With the accelerating trend of global population aging, governments worldwide are facing mounting pressure on pension sustainability, healthcare systems, and long-term care (LTC) services. Within the framework of social long-term care insurance (LTCI) systems, pioneering countries such as Germany and Japan have established comprehensive LTCI systems. Through dedicated legislation, notably the Nursing Care Insurance Law, these countries have developed clearly define frameworks for financing, eligibility assessment, and service provision. Their experiences demonstrate that well-structured institutional arrangements can effectively achieve risk pooling and ex ante risk transfer (1, 2). In contrast, the United States has adopted a more market-oriented approach, combining private LTCI with public programs such as Medicaid to form a pluralistic and decentralized LTC system (3, 4). In recent years, reforms in countries such as South Korea and the Netherlands have further illustrated how diverse welfare state models integrate public financing, community-based care, and multi-level governance within LTC systems (5). Collectively, the successful experiences of these developed countries provide important insights and valuable lessons for the development of China’s LTC policy framework.

In China, the rapid expansion of the older adult population has intensified the urgency of establishing a robust LTCI system. By the end of 2023, China’s population aged 65 and older had reached 217 million, accounting for 15.4% of the total population. Moreover, the number of older adults with disabilities is projected to exceed 77 million by 2030 (6, 7). Since the launch of the initial pilot in Qingdao, Shandong Province, in 2012, China’s LTCI program has progressed from limited experimentation to a substantially expanded pilot phase. In 2020, the National Healthcare Security Administration and the Ministry of Finance issued the Guidance on Expanding the Pilot Program for the LTCI System. This policy document marked the formal transition of China’s LTCI initiative into a stage of accelerated nationwide promotion, and this phase is characterized by policy expansion and an exponential growth in related policy documents (8, 9).

In parallel with these institutional developments, academic research has gradually shifted from macro-level system design toward systematic evaluation of policy content and implementation outcomes. Existing studies primarily focus on analyses of early pilot policies (10–12), synthesizing experiences from pilot regions (13, 14), and comparative evaluations of different pilot models (15–18). However, systematic evaluations of LTCI policies themselves, particularly through policy scoring approaches, remain limited.

In recent years, policy text analysis based on policy instrument theory has been increasingly applied across a wide range of public policy studies. Policy instruments are defined as the tools and mechanisms employed by governments to achieve policy objectives and directly shape implementation effectiveness (19). This approach typically involves construction of two- or multidimensional analytical frameworks. For example, Wang et al. employed a two-dimensional framework of “policy instrument–policy rating” to analyze the composition, strengths, and weaknesses of LTCI policy instruments (20). In the domain of policy evaluation, the Policy Modeling Consistency (PMC) index model is widely used due to its relative objectivity in assessing internal policy coherence and multidimensional performance. Representative applications include the evaluation by Wang et al. of 16 pilot policies, which proposed strategies to enhance equity and sustainability (21). Similarly, Peng et al. assessed the sustainability of China’s LTCI system (22), while Duan et al. conducted a quantitative analysis of the diffusion characteristics of LTCI policies (23). Although these studies provide valuable insights, they tend to focus on specific policy dimensions and rarely examine the internal coordination between policy instrument configurations and structural differences across policy levels.

We, therefore, aimed to establish a two-dimensional analytical “policy instrument–policy level” framework to conduct a qualitative analysis of LTCI policy texts from the promotion phase. Furthermore, we integrate the PMC index model for policy scoring. This combined approach will substantively enrich research in the field of LTCI policy design and provide robust, evidence-based support for relevant decision-making authorities.

We systematically evaluated China’s LTCI policies through a two-dimensional framework and the PMC index model. Structural imbalance exists in the use of policy instruments, characterized by over-reliance on environment-based instruments and a relative insufficiency of supply-based and demand-based tools. This imbalance is pronounced in areas such as capital investment and public–private partnerships.

As crucial levers for governments to achieve governance objectives, the rational configuration of policy instruments directly impacts the effectiveness and sustainability of policy implementation (36). Our dimensional analysis reveals that the excessive proportion of environment-based instruments, coupled with the underutilization of supply-based and demand-based tools, not only constrains the comprehensive achievement of policy goals but may also trigger a series of derivative issues in long-term systemic development. This finding is consistent with prior research (19, 37).

