From Fragmented Trials to Integrated System: A Selective Examination upon the Public Long-Term Care Insurance Pilot Project in East China

From Fragmented Trials to Integrated System: A Selective Examination upon the Public Long-Term Care Insurance Pilot Project in East China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Fragmented Trials to Integrated System: A Selective Examination upon the Public Long-Term Care Insurance Pilot Project in East China Wei Chen, Ruiling Zhao, Jiarui Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6124261/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The growing prevalence of “longevity but unhealthiness” poses a significant burden on over one hundred million households in China, promoting the construction of long-term care insurance (LTCI) as a formal source of care option tailored for the increasing older individuals. This qualitative exploratory study focuses on five neighboring cities situated along the Yangtze River Economic Belt in East China. Firstly, an extensive thematic analysis of LTCI-related policy documents was conducted to extract textual data. This analysis extracts five dimensions including “government liability”, “operating agent”, “beneficiary eligibility”, “fundraising source”, and “care supply” to provide a visual demonstration of the intercity similarities and variations. Secondly, 22 in-depth interviews were conducted via purposive and snowball-sampling methods. A three-stage thematic analysis was employed to further construct a five-dimensional structural design and uncover their inner interrelationships, with a goal of optimizing a three-layer integrated LTCI framework that holds regional reference significance. East China public long-term care insurance integrated framework big disability graded care supply Figures Figure 1 Introduction By the Seventh National Census in China, individuals aged 65 and above has reached 190 million, accounting for 13.5% of the total population [ 16 , 28 ]. With China’s rapid demographic transition towards a medium-aging society, one in three would be older adult [ 37 ]. The overall accelerating trend of population aging makes the sheer size of the disabled and semi-disabled individuals an irreversible reality, with the number being predicted to over 42 million in 2021 [ 17 ]. The mildly disabled will be the largest group, while the severely disabled as the most intensive users of nursing care with more outpatient visits and longer hospital stays will grow the fastest [ 13 ], by an average growth rate of 6.5% in 2030 [ 5 ], meaning that sharp healthcare costs will soar in the coming decade [ 24 ]. Given the reality that “longevity risk” of “longevity but unhealthiness” with higher risks of disabilities is quietly approaching [ 7 ], the long-term care (LTC) required by the disabled has become common in the post-war industrial societies [ 27 ], with LTC expenses being predicted to be doubled by the unprecedented acceleration of aging trend by 2030 [ 21 ]. Therefore, “longevity risk” and “disability risk” are forming a new superposition of social risk, prioritizing the construction of long-term care insurance (LTCI) as a formal source of care particularly targeting the growing older individuals [ 6 ]. In December 1998, Chinese government promulgated “Decision on Establishing the Basic Medical Insurance System for Urban Employee” (UEBMI), which was followed by the New Cooperative Medical Scheme (NCMS) in 2003 and the Urban Resident Basic Medical Insurance (URBMI) in 2007, constituting a near-universal healthcare scheme with health insurance coverage for more than 95% of the population by 2011 [ 12 , 41 ]. With the increasing prevalence of smaller-sized family structures [ 22 ] and the decline of informal care system based on filial piety, LTC puts a significant burden on older adults, both in providing care at home and managing the associated financial costs. However, the existing social insurance system cannot effectively mitigate this risk [ 23 ]. The 14th (2021–2025) Five-Year Plan for China’s National Economic and Social Development declaims the proposal to “improve the multi-layer social security system and steadily establish a long-term care insurance system”, highlighting the national policy inclination to systematically explore a sound elder disabled-friendly LTCI. A dedicated LTCI system could be implemented as a crucial component of China’s social security schemes, which include pension, healthcare, work injury, unemployment, and maternity leave [ 43 ]. It would focus on improving the quality of life for individuals with disabilities and dementia, and to release the financial burden of purchasing essential nursing care products [ 7 ]. In October 2016, the State Council of China issued “Healthy China 2030 Plan” and has made periodic strides in promoting LTCI’s pilot projects. In September 2020, the National Medical Insurance Administration and the Ministry of Finance jointly proposed “Guiding Opinions on Expanding the Pilot Programme of Long-Term Care Insurance System”, extending the original 15 cities to 29 involving 27 provincial administrative units [ 29 ]. Many other cities voluntarily followed subsequently, reaching to 49 cities. All these cities issued policy documents to guide the pilot process [ 17 ]. The number of insured individuals has reached 169.9 million with 1.21 million beneficiaries by 2022, while the LTCI fund revenue and expenditure are 24.08 billion and 10.44 billion respectively [ 30 ]. However, neither the initial 15 LTCI pilot experiences nor the further expanding pilot programs have addressed the national ambition of setting up a LTCI policy framework within the 13th Five-Year Plan period (2016–2020), yet there are two years left before the 14th Five-year (2021–2025). Though establishing a hypothetical public LTCI insurance covering 1.4 billion population gradually rises to the level of a nationally institutional arrangement, unifying fragmented pilot practices and rolling out a standardized LTCI remains a challenging task. This is particularly true when it comes to developing a dedicated LTCI premium structure, a structured care service system, dynamic assessment tools, and low turnover of nursing staff. Confronted with a dearth of empirical “local knowledge” to draw conclusions for the ongoing pilots, it is of paramount importance to assemble more “local facts” to identify more intervention strategies. The research on LTCI has become an international academic frontier for coping with the ageing tendency and the accompanying nursing expenditures [ 4 ]. Prior to this study, quite a few literatures on mainland China drew on pilot documents to review LTCI’s improvements in self-rating health and mental health [ 10 , 14 , 42 ]. Some were panel studies drawing secondary data from the China Health and Retirement Longitudinal Study (CHARLS) database, the Chinese Longitudinal Healthy Longevity Survey (CLHLS) database, etc. to exploit the first batch of 15 pilots during 2015–2017 to examine the impact on the reduction of medical expenditures such as ADL-related care fees and out-of-pocket medical costs, etc. [ 20 , 24 ], or selecting one single city to evaluate the effect on the inpatient and outpatient utilization in hospitals [ 11 ]. There were also correlation studies emphasizing the healthcare accessibility, equity, and equality, such as ones that put forward a framework of “value-based healthcare” for balancing financial pressures and self-rating health [ 24 ], and advocated for a wider LTCI coverage to narrow down healthcare inequality among low-income, rural and vulnerable older adults [ 35 , 39 , 44 ]. Besides, there were studies choosing qualitative research methods, e.g., to propose optimized opinions for promoting the full establishment of LTCI based on Northeast of China [ 17 ]. In this study, the Yangtze River Economic Belt of East China which has a relatively large number of LTCI cities as well as owns nearly the strongest economic aggregate was selected for the target region, and then five adjacent cities that started the LTCI pilot earlier with strong implementation capacities are successively included as the scrutinized objects to conduct an in-depth exploratory study, to further enrich prominent “local facts” of LTCI in mainland China to accelerate its system optimization. In contrast to most of the aforementioned academic materials, this qualitative exploratory study mainly revolves around issues of an integrated institutional framework of the LTCI system with the following related objectives: (1) By consolidating the key points of the public LTCI policies implemented in the pilot cases, we aim to identify their shared characteristics and variations, to facilitate more effective policy adjustments for improved outcomes. (2) Gathering primary data by analyzing the perspectives, experiences, and involvement of various stakeholders, including LTCI providers, administrators/operators, and beneficiaries. The objective is to conduct an empirical analysis, delving into the insights obtained during the 2nd -round of the pilot program up to the present stage. (3) Based on thematic analysis of policies and interviews, we will consolidate essential dimensions and identify their potential interrelationships, to ultimately construct an integrated public LTCI framework as a unified approach for promoting LTCI in the long run. Methods Recruitment criteria of the urban cases’ selection Given that “the particularity of each case can be seen as a typical theory” [1], this study devotes to exploring the intrinsic value of selected cases. By employing a research strategy that involves comparing the typology of cases with strong comparability, this study aims to emphasize the similarities in institutional construction paths among adjacent cities. This approach sheds light on the development of a geographically transferable LTCI framework and offers essential practical insights for subsequent regions. The Yangtze River Economic Belt in East China is firstly chosen due to its widespread adoption of LTCI and a commitment to achieving an “independent LTCI” model characterized by extensive participation. Secondly, there are certain recruitment criteria ensuring the comparability among targeted cities: (1) being in a deep-aging phase; (2) encompassing all individuals enrolled in UEBMI or URRBMI; (3) possessing financial viability of the LTCI program. Thus, Shanghai (municipality directly under the central government), Nanjing, Suzhou, Nantong and Changzhou (Jiangsu province), are selected for a one-year empirical study since September of 2022. Data collection and analysis The research process commenced with the collection of pertinent governmental policy documents, including internal discussion and public release from January 2016 till now, for the purpose of conducting a thematic analysis of the LTCI-related policies to identify and report aspects within the textual data, and figure out policy-makers’ goals and intentions [31]. By updating and reviewing these polices, this study consistently captures the large and small changes and improvements happened in these targeted cities, as well as combs important policy-making indicators of each city to identify certain common key dimensions. In so doing, this study seeks to formulate an integrated overview of LTCI policies in targeted cities of East China, and to facilitate the identification of intercity innovative patterns. In accordance with the Declaration of Helsinki and adhering to the principles of confidentiality and anonymization, the study does not involve any sensitive issues throughout the entire interview process. In-depth interviews were conducted with various stakeholders for yielding valuable textual data. Table 1-2 provides an overview of the demographic and basic information of 22 research participants selected through a combination of purposive and snowball sampling methods [32]. As table 1 displays, 12 nursing staff and administrators are from LTCI-designated institutions and governmental authorities. Table 2 contains 5 male and 5 female beneficiaries aged between 46 and 91 years. This study obtained informed consent about the purpose, theme, procedure of this study from the respondents and their families, who rendered clear cognition without obvious expression difficulties. Two semi-structured interview guides were prepared in advance, which were designed with open-ended questions and probes to facilitate in-depth exploration. One guide focused on capturing the perceptions of administrators regarding the regional policies and LTCI implementation. The other guide elicited experiences of