Behind the 40 million disabled elderly people, why is there a care debt that is still unfair?

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Behind the 40 million disabled elderly people, why is there a care debt that is still unfair?

Technology Guide North

2026.11.10 22:42

· From Beijing

Full text 7306 words

As of the end of 2025, the domestic elderly population aged 60 and above has exceeded 320 million, of which approximately 40 million are disabled or semi-disabled. Calculated, one in every eight elderly people needs special care. Looking across the country, there are only 20,000 professional home bathing assistants.

20,000 people correspond to 40 million care needs. This disparity in figures marks the hardest nut to crack in the life service industry - most of the service targets are elderly people with both mobility and cognitive decline. The professional threshold is much higher than that of ordinary housekeeping. A single door-to-door service must take into account multiple tests such as operating standards, physical exertion and emotional comfort. The labor cost of the industry is high, but there is a realistic upper limit on the unit price per customer.

Even if you choose home care, the care burden will be converted into the time opportunity cost of family members. Relevant calculations show that the comprehensive care burden exceeds 2,400 yuan per month.

The bigger practical dilemma is that to this day, the domestic home-based elderly care industry has not yet developed a set of profit models that can be replicated on a large scale. Almost all companies entering the industry are groping between costs and payment capabilities. The vast majority of platforms choose to bypass heavy operations and only do information matching to earn the traffic price difference.

JD.com chose to enter the game in reverse, and transferred the self-operated management and control, standardized training, contract fulfillment network and digital capabilities that it has honed in the commodity field over the past two decades to the service track, trying to use systematic operations to hedge against the non-standard attributes of the industry. However, it is difficult for individual exploration to hold up the weight of the entire industry. The breakthrough of home care requires not only companies to polish their services, but also systematic support from policies, payment systems and social cognition.

Why is this bone so hard to chew?

Home-based elderly care is far from as simple as cleaning the house and helping the elderly take a bath.

The pressure on the demand side is a long-term war of attrition, and the gap on the supply side is a structural talent gap. Under the squeeze from both ends, the industry has long been trapped in the deadlock of "cannot find people and cannot trust people."

The boundaries of care are far beyond ordinary housekeeping, and the cost is very rigid.

23-year-old Wu Lahati is a senior care caregiver at JD Housekeeping, specializing in bathing assistance services. Colleagues and customers are accustomed to calling him Hati.

After more than a year of working in the industry, he has served three to four hundred elderly people. The one who impressed him most was an 85-year-old grandfather. The old man had not bathed for more than four years. He was bedridden for a long time and had muscle atrophy. He usually refused to communicate with others. It was not until the smell in the house was unbearable that his family placed an order for help.

The entire service process is cumbersome and rigorous. The vital signs must be measured, the skin condition must be checked, and the elderly person's physical tolerance must be confirmed first. During the transfer, multiple people must cooperate to avoid bumps and dislocations. The dirt accumulated over four years must be gently cleaned several times, and the elderly person's complexion and breathing must be observed at all times throughout the process to prevent chest tightness and dizziness. Including commuting, preliminary assessment, operation execution, and follow-up sorting, a single service often takes more than half a day.

Care for the elderly with cognitive impairment is even more challenging. Harti once served an elderly man with Alzheimer's disease, whose lower limbs were atrophied and unable to move. During the service, the old man kept struggling, scratching and slapping, and several marks were scratched on his hands. The family was too embarrassed to ask for compensation, but he refused: "The old man didn't mean it, it was the impact of the disease." After several services, although the old man still occasionally got emotional, he could recognize him and no longer had strong aggressive behavior.

In the home care scenario, caregivers have multiple roles as caregivers, safety officers, and emotional counselors. Simply completing a bath for a disabled elderly person involves a whole set of professional processes including health assessment, risk prediction, standardized operations, and emergency response. The professional threshold and human investment are far beyond the capabilities of ordinary housekeepers.

Talent gap: high training costs and faster loss

The higher the service threshold, the scarcer the qualified talents become; and industry prejudice and current career advancement paths are limited, which continues to drive up the turnover rate.

Chen Jingyi, a designer and trainer of home care and elderly care products at JD.com, feels this deeply. She graduated with a major in geriatric services and management. Among more than two hundred graduates in the same class, less than ten are still in the geriatric care industry.

"School teachers will tell students that they can transfer to management positions after working on the front line for a few months, but the reality is that cultivating a manager who can take charge of his own work requires many years of life experience and emergency response experience, and many young people cannot wait." Chen Jingyi said frankly.

