Institute for Economic Studies, Keio University
Keio-IES Discussion Paper Series

The impact of contracting formal care benefits on caregivers’ well-being:
evidence from Japan
Rong Fu, Dung Le, Yoko Ibuka
10 March, 2023
DP2023-005
https://ies.keio.ac.jp/en/publications/22453/

Institute for Economic Studies, Keio University
2-15-45 Mita, Minato-ku, Tokyo 108-8345, Japan
ies-office@adst.keio.ac.jp
10 March, 2023

The impact of contracting formal care benefits on caregivers’ well-being: evidence fromJapan
Rong Fu, Dung Le, Yoko Ibuka
Keio-IES DP2023-005
10 March, 2023
JEL Classification: I14, I18, I31, I38
Keywords: formal long-term care; informal caregivers; well-being; difference-in-difference;
event study
Abstract
This study investigates how changes in formal care availability affect informal caregivers’
well-being, adding to the heated discussion on what constitutes an appropriate level offormal care that is both sustainable and adequate. We leverage a reform of Japan’s public
long-term care insurance, which contracted formal care benefits among a group ofrecipients. Using a difference-in-difference approach with fixed effects to a nationally
representative sample of informal caregivers, we examine the aggregated impacts of thereform and how they evolve over time. We find that the reform had a negative impact on
caregivers’ well-being, reflected in decreased mobility and stability, and increased stressfrom financial strains and domestic work. The negative impact was particularly pronounced
among female caregivers, while male caregivers experienced an improvement in mental
health, particularly those with higher income levels. The reform also led to an increased
likelihood of regular caregiving, which may contribute to the well-being decline. Additionally,
we find that the reform had negative effects on the well-being of care recipients, indicatingthat reducing formal care services is unlikely to have any positive impact on either the
caregivers or the recipients. The study highlights the importance of considering the wellbeing of both caregivers and care recipients when evaluating the cost-effectiveness of
reducing formal care availability and recommends policies that protect female caregivers
against health and financial issues.
Rong Fu
Faculty of Commerce, Waseda University
1-104 Totsuka-cho, Shinjuku-ku, Tokyo, 169-8050, Japan
nataliefu1988@gmail.com
Dung Le
KGRI, Keio University
2-15-45, Mita, Minato-ku, Tokyo, 108-8345, Japan
ldd@keio.jp
Yoko Ibuka
Faculty of Economics, Keio University
2-15-45 Mita, Minato-ku, Tokyo 108-8345, Japan
ibuka@econ.keio.ac.jp
Acknowledgement : This paper uses the confidential data provided by the Ministry of Health,Labour and Welfare (MHLW) (Approval number: 2020-0727-3). The data can be obtained bysubmitting an application to the MHLW
(https://www.mhlw.go.jp/toukei/sonota/chousahyo.html). The authors were financially
supported by the Open Research Area for the Social Sciences program (ORA) of the Japan
Society for the Promotion of Science (JPJSJRP20181403).

The impact of contracting formal care benefits on caregivers’
well-being: evidence from Japan1

Rong FU2, Dung LE3, Yoko IBUKA4This paper uses the confidential data provided by the Ministry of Health, Labour and Welfare(MHLW) (Approval number: 2020-0727-3). The data can be obtained by submitting an application to
the MHLW (https://www.mhlw.go.jp/toukei/sonota/chousahyo.html). The authors were financially
supported by the Open Research Area for the Social Sciences program (ORA) of the Japan Society for
the Promotion of Science (JPJSJRP20181403). Institutional Review Board approval was not requiredsince the authors used secondary data.
2
Corresponding author. School of Commerce, Waseda University, 1-6-1 Nishiwaseda, Shinjuku-ku,
Tokyo, 169-8050, Japan. Declarations of interest: none. E-mail: nataliefu@waseda.jp
3
Faculty of economics, Keio University, 2-15-45 Mita, Minato-ku, Tokyo 108-8345, Japan.
Declarations of interest: none. E-mail: ldd@keio.jp
4
Faculty of economics, Keio University, 2-15-45 Mita, Minato-ku, Tokyo 108-8345, Japan.
Declarations of interest: none. E-mail: ibuka@econ.keio.ac.jp
11

Abstract
This study investigates how changes in formal care availability affect informal caregivers’ wellbeing, adding to the heated discussion on what constitutes an appropriate level of formal care that isboth sustainable and adequate. We leverage a reform of Japan’s public long-term care insurance, which
contracted formal care benefits among a group of recipients. Using a difference-in-difference approachwith fixed effects to a nationally representative sample of informal caregivers, we examine theaggregated impacts of the reform and how they evolve over time. We find that the reform had a negative
impact on caregivers’ well-being, reflected in decreased mobility and stability, and increased stress fromfinancial strains and domestic work. The negative impact was particularly pronounced among female
caregivers, while male caregivers experienced an improvement in mental health, particularly those withhigher income levels. The reform also led to an increased likelihood of regular caregiving, which may
contribute to the well-being decline. Additionally, we find that the reform had negative effects on thewell-being of care recipients, indicating that reducing formal care services is unlikely to have any
positive impact on either the caregivers or the recipients. The study highlights the importance ofconsidering the well-being of both caregivers and care recipients when evaluating the cost-effectivenessof reducing formal care availability and recommends policies that protect female caregivers against
health and financial issues.

Keywords: formal long-term care, informal caregivers, well-being, difference-in-difference, event
study
JEL codes: I14, I18, I31, I38

2

1. Introduction
The rapid demographic transition, accompanied by global growth in the older population, hasintensified the need for long-term care (LTC) (Agree & Glaser, 2009). Research indicates that indeveloped and aging societies, such as Japan, family members constitute the primary caregivers forolder people (Colombo et al., 2011; Ministry of Health Labour and Welfare, 2014).
However, informal care power has been decreasing for decades, and this trend is expected tocontinue due to smaller family sizes, lower fertility rates, increased mobility of younger generations,and a higher proportion of women in the labor force, who are typically primary family caregivers. To
address this issue, many countries have established formal LTC systems. Japan was one of the early
adopters of such a system, implementing a public insurance scheme for LTC in 2000, which was
successful in supporting the elderly to lead independent lives with dignity and reducing the burden ofcare duties on family caregivers (Tamiya et al., 2011).
The growing demand for LTC, coupled with a decline in informal care, has placed significant
pressure on the fiscal sustainability of public LTC systems, especially given the global economic
stagnation. The annual growth rate of public LTC was 4.6% from 2005 to 2015 among OECD countries,
more than double the contemporary GDP growth rate (OECD, 2017). According to projections, publicresources devoted to LTC as a proportion of GDP may triple or more by 2060 (De La Maisonneuve &Martins, 2013). Therefore, balancing the provision of adequate formal care with ensuring the fiscal
sustainability of such coverage is one of the most challenging tasks for governments.
In response, many governments have implemented reforms on LTC systems, which often involve
lowering the level of welfare protection (Ranci & Pavolini, 2013). In this context, Japan implemented
a significant reform in the insurance system in 2006, aiming to maintain the system’s fiscal
sustainability by contracting formal care availability for a group of care recipients with moderate careneeds. However, contracting formal care raised public concern about potential decreases in both carerecipients’ and caregivers’ well-being, as informal care is a substitute for formal care, especially amongrecipients with moderate care needs (Bonsang, 2009; Bremer et al., 2017). Thus, ongoing discussions
3

revolve around what level of formal care is both sustainable and adequate. In particular, understanding
how changes in formal care availability affect informal caregivers’ well-being is critical from a policy
perspective.
To obtain this objective, we analyze the impact of the 2006 reform of Japan’s public LTC insurance
on caregivers’ well-being. Using a difference-in-difference approach with fixed effects, we examine theimpact of the reform on caregivers’ physical and mental health and how these effects change over time.
Our analysis reveals that reducing formal care has a negative impact on caregivers’ well-being,
manifested in decreased mobility and stability, as well as increased stress from financial and domestic
responsibilities. The reform led to an increased likelihood of regular caregiving, which may contributeto the well-being decline. However, the impact is not uniform across all caregivers. Female caregivers
are particularly vulnerable to the negative effects of a lack of formal care, while male caregivers withhigher incomes benefit from reduced stress levels. The results also show negative impacts of the reformon the well-being of care recipients, indicating that reducing formal care services is unlikely to haveany positive impact on either the caregivers or the recipients, suggesting no welfare improvement interms of well-being.
We suggest that future reforms on LTC systems should consider the diverse impact of informal
caregiving on caregivers’ well-being. A balanced approach that combines formal and informal careshould be considered to ensure fiscal sustainability while also protecting the well-being of both those
who may find informal caregiving challenging and those who may benefit from it.

2. Literature
2.1 Conceptual Frameworks
Several conceptual frameworks have been developed to understand the relationship between theload of informal care and caregivers’ well-being. These frameworks serve to evaluate how theavailability of formal care affects the welfare of caregivers. The caregiver stress model is a widely usedframework that proposes two main stressors that stem from providing informal care: primary and4secondary stressors (Pearlin et al., 1990). Primary stressors denote strains or problems that are directly
related to the caregiving situation, such as lengthy care hours. Secondary stressors consist of challenges
associated with executing multiple roles within the family or society in addition to the caregiving
responsibility, such as being a spouse or holding a formal job. Primary stressors are deemed the sourcesof secondary stressors.
According to the stress model, formal care availability is considered a component of the caregiving
setting that affects caregivers’ well-being by modifying the two stressors. Formal care may serve as anexternal resource to cope with caregiving situations, reducing care intensity for caregivers and freeing
up time for them to do other responsibilities. Therefore, the contraction of formal care options may
negatively affect caregivers’ well-being by amplifying care burden and the likelihood of conflicts withfamilial and occupational responsibilities, as well as financial strains. This escalation of stress can resultin physical and mental issues for informal caregivers (Lazarus & Folkman, 1984; McEwen, 1998).
Moreover, the literature finds that female caregivers are more susceptible to caregiving stressors(Pinquart & Sörensen, 2006), and that they tend to report higher care burdens and lower well-being thanmale caregivers owing to perceived and coping differences (Sharma et al., 2016).
However, the notion that caregiving is always detrimental to caregivers’ well-being may overlook
the potential benefits of providing informal care. An alternative perspective recognizes the advantagesof caregiving. Caregivers who possess control over their caregiving situation and perceive it as a choice,rather than a burden, may encounter less stress and exhibit greater well-being (Roth et al., 2015).
Additionally, psychological research suggests that individuals may experience less stress when they
believe that they have controlled over an unfavorable event, as opposed to those who feel powerless(Rotter, 1966). Caregivers may also derive personal growth, altruism, and a sense of purpose fromproviding care (Brown & Brown, 2014; Marino et al., 2017).
Overall, providing informal care may have both positive and negative impacts on caregivers’ wellbeing. The measurement of well-being outcomes typically involves a blend of these competing impacts,5and the predominance of one over the other may hinge on the magnitudes of the costs and benefits
associated with caregiving.

