Pilot for nearly a decade, how does long-term care insurance support 35 million disabled elderly people?

Bitter medicine, disinfectant smell mixed with sweat and urine hit him in the face. Even wearing a double mask, he almost was “sent away.”

Liu Yi still remembers the first time he stepped into a client’s home: the weather was hot and stuffy. When he opened the door, an elderly person with disabilities was lying on a messy bed. The 39-year-old Liu Yi described the smell as “the scent of twilight.”

Previously, Liu Yi was a builder with 12 years of experience. In 2024, he left the declining construction industry to explore a new career path. After several setbacks, he attended training for elder care workers, obtained a certification, and started working at a care station in Changning District, Shanghai. Now, he has been a long-term care insurance caregiver for nearly half a year, helping disabled seniors turn over, wash, and massage—his daily routine.

According to the fifth nationwide sampling survey of the living conditions of urban and rural elderly conducted in 2021 by the Ministry of Civil Affairs, the National Aging Office, and four other departments, China has about 35 million disabled elderly. By 2035, this number will reach 46 million, and by 2050, around 58 million.

Data from the National Bureau of Statistics show that by the end of 2025, China’s population aged 60 and above will be about 323 million. This means that among every ten seniors over 60, one may need care from others.

Long-term care insurance aims to provide nursing services for disabled seniors, easing family caregiving burdens, and is also called the “sixth social security insurance.” Starting as a pilot in 15 cities including Shanghai, Ningbo, and Changchun in June 2016, the program expanded to 49 cities by September 2020.

After nearly a decade of pilot programs, long-term care insurance is entering a countdown to nationwide implementation. At the National Conference on High-Quality Development of Long-Term Care Insurance held on December 22, 2025, Zhang Ke, Secretary of the Party Leadership Group and Director of the National Healthcare Security Administration, stated, “‘The 14th Five-Year Plan’ period will see the long-term care insurance system shift from pilot to full-scale establishment.”

The “14th Five-Year Plan” also emphasizes actively responding to population aging, improving policies for the development of elderly care services and industries, implementing long-term care insurance, establishing a comprehensive care system for the disabled and cognitively impaired elderly, and expanding rehabilitation and palliative care services.

In 2026, elderly care issues will be a focus at the National Two Sessions, and improving the long-term care insurance system will be a key topic.

For example, National People’s Congress (NPC) deputy Yan Jianguo suggested quickly drafting a “Long-Term Care Insurance Law” to unify standards across provinces and cities; Chinese People’s Political Consultative Conference (CPPCC) member Liu Meilin proposed improving fairness and convenience of the system by standardizing assessment procedures, refining benefit mechanisms, and strengthening process supervision.

Xu Yongguo, Executive Director of the Healthy Yangtze River Delta Research Institute at Shanghai Jiao Tong University, pointed out that transitioning from pilot to full-scale requires forming an inclusive system covering rural and remote areas. Challenges include sustainable funding, uneven service supply between urban and rural areas, and inconsistent standards across regions.

Liu Yi checked on the bedridden elderly person, helping him wash his body. Ni Yuyao / Photo

Easing the Burden on Caregivers

Elderly people have varying degrees of disability, requiring different types of care.

Led by Peking University’s National Development Research Institute, the “China Health and Elderly Tracking Survey” classifies disabled seniors into three levels: mild disability with limited complex abilities like financial management and shopping; moderate disability with 1-2 basic activities like dressing, bathing, and toileting affected; and severe disability with more than three basic activities impaired.

Zhang Yue is an only child. Her social media bio reads: “Full-time caregiver, looking for part-time work.”

In 2022, her 74-year-old father suddenly suffered a stroke. Zhang Yue had to interrupt her life in New Zealand and return to Shanghai to care for her father with her mother. Over the past few years, her father tried various elder care products, staying in health resorts, nursing homes, and retirement communities, but none were satisfactory.

After falling ill, her father became stubborn and dependent on family. While in the care home, he would call his daughter multiple times a day. Zhang Yue couldn’t focus on her job and had to resign, bringing her father home to care for him, while earning some pocket money through part-time work. “Staying at home with the old folks every day, I also feel lost and get angry sometimes.”

After her father became unable to care for himself, Zhang Yue and her mother learned about long-term care insurance. In Shanghai, employees or residents with medical insurance over 60 years old can apply if disability persists for more than six months. After a unified assessment of elderly care needs, seniors with disability levels from 2 to 6 can receive corresponding care services. Each assessment is valid for up to two years.

In 2023, Zhang Yue’s mother applied for long-term care insurance for her father through their community. The assessment classified him as level 3 disabled. He can receive three home care visits per week, each lasting one hour.

