Behind 320 million elderly people: Why does the government take on the "household chores" for you?

Recently, the General Office of the Communist Party of China Central Committee and the General Office of the State Council jointly issued the Opinions on Accelerating the Establishment of a Long-Term Care Insurance System, clarifying the need to build a long-term care insurance system that covers all people, integrates urban and rural areas, and is fair and uniform. This means that long-term care insurance (LTCI) has officially moved from limited pilot programs to nationwide implementation.

Many people may wonder: Isn’t care work, for a long time, essentially a matter within families? Why does the country have to step in and set up a mandatory insurance system?

Starting from this question, I reviewed many papers and field research, and found that the answer lies both in Harvard law professor Martha Fattman’s “vulnerability theory” and in the real predicaments faced by tens of millions of Chinese families. Establishing LTCI, in essence, is about breaking the entrenched belief that “care is a private family matter,” revealing a deeper truth: what appear to be personal affairs—childbearing and caregiving—are in fact public matters that bear on social sustainability. And economic measures are the key lever for solving this dilemma.

First, let’s look at some figures. China’s elderly population aged 60 and above has reached 320 million. Among them, about 35 million are older adults who are unable to care for themselves. This means that caregiving pressure is spreading at an astonishing speed to tens of millions of families, and at bottom, this pressure is economic pressure.

The grassroots research by 半月谈 (China Half-Monthly) clearly presents the reality of rural elderly care. There, many older people receive only a little over 100 yuan per month in basic pensions. Faced with nursing home costs of two to three thousand yuan or more, they have become the “sandwich layer”—slightly better off than those receiving the “five guarantees” benefits, but worse off than people in cities. They cannot get into welfare institutions and cannot afford to hire care workers, so they can only “tough it out” by themselves.

A netizen from Gansu, in order to take care of his 82-year-old father, pays 1,000 yuan per month to have relatives help, yet he still can’t relax; a netizen from Anhui laments that with a pension of only a bit over 100 yuan per month, even routine medicine expenses are hard to cover, let alone dignified aging. The caregiving burden of more older adults who cannot care for themselves is either placed on their equally elderly spouses, or shouldered by children who are forced to quit their jobs. Family savings are consumed and the value of labor is sacrificed.

The predicament of rural elderly care is essentially a microcosm of structural weaknesses in the society-wide care system. A model that makes families bear the cost of care on their own is, at its core, shifting the cost of reproducing the labor force onto individual households—especially onto women. What happens as a result? An enormous number of families fall into a double drain of finances and energy, and labor supply and social consumption vitality are invisibly constrained. In plain terms, this is a lack of public responsibility, but it causes private costs to overflow without limit.

Long-term care insurance is precisely aimed at this dilemma.

So why must the state and society step in to deal with caregiving matters that were originally regarded as “private affairs”? The “dependency typology” theory introduced by Fattman, as cited in 郭晓飞’s Reimagining “Vulnerability,” offers a clear economic perspective.

Fattman divides dependency into two categories. One is “inevitable dependency”—infants and young children, older adults, and people with disabilities who are unable to live independently and must rely on others for care. The other is “derivative dependency”—those who are forced to invest time, energy, and money in caring for these groups, and who themselves also need support from external resources.

This typology punctures a widely held myth that has persisted for a long time: so-called “independence” is nothing more than an illusion. At some point in everyone’s life, they become “inevitable dependents.” And the “derivative dependency” of caregivers is, in reality, them taking on the cost of reproducing the labor force on behalf of society.

Fattman’s core argument is straightforward: the unpaid caregivers within families are actually subsidizing the entire society. Without this caregiving labor, no new labor force would emerge; without the dignity afforded to older age, there would be no basis to talk about intergenerational replacement and sustained development. Yet for a long time, we have simply categorized this labor with public value as a private responsibility of families. The most typical example is that many full-time women raise children and handle household chores at home but do not receive social recognition.

Of course, this is not a China-only problem. Harvard economist Reg Mankiw once likened childbearing to “buying a Porsche,” arguing that the costs should be borne entirely by individuals: “If you can afford a Porsche or a child, that’s great, but don’t expect others to pay.” However, he overlooks a key fact: automobile manufacturers can receive multiple state subsidies such as tariffs and infrastructure support, while caregivers who shoulder the responsibility of social reproduction can only fend for themselves.