2.2 Empirical Evidence
Previous empirical research has found a positive association between formal care usage andinformal caregivers’ well-being (Ruppanner & Bostean, 2014). 5 Formal care availability has beenshown to mitigate the negative impacts of informal caregiving by reducing feelings of unhappiness,loneliness, poor self-rated health, and high frailty indices. Moreover, the strength of the association
between formal care usage and caregivers’ well-being appears to be greater when formal care programs
are more generous (Uccheddu et al., 2019; Verbakel, 2014; Wagner & Brandt, 2015). This positive
association is thought to stem from the fact that professional care providers take on some of the
caregiving responsibilities, thereby decreasing the burden on informal caregivers (Suanet et al., 2012;
Verbakel et al., 2016). This shift in caregiving responsibilities can occur at different levels, ranging fromthe likelihood of providing care (i.e., extensive level) to the intensity of care provision (i.e., intensive
level) and the types of care tasks undertaken by informal caregivers. For example, when professional
caregivers are responsible for more complex care tasks, informal caregivers are often left with lessdemanding tasks such as administrative paperwork.
While these studies offer important insights into the relationship between formal care availability
and the well-being of informal caregivers, they do not establish causality. A few studies have attemptedto address this gap by using different methods. Gonçalves, von Hafe, and Filipe (2021) employed panel
data to match couples who seek formal care with those who do not to investigate the impact of formalhome care usage on spousal health. Their findings suggest that formal care has no significant impact on
the physical or mental health of spouses. Dong et al. (2019) used the instrumental variable method to
examine how a shift from nursing homes to formal home care affects the well-being of spouse caregivers.

5

Another rich body of empirical studies examines the relationship between informal caregiving and caregivers’ wellbeing.
For details, see the systematic review by Bom et al. (2019) and the studies by Kumagai (2017) and Niimi (2016) using Japanesedata.
6They found that the reduction worsened physical health but improved mental health, which is explainedby increased care obligations and greater satisfaction, respectively.
Our study makes several contributions to the literature. Firstly, we establish a quasi-experimental
setting that allows for causal inference by examining the exogenous reduction in formal care benefits
among a group of care recipients. Secondly, our dataset captures a diverse range of well-being aspects,
including specific physical health issues and factors contributing to depressive symptoms. This
information contributes to a deeper understanding of the reasons underlying the impact of caregiving
on well-being. Thirdly, our study goes beyond examining the overall effects of reducing formal carebenefits, and instead explores the population average impacts over time and the heterogeneous effects
across different groups. This provides a more nuanced and complete picture of the impacts of formalcare benefits on informal caregivers’ well-being. While a previous study in Japan has investigated therelationship between formal care and caregivers’ well-being (Miyawaki et al., 2020), our study expandson this by analyzing the long-term impacts of the policy reform, exploring a broader range of wellbeing outcomes, and providing a more detailed breakdown of the impacts. Furthermore, we accounted
for multiple sets of fixed effects and possible geographic linear trends that were not previously
considered, and carefully selected our data period to exclude any confounding impacts from other policy
reforms. This rigorous methodology enhances the accuracy and reliability of our findings. We also
investigated how the reform has affected the well-being of care recipients, providing a morecomprehensive picture of the consequences of the reform.

3. Background
3.1 The Long-Term Care Insurance
In 2000, Japan introduced a public long-term care insurance (LTCI) system with the aim ofsocializing care for dependent older people and easing the burden on family caregivers. Participation in
the LTCI is mandatory for all citizens aged 40 and older, and the monthly premium is determined basedon their age and income. Citizens aged 65 or older and those 40+ with specific types of disease are7eligible for LTCI benefits (i.e., recipients) provided they receive a care-need certificate issued by local
authorities after undergoing an assessment of their physical and mental status (Fu and Noguchi 2019).
Recipients of formal care are required bear 10% of the costs until they reach a monthly upper limit.6
The upper limit is determined by the recipient’s care-need level, which is divided into six categories
ranging from the mildest support-required level (SL) to the most severe care-required level (CL5), with
CL1, CL2, CL3, and CL4 in between.7 The upper limit for monthly care costs is highest for CL5 anddecreases as the care-need level decreases. Notably, neither the assessment of care needs nor the upper
limit requires a means test.
The demand for formal care tends to increase with care-need level, particularly for recipientsclassified as CL3 or above, which poses a significant fiscal challenge for the government (Campbell etal., 2010). Public expenditures on LTCI double within the first five years of its introduction, rising from
0.7% of GDP in 2000 to 1.3% in 2005 (MHLW, 2019). To ensure fiscal sustainability, the government
implemented a reform in April 2006, which aimed to reduce benefits for recipients with moderate careneeds, namely those in the SL and CL1 categories. This change could potentially result in an increased
reliance on informal caregiving.8

3.2 The 2006 Reform
The 2006 reform was a two-part process. First, it refined the care-need levels, renaming SL to SL1
and adding a new category called SL2. This increased the total number of care-need levels to seven,ranging from the mildest (SL1 and SL2) to the most severe (CL5). Recipients who were previouslyclassified as SL were reassigned to SL1, while those previously classified as CL1 were reclassified as
SL2 if their health was expected to remain stable for the next six months; otherwise, they remained in
CL1.
6

Recipients have to pay 100% out-of-pocket if their monthly service use exceeds the upper limit.
The assessment exam determines the care-need level.
8
The reform encompassed adjustments to both institutional and home care. We did not delve into the impact of the institutionalcare reform on the well-being of informal caregivers. This was because changes in institutional care were less likely to affectthose who provided care for recipients at home.
78Second, the reform limited the type and quantity of formal care available to SL1 and SL2 recipients.
The available services were narrowed down to focus on preventing recipients’ health conditions fromdeteriorating, with popular services such as housekeeping and transportation assistance to hospitals nolonger available for these groups. Prior to the reform, recipients in SL or CL1 categories used more than
60% of housekeeping services and over half of transportation assistance services (MHLW, 2004). The
exclusion of these services may have had a significant impact on the well-being of both recipients andcaregivers. In addition, the monthly upper limit for formal care benefits was reduced. The reduction
was most significant for recipients in the SL1 category, who could use services worth up to 61,500 JPY
per month (17.2% of the upper limit for CL5) before the reform, but only 50,030 JPY thereafter (13.9%
as a percentage of the upper limit for CL5) (Fu et al. 2017). Notably, the reform did not alter the typeor quantity of care provided to CL2–CL5 recipients; therefore, they may serve as the control group, as
described in Section 4.2.

4. Methods
4.1 Data
We employed the Comprehensive Survey of Living Conditions (CSLC), a nationally representativeand repeated cross-sectional survey in Japan that covers non-institutionalized populations, to conduct
our study.9 This survey, conducted every three years by the MHLW, consists of four questionnaires
assessing household, health, income/savings, and LTC.
The household and health questionnaires, administered to over 600,000 respondents from morethan 300,000 households in each wave, collect information on demographic, socioeconomic, and healthstatus of each household member. The income/savings and LTC questionnaires involved approximately
100,000 and 6,000 respondents, respectively, supplementing the household and health questionnaires
with information on individual income and LTC. The income/savings and LTC questionnaires are

9

The dataset is widely used in academic research (Tamiya et al. 2011; Shigeoka 2014; Fu et al. 2017).
9

separate samples and do not overlap, and therefore income information was not used in the estimations
due to our focus on LTC.
We identified each pair of care recipient and his/her co-residing primary informal caregiver using
the household and LTC questionnaires.10 We then obtained demographic, socioeconomic, and healthstatus information for each caregiver from the household and health questionnaires. Our sample
included data from surveys conducted between 2001 and 2013, with the earliest available LTC
questionnaire in 2001, one year after the introduction of LTCI, and excluding waves after 2013 to avoid
potential confounding effects from the 2015 coinsurance rate reform. 11 The final sample included
18,603 caregivers who provided care to a recipient in the same household.12

4.2. Measurements
4.2.1 Treatment and control groups
We employed the exogenous variation in care-need levels, which arose from the 2006 reform, toexamine the influence of formal care benefits on the well-being of caregivers. The treatment groupconsisted of informal caregivers of recipients classified as SL prior to the reform and as SL1 following
it. These recipients, and therefore their caregivers, experienced a reduction in the variety and amountof formal care services available. The control group included caregivers of recipients classified as CL2or CL3 before and after the reform, who were unaffected by the policy change.