service providers and recipients, delving into their roles, involvement, and feedbacks, e.g., a) “How do you fulfill the assessment with the LTCI applicants?” (Probe: “What type and format of evaluation tool is utilized to determine the eligibility?”); b) “Could you explain the premiums and reimbursements of the LTCI?” (Probe: “What mode of fundraising and how much is paid by beneficiaries?”); c) “What are your views on frequency and quality of the LTC?” (Probe: “How is the professional level of the care supply process?”). Between September and December 2022, interviews were conducted through one-on-one in-depth interaction in Mandarin Chinese. Each interview lasted between 25 to 40 minutes and was recorded using on-site audio-recording methods. Confidentiality was maintained, and notes were taken to supplement the recordings. Thematic analysis method [36] was employed to extract core themes, utilizing NVivo 11.0 software to perform a three-stage thematic analysis [15]. Raw data and verbatim transcriptions were imported and converted into text format, to facilitate the identification of key concepts. During the coding process, open codes were generated based on the content of the interviews, such as the code “only employees enrolled in the UEBMI or residents enrolled in the URRBMI can be the beneficiaries”. The coding process was flexible and not limited to predefined categories, allowing for the exploration of emerging themes and concepts within the data. In the second stage, axial coding was employed to consolidate and organize related codes into coherent themes that were relevant to the research objectives. Examples of such themes include universal LTCI coverage or LTCI generosity” and “financial reliance on the medical insurance’s funding pool”. This process allowed for a deeper understanding of the interconnectedness of the coded data. During the third stage of selective coding, the focus was on systematically identifying and capturing the most prominent and significant themes [25]. An example of such a theme could be “maintaining a balanced budget between adjusting the payment burden of fundraising subjects and ensuring funding sustainability”. This stage aimed to distill the core findings and insights from the data analysis. Throughout the analysis, a continuous iterative process was followed, cross-checking the imported themes with their corresponding codes to ensure the authenticity and accuracy of the data. This meticulous approach helped maintain the integrity of the findings and their alignment with the original data sources. Research findings Chart the five dimensions of the public LTCI scheme of the five selected cities Conducting a thorough analysis of policy documents on the public LTCI scheme in the five cities, five dimensions were developed (see Chart 1 for details): (1) government liability; (2) operating agent; (3) beneficiary eligibility; (4) fundraising mechanism; (5) care supply. Conceptually, government liability mainly refers to what concrete public sectors are involved in the LTCI scheme and the extent of their involvement. Correspondingly, an operating agent is usually assigned through openly bidding to assume different proportions of procedural and handling affairs, e.g., the beneficiaries’ application, the disability grades’ assessment, the calculation of LTCI funds for benefits’ allocation, etc. Regarding beneficiary eligibility, it pertains to the target insured population who should be evaluated by setting up specific indicators as standardized assessment tools for determining whether they are qualified to be the target beneficiaries of the LTCI, e.g., UEBMI and URRBMI enrollees. The fundraising source/level, as the core issue for the sustainability of LTCI, is the financing mechanism which is primarily a multi-channel structure involving the transfer of UEBMI’s pooling funds, financial subsidies, the optimized “premium rate” through adjusted “contribution amount” within the ongoing UEBMI accounts, etc., via different manners of transfer as well as different ceiling amounts. Lastly, care supply reflects the actualization of the LTCI-covered benefits based on a further subdivision of nursing care within varying caretaking fields. A zero-sum game: the interaction between government liability and operating agent Five key dimensions in Chart 1 intuitively embody the comparisons among different pilot cities in their varying efforts of localized policy effect. Moreover, it lays a foundation for in-depth analyses of these dimensions and their interrelationships, to contribute to theory-building. It is firstly notable that there are some interactions between government liability and operating agent. The Suzhou municipal social insurance agency places the majority emphasis on financing transfer, while the tendering commercial agents merely participate in certain management issues, according to one local officer, “as profit-driven is the essential feature of commercial institutes, it is easy to breed violations in the absence of strict policy constraints and rigorous supervision” (GS-4). It is slightly different that the Changzhou municipal government not only entrusts its medical insurance bureau but also releases partial power to allow the tendering commercial operators participating in product development. The Nanjing municipal government is dedicated to promoting a significant portion of private sectors to complement its public LTCI pilot program, as a nursing home manager exemplified the streamlined procedures: NS-4: After filling out application form on the governmental “My Nanjing” App, Taiping Insurance Jiangsu Branch will conduct initial screening. Next, a designated evaluation agency will take door-to-door assessment. It usually takes a month to get in-home service delivery. In Shanghai, there is a clear division of labor and collaboration between administrative power and service management. The municipal or district-level authorities primarily delegate power to designated institutions for jointly making policies and reconciling care management matters. A nursing home operator provided this explanation: NS-1: The district medical insurance bureau invited one evaluation agency to jointly formulate standards for LTCI’s management and operating specification, and cooperated with one commercial smart medical care company to explore the standards for care needs plan. The Nantong government adopts minimal intervention by supporting a competitive “joint operation model” among designated commercial institutes, wherein their power and rights are predetermined proportionally, just as the head of the medical insurance bureau described: GS-3: The government must implement an “elimination mechanism” which combines the market regulation and assessment results together, home care institutions that fail the assessment for two consecutive years will not renew their contracts. In general, there is a noticeable decline in the dominance of regional government authorities in Suzhou, Changzhou, Nanjing, Shanghai, Nantong. Conversely, these cities exhibit an increasingly liberal development orientation. The relationships between government authorities and operating agents can be described as a zero-sum game when considering their respective levels of involvement in power participation and transactional participation. Two-dimensional fundraising design for ELTCI and RLTCI: mode, source, level Currently, fundraising mechanism among various LTCI pilot cities demonstrates divergence and fragmentation, primarily regarding mode selection, source composition, and funding level. LTCI in China can be further divided into “Employee LTCI” (ELTCI) and “Residents LTCI” (RLTCI), the fundraising mode of which includes proportional financing and quota financing. Proportional financing customarily takes the manner of proportional deduction accompanied by quarterly or annually adjustments of the UEBMI’s or the URBMI’s pooled funds to retain the LTCI funding pool, while the RLTCI fund is slightly lower. Whereas, nearly all of the pilot cities (except for Shanghai and Qingdao in Shandong province) apply the quota financing, which emphasizes multi-source funding suppliers including UEBMI/URRBMI’s fund transfer, government subsidy, employer contributions, individual payments, welfare lottery proceeds, etc., reflecting a welfare pluralism orientation within differing calculated funding amounts. Besides, there are varying degrees of innovations, for example, the “age-based quota financing” in Nanjing setting the age of 60 as a boundary, and the “big quota financing integrating with small proportional financing” in Nantong: GS-3: In 2023, Nantong has fine-tuned its fundraising methods. That the quota raised from the pooling fund of medical insurance is changed to the “insurance type-based proportional transfer”, namely, 3% and 1.5% are from employee and resident medical insurance respectively, while individual contribution remains unchanged. Regarding funding level, Shanghai adopts a proportional approach by allocating 0.5% of the employee medical insurance contribution base and deducting lower fees from the pooling fund of URBMI, to integrate the LTCI funding pool comprehensively. When reimbursement rates need to be increased, it primarily relies on adjusting the pooling funds of UEBMI/URRBMI without imposing additional financial burdens on individuals, “ 90% of in-home services is reimbursed. The medical caregivers are worth RMB 65 per hour. Shanghai older adults only need to pay RMB 6.5 each time and RMB 182 per month for 28 hours’ service time” (P-2). The other four cities deploy quota financing of RMB 100 annually as the ceiling fee, but the main financiers within their respective LTCI take slightly different proportions. Overall, there is a tendency of improved insurance benefits, just as the situation in Nanjing, “ For those in-home nursing care beneficiaries, the payment standard of severely disabled people is raised to 50 yuan per hour for 30 hours per month. For those living in institutions, the payment adjustment is 70 yuan each day and 2100 yuan per month” (GS-2). No matter which type of fundraising mode, how to adjust the payment burden and ensure funding sustainability is always the most critical issue. Two interpretive concepts of “balanced premium rate” and “contribution amount” are introduced accordingly. Under the same mode, the balanced premium rate from the ELTCI is lower than the RLTCI, while the contribution amount from the ELTCI is higher than the RLTCI [34]. That is to say, the ELTCI could select proportional financing at a rate of 0.4~1% to combat the potential expenditure gaps during peak periods of population disability, as this manner with a certain cumulative function would sustain a normal and steady operation for the future twenty years [38]. Nevertheless, the current quota financing by the RLTCI with financing amounts from RMB 60 to RMB 100 is far lower than experts’ estimate, making its capital pool vulnerable to financial crises [34]. Facing comparably greater financing pressure, it is advised to adopt the “pay-as-you-go” logic for considerations of lower institutional operating costs, smaller payment burdens, higher acceptance in the early fundraising promotion stage, etc. Who is deserved? Beneficiary eligibility under the concept of “big disability” When dealing with older adults, there might be instances where medical institutions exploit information asymmetry, leading to eligibility criteria based on subjective judgments, and cost-effectiveness control driven by institutions’ explicit preferences. These opportunistic care providers, improperly leverage their privileges for “cream skimming”, and introduce selection bias through underprovision of high-priced services [19]. Inspired by the “assets building” concept introduced in 1991, there has been a shift toward a needs-based approach to achieve effective functional outcomes [33]. This involves replacing redundant manufacturing and excessive provision of downstream care services with medium- and high-quality ones tailored to individual needs. LTCI thus requires a complex screening structure for determining beneficiary eligibility. It necessitates a hierarchical quantitative evaluation system that aligns with a layered care supply mechanism. In Nantong, Barthel Index and Mini-Status Examination rating scale are integrated as its two-dimensional measurement tools: GS-3: Moderately disabled persons scored 40-60 points via 10-item ADLs in Barthel Index can be in the insurance coverage…And, Mini-mental State Examination is to assess those over 6 years old with moderate dementia. Shanghai, Suzhou and