https://orcid.org/0000-0003-4054-1058
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ABSTRACT
A fast-ageing population implies an upsurge in demand for caregiving. We examine the causal effect of informal caregiving on caregivers’ realized and forgone healthcare utilization based on data from China. Accounting for the potential endogeneity in caregiving, we find that caregivers not only use more outpatient care and self-treatment, but are also more likely to forgo necessary inpatient care. Caregiving also increases the out-of-pocket expenditures of all types of healthcare. Further mechanism analysis shows that caregiving worsens caregivers’ health and takes up time and economic resources for healthcare utilization, which causes the coexistence of increased realized and forgone healthcare use. Heterogeneity analysis reveals that those with tighter budgets and higher marginal costs for healthcare (e.g. rural or less educated caregivers) tend to bear larger increases in caregiving-driven health costs. Our results shed light on the overlooked benefit of long-term care policies if accounting for the spillover effects of informal care provision on caregivers’ healthcare use, particularly for disadvantaged groups.
Acknowledgments
We want to thank Xinyan Huang, Ning Jia, Hong Liu, Paiou Wu, Nina Yin, and the participants at the 13th International Symposium on Human Capital and Labor Markets and the 20th Quarterly Meeting of China Labor Economists Forum for their helpful comments and suggestions. We are very grateful for many helpful comments from the editor and three anonymous referees. Any errors are our own.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement for basic data sharing policy
Raw data were generated at the China Health and Retirement Longitudinal Study (CHARLS) team at Peking University (see http://charls.pku.edu.cn/en/). Derived data supporting the findings of this study are available from the corresponding author upon request.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/00036846.2023.2211338.
Notes
1 Niimi (Citation2016) finds that informal caregiving to parents or parents-in-law is negatively associated with the subjective well-being for unmarried caregivers, but not for the married ones.
2 See Lloyd-Sherlock et al. (Citation2017), Villalobos Dintrans (Citation2018), and Dabove (Citation2021) for an overview.
3 Hukou is a household registration institution with ‘the power to restrict population mobility and access to state-sponsored benefits for the majority of China’s rural population’ (Chan and Buckingham Citation2008). The two main types of hukou are ‘agricultural hukou’ and ‘non-agricultural hukou’. In a few regions the two are combined into a ‘unified hukou’.
4 We also check if our results are robust to adding controls of employment status (work or not), health status (the number of chronic diseases), the number of siblings, and other non-labour income sources (the per capita household rent income plus financial assets income), as these variables might influence the healthcare use or confound the caregiving decisions. Table A.1 in Online Appendix III suggests that the results are almost the same as the main results in Section 4.1.
5 Several studies use measures of patient functioning or indicators of whether parents or parent-in-law are alive as IVs of caregiving because they are highly correlated with the demand for informal care. But the bereavement of parents(in-law) and concerns for patients may correlate with the decrements in caregivers’ physical and mental health, which might directly influence their healthcare utilization (Stroebe, Schut, and Stroebe Citation2007). Therefore, we do not use these IVs for our main analysis, but rather revisit them for an additional IV to facilitate the overidentification test in one of the robustness checks in Online Appendix IV. Another possible source of IV is the availability of local elderly care facilities (e.g. the number of nursing homes in the community), as they might partially substitute for informal care. Though our IV avecare5 can capture similar information of local demand and supply condition for elderly care, still we would like to include this type of IV as additional IVs to check the robustness of the results and show the joint validity of IVs in Section ‘2. Instrument validity tests’ in Online Appendix IV.
6 There are few observations born earlier than 1934 or later than 1964, so we lump them into two cohorts, respectively. In sensitivity analysis in Online Appendix IV, we experiment with alternative constructions of IV in Table B.1 and find qualitatively similar results.
7 In column (8) of Table B.2 in the sensitivity analysis in Online Appendix IV, we replace the city fixed effects with community fixed effects to control for a finer level of time-invariant confounders. We find similar results with those in the main results in Section 4.1.