10

The procedure we used to identify informal caregivers was as follows. We posed a question to each recipient, namely “Please
report the household-member identification number of your main caregiver living with you,” and we then cross-referenced
this number with the identification numbers of all household members of the recipient to identify the primary caregiver.
11
The 2015 reform increased the coinsurance rate from 10% to 20% for recipients with incomes equivalent to the current labor
force. This change may have a significant impact on the utilization of formal care services among recipients with relatively
high levels of care needs, particularly those classified as CL3 and above.
12
Since our study focuses on co-residing caregivers, we are unable to examine the effects of the reform on caregivers who
reside separately from recipients. The overall effect, including non-co-residing caregivers, is ambiguous. On one hand, nonco-residing caregivers may be more vulnerable to reductions in formal care benefits due to the burden of commuting to providecare, potentially increasing the time constraint. On the other hand, co-residing caregivers may provide more time-elastic carethan non-co-residing caregivers, making them more sensitive to the reduction in benefits. Depending on the magnitude of thesecompeting impacts, our findings regarding co-residing informal caregivers may either underestimate or overestimate theoverall impact of the reform on informal caregivers.
10

It is worth noting that we excluded caregivers of CL1 recipients throughout the research period
and those of SL2 recipients after the reform, as we could not establish whether CL1 recipients werereassigned to SL2 (potentially “treatment”) or continued to be classified as CL1 (potentially “control”).
Moreover, the control group did not include caregivers of CL4 and CL5 recipients. Although thesecaregivers were not affected by the reform, they might differ from those in the treatment groupsystematically because they cared for recipients with the most severe conditions. To test the robustnessof the results, we incorporated these caregivers into the control group and compared the estimates withthe primary findings in Section 5.6.
4.2.2 Outcome variables
In order to evaluate the well-being of caregivers, we constructed five dummy variables with ahealth-related focus, namely “Any symptom,” “Outpatient visits,” “Limitations in activities of dailyliving (ADL limitations),” “Self-reported poor health,” and “Being stressed.” Each of these dummies
took on a value of one if caregivers reported the corresponding condition and a value of zero if they did
not, thereby signifying a less favorable health status.
Additionally, we formulated a collection of dummy variables for the subcategories of “Anysymptom” and “Being stressed” to scrutinize the physical and mental health of informal caregivers at amore granular level. Each dummy variable obtained a value of one if caregivers reported the relevant
condition, and a value of zero if they did not. Within the “Any symptom” category, we identified elevensubcategories associated with organ systems or physical components, including “systemic symptoms,”“respiratory,” “musculoskeletal system,” “limb,” “injury,” “eyes and ears,” “chest,” “digestive system,”“gum,” “skin,” and “urinary tract.”13 In order to ensure consistency across survey waves, we partitioned

13"Systemic symptoms" encompassed indications such as fever, dizziness, and headaches, among others. Symptoms related
to the respiratory system, such as nasal congestion and coughing, were categorized under the "respiratory system." Themusculoskeletal system included manifestations such as back pain and arthralgia, while "limb" symptoms were characterized
by sensations of numbness or chills in the hands or feet. "Injury" encompassed traumatic occurrences such as bone fracturesor lacerations. "Eye and ear" symptoms included vision impairment and tinnitus, while "chest" symptoms were marked bypalpitations and chest pain. "Digestive system" symptoms comprised issues such as heartburn, diarrhea, and stomach aches,
whereas dental issues and toothaches were subsumed under the "gum" condition. "Skin" issues encompassed symptoms suchas rashes and itchy skin, while problems associated with the "urinary tract" were related to urinary complications.
11the causes of “Being stressed” into nine groups: “family relationships,” “social networks,” “reason forliving,” “having no free time,” “financial strain,” “own health and long-term care issues,” “family healthand long-term care issues,” “childcare and domestic work,” and “marriage, love, and sexual life.” A
detailed depiction of the outcomes is shown in Appendix Table A1.
4.2.3 Heterogeneity analyses
Existing literature suggests that male and female caregivers may exhibit divergent perspectives
regarding the provision of informal care (Pinquart & Sörensen, 2006). A recent study in Japan has shown
gender differences in the effects of informal caregiving on health and well-being (Le & Ibuka, 2023).
These discrepancies may arise due to differences in their perceptions of the stress and rewards
associated with caregiving and result in distinct responses to policy reforms. Hence, in addition to
conducting a full-sample estimation, we performed heterogeneity analyses by gender to examine
potential variations in the impact of the reform between male and female caregivers.
To gain a deeper insight into the underlying reasons for gender-based differences in the effects on
well-being, we conducted estimations by the socioeconomic and demographic characteristics of female
and male caregivers. These factors included income level, as approximated by per-capita monthly
household expenditures (either Low HH-Exp or High HH-Exp, depending on whether the expenditure
was below or above the sample median, respectively), and the caregiver-recipient relationship (spouse,
parents, or parents-in-law).
4.2.4 Covariates
To mitigate potential confounding factors, we employed a series of control variables in our analysis,
including caregivers’ age (in years), marital status (with married as reference, single, widowed, anddivorced), working status (working and not working) health insurance status (with national healthinsurance as reference, employee health insurance, advance elderly health insurance, and other),pension status (seven types of pensions with basic pension as reference), gender and age (in years) of
the care recipients, and number of family members.

124.3 Empirical Strategy
4.3.1 Event study
Drawing upon the definitions of the treatment and control groups, we conducted an event study
using a difference-in-difference approach with fixed effects (DD-FE) to evaluate the population-level
impact of the reform and how it varied over time14 Given that all outcomes are binary, we employed alinear probability model,15
Y!" = # α" Treat !" ´Year" + 𝐗 !" 𝜷 + 𝛌# + 𝛌" + 𝛌$ + 𝚲$ + 𝜏!" ,"where 𝑡 = 2001, 2007, 2010, 2013.

(1)

Y!" denotes the outcomes of well-being for respondent 𝑖 in year 𝑡, as previously defined. Treat !"represents the treatment status and Year" is a set of year dummies with Year#$$% being omitted as thereference year. Thus, α" is the set of coefficients of interest. Given that 2004 is the reference year, we
anticipate that the pre-reform coefficient α#$$& is statistically insignificant, indicating no pre-trend
across treatment status prior to the reform. The null α#$$& also suggests that the reform did not havean anticipation effect. The coefficients of years post the reform—α#$$' , α#$&$ , and α#$&( —capture
the average impacts of the reform on the population in each survey year that follows. Based on thetheoretical framework, the sign of the post-reform coefficients may be positive, negative, or zero. They
could be positive if the negative well-being impact induced by the formal care contraction outweighs
the positive impact; they could be negative if the opposite is true; and they can be zero if the two impacts
cancel one another out.
The post-reform coefficients also enable us to monitor the impact of the reform over time. If themagnitude and statistical significance of the coefficients remain constant or increase over time, we may

14

Given that our data are repeated cross-sectional, we refrained from utilizing propensity score matching (PSM) before
conducting the DD estimation, as done by Miyawaki et al. (2020). While PSM can be useful in balancing observed differences
between treatment and control groups in cross-sectional or panel data, it may not be effective when dealing with repeatedcross-sectional data (Smith and Todd, 2005). Moreover, the unconfoundedness assumption of PSM is unlikely to hold in ourstudy, given that treatment status was assigned based on care-need levels of the recipients.
15
We opted for a linear probability model instead of logit or probit models for improved interpretability of interaction terms(Puhani, 2012).
13

infer that the reform had a long-term impact on caregivers’ well-being. Alternatively, if the coefficients
become statistically insignificant or their magnitudes regress to zero over time, we may infer that the
impact of the reform was temporary. 𝐗 !" represents the set of covariates, while 𝛌) , 𝛌" , and 𝛌*represent the FE at the care level, year level, and prefecture level, respectively. In addition, 𝚲* includes
either a prefectural linear trend by treatment status 𝑐𝛌* , a prefectural-year trend 𝑡𝛌* , or both. The linear
trends control for geographical variations in the outcome variables over treatment status and time. As
indicated in Table 1, we considered four models, which include all possible combinations of linear
trends. Finally, 𝜏!" is the error term.
[Table 1]
4.3.2 Difference-in-difference with fixed effects
We also employed a 2×2 DD-FE model to evaluate the overall effect of the reform. Specifically,
we substituted the interaction terms in Equation (1) with a single interaction between the treatment
indicator (Treat !" ) and a dummy variable indicating the post-reform period (Post " ),Y!" = 𝛾Treat !" ´Post " + 𝐗 !" 𝛅 + 𝛌) + 𝛌" + 𝛌* + 𝚲* + 𝜏!" .

(2)

The parameter 𝛾 represents the aggregate impact of the reform over the entire study period. The
magnitude and statistical significance of 𝛾 are determined by the performance of each post-reform α"
in Equation (1). Compared to the event study approach, the DD-FE approach requires a smaller sample
size and is advantageous for analyzing heterogeneity among subgroups of caregivers. We conducted
heterogeneity analyses by caregiver gender and socioeconomic and demographic statuses for eachgender, except for male in-law caregivers due to the insufficient sample (23 people). Furthermore, totest the robustness of the results, we applied an alternative specification of Equation (2) by replacing
Treat !" with Robust !" , where caregivers of CL2–CL5 recipients served as the control group,
Y!" = ρRobust !" ´Post " + 𝐗 !" 𝛔 + 𝛌) + 𝛌" + 𝛌* + 𝚲* + 𝜏!" .

(3)

We expected ρ in Equation (3) to be close to 𝛾 in terms of sign, magnitude, and statisticalinference. We clustered standard errors at the levels of care level, year, and prefecture for all estimations.

14One of the primary concerns when using the DD-FE approach is whether the common trend
assumption holds. In addition to the α#$$& from the event study as an indication of the pre-trend, we
also conducted a placebo test based on Equation (2) by assuming a placebo reform in 2003,
Y!" = θTreat !" ´Placebo" + 𝐗 !" 𝛑 + 𝛌) + 𝛌" + 𝛌* + 𝚲* + 𝜏!" .

(4)

Placebo" takes the value of zero for the period before 2003 and one for the period between 2003
and 2006; thus, θ shall be non-significant if the common trend holds. The other variables are identicallydefined as in Equation (2).16 We selected the primary model for Equation (1) and (2) based on theirperformance in the placebo estimation. In the primary model, the common trend should hold for bothmain and heterogeneity estimations.
Another major concern in our study was whether the composition of the treatment and control
groups changed before and after the reform. Appendix Table A2 verifies that the proportions ofrecipients categorized as SL and SL1 (treatment) and CL2–CL3 (control) remained stable before andafter the reform. Appendix Table A3 additionally demonstrates little before-and-after difference in
caregiver and recipient characteristics across treatment status. Therefore, the confounding effect ofchanges in caregiver composition was minimal in our study. Lastly, we addressed the multiple-testing
issue that could arise from examining the impacts of the reform on various outcomes. In addition toclustering standard errors, we adjusted standard errors according to the Simes (1986)’s method for
multiple hypothesis testing.