The cost of trial and error for enterprises is also high. Chen Jingyi saw an intern being bitten while helping an elderly person with cognitive impairment remove and put on dentures, and she subconsciously wanted to fight back. She also encountered an old person experiencing sudden physical stress while taking a bath, and the newcomer was either beaten or froze in place at a loss. Care services are directly related to the personal safety of the elderly. One mistake may lead to serious consequences. Companies dare not easily let new people take up the job independently. The training cycle is lengthened and labor costs also rise.

Social cognitive biases continue to compress the talent supply. Yueyang, who is also a practical lecturer in nursing care, when she received the admission notice of home economics at the age of 18, her mother directly advised her to drop out of school: "Home economics? Should you graduate and become a nanny?" Even if many young employees recognize the job, they will inevitably choose to escape under the pressure of their family members to "serve people".

The "2025 National Bulletin on the Development of the Aging Industry" shows that as of the end of 2025, there were 1.395 million people employed in elderly care services nationwide, including 685,000 employees in elderly care institutions, and only 47.4% of the institutions were certified caregivers. 1.395 million practitioners face 40 million disabled and semi-disabled elderly people. Even if they are operating at full capacity, the supply gap is still huge.

What is even more troublesome is the structural contradiction in talent flow. Most of the experienced and certified caregivers are employed in elderly care institutions, and it is difficult for them to enter the home service market. Among JD.com's own care team, more than 80% of the staff had no experience in elderly care before joining the job, and almost all front-line staff had to be trained from scratch.

Chen Jingyi chose to stay behind the scenes to polish the standards, hoping to break down home care into replicable and trainable professional actions, lower the training threshold, and fill this "invisible gap."

The gap between standards and reality: non-standard products drive up marginal costs

The service standards that have been used in the industry for many years are mostly formulated based on well-established elderly care institutions. When applied to thousands of ordinary families, they often appear to be "acclimated".

For example, when transferring between a bed and a wheelchair, the standard process only includes horizontal movement. However, in reality, many homes have narrow spaces and the wheelchair cannot be pushed to the edge of the bed. The caregiver can only carry the transfer with bare hands. Once exhausted, the elderly may fall, suffer bone fractures, and dislocate. For every additional family type and elderly person's physical condition, the service process will need to be adjusted one more time, making it difficult to reduce marginal costs.

Demand always runs ahead of standards. Many family members hope to give showers to bedridden elderly people. In the past, industry standards generally only recommended sponge baths.

When Chen Jingyi was testing the bathing aid service, she met a 97-year-old man who had been bedridden for a long time and had pressure sores. His muscles atrophied to the point where his hands and feet were curled up in his arms. The family insisted on showering the elderly man, so the team could only take temporary protective measures, wrapping the exposed power strips in plastic bags to prevent leakage, and using waterproof dressings to protect the wounds to avoid infection. It took the cooperation of many people to complete the service.

"Behind this type of request is that the demand has not been met." In Chen Jingyi's view, standards must be optimized step by step according to real family scenarios. There is no shortcut in this process. It can only be done one by one, one by one, to find a balance between the bottom line of safety and user needs.

A set of SOPs and a fulfillment network: Exploration of industry standardization

The common practice in the market is asset-light matching. The platform is only responsible for dispatching orders and does not control the entire chain of service standards, contract fulfillment processes, and after-sales experience to avoid cost pressure. However, under this model, service quality is uneven, user trust is difficult to establish, and the industry has never been successful.

JD.com has chosen a path of heavy investment, first building a service standard system, then completing talent cultivation, gradually building a cross-city fulfillment network, and relying on door-to-door services to accumulate user trust.

Home care standards grow from field testing

Before JD Housekeeping launched the bathing aid service, Chen Jingyi and her team first visited 23 elderly households in Beijing to provide on-the-spot services according to a preliminary process, and then reversely revised the standards based on the problems of each household.

In the end, home care services were divided into five major standardized operating procedures: food, living, bathing, health monitoring, emergency response, psychological care, and home rehabilitation. Everything from the force-generating posture of turning over and shifting, the steps to measure vital signs before bathing, to the emergency response plan for sudden illness, are all clearly standardized.

The entire set of internal standards has been refined into hundreds of details. Currently, two types of SOPs, namely service skills and timeliness, are implemented, totaling about 40 items, covering all currently online services.

