Changing Welfare Policies and (Long-term) Care … Changing Welfare Policies and (Long-term) Care Relations ... 80% 90% 100% t r ad.U S - M i l u n s ili e ... fare state Separate

Changing Welfare Policies and (Long-term) Care Relations

Prof. Dr. Heinz RothgangCentre for Social Policy Research

University of Bremen

“Relationistic Sociology and Care Relations in a Changing Welfare State”

Workshop of the Research Network “Welfare Societies”July 29th 2011 in Delmenhorst

Prof. Dr. Heinz Rothgang 2

ContentsI. Terminological clarification

II. Action theory: care-giving as a make-or-buy decision

III. The need of long-term care as a new social risk

IV. Welfare State Arrangements in the OECD World

V. Welfare state policies in long-term care

VI. Who cares?

VII. The political issue: How to guarantee future care-giving?







VI. Who cares?



I. Terminological clarification• Care:

– Care vs. cure– Nursing care vs. social care– Care management vs. case management– Care for

• Children, chronically ill, people with dementia, etc. • People in need of long-term care (=LTC)

• Care relations: – Care-giver vs. cared for – Welfare state agents vis-à-vis care relations

• Welfare state and (long-term) care relation – Changing LTC relations challenge welfare states– Welfare state policies influence care relations







VI. Who cares?



II. Action theory: Care-giving as a make or buy decision • Care arrangements reach from purely informal to purely

formal care with all kinds of mixed arrangements in-between

• Family chooses arrangements. Determinants are1. Affection (individual care relation)2. Sense of obligation, religious beliefs (culturally) 3. Availability of formal care (national and regional level)4. Opportunity costs (=incentive structure)

• Publicly financed benefits • Prices for formal care • Satisfaction from care-giving• Opportunities to earn in the labour market

• 2, 3, and 4 in particular may change over time– For Germany: § 8 SGB XI defines care-giving as a “gesamt-

gesellschaftliche Aufgabe” moral obligation to care decreases


II. Action theory: Care-giving as a make or buy decision (1/3)

Source: Eurofamcare – Final Conference


I.2 Action theory: Care-giving as a make or buy decision (2/3)

Quelle: GEK-Pflegereport 2009

Tabelle 1: Regressionsmodelle: Pflegearrangements stationär ambulant Geld

Konstante 54,50 *** 27,24 *** 18,26 *** Vollstationäre Heimplätze je 100 Personen älter 75 Jahre

1,71 *** -0,35 *** -1,36 ***

Beschäftigte in amb. Diensten in VZÄ je 100 Personen älter 75 Jahre

-1,84 *** 4,19 *** -2,34 ***

Arbeitslosenquote -0,66 *** -0,14 ** 0,81 *** Personen je Haushalt -14,83 *** -3,38 * 18,20 *** Agglomerationsraum 0,81 -1,21 * 0,31 Verstädterter Raum 0,36 -0,72 0,36 Kreisfreie Stadt 1,91 ** -0,77 -1,14 Neue Bundesländer 4,40 *** -0,33 -4,07 *** Heimkosten 0,00 * 0,00 -0,00 * Anmerkung: *** P < 0,1 %; ** P < 1 %; * P < 5 % Referenzkategorien: Ländlicher Raum; Kreise; alte Bundesländer


83%

60% 59%70% 64% 60%

47%

8%

20% 15%6% 11%

0% 10%

8%20% 26% 24% 25%

40% 33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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libera

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selber gepflegt nur organisiert nicht beteiligt

Befragte, bei denen ein naher Angehöriger pflegebedürftig wurde(ist) (n=306)

Blinkert / KlieAnnabergstudie 2006

I.2 Action theory: Care-giving as a make or buy decision (3/3)


II. Action theory: Care arrangements (% of all cases)

Quelle: BARMER GEK Pflegereport 2010

Ambulante Pflege-dienste

Ausschließlich durch Angehörige

Vollstationäre Pflege


II. Action theory: nursing home beds per population

Quelle: GEK Pflegereport 2009


II. Action theory: Regional variation in nursing home rates (1/2)Nursing homes rates in level I Nursing home rates in level II


II. Action theory: Regional variation in nursing home rates (2/2)Nursing homes rates in level III Average daily rate in nursing homes







VI. Who cares?



III. The need of long-term care …… as a new social risk

– Dependency in itself is not new, but • the numbers of dependents has increased• the traditional forms of care-giving seem to loose capacities higher visibility a new problem arises

– Welfare states react (late) constituting a “new” risk• In the EU long-term care was not covered as a risk of its own, thus

the ECJ subsumed it under “health” (Molenaar case 1998)• With few exceptions national legislation only started in the 1990s

… as a new social risk– is relevant for all parts of the population and – has a high quantitative relevance


III. The need of long-term care as a social risk

Among the elderly (65+) the risk is at about 10%

Only 2.6% of the total population is in need of long-term care

But: more than half of all those dying in a certain year are in need of long-term care more than half of us will be in need of long-term care

Long-term care is not a fringe risk, but a social risk that should be addressed

Insufficient coverage is an issue for social policy

Share of LTCI beneficiaries among those who died in …

40,3 41,6 43,5 45,4 47

60,2 61,964,3 65 66,7

0

10

20

30

40

50

60

70

80

2001 2003 2005 2007 2009

Jahr

Männer Frauen





IV. Welfare State Arrangements in the OECD World1. Some figures2. Typologies3. The role of women


VI. Who cares?



IV. Welfare State arrangements: expenditures


IV. Welfare State arrangements: public-private expenditure mix


IV. Welfare State arrangements: expenditures to arrangements


IV. Welfare State arrangements: Care Arrangements


IV. Welfare State arrangements: Typology • There is no well established typology of LTC systems;

Esping-Andersen’s typology is not really useful for LTC

• Attempts for classifications include– Anttonen & Sipilä (1996):