5. Results
5.1 Basic Statistics[Table 2]
Table 2 shows the basic statistics for outcomes, caregiver characteristics, and covariates adjusted
in the estimations. The first two columns (1) and (2) provide information on the control group before
16

We also conducted a placebo test, in which caregivers of CL2 and CL3 recipients were given a placebo treatment. The
control group consisted of caregivers of CL4 and CL5 recipients. Appendix Figure B2 summarizes the results. Except for
intensive care, we found little difference in well-being between the placebo treatment and the control after the reform.
15and after the policy reform, respectively, while columns (3) and (4) present the corresponding
information for the treatment group. Columns (5) and (6) display the before-and-after differences forthe control and treatment groups, respectively, along with the respective statistical significance. Finally,column (7) shows the simple DD estimate for each variable.
Upon examining column (7), we find that caregivers in the treatment group reported higher
probabilities of having symptoms and outpatient visits after the reform than those in the control group,
respectively. The treatment group was more likely to report specific symptoms, with musculoskeletal,
systemic, and respiratory symptoms being the top three. After the reform, the treatment groupexperienced increased stress due to financial strain, domestic work, social networks, and health and
LTC issues. However, they were less stressed concerning family health and LTC issues. The treatmentgroup was also more likely to care for a spouse, not working, and living in smaller households after thereform. Additional statistics by the gender and socioeconomic status of caregivers are presented inAppendix Figures A1–A3 and Appendix Table A5. Generally, female caregivers reported more
symptoms and stress. Caregivers with higher incomes and those caring for spouses were more likely tohave poor health outcomes, regardless of gender.17

5.2 Placebo Test for Common Trend and Model Selection
The discrepancies in caregiver characteristics between the treatment and control groups
highlighted the significance of assessing the assumption of a common trend, which denotes whether
these differences were consistent over time. Accordingly, we conducted a thorough analysis of theplacebo effects on the main outcomes based on Equation (4), before presenting the main findings.
[Figure 1]
As illustrated in Figure 1, all four models demonstrated a common trend between the treatment andcontrol groups prior to the reform. Furthermore, Appendix Figure B1 displays the heterogeneous

17

The basic statistics for the robustness estimation, which include caregivers of CL2–CL5 recipients as the control, are shownin Appendix Table A4.
16

placebo effects based on caregiver gender, indicating that the four models varied in their capacity tosatisfy the common trend assumption. Notably, Model 3 was the most effective in adhering to thisassumption in both the main and heterogeneity estimations. Thus, we adopted Model 3 as the primarymodel, which controlled for year FE, care level FE, prefecture FE, and prefecture-year trends. For
reference purposes, we presented the main results from all models in Appendix C, where we confirmedthat the direction, magnitude, and statistical inferences of the impacts were consistent across the models.

5.3 Main Results
5.3.1 The population average impact of the reform over time
Figure 2 depicts the estimates from Model 3 of the DD-FE event study. Consistent with the resultsof the placebo tests, the coefficients prior to the reform in 2001 were statistically insignificant and close
to zero in magnitude. This finding corroborated the conclusion that the treatment-control disparities
were time-invariant and further indicated that the reform had no anticipatory effect.
[Figure 2]
Regarding the post-reform coefficients, we found that caregivers reported a significant increase inany symptoms (approximately 8 pp), with the impact appearing to attenuate over time. Moreover,although the reform did not have an immediate impact on the likelihood of regular outpatient visits, theextent of the impact increased over time, and caregivers visited hospitals significantly more often in thelater stages of the study (approximately 7 pp). The reform did not appear to have any statisticallysignificant impact on the other well-being outcomes.
[Figure 3]
Subsequently, we examined which specific symptoms were responsible for the significant increasein the likelihood of having symptoms. Figure 3 depicts the impacts on each symptom breakdown overtime. Many of the symptoms increased immediately after the reform, with the top three being
musculoskeletal system (10.3 pp), systemic symptoms (7.4 pp), and eye and ear conditions (7.2 pp).
Caregivers seemed to have encountered more difficulties in functions related to mobility and stability.
17

The deterioration in these symptoms appeared to be somewhat attenuating, yet generally steady overtime.
[Figure 4]
Moreover, we investigated the impacts of the reform on each specific reason for stress over time.
Although caregivers’ overall stress levels did not change substantially following the reform, Figure 4
reveals that they tended to be more concerned with financial strain (4.2 pp) and domestic work (3.3 pp),while being less concerned with reason for life (4.3 pp) and family relations (7.7 pp). The heightened
concerns indicated that the objective reasons for stress, such as the opportunity costs of caregiving andthe difficulties of allocating time between caregiving and other household tasks, have worsened since
the reform. The reduced concerns suggested that the subjective causes of stress, such as low self-esteem
and interpersonal tension, have improved after the reform. The changes in specific stresses were lesspersistent than changes in physical symptoms and faded with time, indicating that the mental healthconsequences of greater caregiving burden appeared to be transient.
5.3.2 The aggregated impact of the reform
We also evaluated the aggregated effects of the reform over the entire study period using the 2×2
DD-FE model. The results in Appendix Table D1 indicate that the aggregated effects were largely
consistent with the time-varying effects in terms of their direction, size, and statistical significance. In
addition, we conducted a multiple-hypothesis testing adjustment to examine the robustness of ourfindings. As shown in Appendix Table D2, the impacts on the main well-being outcomes and specificsymptoms remained statistically significant after the adjustment, while the impacts on specific stressors
were less resilient.

5.4 The Heterogeneous Impacts of the Reform[Table 3]
5.4.1 Gender disparities18

We also examined the gender disparities in the impact on caregivers’ well-being. As shown in Panel
A of Table 3, the gender-specific effects of the reform were evident. Female caregivers reported asignificant decline in physical health, including symptoms, regular outpatient visits, and limitations in
ADL. In contrast, male caregivers were less likely to experience stress. Panels B and C further revealed
that female caregivers were more likely to experience musculoskeletal, systemic, chest, respiratory, andskin conditions, as well as stress related to financial strain and domestic work. Male caregivers, on theother hand, reported no decline in physical health and were less concerned about their own health and
LTC needs, as well as their family’s health.18
These gender-specific findings prompted the question of what factors drove men and women to
respond differently to increased care burdens. To explore this question further, we examined the genderdisparities in the impact of the reform based on their socioeconomic status (income level) anddemographic status (caregiver-recipient relationship).
5.4.2 Gender disparities by caregivers’ characteristics[Figure 5][Figure 6]
Figures 5-6 present the gender-specific effects of the 2006 LTC reform on caregivers’ well-being,across their income levels and caregiver-recipient relationship. The decline in well-being for female
caregivers was concentrated among those with higher household income (High HH-Exp) who cared fortheir spouses or parents-in-law. Appendix Figures F1-F3 reveal that these female caregivers were more
likely to report musculoskeletal, systemic, and chest conditions, as well as higher financial stress. Figure
6, on the other hand, shows that male caregivers with higher income levels who cared for their parents
experienced significant improvements in mental health. Appendix Figures F1-F3 indicate that thesemale caregivers were less concerned about their own and their family’s health and LTC issues.

18

Appendix Table E1 indicates that the statistical significance of the impacts on female caregivers' well-being outcomes andspecific symptoms persisted even after adjusting for multiple-hypothesis testing, which lends credibility to these findings. In
contrast, the statistical significance of the impacts on male caregivers did not survive the multiple-hypothesis testing,suggesting that caution is warranted when interpreting the findings for male caregivers.
195.5 Additional Impacts of the Reform
The primary findings reveal that the reform had unfavorable effects on the well-being of informal
caregivers. We conducted two further investigations to ascertain any additional impacts of the reform,
with the aim of obtaining a more comprehensive understanding of the reform’s consequences.
5.5.1 The impact on caregiving behaviors
Our first investigation aimed to determine whether the reform had any impact on caregiving
behaviors. To accomplish this, we established a binary outcome variable “Regular caregiving” that
distinguishes between providing informal care on a scheduled basis versus as-needed basis.19 Using
Equation (2), we examined whether the reform augmented the probability of providing care regularly.
Appendix Table G1 demonstrates that the reform resulted in a 17.2-pp increase in the likelihood of
regular caregiving. The elevation was particularly conspicuous among female caregivers with low
income (20.3 pp) or those caring for their spouses and parents-in-law (23.8 pp). It is plausible that theintensified frequency of caregiving contributed to the negative effects on the well-being of informal
caregivers.
5.5.2 The impact of the reform on care recipients
Furthermore, we examined whether the reform had any effect on the well-being of care recipients.
On the one hand, formal care by professionals may improve the well-being of care recipients. On theother hand, informal care by family members and close relatives could have strengths in terms of tailormade care based on long-term relationships. If the latter is true, the overall impact of the reform on thewelfare is ambiguous as it decreased the wellbeing of the caregivers but increased that of care recipients.
Thus, we assessed this by replicating the set of outcome variables described in section 4.2.2 for all carerecipients in the LTC questionnaires. We then analyzed the impacts using Equation (1). Appendix Figure
19

The query utilized to ascertain care intensity from the primary family caregiver was "What is the duration for which yourprimary family caregiver provides care on a daily basis?" The possible responses consisted of five options, namely "full day,""half day," "2 to 3 hours," "only when needed," or "other." Subsequently, if respondents selected any of the first three choices,
we ascribed a value of one to the outcome variable. If they chose the fourth option, we designated a value of zero. The variableindicated the presence or absence of regular informal caregiving.
20

G2 displays that care recipients were 6.6-pp and 5.7-pp more likely to have outpatient visits andlimitations in ADL immediately following the reform. These increases persisted throughout the study
period. The reform appeared to lead to the deterioration of well-being for both caregivers and recipients.

5.6 Robustness Checks
The robustness of the main results, based on Equation (3), is demonstrated in Appendix Figures
H1-H3. The estimates obtained from the robustness checks were found to be similar to those of the main
results in terms of their direction, magnitude, and statistical inference.

