In the period 2017-2050 the share of 65+ people in the German population is expected to grow from 21.6% to 28.3% (EU-28: 20%-28.5%), with most of the growth occurring before 2030. At the same time, the share of 85+ will expand by more than a factor 3 (from 2.7% to 6.6% / EU-28: 2.7%-6.1%).
Over the same period, the old age dependency ratio measured as the proportion of 65+ as a percentage of the 15-64-year olds will rise from 32.8% to 64.6% (EU-28: 30.5% to 55.3%). Life expectancy for men and women at age 65 is projected to rise from 13.8/18.5 years (EU-28: 17.2/20.7) to 18.5/22.7 years (EU-27: 22.4/25.6) between 2018 and 2060.
Estimates of the number of LTC dependent elderly in 2030 ranges from 3.17 to 3.37 million. By 2050 around 4.4 million people are expected to be in need of LTC.
Under an assumption of no policy change the Ageing Report scenario suggests that public expenditure as share of GDP would rise from 1.3% to 2.7% (EU-27: 1.6%-3.1%) by 2070. The impact of a progressive shift from the informal to the formal sector of care in Germany would entail an estimated increase by 178% in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).
The German LTC system is based on a model of subsidiarity which emphasizes a strong role for informal care alongside formal care services offered at home, with institution-based care viewed as a last resort (cf. Rothgang 2010). Enabling the autonomy of beneficiaries for as long as possible – and thereby reducing dependency on inpatient care – as well as formally recognizing the contributions made by unpaid carers have been amongst the system’s central policy objectives (see Schulz 2010).
The German LTC system was created with one major prerequisite in mind – i.e. strict cost control – which is to be achieved via a tight definition of the ‘need for care’, capped benefits and thus a strict entitlement rule (Götze & Rothgang 2014). This prerequisite has often been at odds with the LTC system’s other policy objectives, which include:
- Providing social protection against the risk of needing care in a manner that is akin to insurance against illness, accidents and unemployment, and protecting income in old age;
- Helping to reduce the physical, mental, and financial stresses related to the need for care;
- Enabling people to stay in their home or to ‘age-in-place,’ for as long as possible, with services based on the principles of prevention and rehabilitation before care, outpatient care before inpatient care and short stay care before full-time inpatient care;
- Improving social security for carers who are otherwise not employed in order to foster the provision of informal care to relatives/friends and to alleviate the effects of having to give up employment as a result of caregiving responsibilities;
- Expanding and consolidating the care infrastructure and encouraging competition amongst service providers (Schulz 2010: 1-2).
The social and private long-term care insurance (LTCI) were introduced on 1 January 1995 as a compulsory insurance to cover a portion of long-term care nursing costs. All persons insured by social health insurance (SHI) funds were automatically assigned to the respective social LTCI funds and all those insured by private health insurance companies (PHI) to a private LTCI. Therefore, every health insurance company includes a separate long-term care insurance plan.
In 2013, 69.8 million citizens were covered by social LTCI and 9.5 million citizens by a private LTCI. There are no differences in benefits between social and private LTCI. Premiums for social LTCI are independent of the individual’s health risk but are calculated as a fixed proportion of the insured person’s labour income. Employers bear almost half of the premium and children and spouses with no substantial individual labour income are co-insured at no extra costs. By contrast, private LTCI premiums are not based on income but on the age at the time of enroling in the private health insurance. However, the amount of premiums paid by individuals to the compulsory private LTCI is restricted.
In 2011, 41% of nursing homes were private and for-profit, 54% were private and non-profit and 6% were public. As for home care, 63% of providers were private and for-profit, 36% were private and non-profit and 1% were public. It is worth noting that market shares (measured in number of care recipients) are slightly lower for private-for-profit providers because they are smaller on average.
Generally, there are three different arrangements through which a recipient can receive long-term care: a care allowance, (in kind) home care services and residential care. The care allowance relates to informal care, i.e. the person in need of care only receives financial support, typically lives at home and is cared for by close relatives. In-kind home care means that a professional care provider regularly visits the recipient at home. The provider is directly paid by LTCI (unless the care received exceeds the appropriate level of benefits in which case the difference is borne by the care recipient). Residential care refers to either short-term or long-term stay in a nursing home.
In 2011 2.5 million people received benefits from social or private LTCIs. Of these, 47% benefited from a care allowance, 23% received home care in kind and 30% were in residential care (including short-term residential care and in-kind day care). The number of recipients has increased by 24% per year between 1999 and 2011 while total expenditure of the social LTCIs has grown by 35% from 16.3 to EUR 22.0 billion.