It is crucial to clarify that the “over-reliance” on environment-based instruments does not negate their intrinsic importance, but rather indicates their disproportionately dominant position within the policy instrument mix. This is manifested as the construction of an institutional framework through indirect means such as target planning, regulations, and supervision, which compresses flexible space for applying supply-based and demand-based instruments. Consequently, the capacity of supply-based instruments—which provide direct “hardware” and “software” support such as funding, technology, talent, and public services to establish the material foundation for policy goals—is significantly weakened. Simultaneously, demand-based instruments have failed to fully activate or mobilize the vitality of social resource allocation, leading to an ineffective linkage between policy objectives and market mechanisms.

The causes of this structural imbalance in policy instruments can be attributed to two main factors. First, the imbalance is partly rooted in the “incrementalism” that characterizes China’s policymaking process. The adoption of incrementalism as a primary decision-making model facilitates the formulation of more feasible policies and helps minimize implementation errors (38). The progression of LTCI from regional pilots to expanded trials and nationwide implementation represents a complex and enormous undertaking. This process involves the construction and coordination of multiple dimensions (including the policy system, fiscal budgets, and infrastructure) and entails the interest negotiation among decision-makers representing different stakeholder groups. A series of incremental reforms allows these decision-makers to continuously achieve consensus, thereby facilitating the smooth formulation and adoption of policies. Second, the imbalance also stems from the “rationalist” behavioral strategies of local governments. Local governments rationally conduct cost-effectiveness analyses to determine optimal solutions. Crucially, however, such decision-making often prioritizes maximizing benefits within their own jurisdictions. From a national perspective, this localized rationality can aggregate into a risk of structural imbalance across the broader policy landscape.

Our results further indicate that central and local governments exhibit distinct priorities in their use of policy instruments. Central policies demonstrate greater balance and guidance, whereas local policies tend to prioritize environmental shaping and rule specification. However, the systemic coordination between the two levels urgently requires strengthening. As the top-level designer of the LTCI policy, the central government’s core objectives are to establish a nationally unified institutional framework and ensure the scientific rigor and equity of the policy direction. Consequently, its selection of policy instruments emphasizes balance and guidance (39). Specifically, the central level formulates nationwide pilot guidance to clarify the fundamental principles for core elements such as coverage, financing standards, and benefit levels of LTCI. This aims to preclude regional policy deviations that could lead to either excessive or insufficient provision.

Furthermore, through the deployment of instruments such as fiscal subsidies and pilot demonstrations, the central government incentivizes local policy practice and steers local initiatives toward alignment with the national framework, thereby safeguarding the systemic integrity of the LTCI program (40). In contrast, local governments, as the primary implementers of LTCI policies, must tailor policies to local conditions, including socio-economic development levels, demographic structures, and the distribution of care resources. Consequently, they lean more heavily on environment-based instruments for environmental shaping and rule specification. For instance, localities enact regional regulations and management measures to set accreditation standards for care institutions and specify qualification requirements for care personnel, thereby fostering an orderly market environment for LTCI implementation. They also determine fee schedules for care services and delineate service areas based on local factors such as the distribution of disabled older adult and cost-of-living indices.

Nevertheless, significant shortcomings persist in the coordination between central and local LTCI policies. Local governments may misinterpret the core intent of central directives during the rule-specification process, leading to policy deviations from central requirements. Conversely, the mechanisms for information sharing and collaboration between levels are underdeveloped. The central government often lacks real-time insights into the challenges and experiences encountered during local implementation. Simultaneously, local governments may not receive timely central guidance when making policy adjustments. This disconnect hinders the rapid translation of successful pilot innovations into nationwide institutional practices. Moreover, it contributes to policy fragmentation in some regions, which is detrimental to the unified national advancement of the LTCI system (41, 42).

The PMC index evaluation indicates that while China’s LTCI policies demonstrate an acceptable overall performance, significant room for improvement remains in areas such as policy target coverage, policy timeframe planning, and inter-level policy coordination. As an important diagnostic tool utilized to gage policy quality, the PMC index model provides a multidimensional assessment of LTCI policies during their promotion phase. The results, showing an overall acceptable performance, are attributable to scientifically sound designs in core areas such as the financing mechanism, service provision framework, and pilot implementation models, which have effectively responded to the LTC security needs of the disabled population amid population aging (43). However, the current LTCI policy target coverage focuses on older adults with disabilities. Moreover, most pilot regions tie eligibility for LTCI to enrollment in either the employee basic medical insurance or the urban and rural resident basic medical insurance, thereby systemically excluding certain population groups. The care needs of mildly or moderately disabled older adults are not yet fully addressed. This group often faces a dilemma between “inadequate care services” and “not meeting the severe disability assessment criteria,” resulting in a coverage gap within the policy safety net (44, 45). In contrast, specific populations not enrolled in basic medical insurance—such as flexible workers, new-economy practitioners, and left-behind older adults in rural areas—find it challenging to be included in the LTCI scheme, indicating an imperative need to enhance the policy’s inclusivity.