VI. Discussion and Conclusion
This study delved into the repercussions of formal care benefits contracting on informal careprovision and the well-being of informal caregivers. The analysis leveraged the 2006 reform of LTCI
in Japan and employed a difference-in-difference methodology to isolate the impact of the reform. The
estimations were carried out using not only the full sample of the CSLC, but also subsamples stratified
by caregivers’ gender and socioeconomic statuses. In addition, the study scrutinized the impact of thereform on each of the sub-components of two well-being outcomes, namely self-reported symptoms
and stress.
We affirm that the reform had adverse effects on the physical health of informal caregivers,
particularly in terms of self-reported symptoms and outpatient visits. Musculoskeletal, systemic, andchest conditions were identified as the primary reasons for symptom increases. While there was minimalchange in overall mental health, caregivers expressed more concern about their financial situation andability to manage domestic tasks, while experiencing less stress regarding family relationships. The
reform had a lasting impact on physical conditions, while its impact on mental health was temporary.
Female caregivers experienced a substantial decline in both physical and mental well-being, while malecaregivers experienced an improvement in mental health, particularly those with higher income levels.
We further confirm that the reform led to an increase in the likelihood of regular caregiving, indicating
21

that the reduction in formal care benefits led to a greater care burden on informal caregivers. Moreover,
the reform also had negative effects on the well-being of care recipients, indicating a ripple effect on
the well-being of both informal caregivers and care recipients.
Consistent with the existing literature, our findings suggest that the benefits of informal caregiving
are generally outweighed by primary and secondary stressors, making contracting formal care a risky
proposition for informal caregivers’ well-being (Bauer & Sousa-Poza, 2015). Caregivers experience
physical strain due to increased care burden, primarily affecting their musculoskeletal systems, leading
to mobility and stability difficulties (primary stressors). Additionally, without adequate formal care
support, caregivers lose a vital external resource to cope with caregiving situations, making it
challenging to balance their roles as caregivers and their other familial and societal roles (secondarystressors). Our study also found that informal caregivers are increasingly concerned about their financial
status, which reflects the opportunity cost associated with providing more informal care (Heitmueller& Inglis, 2007). Furthermore, the findings add to the literature by revealing that physical deterioration
caused by increased care load is greater and lasting more than mental deterioration. Although thepsychological benefits of providing care may reduce (and in some cases outweigh) the secondarystressors, the physical load of caregiving is not thereby alleviated. This suggests that the consequencesof the primary stressors may be particularly pronounced, necessitating a comprehensive solution torelieve them.
The gender-specific variations in the trajectory of well-being are also a novel contribution to theextant literature. These gender-specific effects suggest that the impact of the reform on caregivers’ wellbeing was highly dependent on their individual characteristics and circumstances. The provision of
informal care was predominantly a female role. However, contemporary trends indicate that women
increasingly demonstrate a greater inclination to participate in paid employment and become significant
contributors to their families’ economic welfare. Consequently, women caregivers face a higher
opportunity cost in terms of lost income due to providing informal care (Carmichael & Charles, 2003;
Schmitz & Westphal, 2015). Our sample of female caregivers is characterized by a younger age group22and a higher likelihood of being married when compared to their male counterparts (refer to Appendix
Table A5). Balancing their professional, social, and marital obligations while providing more care posesa significant challenge for these caregivers (Fu et al. 2017; Schmitz and Stroka 2013; Van Houtven,
Coe, and Skira 2013). Conversely, it is plausible that male caregivers with higher income have greater
flexibility in terms of time and resources to allocate towards caregiving, which may contribute to theenhancement of their mental well-being. Moreover, our sample of male caregivers primarily attends tothe needs of their wives or parents (refer to Appendix Table A5), which may provide them with greater
satisfaction as they engage in more intimate relationships while providing care. The informal careprovision entails minimal opportunity cost and substantial psychological rewards for male caregivers,
thereby conferring considerable benefits (Collins & Feeney, 2000; Penning & Wu, 2016).
Disparities in the nature of care provided by male and female caregivers may also contribute to thegender-specific impacts of the reform. According to existing literature, informal caregiving is often ademanding and challenging task, and caregivers may have little choice in assuming this role (Pearlin
2010). This situation is especially pronounced for female caregivers in Japan, where societal gendernorms tend to dictate their primary responsibility in providing informal care (Kumagai, 2017; Sharma
et al., 2016). Furthermore, research suggests that caregivers experience heightened emotional stress andphysical health issues when compelled to provide care (Schulz et al., 2012), particularly when formalcare options are limited (Wagner & Brandt, 2018). Hence, female caregivers may be more vulnerable
to reductions in formal care benefits than their male counterparts. Although this hypothesis is suggestive,
the gender disparity in caregivers with similar income levels or caring for spouses supports thisargument. Even when male and female caregivers have comparable opportunity costs or psychologicalrewards associated with caregiving, female caregivers remain more susceptible to formal care benefit
reductions than male caregivers.
The adverse impact of the reform on the well-being of care recipients, as evidenced by our findings,
stands in contrast to the literature that suggests potential benefits of informal care over formal care forrecipients. For example, Cohen et al. (2002) posit that informal caregivers, who are often family
23members or close acquaintances, possess a profound understanding of the care recipient’s requirements,
inclinations, and values. This knowledge enables them to offer more individualized care that is better
tailored to the recipient’s needs. However, our results underscore the fact that even for recipients withmoderate care needs, formal care services provide specialized and professional care that may provechallenging for informal caregivers to deliver. As such, reducing formal care services is unlikely to haveany positive impact on either the caregivers or the recipients.
This study has some limitations owing to the lack of data. First, while we confirmed thatthe composition of caregivers changed little in observable characteristics following the reform, it may
have changed regarding unobservable characteristics. Second, we could not assess the care burden using
a broader range of measurements. Providing care regularly may reflect a portion of the care burden, but
not all of it. This is especially true for female caregivers with high income or caring for spouses. Their
great decline in well-being is likely because of care burdens that were not quantified by care frequency.
Further studies using longitudinal datasets with comprehensive information to track an individual overtime are necessary to clarify our results.
Our study highlights the importance of considering the well-being of caregivers when evaluating
the cost-effectiveness of contracting formal care availability based on care needs. Although theadvantage of providing formal care to recipients with moderate care needs may appear to be smaller
than the cost, it does help the caregivers of those recipients. Therefore, any loss in caregivers’ wellbeing should be considered when evaluating the impact of contracting formal care benefits. Our findings
also suggest that the well-being loss observed in our study may be a lower bound of the potential impacts
of a reform targeting a wider range of recipients, including those with more severe conditions.
Contracting formal care benefits may have more negative consequences if future reforms are aimed ata broader range of recipients. Therefore, policymakers should consider alternatives to the need-based
method, such as affordability-based methods, to contain public spending on LTC. In fact, thegovernment has already launched an affordability-based reform in 2018, raising the co-insurance rate
for affluent recipients. Future research is needed to assess the impact of this reform. Furthermore,24

policymakers should consider the heterogeneity of caregivers when designing policies to support them.
Female caregivers are particularly susceptible to an increased care burden, and thus policies should be
implemented to protect them against financial and health issues. These policies could include respitecare, counseling services, and financial assistance.

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consequences for caregivers? Journal of European Social Policy, 24(5), 424–441.
https://doi.org/10.1177/0958928714543902
Verbakel, E., Metzelthin, S. F., & Kempen, G. I. J. M. (2016). Caregiving to Older Adults:
Determinants of Informal Caregivers’ Subjective Well-being and Formal and Informal Support
as Alleviating Conditions. The Journals of Gerontology Series B: Psychological Sciences andSocial Sciences, gbw047. https://doi.org/10.1093/geronb/gbw047
Wagner, M., & Brandt, M. (2015). Loneliness among informal caregivers aged 50+. In A. BörschSupan, T. Kneip, H. Litwin, M. Myck, & G. Weber (Eds.), Ageing in Europe - Supporting
Policies for an Inclusive Society (pp. 179–188). De Gruyter.
Wagner, M., & Brandt, M. (2018). Long-term Care Provision and the Well-Being of Spousal
Caregivers: An Analysis of 138 European Regions. The Journals of Gerontology: Series B,
73(4), e24–e34. https://doi.org/10.1093/GERONB/GBX133

28

Table 1. Model specifications per 𝚲$Model 1Model 2Model 3Model 4Prefecture-treatment trend 𝑐𝛌*

No

Yes

No

Yes

Prefecture-year trend 𝑡𝛌* ,

No

No

Yes

Yes

29

Table 2. Basic statistics
Control

Outcomes
Any symptom (%)
Outpatient visits (%)
ADLs (%)
Self-rated poor health (%)
Stress (%)
Specific symptoms (%)
Musculoskeletal system
Systemic symptoms
Chest
Limb
Respiratory
Eye and ear
Digestive system
Gum
Skin
Urinary tract
InjuryReasons of stress (%)
Financial strain
Childcare and domestic work
Social networks
Having no free time
Marriage, love and sexual life
Reason for living
Own health and long-term care issues
Family relationships
Family health and long-term care issues
Caregiver’s demographic status
Female (%)
Recipient-caregiver relationship
SpouseTreatment

Diff

Diff

DD

(2)-(1)(5)(4)-(3)(6)(6)-(5)(7)

Before
(1)

After
(2)

Before
(3)

After
(4)

