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The renowned health researcher and health economist Heinz Rothgang, Professor at the University of Bremen (Germany), told us about the situation of Long Term Care in Germany after Covid-19 pandemic. The German government acted to support nursing homes – the most hit by pandemic – as well as healthcare staff to minimize the catastrophe. Digitalization may help to cope with easing documentation of Long Term Care to revise the whole system.
Mainstream literature on Long Term Care tends to cluster Germany and Italy among the countries with a strong State intervention through cash benefits. If any, which are the main advantages and disadvantages to ground the Long Term Care provisions on cash benefits?
Long Term Care benefits are funded by mandatory contributions from all employees in Germany (currently 3,5% – 3,4% of annual salary). The scheme is either provided by your statutory health insurance or your private health insurance. The type of Long Term Care support you receive depends on your situation and the type of insurance you have. There are therefore two distinct and regulated branches which cover the whole population. Everyone is covered for Long Term Care and you – as a citizen – get Long Term Care benefits irrespective of your age or financial situation. The German beneficiaries have thus the choice to freely spend the half (around 50%) of their total in-cash benefit. They can decide to address them to a nursing home, domiciliary or other services. They may also prefer their families to take care of them. The free choice, I think, is one of the biggest advantages of the German system.
As for disadvantages, from a gender perspective, it is still an incentive for poor women to do informal care work. Even though – nowadays – the range of informal caregivers is broader, two thirds of the caregivers are women. If we neglect the aspect of wage (ndr, formal paid work), I think the rate of females involved in informal caregiving is even higher. Therefore, the first disadvantage is related to a gendered perspective.
The second disadvantage concerns the monitoring of the quality of services in the black market. When beneficiaries decide to invest in informal care, we cannot check for quality of care services. There is little control over what happens for – at least – half of people that receive in-cash benefits and decide to use it for informal care. Also, we do not have full control – as in Italy – of the rate of informal carers living in disabled or old-age people’s households.
To sum up, the pros of having in-cash benefits in Long Term Care are flexibility and freedom to choose. Their management is also cheaper for social insurance. On the other side, the disadvantages are gender issues and quality of care in the black market.
The second question is related on Covid-19 crisis and the Next Generation EU funds. Did Long Term Care achieve a central role in German public and political debate during the pandemic?
Not actually. Let me start with what has been the role of Long Term Care in the Covid-19, during the first and the second wave.
About 60% of total deaths were registered in nursing homes. There have been a lot of measures to close nursing homes, thus cutting down the relations with the world outside. Neither family, nor doctors were allowed to visit them. There were – moreover – a severe restriction within nursing homes. Guests could not eat together, establish relationships.
Generally speaking, we never had strict restrictions as we had in Italy. However, those addressed to nursing homes were the strictest ones. When in 2021 the vaccination campaign was launched, people in residence homes had the priority. The same happened for the second vaccination campaign. Since last year, the utilization rates are increasing; anyway, the mortality is still higher than outside. In 2021 the providers of nursing homes declared they had economic difficulties in residences’ management. They had to pay for extra glows, masks, tests, etc. Beds were empty because people left them to go back home. The German government introduced a “rescue umbrella”. This was a rescue program (about 9 billion euros) that has been spent to cover additional costs for nursing institutions and homes as well as, more generally, providers in healthcare. We are not waiting for the European funds to launch programs and reforms; we have done it before in Long Term Care. You won’t even find debates about the National Recovery and Resiliency Plan in the newspapers.
Moreover, during Covid-19, the Government introduced the “Corona Premium”. The premium was addressed to nurses working with patients during Corona, they got 1.000 euros. It was meant to show the public gratitude to nurses. In the end, we spent 1 billion euros of premium. However, nobody was satisfied with premiums. The nurses – beyond receiving gratitude – were trying to avoid pain due to the Covid-19. We spent a lot of money on premiums, without getting a positive feeling from the nurses.
During Covid-19, did civil society organizations attempt to bring into political agenda issues concerning Long Term Care policies?
Even before Covid-19 we had some public discussions about Long Term Care policies. The discussion concerned, particularly, under-staffing in nursing homes. In 2019, we – at the University of Bremen – developed a staffing scheme to be adopted in 2020. We presented the results in Berlin to the Ministry at that time. We were saying that the German Long Term Care system needed more than an additional 100.000 nurses. This is now gradually implemented. We hired in 2021 additional 20.000 nurses and in July we will have 25.000 nurses more. Next year it could be refinanced. During the Corona crisis, nurses were unable to work because they had to stay home, since the situation was getting worse. The debate was – of course – enforced. Geriatric nurses, moreover, are underpaid. We had this discussion long ago. Covid reinforced the debate. Now, from September onwards, providers of Long Term Care have to pay according to collective agreements. Nurses’ wages are expected to go up. Up to now, most nurses do not have collective agreements. That’s not the consequence of Covid-19: the debate was still there. Same goes with digitalization. The debate spread before pandemic; however Covid-19 showed us digitalization could ease the documentation of Long Term Care.
What is the main development in German Long Term Care politics?
Germany is a social insurance state. Everything is centered around social insurance, in this case Long Term Care insurance. Most of the regulations are done by the Long Term Care insurance funds vis-à-vis the providers. On the side of missing interests in the public area, I would say the nurses’ bargaining power is weaker. Only a few people are part of their pressure groups. That is a missing bond in Long Term Care politics. The interests of the nurses are not well-represented within the institutional setting.
Moreover, a lot of regulation depends on 16 Federal States (and not the central one). We had a reform – the federalist reform – where we said that the policing rights (e.g., control law, regulatory law in Long Term Care) is up to Federal States. This is a peculiar characteristic which means a lot for policy and politics together.
How can be conceptualized inequalities in services’ provisions among German Federal States?
If you have a North-South divide, we have an East-West divide. We have a social insurance system; the benefits are the same everywhere. The benefits you receive from social insurance are the same in Bavaria and in Thuringia. The disadvantaged regions – to some extent – are advantaged. For example, in Thuringia the daily rate for staying in nursing homes is lower. Since the cost of living is lower as the wages are. However, the national insurance is higher; the part you have to pay out-of-pocket is smaller. Our variation – in respect to Italy – is smaller because of the national insurance system and co-payments out-of-pocket differ as well. We also have different staffing ratios in nursing homes. The richer part of the country has a higher number of staff members, but the co-payments are higher as well. So, it is difficult to compare. The collection of data (in informal care, hospitals, nursing homes) is overall difficult to achieve to allow for comparison of data.