Changzhou choose the self-designed assessment tools called “Unified Needs Assessment for Eldercare” to reflect the ADLs, but also to assess mental status/sensory perception and communication/social participation/disease conditions for 6-disability levels [3], besides, Changzhou emulates Nantong to include juvenile disability into its evaluation table. Though Nanjing temporarily assesses 10-item ADLs and 4-grade physical disabilities without including the dementia group, it has particularly refined the care services for disabled children aged 0-6 since 1 st March 2024, “ with 6 rehabilitative services of life self-care ability exercise, fine movement training, mouth muscle training, listening ability training, limb joint training, and directional force exercise by nurses and rehabilitation therapists” (NS-4). This study underscores the importance of incorporating the concept of “big disability” in the LTCI inclusion criteria. It advocates for a fair age value for beneficiaries and recognizes cognitive impairments as equally significant factors. Besides, LTCI requires a needs-led mechanism to eliminate unnecessary costs and to prevent self-serving calculations of profit margins, a pyramid-shaped care supply structure is thus envisioned to establish an organized nursing care service market, ensuring fairness for all insured individuals and mitigating health disparities influenced by age, functional conditions, socioeconomic factors, and other underlying causes. A full path of “graded care supply” under an insurance-based LTC system As the ultimate goal of LTCI scheme is to secure beneficiaries and their families with highly accessible care supply, it is essential to facilitate a synchronous insurance-based LTC “seller market” of efficiently organized nursing care service systems. Ensuring a balanced supply-demand product chain is thus a crucial prerequisite for an independent insurance regime. A concept of “graded care supply” is proposed accordingly, indicating that a structured care supply system is to be devised with a subdivision of “in-home nursing care” (installation of assistant tools /home beds/nursing training, etc.), “institutional nursing care” (residential care/respite service/rehabilitation/institutional hospice care, etc.), and “inpatient nursing care” (discharge preparation/medical rehabilitation/hospital hospice bed/palliative care, etc.). The “full path of graded care supply” can be conceptualized as an all-encompassing and multi-stage path for nursing care provision, covering various phases of chronic disease, partial disability, total disability, and end-of-life to correspond to the “whole life cycle”. It thus enables the tracing and attribution of responsibilities in the event of nursing care risks or accidents. Regarding in-home nursing care, a nursing staff in Nanjing provided insights, “ I come to an 83-year-old bedridden Gramma’s home three times a week. Her bedsores due to lumbar disc herniation were cured, but loneliness and a sense of loss often “strike” her a lot. Not only a type of care, in-home manner also brings about spiritual and mental comforts” (NS-3). About institutional nursing care, a Shanghai respondent with uremia, expressed a desire for improved services, “ I need to take a wheelchair and be accompanied. The companion service is not on the service list, so my application was refused. My nursing assistant said she would be punished if being found to go out without regular procedure!” (P-1). As regards hospital nursing care, a 91-year-old single elderly from Suzhou shared her utilization experience of discharge preparation, “ I am complete immobility for two years, and the shuttle bus between hospital where I have rehabilitative care and nursing home provides great convenience. I might apply for one hospice bed when I am dying.” (P-10) In summary, through the extraction of key themes based on the five dimensions, underlying relationships are identified as in-depth theoretical contributions, leading to the development of an integrated three-layer framework which is anticipated to hold regional reference significance, as shown in Figure 1 for details. Discussion As the largest pilot trials of LTCI with the most aging population, the policy implementation and the national-level institutional preparation in China reflect a “social model” orientation, which breaks through the cognitive barriers of “disability is individualized” and reconstructs governmental and public responsibilities towards disability. Moreover, to the best of our knowledge, this is the first study of its type with an endeavor to integrate a framework of public LTCI system by identifying and structuring key influential dimensions from pilot cases in mainland China. The framework architecture highlights the internal three-layer structure of LTCI, including the specific functions performed within each layer. Additionally, the framework aims to dynamically outline the interconnectivity among these layers, allowing for a comprehensive understanding of how different layers interact and work together to achieve the overall goals of the program. As the initial layer of the LTCI framework demonstrated in Fig. 1 , interaction occurred between government liability and operating agent is examined from a macro perspective and concluded that an overall trend is towards a collaborative partnership with bilateral participation between public and private sectors, which is in line with some research opinion of developing public LTCI with more private sectors accompanying [ 22 ]. That is to say, all five cities prioritize a path selection of social insurance model as the operational logic, neither a complete universal government allowance nor direct commercial insurance, but combining both to varying degrees. The concept of a “game degree” is thus employed to encapsulate the zero-sum relationship between governmental intervention and organizational participation. This perspective allows to understand the continuum of power implementation, which involves varying degrees of authoritative control and power release, and a nuanced recognition of how government intervention and organizational participation interact within the LTCI framework is gained. As a pillar link, the middle layer of the framework serves as a crucial part emphasizing financing as an indicator of the supply side and the beneficiary as an indicator of the demand side. These aspects inherently represent the central dimensions and require careful consideration of efficiency and fairness from both ends of the system. It is firstly innovative to typologize LTCI into ELTCI and RLTCI as two tracks in this study, which lays an understandable foundation for further analysis of proportional financing and quota financing. Based on accurate settlement and cost-effective budget, varying degrees of refinement and innovation of the ongoing financing have also been identified, e.g., Nantong’s “insurance type-based proportional financing”, Nanjing’s “age-based quota financing”. When determining eligible individuals as end users, an inclusive concept of “big disability” is adopted to promote the idea of comprehensive insurance coverage that does not discriminate any age or specific types of disabilities. Some pilot practices echo this view, e.g., Nantong, Changzhou, and Nanjing enlarge their insurance generosity to include juvenile disability aged above 6 and disabled children aged 0–6 years old. In view of this, a complete set of evaluation tools equipped with a comprehensive guidance manual turns out to be the key means to implement the above humanized screening design to the greatest extent. Therefore, it is crucial to establish a care supply structure that aligns closely with funding basis and evaluation system [ 2 ]. At the bottom layer, a careful consideration of graded “exquisite care” is positioned to prevent the repetitive production of homogeneous care services. Such a phenomenon often leads to the “crowding-out effect”, where an excessive focus on low or medium levels of care hampers the cultivation of a higher-level service market. The market characterized by excess or insufficient supply of services, hinders the unimpeded switching between different care models. Furthermore, it is important to avoid the imposition of improper categorization of nursing care, as it can lead to unintended consequences such as exacerbating the severity of beneficiaries’ functional conditions. Instead of pursuing continuous but ineffective growth, this study suggests straightening out a laddered structure of care supply’s production chains based on the “grading care”. This approach emphasizes the ultimate significance of constructing the public LTCI, which lies in providing the most appropriate and suitable nursing care. More than that, a sound nursing care supply layer can in turn help polish the upper financing and eligibility links, to form an internal circle and promote a more rationalized public LTCI framework. Policy and practice implications Concerning the institutional references, pioneering OECD countries usually run LTCI systems in varying typology of policy-making regimes, e.g., “universal care allowance” in Nordic countries, “social insurance model” sustained by the public social insurance and the “pay-as-you-go” manner in Germany, the Netherlands, Japan, etc., “commercial insurance model” targeting low-income elder disabled with low-degree “safety net” function by means-tested assessment in the United States and Britain, and “mixed model” combining universal care allowance with marketized care insurance in France [ 4 ]. China’s public LTCI program takes a socialized design logic, mainly reflected in its joint payment mechanism to secure sustainable operation with moderate public sector involvement and modest government funding. On this basis, it is also recommended to launch private LTCI as an effective supplement especially when an ever-increasing scale of nursing care needs is anticipated to overflow the current payable care supply categories, which can refer to a study in Hong Kong to start a private LTCI plan [ 18 ]. It is explicated that commercial LTCI can efficiently and accurately capture the needs of the insured individuals and their families with high purchasing power, and optimizes care products especially when nursing levels rise with the aggravating extents of the disability plights. A path selection of properly integrating public LTCI and private LTCI as two symbiotic and complementary secondary systems, would be more suitable for the policy design of the “sixth pillar insurance” in China. At the practical level, the China Banking and Insurance Regulatory Commission issued “A Notice on the Pilot of Conversion of Life Insurance and Long-term Care Insurance Liability Business” [ 9 ]. Conversion business refers to the conversion of “death or maturity payment liability” in life insurance policies into “nursing payment liability” in the LTCI system, so that individuals can receive insurance benefits in advance when entering the designated nursing state due to a specific disease, accidental injury, etc. in fact, several insurance companies have begun to identify products that can be used for the conversion business since 1st May 2023. Rather than post-compensation after death, conversion business is a prepayment mechanism for life insurance benefits, which makes full use of the existing insurance products to improve the supply capacity of LTCI, and releases the beneficiaries’ out-of-pocket pressure. Aside from an integration of public and private LTCI systems, an integrated policy design of urban and rural tracks into a unity should also be considered to reduce the urban-rural discrepancies. This is consistent with some literatures that LTCI triggered discrepant health outcomes [ 44 ], and may not improve the self-rating health of rural older beneficiaries [ 22 ], especially for the low-income groups or who has no formal job to obtain a pension and to afford out-of-pocket expenses [ 40 ]. Although the provision of graded nursing care services in kind is the mainstream benefit of LTCI for now, it is also suggested that different amounts of cash payments be allocated to rural areas where LTC infrastructure is inaccessible and the healthcare delivery system is scarce, which echoes some scholars’ call for the central government to make financial transfers to support rural regions [ 21 ]. Regarding policy and practice implications for the quality of care, it is essential to increase the proportion of geriatric medicine and nurses to enhance the professional weight of care supply. However, if calculated at a 1:4 service ratio, a vacancy