50.67
56.54
22.61
28.18
75.12

49.65
59.75
23.43
31.97
73.95

44.31
48.75
17.98
23.32
65.63

49.29
60.13
21.69
30.32
64.48

-1.02
3.21
0.82
3.79
-1.17

36.80
25.99
9.71
18.54
10.18
22.50
16.19
11.27
9.50
7.78
2.94

36.03
23.70
7.14
18.56
9.71
20.51
15.47
9.93
7.56
8.71
2.10

29.02
20.31
5.25
14.62
6.70
17.30
12.83
7.37
8.59
7.14
2.79

35.63
24.41
7.63
18.57
11.88
19.79
15.74
9.05
8.01
9.99
2.26

-0.77
-2.29
-2.57
0.02
-0.47
-1.99
-0.72
-1.34
-1.94
0.93
-0.84

11.81
6.62
5.73
14.32
1.79
5.41
35.12
13.78
59.02

13.74
5.74
5.24
14.13
1.19
6.09
19.48
13.74
57.99

10.50
4.06
5.01
7.28
1.67
4.77
31.03
16.59
41.53

15.52
6.07
8.16
8.26
1.39
6.47
19.20
15.42
34.43

1.93
-0.88
-0.49
-0.19
-0.60
0.68
-15.64
-0.04
-1.03

77.70

72.82

71.41

67.05

-4.88

39.90

40.12

31.69

37.06

0.22

30

***
***

**
***
*
*
**
*
**
*
*
***

***

4.98
11.38
3.71
7.00
-1.15

**
***
**
***

6.00
8.17
2.89
3.21
0.02

**
***

6.61
4.10
2.38
3.95
5.18
2.49
2.91
1.68
-0.58
2.85
-0.53

***
**
**
**
***
*
*
*

7.38
6.39
4.95
3.93
5.65
4.48
3.63
3.02
1.36
1.92
0.31

***
***
***
*
***
**
*
*

5.02
2.01
3.15
0.98
-0.28
1.70
-11.83
-1.17
-7.10

***
**
***

*
**
***

***

3.09
2.89
3.64
1.17
0.32
1.02
3.81
-1.13
-6.07

-4.36

**

0.52

5.37

***

5.15

**

*
***

*
**

**

Parent
Parent-in-law
Caregiver’s socio-economic status
Household Per-capita Expenditure < median (%)
Covariates
Age (year)
Marital Status (%)
MarriedSingleWidowedDivorced
Working (%)
Health Insurance (%)
National health insurance
Health insurance
Advance elderly health insurance
OthersPension (%)
Basic pension
Basic pension and employee pension
Basic pension and mutual aid pension
National pension
Employee pension
Mutual aid pension
Governmental pension
Male Care recipients
Care recipients’ age (year)
Household size (person)
N

23.91
32.17

30.73
25.22

27.41
37.69

33.84
25.51

6.82
-6.95

***
***

6.43
-12.18

***
***

48.37

48.02

47.57

47.03

-0.35

62.93
(29.24)64.43(18.93)

60.11(12.75)

63.41(13.37)1.50(0.59)**

3.30(0.58)

***

1.80

85.10
7.17
4.67
3.06
38.41

81.43
10.15
4.37
3.91
40.26

82.76
9.21
3.85
4.18
52.04

79.05
11.19
3.94
5.73
44.65

-3.67
2.98
-0.30
0.85
1.85

***
***

-3.71
1.98
0.09
1.55
-7.39

**
*

-0.04
-1.00
0.39
0.70
-9.24

62.80
35.66
0.00
1.53

48.19
32.53
17.71
1.57

58.56
40.37
0.00
1.08

43.51
35.68
19.55
1.26

-14.61
-3.13
17.71
0.04

***
***
***

-15.05
-4.69
19.55
0.18

***
***
***

-0.44
-1.56
1.84
0.14

17.83
10.43
1.81
9.30
11.03
2.82
0.68
0.41
80.96
(20.67)
3.74(1.69)
2,325

22.30
17.88
2.67
3.77
11.36
2.43
0.24
0.41
82.04
(9.26)
3.52(1.57)
4,008

13.49
8.35
1.18
6.85
9.74
3.21
0.75
0.29
80.35
(8.53)
3.77(1.68)
838

19.44
14.07
2.33
3.76
10.57
3.67
0.36
0.35
82.57
(28.60)3.33(1.50)
1,060

4.47
7.45
0.86
-5.53
0.33
-0.39
-0.44
0.00
1.08
(0.37)-0.22(0.04)

***
***
**
***

5.95
5.72
1.15
-3.09
0.83
0.46
0.75
0.29
2.22
(0.97)-0.45(0.07)

***

1.48
-1.73
0.29
2.44
0.50
0.85
1.19
0.29
1.14
(0.85)-0.23(0.08)

-0.54

*
*

**
***

-0.39
-5.23

**

-0.19

*
***

*
***

**
**
***

***

*

***
***

Notes: Standard deviations are in parentheses for continuous variables. The t-statistic for testing the treatment-control difference in the proportion of advance elderly health insurance prior to thereform is not available because of the zero proportions. *Inference: *** p < 0.01; ** p < 0.05; * p < 0.1.

31

Table 3. Gender disparities in the impact of 2006 reform
Female (N=6,339)
Coef.
S.E.
p-value
Panel A: Main outcomes
0.061* (0.037)
Any symptom
0.079 ** (0.035)
Outpatient visits
0.062 ** (0.031)
ADL limitations
0.036(0.033)Self-rated health
0.033(0.032)
Being stressed
Panel B: Specific symptoms
0.100 ** (0.034)
Musculoskeletal system
0.069 ** (0.031)
Systemic symptoms
0.065 *** (0.017)
Chest
0.043
(0.028)Limb
0.074 *** (0.020)
Respiratory
0.045(0.028)Eye and ear
0.041(0.027)
Digestive system
0.034(0.021)Gum
0.044 ** (0.020)
Skin
0.031
* (0.018)
Urinary tract-0.009(0.011)
InjuryPanel C: Reasons for being stressed
0.059 ** (0.025)
Financial strain
0.040 ** (0.017)
Domestic work
0.029
(0.018)Social networks
0.016(0.026)
Having no free time
0.014
* (0.008)
Marriage, love and sexual life
0.007
(0.016)
Reason for living
0.022(0.032)
Own health and LTC issues-0.021(0.027)
Family relations-0.017(0.035)
Family health and LTC issues

Male (N=3,362)
Coef.
S.E.
p-value

0.099
0.026
0.049
0.288
0.315

0.050
-0.016-0.058-0.009-0.128 **(0.057)(0.053)(0.050)(0.050)(0.063)

0.381
0.760
0.247
0.865
0.043

0.004
0.025
0.000
0.119
0.000
0.105
0.122
0.110
0.028
0.088
0.434

0.081
(0.053)0.054(0.048)0.003(0.032)0.031(0.042)-0.034(0.033)-0.006(0.043)-0.012(0.039)-0.009(0.036)-0.085 ** (0.033)-0.056(0.035)0.002(0.017)

0.127
0.261
0.917
0.466
0.311
0.890
0.770
0.794
0.009
0.112
0.914

0.016
0.018
0.119
0.544
0.066
0.655
0.495
0.443
0.631

-0.017-0.0060.019
0.013-0.022-0.020-0.097-0.030-0.106

0.646
0.791
0.451
0.690
0.290
0.443
0.063
0.418
0.087

*
*

(0.038)(0.024)(0.025)(0.033)(0.021)(0.026)(0.052)(0.038)(0.062)

Notes: All estimates were derived based on subsample estimation using Model 3 of Equation (2), which controlled for the full setof caregiver characteristics and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year
trend. N stands for number of observations, S.E. for standard errors that were clustered at the level of care level, year, and prefecture.
*Inference: *** p < 0.01; ** p < 0.05; * p < 0.1.

32

Figure 1. Placebo impacts on informal care provision and caregivers’ well-being across models
Notes: The markers with 95% confidence intervals represent the estimates of θ from Equation (4). Model 1 controlled for the fullset of caregiver characteristics and recipients’ gender and age, as well as year FE, care level FE, and prefecture FE. Based on Model
1, Model 2 further controlled for prefecture-treatment trend, Model 3 further controlled for prefecture-year trend, and Model 4
further controlled for both trends. Standard errors are clustered at the municipal level. Standard errors are clustered at the municipal
level. “Outpatient” for outpatient visits, “ADL” for limitations in ADLs, “SRH” for self-report poor health. Standard errors wereclustered at the level of care level, year, and prefecture.

33

Figure 2. The impacts of the 2006 reform on well-being of caregivers over time
Notes: All estimates were derived based on Model 3 of Equation (1), which controlled for the full set of caregiver characteristics
and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. The y‐axes share auniform scale for visual comparability. The markers stand for the estimates of α! in Equation (1). The thicker and thinner bars
represent confidence intervals at the 90% and 95% levels, respectively. Standard errors were clustered at the level of care level,year, and prefecture.

34

Figure 3. The impacts of the 2006 reform on specific symptoms over time
Notes: All estimates were derived based on Model 3 of Equation (1), which controlled for the full set of caregiver characteristics
and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. The y‐axes share auniform scale for visual comparability. The markers stand for the estimates of α! in Equation (1). The thicker and thinner bars

35

represent confidence intervals at the 90% and 95% levels, respectively. Standard errors were clustered at the level of care level,year, and prefecture.

Figure 4. The impacts of the 2006 reform on specific reasons of stress over time
Notes: All estimates were derived based on Model 3 of Equation (1), which controlled for the full set of caregiver characteristics
and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. The y‐axes share auniform scale for visual comparability. The markers stand for the estimates of α! in Equation (1). The thicker and thinner bars
represent confidence intervals at the 90% and 95% levels, respectively. Standard errors were clustered at the level of care level,year, and prefecture.

36

Figure 5. Heterogeneous impact of the 2006 reform by gender: caregivers’ income level
Notes: All estimates were derived based on Model 3 of Equation (2), which controlled for the full set of caregiver characteristics
and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. The vertical bars standfor the estimates of 𝛾 in Equation (2). The thicker and thinner horizontal bars represent confidence intervals at the 90% and 95%
levels, respectively. Standard errors were clustered at the level of care level, year, and prefecture.

37

Figure 6. Heterogeneous impact of the 2006 reform by gender: caregiver-recipient relationships
Notes: All estimates were derived based on Model 3 of Equation (2), which controlled for the full set of caregiver characteristics
and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. The vertical bars standfor the estimates of 𝛾 in Equation (2). The thicker and thinner horizontal bars represent confidence intervals at the 90% and 95%
levels, respectively. Standard errors were clustered at the level of care level, year, and prefecture.

38

Appendices

Appendix A

Outcome structure and basic statistics

Appendix B

Placebo tests and model specifications

Appendix C

Main results across models

Appendix D

Results from the aggregated DD-FE Model

Appendix E

Gender disparities in the impacts of the reformAppendix F

Gender Disparities in the impact of the reform across SES

Appendix G

Additional Impacts of the ReformAppendix H

Robustness Checks

39

A. Outcome Structure and Basic Statistics
Table A1. The structure of the outcomes
Main outcomes

Breakdowns
1) Musculoskeletal system
2) Systemic symptoms
3) Chest
4) Limb
5) Respiratory

1. Any symptom

6) Eye and ear7) Digestive system

Physical health8) Gum9) Skin10) Urinary tract
11) Injury
2. Outpatient visits
3. ADL limitations
4. Self-rated poor health
1) Financial strain
2) Childcare and domestic work
3) Social networks
4) Having no free time

Mental health5. Being stressed

5) Marriage, love and sexual life6) Reason for living
7) Own health and long-term care issues8) Family relationships
9) Family health and long-term care issues

Note: All outcomes are binary. Each takes a value of one if the caregivers reported the corresponding condition anda value of zero if they did not.

