of care for the frail elderly. Japan’s public LTCI program has been the only major social insurance system that includes all Japanese residents aged 40 years and older, without exception, and it has integrated a formal provision for community and institutional care services (Ikegami, 1997). The German LTCI system consisted of home care and nursing home care. The balance between the two components and the resultant
Downloaded by [University of Connecticut] at 00:09 09 October 2014
682
S. Shen et al.
financing conditions were important issues for LTCI (Cuellar & Wiener, 2000). Therefore, the public plan was viewed as the most suitable and cost-efficient program (Walker, Alber, & Guillemard, 1993). Nevertheless, some researchers argued that (1) the public insurance fund had an incentive to shift some services from health care to LTCI, (2) it eliminated competition in the LTC market, and (3) the LTCI budget decreased as the number of benefit recipients increased (Arntz, Sacchetto, Spermann, Steffes, & Widmaier, 2006). Consequently, several reforms were proposed to overcome the financial and structural problems (Pavolini & Ranci, 2008). The literature suggests that LTC need is substantial and affected by related factors. Research has focused on the fit or suitability of LTCI plans in terms of the advantages and disadvantages of each one. Considering China’s current situation and future trends in LTC and the LTCI system, there is a dire need for evidence demonstrating which plan should be encouraged in China. Therefore, we gathered empirical data to investigate residents’ preferences and the factors associated with the contribution rates for each plan from the perspective of demand.
METHODS Sample Jiangsu province was the first group to explore the LTCI system in China; therefore, this study was conducted in Jiangsu’s provincial capital, Nanjing, which is located on the southeast coast of China, in the Yangtze River region, with a population of approximately 8.16 million in 2012. The sample was generated by a multi-stage sampling method. First, the sample was divided into 11 groups according to the population sizes of the 11 districts in Nanjing. We calculated the sample size by probabilityproportional-to-size sampling to cover all of the districts in the study region. Second, for each group, a quota sample was conducted based on gender, age, educational level, marital status, and individual income. The distribution of our sample closely matched a credible source of data from “The Sixth National Census” (Nanjing Bureau of Statistics, 2011) in Nanjing. Residents aged 18 to 59 years qualified as respondents. A total of 814 residents were surveyed by face-to-face interviews in July and August 2013. Questionnaires for the study were designed by the entire research group and were pretested before the study. The interviewers were students from the Public Administration College of Nanjing Agricultural University, Nanjing, China. They received training to ensure that they understood the questions and could gather the required information for the study.
683
Long-Term Care Insurance in China
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Measures Standardized questionnaires assessed individuals’ sociodemographic characteristics, expectations of elderly care, and public and private LTCI features. Sociodemographic indicators included gender, age, educational level, marital status, number of sons and daughters, whom the respondent lives with, monthly per capita household income, monthly per capita living expenditures, and annual per capita health care cost (Table 1). Expectations of elderly care were measured by five items: (1) selfrated health, (2) worry about future care problems, (3) main method of future elderly care, (4) knowledge about LTCI, and, (5) who cares for the elder parents (Table 2). Public LTCI preferences were assessed by four items: (1) participation, (2) contribution, (3) desirable payment method, and (4) development trend of public LTCI (Table 3). Private LTCI preferences consisted of three items: (1) participation, (2) main reason for not wanting to purchase the private LTCI, and (3) contribution (Table 3). Factors associated with the contribution rate of each plan, the dependent variables, were calculated for each respondent using the following equations: TABLE 1 Descriptive Statistics for Sociodemographic Variables (N = 814) Sociodemographic variables Gender: Male = 0 Female = 1 Age Education level: Illiterate = 1 Elementary school = 2 Junior high school = 3 Senior high school = 4 College or above = 5 Marital status: Unmarried Married Divorced Widowed Number of sons Number of daughters Individuals the respondent lives with: Spouse and child(ren) Spouse Child(ren) Alone Parents Other Monthly per capita household income/: Monthly per capita living expenditure/: Annual per capita health care cost/:
Mean/Frequency
SD/Percentage
368 446 40.14
45.2% 54.8% 5.714
4 9 52 138 611
0.5% 1.1% 6.4% 17.0% 75.1%
254 533 14 13 0.46 0.47
31.2% 65.5% 1.7% 1.6% 0.539 0.625
449 85 21 163 87 9 4,397.39 1,825.72 1,417.50
55.2% 10.4% 2.6% 20.0% 10.7% 1.1% 2,951.132 1,172.891 2,511.961
684
S. Shen et al.
TABLE 2 Descriptive Statistics for Expectations of Elderly Care (N = 814)
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Expectations of elderly care
Mean/Frequency
SD/Percentage
3.71 4 31 262 415 102 3.06 34 274 188 240 76
0.750 0.5% 3.8% 32.2% 51.0% 12.5% 1.083 4.2% 33.7% 23.2% 29.6% 9.4%
357 16 329 43 63 6 2.02 165 484 146 17 2
43.9% 2.0% 40.4% 5.3% 7.7% 0.7% 0.701 20.2% 59.5% 17.9% 2.1% 0.2%
418 234 124 38
51.3% 28.7% 15.2% 4.7%
Self-rated health: Not at all healthy = 1 Not very healthy = 2 Neutral = 3 Somewhat healthy = 4 Very healthy = 5 Worry about future care problems: Very worried =1 Somewhat worried = 2 Neutral = 3 Not very worried = 4 Not at all worried = 5 Main method of future elderly care: Care from child(ren) Care from relatives Care from institution Care from home nurse Self care Other Knowledge about LTCI: Know nothing = 1 Know a little = 2 Neutral = 3 Know some = 4 Know a lot = 5 Who takes care of the elder parents: Respondent Relatives Home nurse Institution
Contribution rate of public LTCI = appropriate premium of public LTCI every month/monthly per capita household income; Contribution rate of private LTCI = the appropriate premium of private LTCI every year/12 /monthly per capita household income. The independent variables were selected from the sociodemographic variables and the part of the questionnaire on expectations of elderly care (including self-rated health, worry about future care problem, and knowledge about LTCI). Proportion of monthly per capita living expenditures
Long-Term Care Insurance in China
685
TABLE 3 Descriptive Statistics for Public and Private LTCI (N = 814)
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Mean/Frequency Public LTCI Participation: No = 0 Yes = 1 Monthly appropriate premium/: Desirable payment method: Cash Nursing instruments Institutional nursing Home nursing Development trend: Very bad = 1 Bad = 2 Neutral = 3 Good = 4 Very good = 5 Private LTCI Participation: No = 0 Yes = 1 Main reason for not purchasing: Social medical insurance Critical illness insurance Other medical insurance Lack of economic capacity Too young to participate Lack of understanding of private LTCI Distrust insurance company Other Yearly appropriate premium/: Dependent variables Contribution rate of public LTCI: Contribution rate of private LTCI:
SD/Percentage
332 482 436.33
40.8% 59.2% 1, 812.836
226 11 304 273 3.59 16 48 267 405 78
27.8% 1.4% 37.3% 33.5% 0.819 2.0% 5.9% 32.8% 49.8% 9.6%
538 276
66.1% 33.9%
173 23 71 55 110 92 5 9 2, 178.91
32.2% 4.3% 13.2% 10.2% 20.4% 17.1% 0.9% 1.7% 3, 045.494
22.24 9.55
48.219 19.881
accounting for household income was included as an independent variable instead of the monthly per capita living expenditures for expressing more accurate information about living expenditures in the regression model.
Statistical Analysis All data were analyzed using SPSS for Windows (Version 19.0). Cases with missing data were deleted. Descriptive statistics (mean, frequency, percentage, and standard deviations), Pearson correlation coefficient, and multiple linear regression with conditional stepwise analysis, were used. The significance level was set at 0.05.
686
S. Shen et al.
Downloaded by [University of Connecticut] at 00:09 09 October 2014
RESULTS The beliefs of the residents regarding their own health were as follows: somewhat healthy (51.0%), very healthy (12.5%), not very healthy, or not healthy at all (
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Long-Term Care Insurance in China: Public or Private? a
a
Suyan Shen PhD , Fang Li PhD & John Kipkorir Tanui PhD
b
a
College of Public Administration, Nanjing Agricultural University, Nanjing, China b
Department of Agricultural Economics, Moi University, Nairobi, Kenya Published online: 18 Aug 2014.