of 2 million of paramedics and medical social workers needs to be filled [ 26 ]. In Korea, the assessors who carry out assessments and grade the recipients for LTCI services are primarily social workers or staff with nursing background from the National Health Insurance Corporation which is a public organization [ 8 ], but in China, nursing staff almost come from unemployed people who are for poverty alleviation purposes and lack knowledge about diseases, let alone only 10% of the 1,500 primary nursing staff finishing training remained at their jobs after six months when the author conducted the fieldwork in Kunming, Yunnan Province [ 7 ]. Besides, though domiciliary services are the most popular LTCI services in East Asian countries [ 8 ], there are less than 1 million in-home employees in China, merely 20,000 of whom obtain professional certificates annually [ 26 ]. It is advised to improve the coverage rate of “family doctor contract services” for expanding the use of “home bed system” and “domiciliary diagnosis service”, and to implant more medical proportion when delivering the “institutional nursing care”, such as expanding the “therapeutic beds”. Concerning “inpatient nursing care”, it is proposed to strengthen the construction of geriatric departments in general hospitals and to get cross-departmental mutual recognition by promoting the “two-way referral mechanism” between medical care, rehabilitative care, and nursing care. Except for enhancing the irreplaceable “nursing weight” in each nursing fields, it is recommended to expand the pilot practice of hospice care via vocational training, to achieve a care supply path covering the entire life cycle. Conclusion In contrast to simply providing post-illness financial compensation, this study highlights the public LTCI program as an independent “sixth pillar insurance” in China, with its insurance-based institutional construction providing a front-end screening mechanism for risk control of the disabled groups. This mechanism focuses on improving the functionality of ADLs, and mental health outcomes, and reducing the frequencies of outpatient visits, hospitalizations, and length of stay. These findings are closely consistent with earlier research, which demonstrated that the introduction of public LTCI in China resulted in a 41% reduction in hospital stay duration, a 17.7% decrease in inpatient costs, and an 11.4% reduction in medical insurance costs in tertiary hospitals [ 13 ]. Under an integrated multi-layered framework, some institutional commonalities can be concluded: (1) At the individual level, the identification of beneficiaries follows a forward-looking strategy based on the benchmark line of “high risks, high nursing levels, and strict product requirements”. This approach is aimed at implementing the pilot program and building institutional confidence through a stage-wise emphasis on individuals with moderate and severe disabilities. Moreover, there is strong advocacy for the concept of “big disability”, and this inclusive approach recognizes the importance of not limiting access to LTCI based on age or specific disability categories. (2) Multi-faceted compatible evaluation mechanisms are put in place to optimize reimbursement rates and expand coverage to include child and juvenile disabilities. (3) Double-track financing mechanism is implemented to store a stable pool of insurance funds, requiring both inter-generational liability and equality to safeguard the long-term sustainability of LTCI program. (4) Calling for a “graded care supply” structure through which stakeholders with product manufacturing capability could access more participatory space and run in an “organic unity” within the LTCI’s institutional architecture. In short, although China’s LTCI is still in a relatively scattered pilot stage and full of various experimental plots, it will be the trend to promote an integrated multi-dimensional framework to unify the public LTCI system nationwide, without too much urban-rural duality, age and gender discrimination, etc. Declarations Author contributions C.W. and Z.R.L. contributed to the design of the study. C.W. analysed and interpreted the results and wrote the first draft of the manuscript and Z.R.L. and W.J.R. contributed to the manuscript by critical revisions and giving comprehensive feedback on multiple drafts. All authors read and approved the final manuscript. Funding This project has reveived funding from the National Social Science Fund under the grant agreement 20BSH56. Data availability The data that support the fundings of this study are not publicly available but are available from the corresponding author on reasonable request. Ethics approval and consent to participate The study was ethically approved by the ethics committee of Nanjing University of Science and Technology. All participating respondents gave informed written or verbal consent. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. The authors declare no conflicts of interest. References Bendix R. Kings or people: Power and the mandate to rule. 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Financing elderly people’s long-term care needs: Evidence from China. Int J Health Plann Manag. 2018;33(2):479–88. https://doi.org/10.1002/hpm.2488 . Liu PC, Yang YL, Yang YX, Cheng JX. Different impact on health outcomes of long-term care insurance between urban and rural older residents in China. Sci Rep. 2023;13(1). https://doi.org/10.1038/S41598-023-27576-6 . Lockwood LM. Incidental bequests and the choice to self-insure late-life risks. Am Econ Rev. 2018;108(9):2513–50. https://www.jstor.org/stable/26528535 . Ma GB, Xu K. Value-based health care: Long-term care insurance for out-of-pocket medical expenses and self-rated health. Int J Environ Res Public Health. 2022;20(1):192–192. https://doi.org/10.3390/IJERPH20010192 . Mason J. Qualitative researching. London, UK: Sage; 2022. Ministry of Civil Affairs of the People’s Republic of China. Focusing on urgent needs and planning for high-quality development of elderly care talent teams. https://www.mca.gov.cn/n152/n166/c45865/content.html . Accessed 12 Mar 2022. Morgan F. The treatment of informal care-related risks as social risks: An analysis of the English care policy system. J Social Policy. 2018;47(1):179–96. https://doi.org/10.1017/s0047279417000265 . National Bureau of Statistics. Main Data of the Seventh National Population Census. https://www.stats.gov.cn/english/PressRelease/202105/t20210510_1817185.html . Accessed 11 May 2021. National Healthcare Security Administration. Guiding Opinions on Expanding the Pilot of Long-Term Care Insurance System (CHS [2020] No. 37). http://www.nhsa.gov.cn/art/2020/9/16/art_37_3586.html . Accessed 2020. National Healthcare Security Administration. 2022 National Healthcare Security Development Statistics Bulletin. https://www.nhsa.gov.cn/art/2023/7/10/art_7_10995.html . Accessed 2023. Ruhode E. E-Government for development: A thematic analysis of Zimbabwe’s information and communication technology policy documents. Electron J Inform Syst Developing Ctries. 2016;73(1):1–15. https://doi.org/10.1002/j.1681-4835.2016.tb00532.x . Silverman D. Doing qualitative research: A practical handbook. London, UK: Sage; 2005. Sherraden M. Assets and the poor: New American welfare policy. New York: Routledge; 2016. Tang W, Su F. A research on the different financing models of long-term care insurance in China. J Finance Econ. 2021;1134–48. https://doi.org/10.16538/j.cnki.jfe.20210825.102 . Tian Y, Fan LJ, Zhou MH, Du W. Impact of long-term care insurance on health inequality in older adults in China based on the concentration index approach. Int Health. 2023;16(1):83–90. https://doi.org/10.1093/inthealth/ihad025 . Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405. https://doi.org/10.1111/nhs.12048 . Wang JY, Li TR. The age mode of elderly disability in China and the disabled population projection. Popul J. 2020;42(5):57–72. https://doi.org/10.16405/j.cnki.1004-129X.2020.05.005 . Wang XJ. Social insurance actuarial management: Theory, model, and application. Beijing: Science; 2011. Wu B, Cohen MA, Cong Z, Kim K, Peng C. Improving care for older adults in China: Development of long-term care policy and system. Res Aging. 2021;43(3–4):123–6. https://doi.org/10.1177/0164027521990829 . Yang W, He AJ, Fang L, Mossialos E. Financing institutional long-term care for the elderly in China: A policy evaluation of new models. Health Policy Plann. 2016;31(10):1391–401. https://doi.org/10.1093/heapol/czw081 . Yu BY. Challenges and innovation recommendations for social health insurance scheme development in China. Health Econ Res. 2024;41(1):20–2. https://doi.org/10.14055/j.cnki.33-1056/f.2024.01.006 . Zhou WS, Dai WD. Shifting from fragmentation to integration: A systematic analysis of long-term care insurance policies in China. Int J Integr Care. 2021;21(3):11. https://doi.org/10.5334/ijic.5676 . Zhu HY. Unmet needs in long-term care and their associated factors among the oldest old in China. BMC Geriatr. 2015;15(1):46. https://doi.org/10.1186/s12877-015-00459 . Zhu YM, Österle A. China’s policy experimentation on long-term care insurance: Implications for access. Int J Health Plann Manage. 2019;34(4):1661–74. https://doi.org/10.1002/hpm.2879 . Tables Table 1 to 2 are available in the Supplementary Files section. Chart Chart 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6124261","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":423763543,"identity":"501fdd04-7934-4c84-9004-3f2d0e00662c","order_by":0,"name":"Wei Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIie3OsUrDQBzH8b8E4vKTW69cH+KgEC2V3qsYAmZpVOhSqEhD4LoEXAP6MIZAJh+gEAeL4OQmFIciJnWpw5mMgvcdjrvjPtyfyGb7i/HvFeo2jp8J+5ctpC95kciGoCOhU0mh3u1bCbtLyhfMTnBMuZ5f9QulyMkr0PjC+MlTGQ7wyDFMYl1lKPyU3GAECqYmIvnEE5HmoIdcV0BxBoIn6qO/MJLLjYg+G+LraU0UiG1ayMQV0YJD1sSpyUFKcH8lfHXuiW3J0cvyRAChnxbuYHgvAyNhWfDay65vFGPL9ftROlKHy2S9epuNjeRn9VREzm7gTu+bPjq/tNlstn/UF2dLS+lm0yNvAAAAAElFTkSuQmCC","orcid":"","institution":"Nanjing University of Science \u0026 Technology","correspondingAuthor":true,"prefix":"","firstName":"Wei","middleName":"","lastName":"Chen","suffix":""},{"id":423763544,"identity":"3a9785e0-ee04-4c12-b7c7-c9fe4c94a05a","order_by":1,"name":"Ruiling Zhao","email":"","orcid":"","institution":"The Chinese University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Ruiling","middleName":"","lastName":"Zhao","suffix":""},{"id":423763545,"identity":"587586de-2568-430c-91c5-b920ee116e8e","order_by":2,"name":"Jiarui Wang","email":"","orcid":"","institution":"Nanjing University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Jiarui","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-02-28 00:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6124261/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6124261/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78721305,"identity":"a12d0303-de6e-4a67-9aa2-dd46b9ba608a","added_by":"auto","created_at":"2025-03-18 04:49:22","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":484328,"visible":true,"origin":"","legend":"\u003cp\u003eAn integrated framework of public LTCI in mainland China\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6124261/v1/48986a43b8bcf2e38ed7cca1.jpeg"},{"id":78721841,"identity":"e4dd51f9-478f-4f82-9192-283ca20327ed","added_by":"auto","created_at":"2025-03-18 05:05:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1126393,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6124261/v1/37c26d90-716d-4d14-873f-dd57edf64766.pdf"},{"id":78721304,"identity":"3777f7ad-175f-430e-8d8b-87f824eb5bc9","added_by":"auto","created_at":"2025-03-18 04:49:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39250,"visible":true,"origin":"","legend":"","description":"","filename":"Chart1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6124261/v1/9f1d54e403142df0e0fc56d5.docx"},{"id":78721310,"identity":"904449ae-261d-45a4-a66c-fc4f9896189e","added_by":"auto","created_at":"2025-03-18 04:49:22","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":373167,"visible":true,"origin":"","legend":"","description":"","filename":"table.docx","url":"https://assets-eu.researchsquare.com/files/rs-6124261/v1/5c46fa49a1fd34c9c1dc5aee.