40

Table A2. Trends in proportions of care recipients in each care-required
SL

2001

2004

0.11

0.13

2007

2010

2013

Total
0.12

SL1

0.11

0.10

0.09

0.10

SL2

0.13

0.14

0.14

0.14

CL1

0.25

0.32

0.20

0.19

0.21

0.23

CL2

0.23

0.20

0.21

0.21

0.22

0.21

CL3

0.16

0.14

0.16

0.16

0.15

0.15

CL4

0.12

0.11

0.12

0.11

0.10

0.11

CL5

0.13

0.09

0.08

0.08

0.08

0.09

N

3,148

3,893

3,259

3,874

4,000

18,174

Source: LTC questionnaires of CSLC from 2001 to 2013.

41

Table A3. Changes in the characteristics of caregivers after the reformMale Caregivers
Treat_Post

S.E.

Female Caregivers
N

Treat_Post

S.E.

N

Caregiver-recipient relationship
Spouse0.0634(0.0620) 2,320

0.0898**(0.0353)

6,376

Parent-0.0715(0.0616) 2,320

0.0316(0.0306)

6,376

Par-in-law

0.0234(0.0155) 2,320-0.129***(0.0365)

6,376

Low-HH Exp-0.0169(0.0594) 2,320-0.00995(0.0373)6,376

High-HH Exp-0.00849(0.0599) 2,320-0.00113(0.0370)

6,376

Married

0.0368(0.0543) 2,320-0.0297(0.0272)

6,376

Single-0.0403(0.0466) 2,320

0.0221(0.0197)

6,376

Widowed-0.0119(0.0203) 2,320

0.000919(0.0156)

6,376

Divorced

0.0154(0.0314) 2,320

0.00660(0.0139)

6,376

Other health insurance

0.00361(0.0180) 2,311-0.00329(0.00646) 6,348

National health insurance

0.0119(0.0585) 2,311

0.0297(0.0372)

6,348

Employee health insurance-0.0821(0.0562) 2,311-0.0451(0.0370)

6,348

Advance elderly health insurance

0.0666*(0.0368) 2,311

0.0187(0.0228)

6,348

Basic pension

0.0598(0.0411) 2,320

0.0555*(0.0303)

6,376

Basic pension and employee pension-0.0137(0.0458) 2,320-0.00931(0.0226)

6,376

Basic pension and mutual aid pension

0.0218(0.0210) 2,320-0.00232(0.00941) 6,376

National pension

0.0294(0.0334) 2,320

0.0205(0.0152)

6,376

Noncontributory pension

0.0314(0.0453) 2,320-0.0225(0.0207)

6,376

Female0.0088(0.0397) 2,320-0.1434***(0.0374)

6,376

Age

7.8888(5.7086) 2,320

0.4279(0.6273)

6,376

Cerebrovascular

0.1599*(0.0730) 2,320

0.0671*(0.0320)

6,376

Debilitation

0.0674(0.0543) 2,320-0.0170(0.0358)

6,376

Dementia-0.0254(0.0440) 2,320-0.0015(0.0259)

6,376

Broken born

0.0419(0.0448) 2,320-0.0089(0.0278)

6,376

Joint disorder-0.0745(0.0531) 2,320-0.0183(0.0286)6,376Heart disease-0.0666*(0.0353) 2,320-0.0333(0.0243)

6,376

Cancer

0.0057(0.0228) 2,320

0.0044(0.0144)

6,376

IncomeMarital status

Insurance

PensionRecipients Characteristics

42

Respiratory-0.0420*(0.0219) 2,320

0.0129(0.0176)

6,376

Parkinson-0.0218(0.0195) 2,320

0.0179(0.0119)

6,376

Diabetes-0.0141(0.0336) 2,320-0.0231(0.0201)

6,376

Eye and ear-0.0252(0.0316) 2,320-0.0086(0.0220)

6,376

Spinal cord

0.0021(0.0235) 2,320-0.0072(0.0125)

6,376

Notes: Estimates are derived from estimating equation (2) without controlling for covariates. Outcomes are replaced by thecovariates to test the changes in the characteristics of caregivers before and after the reform. Treat_Post indicates 𝛾 in equation
(2).

43

Table A4. Basic statistics for treatment group, control group, and control group including
caregivers of CL4-CL5 recipients

N=2,050

Control(caregivers of
CL2-CL3)
N=6,646

Robust(caregivers of
CL2-CL5)
N=10,777

(1)

(2)

(3)

(3)-(2)

69.07

74.63

74.70

0.08

Spouse

34.63

40.03

40.35

0.42

Parent

30.88

28.19

28.96

1.10

Parent-in-law

31.60

27.81

26.65

-1.68

Working (%)

48.03

39.56

38.36

-1.58

Household Per-capita Expenditure < median (%)

52.73

49.56

49.60

0.05

Cerebrovascular

13.95

36.00

39.32

4.39

Debilitation

22.88

26.56

24.88

-2.48

Dementia

5.80

26.89

26.96

0.09

Broken bone

12.83

17.81

17.67

-0.25

Joint disorder

24.88

14.49

12.57

-3.62

61.91

63.87

64.17

0.72

(13.19)(23.33)(28.22)Married

80.78

82.80

82.12

-1.15

Single

10.29

9.03

9.66

1.37

Widowed

3.90

4.48

4.55

0.21

Divorced

5.02

3.59

3.67

0.25

National health insurance

50.37

53.66

55.40

2.24

Employee health insurance

37.81

33.70

32.57

-1.54

Advance elderly health insurance

10.64

11.09

10.59

-1.03

Others

1.18

1.56

1.44

-0.59

Basic pension

16.73

20.63

21.04

0.64

Basic pension and employee pension

11.46

15.09

15.01

-0.15

Basic pension and mutual aid pension

1.80

2.35

2.36

0.04

National pension

5.17

5.84

5.86

0.07

Noncontributory pension

0.00

0.02

0.01

-0.35

Employee pension

10.20

11.24

11.00

-0.50

Mutual aid pension

3.46

2.57

2.39

-0.74

Governmental pension

0.54

0.41

0.43

0.20
1.05

Treatment

T-testCaregiver's demographic status
Female (%)
Recipient-caregiver relationship

Caregiver's socio-economic status

Recipient's conditions

Covariates
Age (year)
Marital Status (%)

Health Insurance (%)

Pension (%)

Household size (person)

3.53

3.60

3.62

(1.60)(1.62)(1.63)

44

Male Caregivers
90
80
70
60
50
40
30

62.07

63.13

66.01

67.20

63.06

19.35

24.38

38.48

32.91

28.89

13.79

16.09

33.33

27.05

20.54

54.84

44.54

70.70

62.12

52.76

43.33

34.98

56.33

48.22

10

42.29

20

0

Any symptom

Outpatient visits

Any ADL limitations

Self-rated poor

StressSpouseParent28.94

Low HH-Exp

33.02

healthHigh HH-Exp

Parent-in-law

Female Caregivers

90
80
70
60
50
40
30

0

Any symptom

Outpatient visits

Any ADL limitations

Self-rated poor
healthLow HH-Exp

High HH-Exp

SpouseFigure A1.The statistics of main outcomes by gender and SES

45

ParentParent-in-law

Stress

72.96

75.28

77.73

76.14

73.76

22.87

24.18

39.53

29.21

14.65

17.37

23.57

20.66

47.57

52.01

74.74

60.37

56.55

44.10

46.13

61.93

53.29

10

49.28

20

Male Caregivers
50
40
30
20
10
0

MSK

Systemic

Chest

Limb

Respiratory

Eye&earsymptoms

Digestive

Gum

Skin

Urinary tract

InjurySkin

Urinary tract

InjurysystemLow HH-Exp

High HH-Exp

SpouseParentFemale Caregivers

Parent-in-law

50
40
30
20
10
0

MSK

Systemic

Chest

Limb

Respiratory

Eye&earsymptoms

DigestiveGum

systemLow HH-Exp

High HH-Exp

SpouseFigure A2. The statistics of specific symptoms by gender and SES
46

ParentParent-in-law

Male Caregivers
70
60
50
40
30
20
10
0

Financial strain

Childcare &Social networks Having no free Marriage, love & Reason for living Own health &domestic worktime

Low HH-Exp

sexual life

High HH-Exp

SpouseLTC issues

ParentFamilyFamily health &

relationships

LTC issues

FamilyFamily health &

relationships

LTC issues

Parent-in-law

Female Caregivers
70
60
50
40
30
20
10
0

Financial strain

Childcare &Social networks Having no free Marriage, love & Reason for living Own health &domestic worktime

Low HH-Exp

sexual life

High HH-Exp

SpouseFigure A3. The statistics of specific reasons of being stressed by gender and SES
47

LTC issues

ParentParent-in-law

Table A5. Basic statistics by gender and SES
Low HH-Exp

High HH-Exp

SpouseMale Female

Male Female

Male

N=1136 N=3006

N=974 N=2840

Spouse

43.31

39.12

48.46

33.84

Parent

52.82

20.23

47.02

21.90

Parent-in-law

0.70

35.76

2.16

40.99

46.95

40.13

48.74

37.90

FemaleParentMale

Parent-in-law

FemaleMale Female

N=1056 N=2317

N=1164 N=1345

N=31 N=2456

27.01

15.29

65.76

51.13

83.33

54.87

51.04

55.03

56.71

49.43

27.59

48.01

78.03

73.21

56.76

55.94

59.19

56.32

Caregiver's demographic and SES statuses
Recipient-caregiver relationshipWorking (%)
Household Per-capita Expenditure < median (%)
Covariates
Age (year)

65.04

62.75

66.19

62.03

(13.95) (12.38)(12.63) (11.42)(41.00) (20.83)(8.74)(9.04)(8.19)(7.79)