To cite this article: Suyan Shen PhD, Fang Li PhD & John Kipkorir Tanui PhD (2014) Long-Term Care Insurance in China: Public or Private?, Social Work in Health Care, 53:7, 679-692, DOI: 10.1080/00981389.2014.925999 To link to this article: http://dx.doi.org/10.1080/00981389.2014.925999
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Social Work in Health Care, 53:679–692, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2014.925999
Long-Term Care Insurance in China: Public or Private? SUYAN SHEN, PhD and FANG LI, PhD College of Public Administration, Nanjing Agricultural University, Nanjing, China
Downloaded by [University of Connecticut] at 00:09 09 October 2014
JOHN KIPKORIR TANUI, PhD Department of Agricultural Economics, Moi University, Nairobi, Kenya
China faces an overwhelming and urgent need for long-term care (LTC). We explored long-term care insurance (LTCI) plans in China and the factors associated with each plan’s contribution rate. A cross-sectional survey of 814 residents (18–59 years) was conducted to assess the expectations of elderly care, public and private LTCI features. Public LTCI may be more popular whether in terms of participation or contribution. The factors associated with public LTCI contribution rate were healthcare costs, household income, and number of daughters; for private LTCI, the factors were the proportion of living expenditures, worry about future care problems, and healthcare costs. Policymakers should develop public LTCI as a solid foundation and improve private LTCI as a substitute to meet the urgent LTC needs in China. KEYWORDS long-term care, care insurance, private care, public care, China
INTRODUCTION The aging population is a growing phenomenon across developed countries and some developing countries (Uhlenberg, 1992). In 1999, the aging population was identified as a significant challenge for China (Zhong, 2011). Today, China has more than 180 million people over 60 years and the elderly
Received April 25, 2014; accepted May 14, 2014. Address correspondence to Suyan Shen, College of Public Administration, Nanjing Agricultural University, Nanjing, China. E-mail: [email protected] 679
Downloaded by [University of Connecticut] at 00:09 09 October 2014
680
S. Shen et al.
population is expected to increase each year from 5 to 8 million (Xiang, 2012). As people age, their health declines from chronic diseases and disabilities that increase the likelihood of them requiring assistance with daily living (Bernard, Lampley-Dallas, & Smith, 1997), especially the oldest group of elders. This trend will lead to a marked rise in the future for health care (Schulz, 2010). In 2010, the Chinese National Urban and Rural Disabled Elderly Status Report estimated that there were approximately 33 million elderly partially or completely disabled, which accounted for 19% of all elders. By 2015, this figure may rise to 40 million, and approximately 70% of elders may need long-term care (LTC; Wu, 2011). In China, family members have traditionally cared for elders in their homes. However, more recently, the social situation has changed. The number of young people serving as caregivers has decreased because of the one-child policy (Rowland, 2009). The labor market has caused migration from different areas, which has weakened a typical family’s capacity to provide care (Arnsberger, Fox, Zhang, & Gui, 2000) and the costs of private nursing care services continually rise (Smith & Tang, 2004). Apparently, the need for LTC is overwhelming, affecting millions of families and demanding our attention in the long run. Some developed countries facing the aging problem have been forced to take action (Grupp, Richter, & Wolfsdorf, 1992). Germany, the United States, Japan, the United Kingdom, the Netherlands, and other countries have public and private long-term care insurance (LTCI) programs. The government and society have played a fundamental role in establishing public programs in Germany and Japan (Oura et al., 2007; Schneider, 1999). Private plans primarily depend on the private sector to provide insurance for LTC expenditures (Brown & Finkelstein, 2009). Although public and private plans have different operating mechanisms, their mission is to reduce uncertainty about potential LTC expenditures for the very old. In September 2013, the State Council of China issued a document outlining the rapid development of a network of home-care services (Zhu, 2013). Jiangsu province has explored the implementation of LTCI since the beginning of 2013 (Xiang, 2013). Fundamental questions must be answered to establish a viable LTCI system in China. The purpose of this study was to (1) explore the fit of LTCI plans in this context, (2) assess people’s preferences for different plans, and (3) examine factors that influence individuals’ contribution rates to LTCI plans.