The most important benefit of long-term care insurance for Zhang Yue was solving the problem of bathing her father. Bathing a person with limited mobility is physically demanding: first, help him sit steadily on a shower stool, support his shoulders and back, then carefully wipe his neck, arms, and torso.

Previously, Zhang Yue and her mother had to work together to bathe her father. He was proud and wanted to do it himself, but once he slipped and fell in the bathroom.

“Every time we bathed him before, we’d argue,” Zhang Yue said. With a caregiver coming to help, her father gradually let go of his pride and no longer insisted on doing it himself. “It’s like a ‘release’ for us, and we can rest a little.”

Many families like Zhang Yue’s are trapped in caregiving. In 2024, the “China Elderly Health Report” jointly released by Wuhan University and Peking University pointed out that 99% of disabled seniors are cared for by spouses and children, with only 1% receiving formal professional care.

Behind disabled seniors are family members burdened with caregiving. “One person’s disability throws the whole family off balance”—this is their dilemma.

Sociologist Wu Xinyue, teaching at Southeast University’s School of Humanities, is conducting research on long-term care insurance in a county under Suzhou, Jiangsu Province, from 2024 to 2025. She noted, “Family members caring for elderly with long-term disabilities also face higher risks of mental and physical health issues. Long-term care insurance provides these caregivers with some breathing room.”

Wu Xinyue recounted an encounter with a mother and daughter: the mother was diagnosed with Alzheimer’s, sometimes lucid, sometimes confused. The daughter had to stay by her side constantly, and over time, her emotional health deteriorated. In 2020, the mother applied for long-term care insurance, and during caregiver visits, the daughter could go out for walks or meet friends. “These times and spaces help caregivers regain some energy.”

“The establishment of long-term care insurance turns family caregiving from an isolated, helpless private matter into a system-supported public service,” Wu Xinyue told Southern Weekly.

The Stigma of “Grandma Posts”

“Used to draw blueprints with my hands, now I have to handle feces and urine.” When switching careers, Liu Yi also struggled with pride and had to process feelings of shame and disparity.

During caregiver training, most classmates were older women. When they saw this “well-educated young man,” they felt puzzled and asked him if he was in debt to do this job. Some elderly asked him, “You an architect, serving people—aren’t you lowering yourself?”

In Shanghai, about 56,000 long-term care insurance-certified caregivers like Liu Yi work in a city where 37.6% of the registered population is over 60.

Shanghai was one of the earliest cities to pilot long-term care insurance. Since January 2018, the city has fully implemented the system, establishing a comprehensive process from application, assessment, service, settlement, to supervision.

Data from the Shanghai Aging Work Committee, Civil Affairs Bureau, and Statistics Bureau show that in 2024, the city provided 3.535 million home care services under long-term care insurance.

In the caregiving industry, male caregivers like Liu Yi are rare. Among the over 200 caregivers at his current station, only eight are men, who call themselves the “Eight Golden Men.” Men have advantages in physically demanding tasks like bathing, lifting, and turning elderly men.

Wu Xinyue describes long-term care insurance caregivers as “grandma posts.” Most are middle-aged or older rural women who provide home care during the day and return home at night to care for grandchildren.

Media worker Zhang Shanbin has been paying attention to the elderly care industry since 2023. He found that many caregivers have low educational levels. “In many people’s eyes, caregiving is dirty, tiring work with no future.”

The “2025 Elderly Caregiver Occupational Status Survey” by Fushoukang Group, Renmin University, and Shanghai Jiao Tong University shows that 83.25% of domestic elderly caregivers are aged 40-59, less than 2% are under 30, and 89.25% are women.

Caregivers are highly mobile. Some leave their clients when they move, others return home after a few years and leave the industry altogether.

The report states that China faces a shortage of 5.5 million elderly care workers, with a turnover rate of 40-50%.

In Zhang Shanbin’s view, Japan’s care worker system offers lessons for China.

A care welfare worker in Japan provides professional care for disabled and cognitively impaired individuals. Becoming one requires systematic study, internships, and passing a professional exam. The 1987 “Social Welfare and Care Welfare Worker Act” regulates and guarantees this profession.

In many Chinese cities’ long-term care insurance regulations, caregivers are only allowed to provide care services, not household chores like cleaning or cooking. Wu Xinyue said this prevents caregivers from being treated as “cheap nannies.”

However, she knows many caregivers “conveniently do housework,” even if it takes extra time. For example, after bathing and clocking out, they wash the clothes of the elderly, help with eating, and wash dishes—feeling guilty if they don’t finish.

