Since 2026, China's long-term care insurance (LTCI) scheme has shifted from local pilots to nationwide implementation. Amid moderate population aging, nationwide LTCI is essential for equitable access to care for people with disabilities and the sustainable development of an aging society. The Urban and Rural Resident LTCI scheme covers non-employed residents and is financed by individual contributions and government subsidies. This study examines fund balances, regional disparities, and central-local fiscal responsibilities across 31 provincial-level regions in Chinese mainland during 2026-2036.
The data and methods are as follows. First, using China's 2020 Seventh National Population Census and statistical yearbooks, the cohort-component method is employed to project population by urban-rural residence, age, and sex, accounting for urbanization and interprovincial migration. Second, using the 2018 and 2020 waves of the China Health and Retirement Longitudinal Study (CHARLS), a Markov model is constructed based on six activities of daily living (ADLs). Transition probabilities are estimated among five states—independent, mildly disabled, moderately disabled, severely disabled, and deceased—to project disability prevalence among the older population. Third, based on China's existing LTCI pilot policies, annual benefits under the low, medium, and high scenarios are set at 10%, 20%, and 30% of each province's previous-year per capita disposable income, respectively. In accordance with Chinese policies, the 31 provinces are grouped into five tiers. The central government covers 80%, 60%, 50%, 30%, and 10% of government subsidies in these tiers, respectively, with local governments covering the remainder. Fourth, national and provincial policies guide enrollment and contribution rates. Fund revenue, expenditure, balances, and government subsidies are estimated to assess provincial financial sustainability and central-local fiscal responsibilities.
The findings are as follows. First, provincial financial sustainability under the medium-benefit scenario falls into five categories, whereas the high-benefit scenario increases the number of provinces experiencing deficits. Population aging, the size of the adult contributing population, enrollment rates, contribution rates, and benefit levels explain regional disparities. Second, central subsidies as shares of central general public budget revenue, expenditure, and outstanding central government debt peak in 2033 at 0.181%, 0.415%, and 0.046%, respectively. Tiered central subsidies alleviate local fiscal burdens but cannot eliminate structural pressures in regions experiencing advanced population aging and net population outflows.
Policy recommendations include shortening the contribution-rate transition period or temporarily increasing contribution rates in regions with persistent deficits. For provinces with limited fiscal capacity, annual benefit caps should initially be set at 30% of residents' previous-year per capita disposable income, while benefit levels should reflect care costs and actuarial balance. Fiscal burden-sharing should account for demographic structure and fiscal constraints while strengthening provincial pooling and interregional transfers.
This study makes three contributions. First, it extends analysis from local pilots to all provincial-level regions and identifies regional differentiation driven by demographics, financing capacity, institutional parameters, and fiscal capacity. Second, it addresses the understudied resident LTCI scheme and redefines its funding sources under current policies, aligning actuarial assumptions with institutional arrangements. Third, it develops an actuarial framework linking fund operations to fiscal responsibilities. These findings inform enrollment expansion, contribution rates, benefit levels, fiscal capacity assessment, and intergovernmental burden-sharing to promote equitable access to basic long-term care.
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