Long-term care insurance pilots and a severe care-gap proxy among older adults in China: evidence from CHARLS,...

China's long-term care insurance (LTCI) pilots aim to support older adults, but evidence on whether policy rollout is followed by reduced care gaps among functionally limited older adults remains limited.

Using CHARLS 2011-2020, we included respondents aged 60 years or older at first observation and estimated a staggered difference-in-differences model comparing early-adopter pilot cities with never-pilot cities. The primary outcome was a severe care-gap proxy, defined as ADL/IADL difficulty with no help. This estimand describes care-gap trajectories among older adults with functional limitations, not effects among confirmed LTCI beneficiaries or formally eligible disabled older adults. We also examined whether estimates differed according to whether local policy texts explicitly included in-kind home- and community-based services (HCBS), including home-visit provision.

In early-adopter pilot areas, adoption was associated with a higher severe care-gap proxy by 2020 (ATT 0.023; 95% CI 0.001-0.045). The proxy showed high specificity and positive predictive value but limited sensitivity against 2020 activity-level unmet-need items. Estimates were directionally larger in cities without explicit in-kind HCBS wording, and formal/community home-based care did not measurably expand over the same period.

The observed 2020 pattern should be interpreted cautiously because pandemic disruption, measurement differences, attrition, and compositional shifts may have contributed. The findings support nursing-centered monitoring of severe care-gap indicators during policy rollout and more explicit attention to service activation pathways.