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Fragmented Trials to Integrated System: A Selective Examination upon the Public Long-Term Care Insurance Pilot Project in East China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBy the Seventh National Census in China, individuals aged 65 and above has reached 190\u0026nbsp;million, accounting for 13.5% of the total population [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. With China\u0026rsquo;s rapid demographic transition towards a medium-aging society, one in three would be older adult [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The overall accelerating trend of population aging makes the sheer size of the disabled and semi-disabled individuals an irreversible reality, with the number being predicted to over 42\u0026nbsp;million in 2021 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The mildly disabled will be the largest group, while the severely disabled as the most intensive users of nursing care with more outpatient visits and longer hospital stays will grow the fastest [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], by an average growth rate of 6.5% in 2030 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], meaning that sharp healthcare costs will soar in the coming decade [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the reality that \u0026ldquo;longevity risk\u0026rdquo; of \u0026ldquo;longevity but unhealthiness\u0026rdquo; with higher risks of disabilities is quietly approaching [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the long-term care (LTC) required by the disabled has become common in the post-war industrial societies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], with LTC expenses being predicted to be doubled by the unprecedented acceleration of aging trend by 2030 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, \u0026ldquo;longevity risk\u0026rdquo; and \u0026ldquo;disability risk\u0026rdquo; are forming a new superposition of social risk, prioritizing the construction of long-term care insurance (LTCI) as a formal source of care particularly targeting the growing older individuals [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn December 1998, Chinese government promulgated \u0026ldquo;Decision on Establishing the Basic Medical Insurance System for Urban Employee\u0026rdquo; (UEBMI), which was followed by the New Cooperative Medical Scheme (NCMS) in 2003 and the Urban Resident Basic Medical Insurance (URBMI) in 2007, constituting a near-universal healthcare scheme with health insurance coverage for more than 95% of the population by 2011 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith the increasing prevalence of smaller-sized family structures [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and the decline of informal care system based on filial piety, LTC puts a significant burden on older adults, both in providing care at home and managing the associated financial costs. However, the existing social insurance system cannot effectively mitigate this risk [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The 14th (2021\u0026ndash;2025) Five-Year Plan for China\u0026rsquo;s National Economic and Social Development declaims the proposal to \u0026ldquo;improve the multi-layer social security system and steadily establish a long-term care insurance system\u0026rdquo;, highlighting the national policy inclination to systematically explore a sound elder disabled-friendly LTCI. A dedicated LTCI system could be implemented as a crucial component of China\u0026rsquo;s social security schemes, which include pension, healthcare, work injury, unemployment, and maternity leave [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. It would focus on improving the quality of life for individuals with disabilities and dementia, and to release the financial burden of purchasing essential nursing care products [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn October 2016, the State Council of China issued \u0026ldquo;Healthy China 2030 Plan\u0026rdquo; and has made periodic strides in promoting LTCI\u0026rsquo;s pilot projects. In September 2020, the National Medical Insurance Administration and the Ministry of Finance jointly proposed \u0026ldquo;Guiding Opinions on Expanding the Pilot Programme of Long-Term Care Insurance System\u0026rdquo;, extending the original 15 cities to 29 involving 27 provincial administrative units [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Many other cities voluntarily followed subsequently, reaching to 49 cities. All these cities issued policy documents to guide the pilot process [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The number of insured individuals has reached 169.9\u0026nbsp;million with 1.21\u0026nbsp;million beneficiaries by 2022, while the LTCI fund revenue and expenditure are 24.08\u0026nbsp;billion and 10.44\u0026nbsp;billion respectively [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, neither the initial 15 LTCI pilot experiences nor the further expanding pilot programs have addressed the national ambition of setting up a LTCI policy framework within the 13th Five-Year Plan period (2016\u0026ndash;2020), yet there are two years left before the 14th Five-year (2021\u0026ndash;2025). Though establishing a hypothetical public LTCI insurance covering 1.4\u0026nbsp;billion population gradually rises to the level of a nationally institutional arrangement, unifying fragmented pilot practices and rolling out a standardized LTCI remains a challenging task. This is particularly true when it comes to developing a dedicated LTCI premium structure, a structured care service system, dynamic assessment tools, and low turnover of nursing staff. Confronted with a dearth of empirical \u0026ldquo;local knowledge\u0026rdquo; to draw conclusions for the ongoing pilots, it is of paramount importance to assemble more \u0026ldquo;local facts\u0026rdquo; to identify more intervention strategies.\u003c/p\u003e \u003cp\u003eThe research on LTCI has become an international academic frontier for coping with the ageing tendency and the accompanying nursing expenditures [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Prior to this study, quite a few literatures on mainland China drew on pilot documents to review LTCI\u0026rsquo;s improvements in self-rating health and mental health [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Some were panel studies drawing secondary data from the China Health and Retirement Longitudinal Study (CHARLS) database, the Chinese Longitudinal Healthy Longevity Survey (CLHLS) database, etc. to exploit the first batch of 15 pilots during 2015\u0026ndash;2017 to examine the impact on the reduction of medical expenditures such as ADL-related care fees and out-of-pocket medical costs, etc. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], or selecting one single city to evaluate the effect on the inpatient and outpatient utilization in hospitals [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There were also correlation studies emphasizing the healthcare accessibility, equity, and equality, such as ones that put forward a framework of \u0026ldquo;value-based healthcare\u0026rdquo; for balancing financial pressures and self-rating health [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and advocated for a wider LTCI coverage to narrow down healthcare inequality among low-income, rural and vulnerable older adults [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Besides, there were studies choosing qualitative research methods, e.g., to propose optimized opinions for promoting the full establishment of LTCI based on Northeast of China [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the Yangtze River Economic Belt of East China which has a relatively large number of LTCI cities as well as owns nearly the strongest economic aggregate was selected for the target region, and then five adjacent cities that started the LTCI pilot earlier with strong implementation capacities are successively included as the scrutinized objects to conduct an in-depth exploratory study, to further enrich prominent \u0026ldquo;local facts\u0026rdquo; of LTCI in mainland China to accelerate its system optimization. In contrast to most of the aforementioned academic materials, this qualitative exploratory study mainly revolves around issues of an integrated institutional framework of the LTCI system with the following related objectives:\u003c/p\u003e \u003cp\u003e(1) By consolidating the key points of the public LTCI policies implemented in the pilot cases, we aim to identify their shared characteristics and variations, to facilitate more effective policy adjustments for improved outcomes.\u003c/p\u003e \u003cp\u003e(2) Gathering primary data by analyzing the perspectives, experiences, and involvement of various stakeholders, including LTCI providers, administrators/operators, and beneficiaries. The objective is to conduct an empirical analysis, delving into the insights obtained during the 2nd -round of the pilot program up to the present stage.\u003c/p\u003e \u003cp\u003e(3) Based on thematic analysis of policies and interviews, we will consolidate essential dimensions and identify their potential interrelationships, to ultimately construct an integrated public LTCI framework as a unified approach for promoting LTCI in the long run.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eRecruitment criteria of the urban cases\u0026rsquo; selection \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven that \u0026ldquo;the particularity of each case can be seen as a typical theory\u0026rdquo; [1], this study devotes to exploring the intrinsic value of selected cases. By employing a research strategy that involves comparing the typology of cases with strong comparability, this study aims to emphasize the similarities in institutional construction paths among adjacent cities. This approach sheds light on the development of a geographically transferable LTCI framework and offers essential practical insights for subsequent regions. The Yangtze River Economic Belt in East China is firstly chosen due to its widespread adoption of LTCI and a commitment to achieving an \u0026ldquo;independent LTCI\u0026rdquo; model characterized by extensive participation. Secondly, there are certain recruitment criteria ensuring the comparability among targeted cities: (1) being in a deep-aging phase; (2) encompassing all individuals enrolled in UEBMI or URRBMI; (3) possessing financial viability of the LTCI program. Thus, Shanghai (municipality directly under the central government), Nanjing, Suzhou, Nantong and Changzhou (Jiangsu province), are selected for a one-year empirical study since September of 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research process commenced with the collection of pertinent governmental policy documents, including internal discussion and public release from January 2016 till now, for the purpose of conducting a thematic analysis of the LTCI-related policies to identify and report aspects within the textual data, and figure out policy-makers\u0026rsquo; goals and intentions [31]. By updating and reviewing these polices, this study consistently captures the large and small changes and improvements happened in these targeted cities, as well as combs important policy-making indicators of each city to identify certain common key dimensions. In so doing, this study seeks to formulate an integrated overview of LTCI policies in targeted cities of East China, and to facilitate the identification of intercity innovative patterns.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn accordance with the Declaration of Helsinki and adhering to the principles of confidentiality and anonymization, the study does not involve any sensitive issues throughout the entire interview process. In-depth interviews were conducted with various stakeholders for yielding valuable textual data. Table 1-2 provides an overview of the demographic and basic information of 22 research participants selected through a combination of purposive and snowball sampling methods [32].\u0026nbsp;As table 1 displays, 12 nursing staff and administrators are from LTCI-designated institutions and governmental authorities. Table 2 contains 5 male and 5 female beneficiaries aged between 46 and 91 years. This study obtained informed consent about the purpose, theme, procedure of this study from the respondents and their families, who rendered clear cognition without obvious expression difficulties. Two semi-structured interview guides were prepared in advance, which were designed with open-ended questions and probes to facilitate in-depth exploration. One guide focused on capturing the perceptions of administrators regarding the regional policies and LTCI implementation. The other guide elicited experiences of service providers and recipients, delving into their roles, involvement, and feedbacks, e.g., a) \u0026ldquo;How do you fulfill the assessment with the LTCI applicants?