Wu Xinyue believes that strictly separating care services from household chores doesn’t match daily caregiving logic. She suggests that China’s long-term care insurance could learn from Japan and Germany, expanding service scope to include daily living assistance and social support, leaving room for flexible service plans.

Longfang, working at an elderly care company, holds a master’s in social work from East China Normal University and has conducted field research on female workers in Shanghai’s long-term care insurance sector. She describes these women as “strong, energetic subjects.” Even when their own lives are difficult, they try to bring warmth to the elderly.

In nearly half a year of work, Liu Yi has served over thirty elderly people of various backgrounds. He has encountered kindness and also faced scolding and cancellations.

On his third day on the job, the care supervisor assigned him two elderly clients. To get “orders,” he had to do trial shifts. Only after gaining approval from the elderly and their families could he become a regular caregiver, visiting regularly under the long-term care insurance level, providing one hour of home service.

Services include rehabilitation, assistance with eating, and cleaning. Each time, Liu Yi chooses 2-3 items based on needs. All visits are logged with GPS and photos via dedicated software.

Initially, Liu Yi could only serve one or two seniors a day, but now he handles seven or eight. What truly made him accept this profession was the sincere acceptance from the elderly.

He recalls after caring for a nonagenarian grandfather, the old man insisted on seeing him off at the door. Over time, Liu Yi realized he wasn’t doing “low-level work” but providing “critical life support.”

Many regard Liu Yi as an indispensable family member, affectionately calling him “Little Six.” Sometimes, when the elderly’s family goes out, they trust him enough to leave the door open for his visits.

The Fragile Care Market

“Finding a suitable caregiver isn’t easy,” laments Shanghai resident Zhou Yun.

Her mother has been using long-term care insurance since 2021 and has changed four caregivers, with the shortest stint only a month or two. One left due to moving, another was dismissed for irresponsibility. Zhou Yun and her mother have to constantly adapt. “Caregivers vary a lot. Every time we get a new auntie, it takes half a year to a year to get used to her.”

Xu Yongguo pointed out that the long-term care insurance market and regulation often fail simultaneously. The demand side involves people with limited mobility and decision-making ability; the supply side involves non-standardized, emotionally warm, close-contact care, which is hard to ensure quality through pricing. “If a caregiver gives you a bad look or doesn’t care, it’s subjective and hard for third parties to supervise or judge.”

Most services happen in private spaces like homes, making it hard to verify care actions, and insurance fraud cases occur from time to time. The Shanghai Higher People’s Court once reported a case: in 2020, a caregiver in Jiading District colluded with a disabled senior’s family, regularly falsifying “clock-ins” without actual service, and sharing the insurance funds—illegally obtaining about 48,000 yuan over a year.

To address such issues, the national healthcare security administration and other departments have strengthened fund management, using big data comparison and intelligent risk control to verify service authenticity and prosecute serious violations.

Funding for long-term care insurance also draws attention.

Currently, China’s funding models include fixed-rate, fixed-amount, and mixed approaches, with contributions from individuals, employers, medical insurance funds, and government subsidies.

The “Shanghai Long-Term Care Insurance Pilot Measures” issued in 2025 stipulate that 0.5% of the employee medical insurance contribution base is allocated from the medical insurance fund to long-term care; the contribution rate for residents’ medical insurance is slightly lower than 0.5%.

Chengdu, Sichuan, adopts a “fixed percentage for employees and fixed amount for residents” mixed funding model. Employees contribute based on age-based brackets, transferred from the medical insurance account; residents pay a fixed amount, funded by personal payments and government subsidies.

According to Shanghai’s current regulations, long-term care services are divided into three types: community home care, institutional care, and inpatient medical care. In community home care, the price for a licensed nurse is 80 yuan/hour, medical caregivers are 65 yuan/hour, and other personnel like elderly care workers and health aides are 40 yuan/hour. These costs are covered 90% by the insurance fund, with individuals paying about 10%.

“In other words, each service costs only about six or seven yuan for the individual,” says Zhang Yue. Her father receives home care services provided by a medical caregiver.

Her father is a retired urban worker. He can enjoy three one-hour home care visits per week. Family members settle the service fees at the care station every 1-2 months. If he receives 12 visits a month, the total cost is 780 yuan. The individual pays only 78 yuan, with the rest covered by the insurance fund.

Zhang Yue’s concern isn’t the affordability but whether the low price can sustain long-term operation. She suggests increasing the individual payment share to promote a healthy cycle through proper pricing.

The high-level long-term care insurance conference disclosed that, as of now, the system covers about 300 million people, benefiting over 3.3 million disabled individuals, with fund expenditures exceeding 100 billion yuan, reducing individual burdens by an average of 12,000 yuan annually.