Furthermore, LTCI policy remains in a pilot exploration stage. Most regional policy documents are issued as “pilot implementation plans,” which are often characterized by short-term validity cycles and a lack of clear long-term planning. This leads to uncertainty regarding policy continuity once pilot periods expire, revealing a tendency toward short-sightedness in long-term institutional design. Failure to fully account for long-term variables such as the pace of population aging and rising care costs, coupled with the absence of a dynamic optimization plan for adjusting financing standards and benefit levels, may result in future issues such as imbalances in fund revenues and expenditures and a disconnect between protection levels and actual needs.

Our comparative analysis of representative policies reveals that regional economic development stages, institutional foundations, and policy targeting are significant determinants influencing policy design. First, the stage of economic development serves as the material foundation for LTCI policy implementation. It directly determines a local government’s fiscal capacity to invest in the security system, the willingness of market entities to participate, and the affordability of contributions for residents, thereby influencing the breadth and depth of policy design. Zhoushan City, with its developed economy and mature insurance market, possesses substantial fiscal and healthcare fund reserves. This enables support for a multi-tiered system covering both employees and urban/rural residents across the entire region, achieving diversified financing from fiscal budgets, healthcare funds, employers, individuals, and commercial insurance, with correspondingly more varied service models. Fuzhou City, while economically robust, does not match Zhoushan’s level of maturity. Its policy relies primarily on the employee medical insurance system for financing, prioritizing the care needs of disabled employees, thus resulting in more constrained financing channels and coverage. The pilot area in Nanning operates under constrained economic conditions with limited surplus in healthcare funds and fiscal budgets. To mitigate financial risks, the pilot program is restricted to a narrow scope covering specific central and regional institutions stationed in Nanning. It does not establish a unified financing mechanism and only provides basic care benefits.

Second, LTCI does not exist as an independent system; its design must build upon existing local institutional foundations, including the medical insurance administration system, care service networks, and disability assessment mechanisms. The robustness of these foundations directly determines the starting point and implementation pathway of the policy. Zhoushan City has already established a comprehensive urban and rural medical insurance administration network and a diversified care service system. This solid institutional base allows for direct implementation of full regional coverage and the immediate establishment of a multi-level protection model. Fuzhou City, as a national pilot, has developed administration and assessment systems tailored for the employee population but currently lacks the capacity for universal service provision. Consequently, it has adopted a gradualist path, first covering employees with disabilities before expanding to those with moderate disabilities. The pilot in Nanning has yet to establish mature care service and assessment systems and lacks experience in cross-population medical insurance coordination. It is therefore limited to small-scale experimentation within specific units to validate basic administrative processes, resulting in a conservative and narrowly scoped initial policy phase.

Finally, distinct policy targeting directs local governments to prioritize different population groups, care priorities, and institutional functions in their policy design, resulting in the formation of differentiated policy frameworks. Zhoushan’s policy goal is to build a universal, multi-level LTC security system, with its core orientation being inclusiveness and diversification. Accordingly, its policy design covers all basic medical insurance participants, preserves the fundamental coverage of policy-oriented LTCI, and introduces commercial long-term care insurance to address personalized demands. Fuzhou’s policy goal is to fulfill the national pilot mandate and provide replicable operational experience for employee LTCI nationwide, with its core orientation being standardization and demonstration. Thus, its policy design prioritizes the employee group, which has a mature contribution mechanism and well-established information management systems, first addressing the core needs of the severely disabled before gradually expanding coverage. The policy goal of the Nanning pilot in Guangxi is to verify the implementation feasibility of LTCI policy within a limited scope, with its core orientation being “low-risk” and “exploratory.” Consequently, its policy covers only the specific group of central and regional units stationed in Nanning, focusing on minimizing pilot risks and accumulating basic operational data, which renders its design distinctly exploratory and conservative.