Married

69.19

83.97

79.16

87.57

100.00 100.00

51.80

49.00

83.87

95.85

Single

20.86

6.49

12.83

6.34

0.00

0.00

31.36

25.50

0.00

0.04

Widowed

3.26

5.46

3.39

3.91

0.00

0.00

5.50

11.30

16.13

4.07

Divorced

6.69

4.09

4.62

2.18

0.00

0.00

11.17

13.90

0.00

0.00

National health insurance

55.15

56.44

49.95

48.02

52.37

60.86

54.67

52.75

61.29

44.96

Health insurance

26.87

31.75

31.17

41.98

13.85

13.78

41.78

45.37

32.26

53.86

Advance elderly health insurance

15.07

10.34

16.82

9.29

31.69

23.97

0.87

0.53

0.00

0.41

Others

2.91

1.47

2.06

0.71

2.09

1.39

2.68

1.36

6.45

0.78

Basic pension

14.17

25.35

9.24

19.68

17.42

40.61

8.43

11.78

9.68

11.24

Basic pension & employee pension

17.61

11.88

24.23

13.03

26.99

18.60

13.77

9.32

12.90

8.11

Basic pension & mutual aid pension

1.67

1.26

6.06

2.57

4.92

2.46

2.24

1.86

3.23

1.10

National pension

9.51

5.76

5.24

4.23

16.19

12.73

0.09

0.30

0.00

0.04

Employee pension

16.29

9.25

16.53

9.12

24.81

11.87

8.86

7.01

6.45

7.41

Mutual aid pension

4.14

1.06

7.49

2.64

8.24

2.42

3.18

1.42

9.68

1.55

Governmental pension

1.32

0.20

1.03

0.04

2.84

0.04

0.00

0.15

0.00

0.00

3.20

3.79

3.08

3.65

2.91

3.14

3.31

3.46

3.58

4.44

(1.55) (1.72)(1.41)(1.51)(1.48)(1.60)(1.42)(1.36)(1.26)(1.47)

Marital Status (%)

Health Insurance (%)

Pension (%)

Household size (person)48

B. Placebo tests and model specifications

Figure B1. Placebo test: a placebo post period by gender49

Panel A

Panel B

Figure B2. Placebo test: a placebo treatment status

C. Main results across models
50Figure C1. Impact on informal care provision and caregiver well-being across models

51

Figure C2. Impact on caregiver well-being across models: specific symptoms

52

Figure C3. Impact on caregiver well-being across models: reasons for being stressed53

D. Results from the aggregated DD-FE Model
Table D1. Overall impacts of the 2006 reform well-being of caregivers

Panel A: Main results
Any symptom
Outpatient visits
ADL limitations
Self-rated poor healthBeing stressed
Panel B: Specific symptoms
Musculoskeletal system
Systemic symptoms
Chest
Limb
Respiratory
Eyes and ears
Digestive system
Gum
Skin
Urinary tract
InjuryPanel C: Reasons for being stressed
Financial strain
Domestic work
Social networks
Having no free time
Marriage, love, and sexual life
Reason for living
Own health and LTC issues
Family relations
Family health and LTC issues

N

Impact of theReform

S.E.

8,307
8,211
7,571
7,823
8,406

0.074
0.058
0.025
-0.0030.024(0.032)(0.028)(0.026)(0.028)(0.028)

[
[
[
[
[

0.011
0.002
-0.026-0.057-0.031

0.136
0.113
0.076
0.052
0.079

]
]
]
]
]

8,307
8,307
8,307
8,307
8,307
8,307
8,307
8,307
8,307
8,307
8,307

0.098
0.069
0.051
0.045
0.045
0.035
0.031
0.026
0.012
0.009
-0.006(0.031)(0.026)(0.015)(0.023)(0.017)(0.023)(0.022)(0.018)(0.017)(0.016)(0.009)

[
[
[
[
[
[
[
[
[
[
[

0.038
0.018
0.021
0.001
0.012
-0.011-0.013-0.009-0.022-0.022-0.024

0.158
0.119
0.080
0.090
0.078
0.080
0.075
0.061
0.045
0.041
0.012

]
]
]
]
]
]
]
]
]
]
]

7,823
7,823
7,823
7,823
7,823
7,823
7,823
7,823
7,823

0.047
0.030
0.025
0.014
0.005
0.001
-0.001-0.024-0.027(0.021)(0.014)(0.015)(0.021)(0.007)(0.014)(0.026)(0.020)(0.029)

[
[
[
[
[
[
[
[
[

0.005
0.003
-0.004-0.027-0.009-0.026-0.053-0.063-0.085

0.088
0.056
0.053
0.055
0.019
0.028
0.050
0.016
0.030

]
]
]
]
]
]
]
]
]

95% C.I.

Notes: All estimates were derived based on Model 3 of Equation (2), which controlled for the full set of caregivercharacteristics and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. N
stands for number of observations, S.E. for standard errors that were clustered at the level of care level, year, and prefecture,and 95% C.I. for confidence intervals at the 95% level.

54

Table D2. Multiple testing for the aggregated main results: p-values of the estimates
Full
Origin Simes
Panel A: Main results
Any symptom
Outpatient visits
ADL limitations
Self-rated poor healthBeing stressed
Panel B: Specific symptoms
Musculoskeletal system
Systemic symptoms
Chest
Limb
Respiratory
Eyes and ears
Digestive system
Gum
Skin
Urinary tract
InjuryPanel C: Reasons for being stressed
Financial strain
Domestic work
Social networks
Having no free time
Marriage, love, and sexual life
Reason for living
Own health and LTC issues
Family relations
Family health and LTC issues

0.02180.04170.34250.38800.92380.09450.11650.53980.56040.96470.00150.00780.00090.04480.00830.13320.16390.15170.50320.57400.52290.01300.04300.01200.11650.04300.28870.30430.30340.61800.64890.61800.02770.02990.08810.51630.48720.93600.96470.24000.35300.09700.09700.2082
0.61800.61800.96470.96470.41590.5398Notes: The multiple testing is conducted based on Model 3 of Equation (2), which controlled for the full set of caregivercharacteristics and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend.
“Origin” stands for the p-values based on clustered standard errors; “Simes” standards for the p-values further adjusted for
multiple-hypotheses testing.

55

E. Gender disparities in the impacts of the reform
Table E1. Multiple Testing for the aggregated DD results by gender: p-values of the estimates

Panel A: Main results
Any symptom
Outpatient visits
Any ADL limitations
Self-rated poor healthBeing stressed
Panel B: Specific symptoms
Musculoskeletal system
Systemic symptoms
Chest
Limb
Respiratory
Eyes and ears
Digestive system
Gum
Skin
Urinary tract
InjuryPanel C: Reasons for being stressed
Financial strain
Domestic work
Social networks
Having no free time
Marriage, love, and sexual life
Reason for living
Own health and LTC issues
Family relations
Family health and LTC issues

FemaleOriginSimes

Male
OriginSimes

0.09930.02620.04880.28790.31490.17570.08140.12680.39400.40940.38140.76040.24670.86500.04260.75760.91690.73480.91690.36890.00370.02470.00020.11930.00030.10490.12170.11010.02820.08790.43380.02380.08140.00270.17570.00270.17570.17570.17570.08140.17570.52350.1266
0.26140.91690.46620.31090.89030.7702
0.79440.00930.11190.91360.47000.73480.91690.75760.73480.91690.91690.91690.12130.47000.91690.01640.01790.11890.54400.06610.65540.49510.44290.63080.07750.07750.17570.58930.15620.65540.55970.52350.65540.64580.79150.45100.68950.29050.44270.06330.41840.08700.91690.91690.75760.91690.73480.7576
0.41150.75760.4525

Notes: The multiple testing is conducted based on Model 3 of Equation (2), which controlled for the full set of caregivercharacteristics and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend.
“Origin” stands for the p-values based on clustered standard errors; “Simes” standards for the p-values further adjusted for
multiple-hypotheses testing.

56

F. Gender Disparities in the impact of the reform across SES

Figure F2. Heterogenous impact on specific symptoms by gender: income level57

Figure F3. Heterogenous impact on specific symptoms by gender: caregiver-recipient relationship58

G. Additional Impacts of the Reform
Table G1. Overall impacts of the 2006 reform on informal care provision
Impact of the Reform
0.172

S.E.
(0.024)[

95% C.I.
0.219
0.125

]

Low HH-Exp
High HH-Exp
SpouseParentParent-in-law

0.183
0.203
0.162
0.238
0.086
0.238

(0.028)(0.043)(0.043)(0.054)(0.068)(0.045)

[
[
[
[
[
[

0.237
0.287
0.247
0.344
0.220
0.326

0.128
0.119
0.077
0.133
-0.047
0.151

]
]
]
]
]
]

Male sample
Low HH-Exp
High HH-Exp
SpouseParentParent-in-law

0.143
0.107
0.101
0.108
0.173
-

(0.051)(0.081)(0.081)(0.080)(0.075)
-

[
[
[
[
[
[

0.242
0.265
0.260
0.266
0.320
-

0.043
-0.051-0.057-0.050
0.026
-

]
]
]
]
]
]

Full sample
Female sample

59Figure G2. The impacts of the 2006 reform on well-being of care recipients over time
Notes: All estimates were derived based on Model 3 of Equation (1), which controlled for the full set of caregivercharacteristics and recipients’ gender and age, as well as year FE, care level FE, prefecture FE, and prefecture-year trend. The
y‐axes share a uniform scale for visual comparability. The markers stand for the estimates of α! in Equation (1). The thicker
and thinner bars represent confidence intervals at the 90% and 95% levels, respectively. Standard errors were clustered at thelevel of care level, year, and prefecture.

60

H. Robustness Checks

Figure G1. Robustness checks
Notes: For the robustness results, the markers with 95% confidence intervals represent the estimates of γ" from Model 3 ofEquation (3), which controlled for the full set of caregiver characteristics and recipients’ gender and age, as well as year FE,
care level FE, prefecture FE, and prefecture-year trend. For the main results, the markers with 95% confidence intervals
correspond to the estimates presented in Panel A of Table 3. Standard errors are clustered at the level of care level, year, andprefecture.

61

Figure G2. Robustness check: specific symptom

Figure G3. Robustness check: reasons for being stressed62