A qualified elderly care caregiver needs to pass four levels of selection, theoretical training, practical assessment, and on-the-job examination in order before he is qualified to take orders independently.

Chen Jingyi remembers that a nurse with consistently good reviews once conducted a full-body shower for an elderly person with an abdominal dialysis tube without authorization, which caused family members to question her professional ability.

"At that time, the service evaluation concluded that sponge bathing was not a big problem, so she accommodated it. However, water vapor entering along the pipes may cause internal organ infections." After this incident, the team became clearer about the boundaries of the standards - standardization does not mean that it refuses flexible adjustments. Individual needs can be communicated and negotiated, but professional safety red lines cannot be compromised.

There are also things that cannot be fully standardized, such as sentimental value. The whole process of elderly care services revolves around people. Each elderly person has a different personality and cognitive status, and there is no universal set of communication skills.

JD.com’s approach is to incorporate communication skills and emotional counseling into the training content, while continuing to pay attention to the mental state of caregivers. Facing negative scenarios for a long time can easily lead to career exhaustion. Once the condition is not good, arrange a break and avoid visiting with emotions.

Daily housekeeping care + home health care + aging-friendly transformation to build a closed loop of services

Housekeeping care covers daily care, and nurses come to the home to fill gaps in professional medical care. Home aging-friendly renovation implements "safe elderly care" into hardware, and several business lines work together to extend the service radius.

Gao Zhanwei, a nurse born after 1995, previously worked in the ICU of a military hospital. In July 2024, he undertook the first order of home care on the JD.com platform. In December of the same year, he resigned from the hospital and joined full-time. So far, he has served more than 5,000 families, and more than 80% of the patients are elderly.

He admitted that home care and hospital clinical care are two different sets of logics. There is teamwork and complete equipment in the hospital, but in the home scenario, one person has to deal with everything - questions from family members, simple operating environment, and changes in the condition that may occur at any time.

Because of this, the platform is extremely strict with the qualifications of registered nurses. They must hold dual practicing certificates, have more than five years of clinical experience, and have a professional title of nurse practitioner or above.

Not all orders can be accepted after passing the access review. There are thresholds for injections, dressing changes, blood collection, gastric tubes, and urinary catheters. Projects such as PICC catheter maintenance also require corresponding specialist backgrounds. Each skill is assessed separately. High-risk projects have additional quality control interviews. Only after passing the assessment, the system will open the corresponding service permissions.

At present, JD Nurse Home can provide 64 professional services in seven categories, including injections and blood collection, dressing changes and suture removal, and pressure ulcer care, covering 55 core cities across the country, and can be delivered to your door in as fast as one hour.

The "Filial Care Package" for empty-nesters comes to your door once a week and includes risk screening, chronic disease management, medication supervision and emotional companionship. It is equipped with a dedicated health butler to provide simultaneous feedback on the situation. Most of the orders come from children living in other places.

In addition to service personnel visiting your home, an aging-friendly home environment is also an important aspect. JD.com has formed a complete "safe elderly care" solution in the aging-friendly renovation of homes. The core is to naturally integrate anti-skid, power-assisted and other functions into daily homes, such as bathroom handrails, which provide support for the elderly to sit and stand up when going to the toilet, reduce the risk of accidental falls, and protect the elderly's leg joints; bedroom sensor night lights, which automatically light up when the elderly wake up at night, prevent the elderly from touching the dark, and reduce accidental bumps and falls...

Trust is embedded in repurchase and contract performance

Standardization ultimately points to user trust, and trust can only be slowly established through stable and reliable performance.

In the field of housekeeping, being willing to hand over the door password to the service staff is a very high level of recognition. Bi Yue, a Dalian housekeeper, has been working for more than a year and has completed thousands of services. Six to eight long-term household customers have directly given her their home door passwords. Before and after each visit, she would take videos and leave traces. In addition to completing the agreed service content, she would also take the initiative to clean up easily overlooked sanitary corners and place all used tools neatly.

Cleaner Xu Hongwei has an old customer who he has worked with for four or five years. Before moving, he will give priority to confirming the coverage of her orders. Knowing that her new home was beyond the service radius, the client simply relocated to an area that she could serve.

The stickiness of care services will ultimately come down to repeat purchases. The repurchase rate of JD’s short-term care and bathing services for the elderly remains at around 60%. Many short-term care customers will directly purchase 50 or 100 service cards and make multiple appointments a week. Higher repurchase means lower customer acquisition costs, which is an important way for companies to hedge against high service costs.