\u0026rdquo; (Probe: \u0026ldquo;What type and format of evaluation tool is utilized to determine the eligibility?\u0026rdquo;); b) \u0026ldquo;Could you explain the premiums and reimbursements of the LTCI?\u0026rdquo; (Probe: \u0026ldquo;What mode of fundraising and how much is paid by beneficiaries?\u0026rdquo;); c) \u0026ldquo;What are your views on frequency and quality of the LTC?\u0026rdquo; (Probe: \u0026ldquo;How is the professional level of the care supply process?\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eBetween September and December 2022, interviews were conducted through one-on-one in-depth interaction in Mandarin Chinese. Each interview lasted between 25 to 40 minutes and was recorded using on-site audio-recording methods. Confidentiality was maintained, and notes were taken to supplement the recordings. Thematic analysis method\u0026nbsp;[36]\u0026nbsp;was employed to extract core themes, utilizing NVivo 11.0 software to perform a three-stage thematic analysis\u0026nbsp;[15]. Raw data and verbatim transcriptions were imported and converted into text format, to facilitate the identification of key concepts. During the coding process, open codes were generated based on the content of the interviews, such as the code \u0026ldquo;only employees enrolled in the UEBMI or residents enrolled in the URRBMI can be the beneficiaries\u0026rdquo;. The coding process was flexible and not limited to predefined categories, allowing for the exploration of emerging themes and concepts within the data. In the second stage, axial coding was employed to consolidate and organize related codes into coherent themes that were relevant to the research objectives. Examples of such themes include universal LTCI coverage or LTCI generosity\u0026rdquo; and \u0026ldquo;financial reliance on the medical insurance\u0026rsquo;s funding pool\u0026rdquo;. This process allowed for a deeper understanding of the interconnectedness of the coded data. During the third stage of selective coding, the focus was on systematically identifying and capturing the most prominent and significant themes\u0026nbsp;[25]. An example of such a theme could be \u0026ldquo;maintaining a balanced budget between adjusting the payment burden of fundraising subjects and ensuring funding sustainability\u0026rdquo;. This stage aimed to distill the core findings and insights from the data analysis.\u003c/p\u003e\n\u003cp\u003eThroughout the analysis, a continuous iterative process was followed, cross-checking the imported themes with their corresponding codes to ensure the authenticity and accuracy of the data. This meticulous approach helped maintain the integrity of the findings and their alignment with the original data sources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChart the five dimensions of the public LTCI scheme of the five selected cities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConducting a thorough analysis of policy documents on the public LTCI scheme in the five cities, five dimensions were developed (see Chart 1 for details): (1) government liability; (2) operating agent; (3) beneficiary eligibility; (4) fundraising mechanism; (5) care supply. Conceptually, government liability mainly refers to what concrete public sectors are involved in the LTCI scheme and the extent of their involvement. Correspondingly, an operating agent is usually assigned through openly bidding to assume different proportions of procedural and handling affairs, e.g., the beneficiaries\u0026rsquo; application, the disability grades\u0026rsquo; assessment, the calculation of LTCI funds for benefits\u0026rsquo; allocation, etc. Regarding beneficiary eligibility, it pertains to the target insured population who should be evaluated by setting up specific indicators as standardized assessment tools for determining whether they are qualified to be the target beneficiaries of the LTCI, e.g., UEBMI and URRBMI enrollees. The fundraising source/level, as the core issue for the sustainability of LTCI, is the financing mechanism which is primarily a multi-channel structure involving the transfer of UEBMI\u0026rsquo;s pooling funds, financial subsidies, the optimized \u0026ldquo;premium rate\u0026rdquo; through adjusted \u0026ldquo;contribution amount\u0026rdquo; within the ongoing UEBMI accounts, etc., via different manners of transfer as well as different ceiling amounts. Lastly, care supply reflects the actualization of the LTCI-covered benefits based on a further subdivision of nursing care within varying caretaking fields.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA zero-sum game: the interaction between government liability and operating agent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive key dimensions in Chart 1\u0026nbsp;intuitively embody the comparisons among different pilot cities in their varying efforts of localized policy effect. Moreover, it lays\u0026nbsp;a foundation for in-depth analyses of these dimensions and their interrelationships, to contribute to theory-building.\u003c/p\u003e\n\u003cp\u003eIt is firstly notable that there are some interactions between government liability and operating agent. The Suzhou municipal social insurance agency places the majority emphasis on financing transfer, while the tendering commercial agents merely participate in certain management issues, according to one local officer, \u0026ldquo;as \u003cem\u003eprofit-driven is the essential feature of commercial institutes, it is easy to breed violations in the absence of strict policy constraints and rigorous supervision\u0026rdquo; (GS-4).\u0026nbsp;\u003c/em\u003eIt is slightly different that the Changzhou municipal government not only entrusts its medical insurance bureau but also releases partial power to allow the tendering commercial operators participating in product development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Nanjing municipal government is dedicated to promoting a significant portion of private sectors to complement its public LTCI pilot program, as a nursing home manager exemplified the streamlined procedures:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNS-4: After filling out application form on the governmental \u0026ldquo;My Nanjing\u0026rdquo; App, Taiping Insurance Jiangsu Branch will conduct initial screening. Next, a designated evaluation agency will take door-to-door assessment. It usually takes a month to get in-home service delivery.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn Shanghai, there is a clear division of labor and collaboration between administrative power and service management. The municipal or district-level authorities primarily delegate power to designated institutions for jointly making policies and reconciling care management matters. A nursing home operator provided this explanation:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNS-1: The district medical insurance bureau invited one evaluation agency to jointly formulate standards for LTCI\u0026rsquo;s management and operating specification, and cooperated with one commercial smart medical care company to explore the standards for care needs plan.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Nantong government adopts minimal intervention by supporting a competitive \u0026ldquo;joint operation model\u0026rdquo; among designated commercial institutes, wherein their power and rights are predetermined proportionally, just as the head of the medical insurance bureau described:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGS-3: The government must implement an \u0026ldquo;elimination mechanism\u0026rdquo; which combines the market regulation and assessment results together, home care institutions that fail the assessment for two consecutive years will not renew their contracts.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn general, there is a noticeable decline in the dominance of regional government authorities in Suzhou, Changzhou, Nanjing, Shanghai, Nantong. Conversely, these cities exhibit an increasingly liberal development orientation. The relationships between government authorities and operating agents can be described as a zero-sum game when considering their respective levels of involvement in power participation and transactional participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTwo-dimensional fundraising design for ELTCI and RLTCI: mode, source, level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCurrently, fundraising mechanism among various LTCI pilot cities demonstrates divergence and fragmentation, primarily regarding mode selection, source composition, and funding level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLTCI in China can be further divided into \u0026ldquo;Employee LTCI\u0026rdquo; (ELTCI) and \u0026ldquo;Residents LTCI\u0026rdquo; (RLTCI), the fundraising mode of which includes proportional financing and quota financing. Proportional financing customarily takes the manner of proportional deduction accompanied by quarterly or annually adjustments of the UEBMI\u0026rsquo;s or the URBMI\u0026rsquo;s pooled funds to retain the LTCI funding pool, while the RLTCI fund is slightly lower. Whereas, nearly all of the pilot cities (except for Shanghai and Qingdao in Shandong province) apply the quota financing, which emphasizes multi-source funding suppliers including UEBMI/URRBMI\u0026rsquo;s fund transfer, government subsidy, employer contributions, individual payments, welfare lottery proceeds, etc., reflecting a welfare pluralism orientation within differing calculated funding amounts. Besides, there are varying degrees of innovations, for example, the \u0026ldquo;age-based quota financing\u0026rdquo; in Nanjing setting the age of 60 as a boundary, and the \u0026ldquo;big quota financing integrating with small proportional financing\u0026rdquo; in Nantong:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGS-3: In 2023, Nantong has fine-tuned its fundraising methods. That the quota raised from the pooling fund of medical insurance is changed to the \u0026ldquo;insurance type-based proportional transfer\u0026rdquo;, namely, 3% and 1.5% are from employee and resident medical insurance respectively, while individual contribution remains unchanged.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding funding level, Shanghai adopts a proportional approach by allocating 0.5% of the employee medical insurance contribution base and deducting lower fees from the pooling fund of URBMI, to integrate the LTCI funding pool comprehensively. When reimbursement rates need to be increased, it primarily relies on adjusting the pooling funds of UEBMI/URRBMI without imposing additional financial burdens on individuals, \u0026ldquo;\u003cem\u003e90% of in-home services is reimbursed. The medical caregivers are worth RMB 65 per hour. Shanghai older adults only need to pay RMB 6.5 each time and RMB 182 per month for 28 hours\u0026rsquo; service time\u0026rdquo; (P-2).\u003c/em\u003e The other four cities deploy quota financing of RMB 100 annually as the ceiling fee, but the main financiers within their respective LTCI take slightly different proportions. Overall, there is a tendency of improved insurance benefits, just as the situation in Nanjing, \u0026ldquo;\u003cem\u003eFor those in-home nursing care beneficiaries, the payment standard of severely disabled people is raised to 50 yuan per hour for 30 hours per month. For those living in institutions, the payment adjustment is 70 yuan each day and 2100 yuan per month\u0026rdquo; (GS-2).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo matter which type of fundraising mode, how to adjust the payment burden and ensure funding sustainability is always the most critical issue. Two interpretive concepts of \u0026ldquo;balanced premium rate\u0026rdquo; and \u0026ldquo;contribution amount\u0026rdquo; are introduced accordingly. Under the same mode, the balanced premium rate from the ELTCI is lower than the RLTCI, while the contribution amount from the ELTCI is higher than the RLTCI [34]. That is to say, the ELTCI could select proportional financing at a rate of 0.4~1% to combat the potential expenditure gaps during peak periods of population disability, as this manner with a certain cumulative function would sustain a normal and steady operation for the future twenty years [38].