LITERATURE REVIEW The advantages and disadvantages of the two types of LTC plans have been extensively examined. Referred to as later-life needs, LTC needs are often
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Long-Term Care Insurance in China
681
huge and unmet for some elderly people (Holdenrieder, 2006; Williams, Lyons, & Rowland, 1997). As people age, they are likely to need LTC, particularly women approximately 80 years or older who have demonstrated significantly higher care needs (Pfaff, 2010). In response to demographic trends and the inadequacy of existing programs, LTCI was created and enacted to ease the burden of care on the elderly and their families (Morginstin, 1987). The macro-environment (social, political, economic, and technical) and micro-environment (individual characteristics) affect the need for LTCI and its coverage (Stum, 2001). On the macro side, low fertility and mortality, longer life expectancy, changes in family and social values (Yong & Saito, 2012), an increase in nursing home population, quality of service providers, and average income (Doerpinghaus & Gustavson, 2002), have been identified as factors influencing the choice of, and contributions to, a LTCI plan. The factors influencing the micro-dimension are age, gender, health condition, household size, living arrangements, personal income and assets, and health care expenditures (Chung et al., 2009; Gupta & Li, 2004; Kuzuya et al., 2006; Sato, Hashimoto, Tamiya, & Yano, 2006; Schulz, 2010). Considered a more efficient approach, private market-sector insurance is a form of risk pooling that uses an individual’s income and capital to fund LTC (Sutherland, 1999). In Germany, prior to the comprehensive federal approach to LTCI, the market was minimally effective in developing attractive and affordable insurance plans (Schneider, 1999). During that time, underinsurance in Germany’s market setting, and an underdeveloped private market for LTC in the United States, left much of the LTC expenditure risk uninsured (Brown & Finkelstein, 2009). Explanations regarding market failure can be explored from the demand and supply sides. The supply-side factors may limit demand, including transaction costs, imperfect competition, asymmetric information, and dynamic contracting problems (Norton, 2000). The demand-side factors include underestimating the probability of needing care, family as a source of unpaid care or informal insurance, or public substitute offered by the LTCI program (Brown & Finkelstein, 2007). These factors may reduce demand by increasing the price of insurance, which explains the limited size of the private market. Private insurance programs have played a limited role in LTCI, prompting supporters of state-led approaches to initiate social insurance solutions to share the burden of care for the frail elderly. Japan’s public LTCI program has been the only major social insurance system that includes all Japanese residents aged 40 years and older, without exception, and it has integrated a formal provision for community and institutional care services (Ikegami, 1997). The German LTCI system consisted of home care and nursing home care. The balance between the two components and the resultant
Downloaded by [University of Connecticut] at 00:09 09 October 2014
682
S. Shen et al.
financing conditions were important issues for LTCI (Cuellar & Wiener, 2000). Therefore, the public plan was viewed as the most suitable and cost-efficient program (Walker, Alber, & Guillemard, 1993). Nevertheless, some researchers argued that (1) the public insurance fund had an incentive to shift some services from health care to LTCI, (2) it eliminated competition in the LTC market, and (3) the LTCI budget decreased as the number of benefit recipients increased (Arntz, Sacchetto, Spermann, Steffes, & Widmaier, 2006). Consequently, several reforms were proposed to overcome the financial and structural problems (Pavolini & Ranci, 2008). The literature suggests that LTC need is substantial and affected by related factors. Research has focused on the fit or suitability of LTCI plans in terms of the advantages and disadvantages of each one. Considering China’s current situation and future trends in LTC and the LTCI system, there is a dire need for evidence demonstrating which plan should be encouraged in China. Therefore, we gathered empirical data to investigate residents’ preferences and the factors associated with the contribution rates for each plan from the perspective of demand.
METHODS Sample Jiangsu province was the first group to explore the LTCI system in China; therefore, this study was conducted in Jiangsu’s provincial capital, Nanjing, which is located on the southeast coast of China, in the Yangtze River region, with a population of approximately 8.16 million in 2012. The sample was generated by a multi-stage sampling method. First, the sample was divided into 11 groups according to the population sizes of the 11 districts in Nanjing. We calculated the sample size by probabilityproportional-to-size sampling to cover all of the districts in the study region. Second, for each group, a quota sample was conducted based on gender, age, educational level, marital status, and individual income. The distribution of our sample closely matched a credible source of data from “The Sixth National Census” (Nanjing Bureau of Statistics, 2011) in Nanjing. Residents aged 18 to 59 years qualified as respondents. A total of 814 residents were surveyed by face-to-face interviews in July and August 2013. Questionnaires for the study were designed by the entire research group and were pretested before the study. The interviewers were students from the Public Administration College of Nanjing Agricultural University, Nanjing, China. They received training to ensure that they understood the questions and could gather the required information for the study.
683
Long-Term Care Insurance in China
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Measures Standardized questionnaires assessed individuals’ sociodemographic characteristics, expectations of elderly care, and public and private LTCI features. Sociodemographic indicators included gender, age, educational level, marital status, number of sons and daughters, whom the respondent lives with, monthly per capita household income, monthly per capita living expenditures, and annual per capita health care cost (Table 1). Expectations of elderly care were measured by five items: (1) selfrated health, (2) worry about future care problems, (3) main method of future elderly care, (4) knowledge about LTCI, and, (5) who cares for the elder parents (Table 2). Public LTCI preferences were assessed by four items: (1) participation, (2) contribution, (3) desirable payment method, and (4) development trend of public LTCI (Table 3). Private LTCI preferences consisted of three items: (1) participation, (2) main reason for not wanting to purchase the private LTCI, and (3) contribution (Table 3). Factors associated with the contribution rate of each plan, the dependent variables, were calculated for each respondent using the following equations: TABLE 1 Descriptive Statistics for Sociodemographic Variables (N = 814) Sociodemographic variables Gender: Male = 0 Female = 1 Age Education level: Illiterate = 1 Elementary school = 2 Junior high school = 3 Senior high school = 4 College or above = 5 Marital status: Unmarried Married Divorced Widowed Number of sons Number of daughters Individuals the respondent lives with: Spouse and child(ren) Spouse Child(ren) Alone Parents Other Monthly per capita household income/: Monthly per capita living expenditure/: Annual per capita health care cost/:
Mean/Frequency
SD/Percentage
368 446 40.14
45.2% 54.8% 5.714
4 9 52 138 611
0.5% 1.1% 6.4% 17.0% 75.1%
254 533 14 13 0.46 0.47
31.2% 65.5% 1.7% 1.6% 0.539 0.625
449 85 21 163 87 9 4,397.39 1,825.72 1,417.50
55.2% 10.4% 2.6% 20.0% 10.7% 1.1% 2,951.132 1,172.891 2,511.961
684
S. Shen et al.
TABLE 2 Descriptive Statistics for Expectations of Elderly Care (N = 814)
Downloaded by [University of Connecticut] at 00:09 09 October 2014
Expectations of elderly care
Mean/Frequency
SD/Percentage
3.71 4 31 262 415 102 3.06 34 274 188 240 76
0.750 0.5% 3.8% 32.2% 51.0% 12.5% 1.083 4.2% 33.7% 23.2% 29.6% 9.4%
357 16 329 43 63 6 2.02 165 484 146 17 2
43.9% 2.0% 40.4% 5.3% 7.7% 0.7% 0.701 20.2% 59.5% 17.9% 2.1% 0.2%
418 234 124 38
51.3% 28.7% 15.2% 4.7%
Self-rated health: Not at all healthy = 1 Not very healthy = 2 Neutral = 3 Somewhat healthy = 4 Very healthy = 5 Worry about future care problems: Very worried =1 Somewhat worried = 2 Neutral = 3 Not very worried = 4 Not at all worried = 5 Main method of future elderly care: Care from child(ren) Care from relatives Care from institution Care from home nurse Self care Other Knowledge about LTCI: Know nothing = 1 Know a little = 2 Neutral = 3 Know some = 4 Know a lot = 5 Who takes care of the elder parents: Respondent Relatives Home nurse Institution
Contribution rate of public LTCI = appropriate premium of public LTCI every month/monthly per capita household income; Contribution rate of private LTCI = the appropriate premium of private LTCI every year/12 /monthly per capita household income. The independent variables were selected from the sociodemographic variables and the part of the questionnaire on expectations of elderly care (including self-rated health, worry about future care problem, and knowledge about LTCI). Proportion of monthly per capita living expenditures
Long-Term Care Insurance in China
685
TABLE 3 Descriptive Statistics for Public and Private LTCI (N = 814)
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Mean/Frequency Public LTCI Participation: No = 0 Yes = 1 Monthly appropriate premium/: Desirable payment method: Cash Nursing instruments Institutional nursing Home nursing Development trend: Very bad = 1 Bad = 2 Neutral = 3 Good = 4 Very good = 5 Private LTCI Participation: No = 0 Yes = 1 Main reason for not purchasing: Social medical insurance Critical illness insurance Other medical insurance Lack of economic capacity Too young to participate Lack of understanding of private LTCI Distrust insurance company Other Yearly appropriate premium/: Dependent variables Contribution rate of public LTCI: Contribution rate of private LTCI:
SD/Percentage
332 482 436.33
40.8% 59.2% 1, 812.836
226 11 304 273 3.59 16 48 267 405 78
27.8% 1.4% 37.3% 33.5% 0.819 2.0% 5.9% 32.8% 49.8% 9.6%
538 276
66.1% 33.9%
173 23 71 55 110 92 5 9 2, 178.91
32.2% 4.3% 13.2% 10.2% 20.4% 17.1% 0.9% 1.7% 3, 045.494
22.24 9.55
48.219 19.881
accounting for household income was included as an independent variable instead of the monthly per capita living expenditures for expressing more accurate information about living expenditures in the regression model.
Statistical Analysis All data were analyzed using SPSS for Windows (Version 19.0). Cases with missing data were deleted. Descriptive statistics (mean, frequency, percentage, and standard deviations), Pearson correlation coefficient, and multiple linear regression with conditional stepwise analysis, were used. The significance level was set at 0.05.
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S. Shen et al.
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RESULTS The beliefs of the residents regarding their own health were as follows: somewhat healthy (51.0%), very healthy (12.5%), not very healthy, or not healthy at all (