8 Wave 2018 no longer has questions about forgone outpatient and inpatient care, and the questions about self-treatment are different from other waves.
9 We drop individuals with none of the parents or parents-in-law alive because they were not asked about caregiving-related questions.
10 Throughout the paper, ‘incidence’ refers to a dummy for whether something happens.
11 To avoid missing values for those zero costs, we take log (1+ OOP) transformations for the OOP expenditures.
12 Respondents are classified as ‘less than lower secondary’ if they report an education level of ‘No Formal Education (Illiterate)’, ‘Did Not Finish Primary School but can Read’, ‘Sishu (Private Tutoring)’, ‘Elementary School’ or ‘Middle School’. If a respondent reports an education level of ‘High School’ or ‘Vocational School’, he/she is classified as ‘upper secondary’. Respondents are classified as ‘tertiary education’ if they report an education level of ‘Two/three-year College’, ‘College Grad’ or ‘Post-graduate degree’.
13 The exchange rate throughout the paper is as follows: 1USD = 6.4 RMB. Here the average OOP expenditures of outpatient and self-treatment are annualized by multiplying the monthly average by 12.
14 Similarly, here the average OOP expenditures of outpatient and self-treatment are annualized average.
15 Data source: China’s National Bureau of Statistics.
16 The specific amount of money per year of outpatient care is calculated as follows: the estimate × the average of OOP expenditure of outpatient care × 12. Self-treatment below is calculated in the same way.
17 The specific amount of money per year of inpatient care is calculated as follows: the estimate × the average of OOP expenditure of inpatient care.
18 We also check if informal care provision would change care giver’s health insurance, which would further alter the price of health service. And we check if the mechanism of satisfaction or emotion plays a role or not, because care provision can also improve one’s relationship with parents and improve life satisfaction, and people with higher levels of happiness and wellbeing tend to be less sick compared to unhappy people. In Table A.4 of Online Appendix III, we did not find significant results of these effects.
19 Since there are some outliers at both ends of the amount of transfer to parents and the amount of transfer from parents, we apply 98% winsorization replacing values below the 1st percentile and above the 99th percentile. For the net amount of transfer with parents, since there are some negative values, we add the absolute value of the minimum value of this variable before taking the natural logarithm.
20 In China, the mandatory retirement age is 60 for urban male workers and 50 for urban female blue-collar workers (Although retirement age is 55 for urban female cadres, the number of urban female cadres is relatively small).
21 For the increased incidence of chronic diseases, one natural way to interpret it is that caregivers are more likely to have these diseases. But since this measure of chronic disease incidence is a self-report of doctor’s diagnosis, we cannot rule out the possibility that caregivers have long had the disease, but they are more likely to discover (and self-report) these diseases, as they may have better health awareness or access to health examinations while looking after and accompanying parents to hospitals. In any case, the increased (discovered) chronic diseases would still drive up the actual needs for healthcare use.
22 We also check the potential heterogeneous effects by parental age. Bassoli et al. (Citation2022) find that caregiving might increase depression when parents are close to death, which implies that caregivers’ health and healthcare use may depend on the life-cycle stage of their parents. We divide our sample into ‘parent old’ and ‘parent young’. ‘parent old’ is defined as the average age of living parents and parents-in-law being above 80. ‘parent young’ is defined otherwise. Besides the healthcare utilization variables and the health variable ‘sick or not’, we also check the mental health variable ‘CESD-10’ which is a total score of 10 depression-related questions about how often the respondent has the depression-related feeling (A higher score indicates a worse mental status). The results are shown in Table A.7 Online Appendix III. We did not find that caregivers with parents older than 80 have particularly worse health or use more healthcare. Caregiving in both groups increases healthcare use. If anything, the ‘parent young’ group increases to a larger extent.
23 The share of people aged 65 and above has already reached 14.20% in 2021 according to the National Bureau of Statistics of China. See details at https://data.stats.gov.cn/english/easyquery.htm?cn=C01.