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNevertheless, the current quota financing by the RLTCI with financing amounts from RMB 60 to RMB 100 is far lower than experts\u0026rsquo; estimate, making its capital pool vulnerable to financial crises [34]. Facing comparably greater financing pressure, it is advised to adopt the \u0026ldquo;pay-as-you-go\u0026rdquo; logic for considerations of lower institutional operating costs, smaller payment burdens, higher acceptance in the early fundraising promotion stage, etc.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWho is deserved? Beneficiary eligibility under the concept of \u0026ldquo;big disability\u0026rdquo;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen dealing with older adults, there might be instances where medical institutions exploit information asymmetry, leading to eligibility criteria based on subjective judgments, and cost-effectiveness control driven by institutions\u0026rsquo; explicit preferences. These opportunistic care providers, improperly leverage their privileges for \u0026ldquo;cream skimming\u0026rdquo;, and introduce selection bias through underprovision of high-priced services [19]. Inspired by the \u0026ldquo;assets building\u0026rdquo; concept introduced in 1991, there has been a shift toward a needs-based approach to achieve effective functional outcomes [33]. This involves replacing redundant manufacturing and excessive provision of downstream care services with medium- and high-quality ones tailored to individual needs. LTCI thus requires a complex screening structure for determining beneficiary eligibility. It necessitates a hierarchical quantitative evaluation system that aligns with a layered care supply mechanism. In Nantong,\u0026nbsp;Barthel Index and Mini-Status Examination rating scale are integrated as its two-dimensional measurement tools:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGS-3: Moderately disabled persons scored 40-60 points via 10-item ADLs in Barthel Index can be in the insurance coverage\u0026hellip;And, Mini-mental State Examination is to assess those over 6 years old with moderate dementia.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShanghai, Suzhou and Changzhou choose the self-designed assessment tools called \u0026ldquo;Unified Needs Assessment for Eldercare\u0026rdquo; to reflect the ADLs, but also to assess mental status/sensory perception and communication/social participation/disease conditions for 6-disability levels [3], besides, Changzhou emulates Nantong to include juvenile disability into its evaluation table.\u003c/p\u003e\n\u003cp\u003eThough Nanjing temporarily assesses 10-item ADLs and 4-grade physical disabilities without including the dementia group, it has particularly refined the care services for disabled children aged 0-6 since 1\u003csup\u003est\u003c/sup\u003e March 2024, \u0026ldquo;\u003cem\u003ewith 6 rehabilitative services of life self-care ability exercise, fine movement training, mouth muscle training, listening ability training, limb joint training, and directional force exercise by nurses and rehabilitation therapists\u0026rdquo; (NS-4).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study underscores the importance of incorporating the concept of \u0026ldquo;big disability\u0026rdquo; in the LTCI inclusion criteria. It advocates for a fair age value for beneficiaries and recognizes cognitive impairments as equally significant factors. Besides, LTCI requires a needs-led mechanism to eliminate unnecessary costs and to prevent self-serving calculations of profit margins, a pyramid-shaped care supply structure is thus envisioned to establish an organized nursing care service market, ensuring fairness for all insured individuals and mitigating health disparities influenced by age, functional conditions, socioeconomic factors, and other underlying causes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA full path of \u0026ldquo;graded care supply\u0026rdquo; under an insurance-based LTC system\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the ultimate goal of LTCI scheme is to secure beneficiaries and their families with highly accessible care supply, it is essential to facilitate a synchronous insurance-based LTC \u0026ldquo;seller market\u0026rdquo; of efficiently organized nursing care service systems. Ensuring a balanced supply-demand product chain is thus a crucial prerequisite for an independent insurance regime.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA concept of \u0026ldquo;graded care supply\u0026rdquo; is proposed accordingly, indicating that a structured care supply system is to be devised with a subdivision of \u0026ldquo;in-home nursing care\u0026rdquo; (installation of assistant tools /home beds/nursing training, etc.), \u0026ldquo;institutional nursing care\u0026rdquo; (residential care/respite service/rehabilitation/institutional hospice care, etc.), and \u0026ldquo;inpatient nursing care\u0026rdquo; (discharge preparation/medical rehabilitation/hospital hospice bed/palliative care, etc.). The \u0026ldquo;full path of graded care supply\u0026rdquo; can be conceptualized as an all-encompassing and multi-stage path for nursing care provision, covering various phases of chronic disease, partial disability, total disability, and end-of-life to correspond to the \u0026ldquo;whole life cycle\u0026rdquo;. It thus enables the tracing and attribution of responsibilities in the event of nursing care risks or accidents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding in-home nursing care, a nursing staff in Nanjing provided insights, \u0026ldquo;\u003cem\u003eI come to an 83-year-old bedridden Gramma\u0026rsquo;s home three times a week. Her bedsores due to lumbar disc herniation were cured, but loneliness and a sense of loss often \u0026ldquo;strike\u0026rdquo; her a lot. Not only a type of care, in-home manner also brings about spiritual and mental comforts\u0026rdquo; (NS-3).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbout institutional nursing care, a Shanghai respondent with uremia, expressed a desire for improved services, \u0026ldquo;\u003cem\u003eI need to take a wheelchair and be accompanied. The companion service is not on the service list, so my application was refused. My nursing assistant said she would be punished if being found to go out without regular procedure!\u0026rdquo; (P-1).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs regards hospital nursing care, a 91-year-old single elderly from Suzhou shared her utilization experience of discharge preparation, \u0026ldquo;\u003cem\u003eI am complete immobility for two years, and the shuttle bus between hospital where I have rehabilitative care and nursing home provides great convenience. I might apply for one hospice bed when I am dying.\u0026rdquo; (P-10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn summary, through the extraction of key themes based on the five dimensions, underlying relationships are identified as in-depth theoretical contributions, leading to the development of an integrated three-layer framework which is anticipated to hold regional reference significance, as shown in Figure 1 for details.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the largest pilot trials of LTCI with the most aging population, the policy implementation and the national-level institutional preparation in China reflect a \u0026ldquo;social model\u0026rdquo; orientation, which breaks through the cognitive barriers of \u0026ldquo;disability is individualized\u0026rdquo; and reconstructs governmental and public responsibilities towards disability. Moreover, to the best of our knowledge, this is the first study of its type with an endeavor to integrate a framework of public LTCI system by identifying and structuring key influential dimensions from pilot cases in mainland China. The framework architecture highlights the internal three-layer structure of LTCI, including the specific functions performed within each layer. Additionally, the framework aims to dynamically outline the interconnectivity among these layers, allowing for a comprehensive understanding of how different layers interact and work together to achieve the overall goals of the program.\u003c/p\u003e \u003cp\u003eAs the initial layer of the LTCI framework demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, interaction occurred between government liability and operating agent is examined from a macro perspective and concluded that an overall trend is towards a collaborative partnership with bilateral participation between public and private sectors, which is in line with some research opinion of developing public LTCI with more private sectors accompanying [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. That is to say, all five cities prioritize a path selection of social insurance model as the operational logic, neither a complete universal government allowance nor direct commercial insurance, but combining both to varying degrees. The concept of a \u0026ldquo;game degree\u0026rdquo; is thus employed to encapsulate the zero-sum relationship between governmental intervention and organizational participation. This perspective allows to understand the continuum of power implementation, which involves varying degrees of authoritative control and power release, and a nuanced recognition of how government intervention and organizational participation interact within the LTCI framework is gained.\u003c/p\u003e \u003cp\u003eAs a pillar link, the middle layer of the framework serves as a crucial part emphasizing financing as an indicator of the supply side and the beneficiary as an indicator of the demand side. These aspects inherently represent the central dimensions and require careful consideration of efficiency and fairness from both ends of the system. It is firstly innovative to typologize LTCI into ELTCI and RLTCI as two tracks in this study, which lays an understandable foundation for further analysis of proportional financing and quota financing. Based on accurate settlement and cost-effective budget, varying degrees of refinement and innovation of the ongoing financing have also been identified, e.g., Nantong\u0026rsquo;s \u0026ldquo;insurance type-based proportional financing\u0026rdquo;, Nanjing\u0026rsquo;s \u0026ldquo;age-based quota financing\u0026rdquo;. When determining eligible individuals as end users, an inclusive concept of \u0026ldquo;big disability\u0026rdquo; is adopted to promote the idea of comprehensive insurance coverage that does not discriminate any age or specific types of disabilities. Some pilot practices echo this view, e.g., Nantong, Changzhou, and Nanjing enlarge their insurance generosity to include juvenile disability aged above 6 and disabled children aged 0\u0026ndash;6 years old. In view of this, a complete set of evaluation tools equipped with a comprehensive guidance manual turns out to be the key means to implement the above humanized screening design to the greatest extent. Therefore, it is crucial to establish a care supply structure that aligns closely with funding basis and evaluation system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the bottom layer, a careful consideration of graded \u0026ldquo;exquisite care\u0026rdquo; is positioned to prevent the repetitive production of homogeneous care services. Such a phenomenon often leads to the \u0026ldquo;crowding-out effect\u0026rdquo;, where an excessive focus on low or medium levels of care hampers the cultivation of a higher-level service market. The market characterized by excess or insufficient supply of services, hinders the unimpeded switching between different care models. Furthermore, it is important to avoid the imposition of improper categorization of nursing care, as it can lead to unintended consequences such as exacerbating the severity of beneficiaries\u0026rsquo; functional conditions. Instead of pursuing continuous but ineffective growth, this study suggests straightening out a laddered structure of care supply\u0026rsquo;s production chains based on the \u0026ldquo;grading care\u0026rdquo;. This approach emphasizes the ultimate significance of constructing the public LTCI, which lies in providing the most appropriate and suitable nursing care. More than that, a sound nursing care supply layer can in turn help polish the upper financing and eligibility links, to form an internal circle and promote a more rationalized public LTCI framework.