Cognitive Impairments, Health and Long-Term Care Insurance, and the Life Course in Older Adults

Addressing cognitive impairments in older adults is a pressing global challenge.
Cognitive impairment significantly affects individuals' daily functioning and mental
health. Older adults with cognitive impairments often experience worse health
outcomes and higher health and long-term care expenditures compared to those
without, placing significant challenges on households. Evidence suggests that health
insurance can improve health outcomes by enhancing access to needed healthcare,
while long-term care insurance helps reduce long-term care and related healthcare
costs. In addition, life course research indicates that initial advantages can accumulate
over time, increasing health inequalities in later life. The core aim of this thesis is to
examine whether health and long-term care insurance, along with life course factors
such as social support, can be leveraged to improve outcomes associated with
cognitive impairments among older adults. This thesis employs Andersen’s
Behavioural Model and the Cumulative Advantage/Disadvantage Theory as
frameworks for the analyses. Using data from the Korean Longitudinal Study of
Aging, the Chinese Longitudinal Healthy Longevity Survey, and the China Health and
Retirement Longitudinal Study, this thesis employs a variety of statistical techniques
(e.g., growth mixture models, Cox proportional hazards models, staggered differencein-differences, and Sobel tests) to examine the role of health and long-term care
insurance, as well as social support across different life stages, in outcomes related to
cognitive impairments. The findings indicate that Social Health Insurance coverage is
associated with a reduced risk of rapid cognitive decline and mortality among older
adults with cognitive impairments in both China and Korea. Medical Aid in South
Korea and Basic Health Insurance in China appear to protect older adults with lower
educational levels from cognitive decline. In addition, the results suggest that after
incorporating long-term care costs, the likelihood of experiencing catastrophic
expenditures increases significantly compared to when only healthcare costs were
considered. Furthermore, adopting long-term care insurance significantly reduces this
likelihood among older adults with cognitive and/or physical limitations in China,
with stronger effects observed among those with more complex cognitive or physical
health conditions. Besides, the findings reveal that neighbourhood social support in
youth plays a more important role in shaping cognition and depression at older ages
than individual-level social support. These associations remain significant among those with low socioeconomic status during their youth. The results also suggest that
accumulated social support across life stages helps maintain cognitive function and
alleviates depressive symptoms at older ages. The findings suggest that health and
long-term care insurance, along with life course factors such as social support, could
be leveraged to address cognitive ageing and health inequalities. The experience of
South Korea highlights the benefits of incorporating cognitive impairment-related
healthcare services into Social Health Insurance coverage, a strategy other nations
could adopt to better protect older adults with cognitive impairments. This study
recommends that the Chinese government expand long-term care insurance pilot
programs to more regions and implement tiered coverage criteria to provide targeted
financial protection for older adults with complex care needs. In addition, the results
underscore the importance of fostering strong social support across life stages and
highlight the greater role of neighbourhood social support in improving health
outcomes in later life, particularly for the socioeconomically disadvantaged.