Xu Yongguo believes that allocating medical insurance funds is a temporary measure. To prevent long-term care expenses from squeezing other medical protections, future funding should be diversified—such as increasing contributions from individuals and employers, and exploring public welfare funds.

Some cities like Weihai in Shandong and Hanzhong in Shaanxi are experimenting with supplementing long-term care insurance funding through lottery welfare funds and social donations.

Zhou Yun’s mother is severely disabled and needs daily care under long-term care insurance. However, Zhou Yun feels that one hour per session isn’t enough. Some seniors with mild disabilities only need twenty or thirty minutes of care. “Caregivers only need twenty or thirty minutes to look after the elderly, and the rest of the time is idle.”

She hopes future long-term care insurance can offer more flexible service options, such as professional caregivers for at-home disabled elderly.

Currently, many caregivers work on a “run-around” basis. In Shanghai, for example, caregivers serve each household for one hour, sometimes working from 7 a.m. to evening. “Many caregivers don’t want to run around every day,” Zhou Yun said. The home-based model can meet the needs of severely disabled seniors and reduce caregivers’ commuting, making their income more stable.

Severely disabled seniors require higher-level care. This space may be supplemented by commercial long-term care insurance in the future.

However, the market for commercial long-term care insurance remains small. The “Health Insurance Outlook Report 2026” by Taikang Times Research Institute shows that in 2025, China’s total health insurance premium was about 944 billion yuan, with long-term care insurance accounting for only 9%.

Senior insurance broker Chen Ming, who managed the company’s long-term care insurance business, pointed out that young and middle-aged people have a low probability of disability or dementia, so few would buy a product that might only be used decades later. But for disabled seniors to enjoy quality long-term care insurance, insurers must bear high costs. “For insurance companies, such products are not attractive in the market.”

Walking with the Elderly to the Final Downhill

Rural elderly care and disability issues are even more severe but often overlooked.

The fifth nationwide sampling survey shows that 13.9% of elderly in rural areas cannot care for themselves, compared to 9.6% in urban areas.

In recent years, many NPC and CPPCC representatives have focused on rural elderly care. In 2025, NPC deputy Liu Xiaoqing suggested expanding the pilot scope of long-term care insurance to include rural residents gradually. In 2021, CPPCC member Jiang Liping emphasized increasing investment in rural long-term care infrastructure and encouraging social organizations and capital to participate.

Wu Xinyue found in her research that rural families are reluctant to pay for long-term care. They are willing to accept free services but will quickly leave if asked to pay. Therefore, in some areas, long-term care insurance relies heavily on government subsidies and the care institutions subsidize part of the costs.

Many rural elderly have been frugal all their lives and see spending money on elder care as “luxurious.”

In Xu Yongguo’s impression, older generations in rural areas often prepare for their own death early but rarely plan for retirement. “They never think about themselves, only saving more for their children so as not to burden them,” he said.

Zhang Shanbin also mentioned that many people focus on their children’s growth but neglect their own retirement. “Raising children is an investment that brings returns; aging is subconsciously seen as a drain.”

“Rural elderly have low income and more severe disability and dementia issues, which are real challenges for the promotion of long-term care insurance,” Xu Yongguo said. “We need to spend wisely and encourage the integration of technology and elderly services to reduce labor costs.”

As a former architect, Liu Yi often observes age-friendly renovations in clients’ homes. He believes that one major reason for the difficulty in promoting elder care devices and services is that people “refuse to accept aging,” thinking these are “the materialization of decline.”

While helping a disabled elderly person bathe, he noticed many scars on the person’s body from falls. The elderly didn’t want their family to worry and told Liu Yi, “Don’t tell anyone about my injuries.”

Liu Yi also experienced the helplessness of caregiving. When caring for a level 6 (highest level) disabled senior, he often wanted to give up. The elderly couldn’t move or speak, “life was on the edge of falling off a cliff.” Liu Yi felt he was facing a “silent black hole,” exhausting himself without hearing a word of thanks.

He said caregivers are the ones walking the last downhill with these elders. Months or even years of companionship deepen emotional bonds. A few years ago, Long Fang met a caregiver diagnosed with uterine fibroids. During hospitalization, her family rarely visited, but the elderly she served in a wheelchair came to see her.

On January 21, 2026, Liu Yi learned that the ALS patient he cared for had passed away. It was his first experience of life and death since starting the job. He shared on social media: “The old man has become a star, and I can look up at him from now on.”

(Note: Names like Zhang Yue, Zhou Yun, and Chen Ming are pseudonyms.)

Special Contributor to Southern Weekly Ni Yuyao

Editor: Huang Sizhuo