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePolicy and practice implications\u003c/h2\u003e \u003cp\u003eConcerning the institutional references, pioneering OECD countries usually run LTCI systems in varying typology of policy-making regimes, e.g., \u0026ldquo;universal care allowance\u0026rdquo; in Nordic countries, \u0026ldquo;social insurance model\u0026rdquo; sustained by the public social insurance and the \u0026ldquo;pay-as-you-go\u0026rdquo; manner in Germany, the Netherlands, Japan, etc., \u0026ldquo;commercial insurance model\u0026rdquo; targeting low-income elder disabled with low-degree \u0026ldquo;safety net\u0026rdquo; function by means-tested assessment in the United States and Britain, and \u0026ldquo;mixed model\u0026rdquo; combining universal care allowance with marketized care insurance in France [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. China\u0026rsquo;s public LTCI program takes a socialized design logic, mainly reflected in its joint payment mechanism to secure sustainable operation with moderate public sector involvement and modest government funding. On this basis, it is also recommended to launch private LTCI as an effective supplement especially when an ever-increasing scale of nursing care needs is anticipated to overflow the current payable care supply categories, which can refer to a study in Hong Kong to start a private LTCI plan [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It is explicated that commercial LTCI can efficiently and accurately capture the needs of the insured individuals and their families with high purchasing power, and optimizes care products especially when nursing levels rise with the aggravating extents of the disability plights. A path selection of properly integrating public LTCI and private LTCI as two symbiotic and complementary secondary systems, would be more suitable for the policy design of the \u0026ldquo;sixth pillar insurance\u0026rdquo; in China.\u003c/p\u003e \u003cp\u003eAt the practical level, the China Banking and Insurance Regulatory Commission issued \u0026ldquo;A Notice on the Pilot of Conversion of Life Insurance and Long-term Care Insurance Liability Business\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Conversion business refers to the conversion of \u0026ldquo;death or maturity payment liability\u0026rdquo; in life insurance policies into \u0026ldquo;nursing payment liability\u0026rdquo; in the LTCI system, so that individuals can receive insurance benefits in advance when entering the designated nursing state due to a specific disease, accidental injury, etc. in fact, several insurance companies have begun to identify products that can be used for the conversion business since 1st May 2023. Rather than post-compensation after death, conversion business is a prepayment mechanism for life insurance benefits, which makes full use of the existing insurance products to improve the supply capacity of LTCI, and releases the beneficiaries\u0026rsquo; out-of-pocket pressure.\u003c/p\u003e \u003cp\u003eAside from an integration of public and private LTCI systems, an integrated policy design of urban and rural tracks into a unity should also be considered to reduce the urban-rural discrepancies. This is consistent with some literatures that LTCI triggered discrepant health outcomes [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and may not improve the self-rating health of rural older beneficiaries [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], especially for the low-income groups or who has no formal job to obtain a pension and to afford out-of-pocket expenses [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Although the provision of graded nursing care services in kind is the mainstream benefit of LTCI for now, it is also suggested that different amounts of cash payments be allocated to rural areas where LTC infrastructure is inaccessible and the healthcare delivery system is scarce, which echoes some scholars\u0026rsquo; call for the central government to make financial transfers to support rural regions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding policy and practice implications for the quality of care, it is essential to increase the proportion of geriatric medicine and nurses to enhance the professional weight of care supply. However, if calculated at a 1:4 service ratio, a vacancy of 2\u0026nbsp;million of paramedics and medical social workers needs to be filled [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In Korea, the assessors who carry out assessments and grade the recipients for LTCI services are primarily social workers or staff with nursing background from the National Health Insurance Corporation which is a public organization [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but in China, nursing staff almost come from unemployed people who are for poverty alleviation purposes and lack knowledge about diseases, let alone only 10% of the 1,500 primary nursing staff finishing training remained at their jobs after six months when the author conducted the fieldwork in Kunming, Yunnan Province [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Besides, though domiciliary services are the most popular LTCI services in East Asian countries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], there are less than 1\u0026nbsp;million in-home employees in China, merely 20,000 of whom obtain professional certificates annually [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It is advised to improve the coverage rate of \u0026ldquo;family doctor contract services\u0026rdquo; for expanding the use of \u0026ldquo;home bed system\u0026rdquo; and \u0026ldquo;domiciliary diagnosis service\u0026rdquo;, and to implant more medical proportion when delivering the \u0026ldquo;institutional nursing care\u0026rdquo;, such as expanding the \u0026ldquo;therapeutic beds\u0026rdquo;. Concerning \u0026ldquo;inpatient nursing care\u0026rdquo;, it is proposed to strengthen the construction of geriatric departments in general hospitals and to get cross-departmental mutual recognition by promoting the \u0026ldquo;two-way referral mechanism\u0026rdquo; between medical care, rehabilitative care, and nursing care. Except for enhancing the irreplaceable \u0026ldquo;nursing weight\u0026rdquo; in each nursing fields, it is recommended to expand the pilot practice of hospice care via vocational training, to achieve a care supply path covering the entire life cycle.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn contrast to simply providing post-illness financial compensation, this study highlights the public LTCI program as an independent \u0026ldquo;sixth pillar insurance\u0026rdquo; in China, with its insurance-based institutional construction providing a front-end screening mechanism for risk control of the disabled groups. This mechanism focuses on improving the functionality of ADLs, and mental health outcomes, and reducing the frequencies of outpatient visits, hospitalizations, and length of stay. These findings are closely consistent with earlier research, which demonstrated that the introduction of public LTCI in China resulted in a 41% reduction in hospital stay duration, a 17.7% decrease in inpatient costs, and an 11.4% reduction in medical insurance costs in tertiary hospitals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnder an integrated multi-layered framework, some institutional commonalities can be concluded: (1) At the individual level, the identification of beneficiaries follows a forward-looking strategy based on the benchmark line of \u0026ldquo;high risks, high nursing levels, and strict product requirements\u0026rdquo;. This approach is aimed at implementing the pilot program and building institutional confidence through a stage-wise emphasis on individuals with moderate and severe disabilities. Moreover, there is strong advocacy for the concept of \u0026ldquo;big disability\u0026rdquo;, and this inclusive approach recognizes the importance of not limiting access to LTCI based on age or specific disability categories. (2) Multi-faceted compatible evaluation mechanisms are put in place to optimize reimbursement rates and expand coverage to include child and juvenile disabilities. (3) Double-track financing mechanism is implemented to store a stable pool of insurance funds, requiring both inter-generational liability and equality to safeguard the long-term sustainability of LTCI program. (4) Calling for a \u0026ldquo;graded care supply\u0026rdquo; structure through which stakeholders with product manufacturing capability could access more participatory space and run in an \u0026ldquo;organic unity\u0026rdquo; within the LTCI\u0026rsquo;s institutional architecture. In short, although China\u0026rsquo;s LTCI is still in a relatively scattered pilot stage and full of various experimental plots, it will be the trend to promote an integrated multi-dimensional framework to unify the public LTCI system nationwide, without too much urban-rural duality, age and gender discrimination, etc.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.W. and Z.R.L. contributed to the design of the study. C.W. analysed and interpreted the results\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eand wrote the first draft of the manuscript and Z.R.L. and W.J.R. contributed to the manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eby critical revisions and giving comprehensive feedback on multiple drafts. All\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eauthors read\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eand approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project has reveived funding from the National Social Science Fund under the grant agreement 20BSH56.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the fundings of this study are not publicly available but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was ethically approved by the ethics committee of Nanjing University of Science and Technology. All participating respondents gave informed written or verbal consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBendix R. Kings or people: Power and the mandate to rule. Berkeley: University of California Press; 1978.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell JC, Ikegami N, Gibson MJ. Lessons from public long-term care insurance in Germany and Japan. 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Int J Health Plann Manage. 2019;34(4):1661\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/hpm.2879\u003c/span\u003e\u003cspan address=\"10.1002/hpm.2879\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 2 are available in the Supplementary Files section.\u003c/p\u003e"},{"header":"Chart","content":"\u003cp\u003eChart 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"East China, public long-term care insurance, integrated framework, big disability, graded care supply","lastPublishedDoi":"10.21203/rs.3.rs-6124261/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6124261/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe growing prevalence of \u0026ldquo;longevity but unhealthiness\u0026rdquo; poses a significant burden on over one hundred million households in China, promoting the construction of long-term care insurance (LTCI) as a formal source of care option tailored for the increasing older individuals. This qualitative exploratory study focuses on five neighboring cities situated along the Yangtze River Economic Belt in East China. Firstly, an extensive thematic analysis of LTCI-related policy documents was conducted to extract textual data. This analysis extracts five dimensions including \u0026ldquo;government liability\u0026rdquo;, \u0026ldquo;operating agent\u0026rdquo;, \u0026ldquo;beneficiary eligibility\u0026rdquo;, \u0026ldquo;fundraising source\u0026rdquo;, and \u0026ldquo;care supply\u0026rdquo; to provide a visual demonstration of the intercity similarities and variations. Secondly, 22 in-depth interviews were conducted via purposive and snowball-sampling methods. A three-stage thematic analysis was employed to further construct a five-dimensional structural design and uncover their inner interrelationships, with a goal of optimizing a three-layer integrated LTCI framework that holds regional reference significance.\u003c/p\u003e","manuscriptTitle":"From Fragmented Trials to Integrated System: A Selective Examination upon the Public Long-Term Care Insurance Pilot Project in East China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-18 04:49:17","doi":"10.21203/rs.3.rs-6124261/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"db4a022a-cd4c-4440-bcf9-e7eac3ef25ff","owner":[],"postedDate":"March 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-18T04:49:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-18 04:49:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6124261","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6124261","identity":"rs-6124261","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}