The effect of self-directed care on unmet needs of older adults: Quasi-experimental evidence from China

Self-directed care is a service model that grants recipients choice and control over home- and community-based services. China has adopted this model, funded by its long-term care insurance (LTCI), yet its effects remain underexplored. This study examines the impact of self-directed care on unmet needs among older Chinese and explores the underlying mechanisms. Using data from the China Health and Retirement Longitudinal Study (CHARLS, 2013, 2015, 2018, and 2020), this study employed doubly robust difference-in-difference estimators to compare individuals in self-directed and agency-directed care programs with those in non-LTCI cities, with a total of 27,297 observations from 7,627 respondents. Compared to individuals in non-LTCI cities, those under self-directed care reported 0.106 fewer unmet needs and were 4.4 percentage points more likely to be satisfied with life. No significant effects were observed on family caregiving intensity and depressive symptoms. In contrast, agency-directed care had no significant effects on unmet needs, life satisfaction, depressive symptoms, or family caregiving intensity. The findings demonstrate that self-directed care reduces unmet needs by enhancing the service quality provided by family caregivers rather than altering their care intensity. These insights offer practical implications for promoting self-direction and integrating family caregivers into care systems.