The LTCI distinguishes between three levels of increasingly severe care needs. In level I extensive care of at least 90 minutes per day is assessed to be needed. People in level II (severe care) are assessed to be in need of at least 180 minutes of care per day, and in level III (most severe care) recipients are assessed to need at least 300 minutes of care per day. If the need for care exceeds level III by far (so called hardship cases), it is possible to apply for further assistance. Furthermore, the beneficiary is supposed to be in need for care for at least six months. The level of care needs and duration of care are assessed by an independent Medical Review Board of the Statutory Health Insurance Funds (MDK) for the social LTCI and by an equivalent body for the private LTCI. Furthermore, people with “erheblich eingeschränkter Alltagskompetenz” – i.e. people with dementia, mental handicaps or comparable mental-health problems – are entitled to additional support, regardless of the assessed care level.
Every LTCI company pays the same fixed benefits according to the level of care, but irrespective of the price for the actual goods and services, which means that the person in need of care has to bear the difference (Support for care – Hilfe zur Pflege, §§ 61 ff. SGB XII). Meanwhile, the definition of being in need of care is wider in the social assistance law. Even persons with a temporary impairment, i.e. less than six months, or with less need for support than needed in care level I can apply for Hilfe zur Pflege. If recipients or their children or near relatives cannot pay the total difference out of their income or other assets, the difference has to be covered by the social assistance scheme.
The nominal amount of the benefits was not reviewed between 1996 and 2007. Monthly benefits were increased for the first time through the reform act Pflege-Weiterentwicklungsgesetz in 2008, with higher increases for home care and the care allowance in order to strengthen both types of arrangements in comparison to residential care. Since 2014 benefits are assessed every three years and possibly adjusted to keep up with general price inflation.
 Federal Ministry of Health
Number of carers
Data about the number of informal carers in Germany greatly varies depending on whether we use official statistics, which is outdated and clearly underestimates the prevalence of informal care – or unofficial datasets which focus on self-reported informal care provision. According to official data, around 5 million people provide informal care to a dependent person in Germany (i.e. 4% of the total population). However, the data collected through the European Quality of Life Survey (2016) shows that Germany has one of the highest rate of self-reported informal care provision at around 22% of the total population – amounting to more than 18 million carers.
Identification of carers and assessment of their needs
Currently, the majority of people in need of care receive either a care allowance or home care in kind, which is in line with the principle “care at home prior to residential care”. The typical scenario is that either spouses or children between the ages of 50 to 65 years care for the beneficiary. Official numbers of these informal carers, i.e. persons caring non-professionally, are not available. However, under certain circumstances informal carers are eligible for being insured in the social pension insurance (SPI). Around 414.000 informal carers were insured in SPI in 2010. Informal carers are eligible, if they care for someone in need of care at least 14 hours per week. Since January 1st 2013 to fulfil the minimum of 14 hours a week, the informal care provided to more than one beneficiary can be added up. The LTCI of the person in need of care pays the contributions to SPI for the informal carers, if
- The informal carers live in European Economic Area or in Switzerland,
- They care for at least 60 days per year, and
- They are not gainfully employed for more than 30 hours per week, and
- They are not already receiving a full old-age pension.
Since the generation between 50 and 65 years belongs to the so-called baby boomers, their number will increase in this decade. Therefore, there might be an increasing potential of informal care by family members. However, once the baby boomers will reach the age of 80 themselves, starting from 2025, family members will become rarer and thereby increasing demand for professional care is to be expected.
Training and recognition of carers’ skills
Given the concern about the quality of care delivered by informal carers, since 2008, LTCI organisations have been obliged to offer free training courses in LTC for family members and unpaid carers. People receiving informal LTC are required to make use of counselling services offered by accredited care facilities or counselling centres, in order to ensure the quality of such care.
Recognition and definition of carers
Carers are defined in German law (social law XI §19) as people who provide non-professional home care to other people in need of long-term care, due to a physical, mental or emotional illness or disability. Social protection services will only address the needs of carers if they provide at least 14 hours of weekly care to a care-dependent person.
Multisectoral care partnerships
Care coordination has for long been a major issue in LTC provision but a determined effort to overcome this problem was launched with the LTCI reform in 2008 which committed the various involved actors to secure a better coordination and integration of the involved systems. Also, as of 1 January 2009, every person in need of care obtained a legal claim to help and support through a long-term care counsellor. Counselling for persons in need of care and their relatives is provided by case managers employed by long-term care insurance funds at a long-term care support base or through qualified experts.
Access to information and advice
Since 2011, the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth operates a counselling hotline (“Pflegetelefon”) for informal carers where information and advice can be obtained about all aspects of nursing care, including information about the right to benefits, assistance at home, respite, or counselling services among others.
Access to respite care
The Act to Reorient the Long-term Care Insurance (“Pflege-Neuausrichtungs-Gesetz” – PNG), which came into effect partly on the 30th October 2012 and on the 1st January 2013, improved a number of benefits, e.g. the benefits of respite care and short-term residential care for persons receiving care allowance. These benefits cover the following: If the informal carer gets sick or goes on holiday, for example, the LTCI pays benefits for up to four weeks of respite care or short-term residential care, but not more than 1,550 € per year, each. Since the PNG came into effect, the beneficiary of a care allowance still gets half of it during times of respite care or short-term residential care. Having said that, informal carers have to provide care for at least six months before benefiting from access to respite care.