This imbalance is not only unfair to caregivers, but also harms the public interests of society. When caregiving costs rise to a certain level, families either are forced to give up having children, or are dragged into poverty, ultimately leading to insufficient labor supply and a shrinking consumption market—forming a vicious cycle. This is also why, in our earlier series of “encouraging childbearing” articles, we repeatedly emphasized that caregiving for infants and young children requires public subsidies.

With the same logic, the nationwide rollout of long-term care insurance resolves this imbalance through economic measures. Its core logic is to convert the private costs of caregiving into public costs, so that the state, society, and individuals jointly share responsibility.

From the perspective of policy design, the use of economic measures is both pragmatic and precise.

On the financing side, it establishes diversified funding channels involving work units, individuals, the government, and society. The premium rates are uniformly controlled at around 0.3%, linked to income level—avoiding the burden becoming too heavy for any single entity while achieving shared responsibility. On the benefits side, it covers three caregiving modes: care at home, care in communities, and care through institutions. There is no deductible threshold. The payment proportion and maximum cap are clearly defined, enabling precise alignment with the core needs of people who cannot care for themselves. In terms of coverage, it includes everyone such as flexible employment workers and unemployed urban and rural residents, and gradually achieves full population coverage.

The rural “sandwich layer” older adults mentioned above can also be covered by long-term care insurance.

The economic significance of this system lies in the following: make hidden costs explicit, and socialize private spending, thereby releasing productive capacity that has been constrained. Based on pilot experience, the economic value of long-term care insurance has already begun to emerge. As of now, the pilots have covered about 300 million people, benefiting more than 3.3 million persons in need of long-term care, with fund expenditures exceeding one trillion yuan.

A rough estimate: if each care-need elderly person can thus release one family member’s labor capacity, the macroeconomic gains from the system’s operation will far exceed fund expenditures. It not only eases families’ financial pressure, but also drives the development of the care industry, creates new jobs, and forms a virtuous cycle of “safeguarding people’s wellbeing—boosting industries—promoting employment.”

More profoundly, when childbearing and caregiving no longer mean a cliff-like interruption in one’s career path, a gender-equal labor market can truly be established. This is, in fact, consistent with the “childbearing-friendly society” we advocate today.

These practices fully demonstrate that caregiving problems have never been purely private family matters. The state’s involvement in the caregiving field is not an overreach, but an active assumption of public responsibility. Using economic measures such as long-term care insurance to solve the caregiving dilemma is not merely providing welfare backstops; it is balancing costs and activating vitality through institutional arrangements.

Of course, even with nationwide implementation of long-term care insurance, many issues still need to be addressed. For example, insufficient sinking of professional nursing resources into rural areas; the sustainability of diversified financing mechanisms; and the standardization and professionalization of care services… At their core, these are still issues of rational allocation of economic resources and division of responsibilities.

As discussed in 半月谈, rural elderly care cannot simply copy the urban model, and implementing long-term care insurance also needs to be adapted to local conditions. In rural areas, it may be possible to consider combining a “village-and-community bloodmaking” approach, integrating caregiving services with mutual-aid elderly care among rural communities—reducing service costs while better fitting rural realities. Meanwhile, further improve the financing mechanism and encourage social capital to participate, so that the supply of caregiving services is more abundant and of higher quality.

Fattman uses vulnerability theory to reconstruct social contract theory. She argues that the state’s legitimacy lies not in preventing people from killing each other, as Hobbes described, but in actively responding to citizens’ most basic needs for social security. She says vulnerability is a universal condition of human beings, and responding to vulnerability has never been a matter of solitary struggle by individuals; it is a shared responsibility of the state, society, and families.

From this perspective, the comprehensive establishment of long-term care insurance is a key step for China toward a “responsive state.” When caregiving is no longer a one-man show for families, and when the costs of caregiving in the private sphere are reasonably shared, we can truly achieve “aging with support” for the elderly and “getting care when ill,” and be able to grow old with dignity.