Scale data also provides confirmation. JD.com 11.11 started at 8:00 pm on October 12. As of 18:00 on October 30, the platform has generated 150 million service orders, with categories such as housekeeping and cleaning, home appliance cleaning, physical examinations, moving, partial decoration, leasing, and home-based elderly care leading service consumption. Among them, JD’s housekeeping service sales increased by more than 240% year-on-year, daily cleaning, clothing and shoe washing and care sales increased by more than 4 times year-on-year, door-to-door cooking and pet feeding increased by more than 10 times year-on-year; JD’s nurse home accompanying service orders increased by 230% year-on-year. On October 28, a super service day, the FamilyMart bucket was cleaned 26 times in 3 hours and became the best-selling service product on that day.

But even if standardization and high repurchase are achieved, home care services are still hardly profitable. The rigid increase in labor costs, the continued existence of non-standard scenarios, and the ceiling of users' ability to pay are common problems in the industry that all entrants cannot avoid.

Profit Dilemma: The scissor difference between cost and payment

"In the entire home care industry, no company has yet developed a scalable profit model." This is the general consensus in the industry. The core of the dilemma is the huge gap between service costs and users’ ability to pay.

From a cost perspective, elderly care is a typical labor-intensive service industry.

Taking elderly care institutions as an example, manpower is one of the largest costs. Dang Junwu, former deputy director of the China Research Center on Aging, once said that it is difficult to retain people in positions such as caregivers and the turnover rate is high, so institutions have to continue to increase labor costs to stabilize the team. According to industry research on nursing homes, the ratio of caregivers to the elderly must be at least 1:3, so labor costs account for more than 60% of the total operating costs of the institution.

There is a nursing home doing accounting. The hospital has 60 beds and is equipped with 40 employees, including 25 caregivers, as well as medical, administrative, kitchen, front desk, fire control and other personnel on duty. The per capita comprehensive labor cost is about 8,000 yuan per month, and the annual labor cost is close to 4 million yuan. The annual profit margin of this elderly care center is only about 5%.

In addition to expenses such as caregiver salary, training, social security, consumables, safety and after-sales risk reserves, home-based services also have to bear additional commuting costs. At the same time, there are natural constraints on the number of households a single person can serve - a caregiver can serve up to 2-3 households a day. It is difficult to achieve exponential efficiency improvements by relying on technological iterations like the manufacturing industry, and the overall manpower rigidity pressure is often higher than the institutional model.

Turning to the payment side, the income level of the elderly group sets the realistic ceiling for care consumption. One reference data is that according to the social and people's livelihood statistical report released by the National Bureau of Statistics since the "14th Five-Year Plan", the per capita monthly pension for enterprise retirees in my country is 3,162 yuan. The pension level directly restricts the budget space for family care.

According to the JD Consumer and Industrial Development Research Institute's "2026 Family Care Life Panorama Report", more than 70% of the families surveyed are willing to pay for home care services, but the acceptable monthly expenditure for more than half of the families is only in the range of 500-2,000 yuan, and the affordability of rural families is even lower.

According to the results of the fifth sample survey on the living conditions of the elderly in China's urban and rural areas, in 2021, among the elderly who are willing to live in a nursing home, 46.1% can only afford a monthly fee of 1,000 yuan at most, and only 15.8% can afford a monthly fee of 3,000 yuan or more; among rural elderly, the former accounts for as much as 75.3%, and the latter only 1.8%. The same survey showed that 87.3% of the elderly choose to receive care at home.

Choosing to take care at home saves the cost of market-based services, but adds a hidden burden on family members. A survey on the demand for "precision assistance" in Beijing shows that family caregivers of disabled elderly people provide care for an average of 11.5 hours a day, half of them provide care for more than 8 hours a day, and the average number of years of care is close to 12 years.

Based on the CHARLS 2021-2023 survey data, research teams from Wuhan University and Peking University calculated that the comprehensive care burden brought by a disabled elderly person is equivalent to about 2,420 yuan per month, of which 82.2% is the opportunity cost of family members’ care time; if it is a severely disabled elderly person, the actual burden on the family will further increase.

For most ordinary families, professional care expenses of several thousand dollars per month are a heavy practical burden. If the unit price per customer in the market cannot be raised, it will naturally be difficult for companies to cover all operating costs.

At the same time, there are still shortcomings in the support of the existing payment guarantee system. my country's long-term care insurance system is shifting from pilot to rollout. By the end of 2025, there were 309 million people insured in long-term care insurance, 1.9291 million people enjoying benefits, and fund expenditures were 18.644 billion yuan.

