Chuanzhao Chen, Yigang Zhang, Peng Liu
Background China’s long-term care insurance reform is a key component of multilevel medical security for addressing care needs among older adults with substantial functional decline, and it also raises an ethical governance question: how family-based Confucian care responsibilities are translated into modern rules of eligibility, payment, service provision and regulation. Methods This study analyzed core long-term care insurance policy texts from 48 pilot cities through directed content analysis, a 45-item coding framework, policy text indices, K-means clustering and a supplementary comparison with the 2026 national rollout document. The 48-city sample was drawn from the 49-city national pilot framework after one city was excluded because no eligible core implementation text was located. Results Local policy texts most clearly institutionalized needs assessment, payment responsibility and socialized service provision. Home-based or visiting care was widely recognized, but more specific caregiver-support rules, including caregiver training, respite care, family participation in care planning and detailed home-care service packages, remained less developed, as did digital governance. The national rollout document strengthened equity protection and family care responsibility, but detailed caregiver support and age-friendly digital access still require further specification. Conclusion Long-term care insurance in China functions not only as a financing and service instrument within multilevel medical security, but also as a public health governance mechanism that translates filial responsibility, care for vulnerable older adults, people-centered governance and benevolent rule into institutional arrangements.