Social inclusion of carers, access to education and employment
Since 2008, a person who provides home care to a close relative assessed at not less than care level I has the right to a carer’s leave. This consists in an unpaid leave from work of up to six months with continued social insurance coverage (Act on Caregiving Leave). The leave may only be accessed in companies that employ more than 15 people. The employer must be notified in writing at least ten days before the beginning of the leave, including information about the dates and duration of the leave. Moreover, employees are also entitled to a leave of up to 10 days if they need time to organise long-term care for a close relative in a situation of urgency.
In January 2012 a new legislation targeting employees who provide care at home came into effect (Family Care Act). Employees with a family member in need of care at home are indeed allowed to reduce their working hours – in agreement with their employer – to a minimum of 15 hours per week over a maximum duration of two years. The employer can top up the reduced salary by half of the difference between the old and the new salary with an interest free loan from the Bundesamt für Familie und gesellschaftliche Aufgaben (BAFzA). Following the caregiving period, the employee has to work full-time until the credit is paid back. Reconciling professional and informal care responsibilities remains at the core of political priorities in Germany.
Available statistics (on the number of applications by employers for BAFzA loans) suggest that the take-up of the policy was remarkably low (Rothgang, Müller, & Unger, 2013: 22ff.). This is particularly surprising given that 40% of informal carers had either reduced employment or given up employment altogether due to caregiving (Schneekloth, Geiss, Pupeter, Rothgang, Kalwitzki, & Müller, 2017). The limited success of the 2012 act stimulated a more ambitious reform to provide better financial security for informal carers, which culminated in the Care Leave Act of 2015 (Schneekloth, Geiss, Pupeter, Rothgang, Kalwitzki, & Müller, 2017).
The Care Leave Act of 2015 (‘Pflegezeitgesetz’) is the most significant piece of legislation to support carers in Germany. The Act builds on the foundations of previous laws while adding legal entitlement to financial provisions. Among the changes introduced by the law, wage compensation for acute care leave of up to ten days (typically 90% of net earnings) is now available through LTCI in the form of ‘Pflegeunterstützungsgeld’ or ‘care support payments’; family care leave is available for those providing care for minors living outside the home (such as in institutional facilities); and leave of up to three months is available for people supporting family members at the end of life (e.g. those in hospices). Furthermore, the law has allowed for a broadening of the definition of ‘close family relation’ to include step-parents, life-partners and the siblings of spouses/life-partners, as well as the spouses/life-partners of siblings. While financial support for leave exceeding a ten-day period is not provided through the LTCI system, carers may apply directly to the BAFzA for an interest-free loan providing monthly payments covering half of the net earnings foregone due to reduced working hours. Hence, although it represents a substantial achievement in improving the social protection of informal carers, the Care Leave Act of 2015 ultimately still shifts costs on to persons providing lengthier periods of care for family members (Schneekloth, Geiss, Pupeter, Rothgang, Kalwitzki, & Müller, 2017).
The question is whether the 2015 law (Act for a Better Reconciliation of Family, Care and Work) will contribute to a higher acceptance rate. Doubts are justified: the obligation to repay the loan is still a major barrier to reducing working hours or claiming the carer’s leave. Besides, the restrictive legal entitlement to employees of companies with more than 15 employees only (or 25 in the case of part-time carer’s leave) means that a great number of employees are not at all protected. In 2014, nearly 17% of all employees worked in companies with fewer than 20 staff, and 44% were in companies with fewer than 50 (Bechmann et al. 2013). This especially affects women, who often work in small and medium-sized businesses. Finally, it should be mentioned that the new law has attracted only little public attention, not least because it contains complex regulations and is difficult to understand.
At the peak of the COVID crisis, the government took steps to facilitate family members’ caring roles for their (elderly) dependents. Among the changes, the duration of the carer’s grant, a wage compensation benefit for short-term absence from work to fulfil care obligations, and the accompanying leave provision were doubled from 10 to 20 workdays. In addition, the government flexibilised the unpaid family care leave. These measures were introduced as families reported difficulties finding care workers. It underlines not only the inherent familialism, but also that live-in and informal carers are seen as interchangeable by the government.
In addition to provisions on work-life balance for carers, German law (social law XI §19) also allows for the promotion of access to vocational training for carers who wish to return to working life once their care activity is completed.
- UNECE Policy Brief on Ageing No. 22, September 2019
The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
- ESPN Thematic Report on Challenges in Long-Term Care, Germany, EC, 2018
- The German LTC policy landscape, L. Frisina Doetter and H. Rothgang, SOCIUM, Research Center on Inequality and Social Policy University of Bremen, 2017
- ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Germany, 2016
- Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, EC, 2016
- Adequate social protection for long-term care needs in an ageing society, European Commission, 2014