Based on a rough calculation based on this set of data, the per capita annual coverage is about 9,700 yuan, equivalent to about 800 yuan per month. This fund covers both institutional and home care scenarios. This also means that most ordinary families still have to bear a large part of their own care expenses.

On the one hand, there are rigidly high service costs, and on the other hand, there is limited residents’ ability to pay. The gap in the middle is difficult to fill by companies alone.

Wang Youguang, chairman of Jiazi Elderly Care Service Co., Ltd., has been deeply involved in the elderly care business in Beijing for 12 years. He described the living conditions of elderly care service companies as "suffering for 12 years." He lamented at the 2026 Xipu Conference that the market is talking about the 10 trillion silver market, but there are very few main board listed companies that truly focus on the silver economy as their main business, and the actual operating resistance far exceeds the paper numbers.

Qian Lili, Vice President and CGO of Reliable Holdings, also observed that capital and public opinion continue to exaggerate the trillion-dollar market story, creating a huge siege effect outside the industry: outsiders see a prosperous market, but companies on the track generally feel that it is difficult to do business and make profits.

This is also the fundamental reason why the elderly care industry has clear needs and broad space, but has yet to emerge as a leading profitable company.

Breaking the situation requires the joint efforts of many parties

Looking at the entire consumer market, the long-term growth trend of service consumption has been established.

Data from the National Bureau of Statistics show that in the first half of 2026, domestic service retail sales increased by 5.3% year-on-year, 4.2 percentage points higher than the growth rate of commodity retail sales; in 2025, per capita service consumption expenditure of national residents reached 13,602 yuan, an increase of 50.5% from 2020, accounting for 46.1% of residents' consumption expenditure.

The policy side also continues to support the upgrading of the service industry. The State Council's "Opinions on Promoting Capacity Expansion and Quality Improvement of the Service Industry" clearly stated that the scale of the service industry will reach 100 trillion yuan by 2030; the "15th Five-Year Plan" plans to deploy actions to expand the capacity and improve the quality of the service industry. The 2026 Government Work Report proposed cultivating the "China Service" brand for the first time; nine departments including the Ministry of Commerce issued the "2026 Work Plan for Actions to Improve Service Consumption and Benefit the People", which implements 64 specific tasks around six major directions.

However, the particularity of elderly care services is that macro consumption dividends will not automatically translate into industry profits.

What the retail industry competes for is the efficiency of the supply chain, delivering goods to users quickly and well; entering the service era, the focus of competition turns to people management and the implementation of service standards, testing whether the platform can continuously and stably output reliable services.

The light model of traffic matching can only solve the problem of "finding people"; while families of disabled and elderly people with dementia, post-surgery rehabilitation patients, and consumers who pursue quality services, what they really crave is "people they can trust."

The scissor gap between cost and payment also shows that home care is not a problem that can be solved by optimizing corporate operations alone. It is related to the quality of life of tens of millions of families and the operating foundation of an aging society.

For this industry to truly develop healthily, it requires coordinated efforts from policy, industry, and society.

At the policy level, many front-line practitioners call for further expanding the coverage and payment ratio of long-term care insurance, and including more home care services in the reimbursement catalog; through consumption subsidies for elderly care services, tax exemptions, talent training subsidies, etc., two-way reduction of enterprise operating costs and user payment pressure.

At the industrial level, companies need to continue to use standardized and digital means to optimize operational efficiency and reduce management costs and security risks; at the same time, they need to explore a layered service system that takes into account inclusive basic services and high-quality value-added services, and slowly build sustainable hematopoietic capabilities.

In this regard, the self-operated standardization practice that JD.com is promoting has proven that this system can steadily improve service quality and improve human efficiency. If this kind of practical experience can flow within the industry and learn from each other, it is expected to drive up the overall supply level.

At the social level, it is necessary to gradually reverse the stereotyped understanding of the elderly care profession, improve career advancement channels, so that more young people are willing to enter this industry, and alleviate the long-standing talent gap from the root cause.

The care needs of 40 million disabled elderly people are a question that must be answered before the entire society.

Enterprise exploration is the foundation, policy support is the lever, and social consensus is the soil. When all parties work together, home-based elderly care can get out of the dilemma of "approval but not success", allowing professional and dignified care to truly enter every family in need. (This article was first published on Titanium Media APP)

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