• Scandinavian model of public services • mostly Southern European family care model plus• Central European subsidiary model and • British model of means-testing in the middle

– Bettio & Pantenga (2004): • Southern European countries with much informal and little formal care • Northern European countries with universalistic approach and much

formal care– Timonen (2008):

• three paradigms according to the role of the state, the role of individuals / families and the role of private care provision


IV. Welfare State arrangements: Typologies

11

Typology of some EU countries

LTC financing system

Bismarck-Type Beveridge-Type

Type of wel-fare state

Separate LTCI system

No separate LTCI system

Sozial-democratic

Type A Denmark, Finnland,

Sweden

Conservative Type B Austria, Ger-

many, Lu-xembourg,

Netherlandsb

Type C Belgium,

France,a Italy

Liberal Type D United Kingdom, Ireland

Rudimentary Type E: Spanien, Por-tugal, Grie-

chenland


IV. Welfare State arrangements: Cash benefits and women • Throughout the OECD informal care-giving is

predominantly female

• Cash benefits – acknowledge informal care-giving but – tend to stabilize gender roles

• Welfare State programmes differ with respect to cash benefits

– Austria: Pflegegeldgesetz (1993) introduced cash benefits as the only type of benefit

– Germany: Pflege-Versicherungsgesetz (1994) introduced the choice between cash benefits and benefits in kind (formal care)

– Japan: LTCI introduced in 2000 does not contain cash benefits as the Japanese feminists heavily opposed to it.






V. Welfare state policies in long-term care1. Normative Analysis2. The Introduction of LTCI in Germany

VI. Who cares?



V.1 There is a case for mandatory LTC insurance• Private voluntary insurance without a safety net is no

alternative as no civilized society will leave elderly without care if they are in need of care

• Private voluntary insurance besides a – tax-financed – safety net is unlikely to work as private insurance is crowded out– E.g.: in Germany only about 300 thousand insurances has been sold

before mandatory LTCI was introduced– On the other hand: 80% of those in nursing homes relied on means-

tested social assistance

• Means-tested tax-financed social assistance is no solution as– private insurance is discouraged – those who buy insurance are exploited by those who don’t– elderly have to spend down assets and have to live on “pocket money”

Mandatory insurance is useful


V.1 Social insurance has advantages over private insuranceFinancing system: Funding (private) vs. pay-as-you-go (public)

– Advantage of funding: • less vulnerable to demographic change, but not independent (age

wave-, asset meltdown-debate)• Inter-temporal redistribution is achieved – if this is an advantage

– Advantage of pay-as-you-go• flexible to changing environments (e.g. German unification)• immediate benefits

Whenever the introduction of LTCI is a response to actual problems some kind of pay-as-you-go financing is unavoidable

Whenever PAYGO-systems are to be change into funded systems the costs of change are enormous

Premium: risk-related (private) vs. income-related (public)– Risk-related premium effectively excludes elderly from insurance– Income-related contributions (vs. capitation) provides another element

of redistribution additional to imperfect redistribution via tax systems.


V.2 The introduction of LTC insurance (1/4): The Puzzle• LTCI Act was passed 1994 after 20 years of debate:

1. Why was the system introduced at all?– Which problems did the Act address?– Who were the advocates of the reform and why?

2. Why was it introduced at this time? – under a centre-right coalition– in a period of ‘permanent austerity’?

3. Why was it introduced the way it was introduced– with two branches of insurance– with the social insurance following the PAYGO system with capped

benefits etc.?


V.2 The introduction of LTC insurance (2/4)• Underlying problem perception

– Demographic change: number of dependent elderly was expected to grow

– Socio-structural change: care capacities of families were expected to decrease

– Increasing numbers of dependent elderly in nursing homes were relying on (means-tested) social assistance

• LTCI was fostered by two distinct discourses – Welfare state discourse:

• German welfare state aims at status maintenance. • It is “unworthy” if citizens with after a normal working life depend on

welfare just because of needing long-term care• High share of welfare recipients was perceived as social scandal

– Fiscal policy discourse• Municipalities were increasingly suffering from high expenditures for

people in nursing homes. Federal states acted as advocates.


V.2 The introduction of LTC insurance (3/4)• Course of events

– 1974: report of KDA started welfare state debate on LTC– 1980s: federal states put forward reform proposals triggered by

the fiscal policy debate– 1990s: Fiscal strains due to German reunification. Federal Minster

Blüm advocated introduction of LTC insurance• Blüm advocated insurance though he rejected the idea before• There was also a game for power within government.

LTCI was legitimated by welfare state discourse. The introduction, however, was due to fiscal policy discourse.


V.2 The introduction of LTC insurance (4/4)• Reshaping of the welfare state rather than expansion:

– Introduction of LTCI was accompanied by cuts in other welfare state areas

– LTCI marks break with German tradition of service provision according to needs (as in health insurance)

– LTCI Act was shaped in order to prevent any “cost explosion”thereafter

• Tight definition of dependency• Capped benefits (nominally fixed)• Discretionary adjustment of benefits

• Compromise between Christian Democrats and Liberals: two-pillar system with

– Social LTCI as PAYGO system, but– Private mandatory System as funded system







VI. Who cares? 1. Care-giving – today2. Care-giving – past developments3. Care-giving – the future



VI.1 Care-giving – today


VI.1 Care-giving – todayMain Carer of Dependent People in Private Households

Share in % 1991 1998 2002 Change 1991-2002

Sex Male 17 20 27 + 10 Female 83 80 73 - 10

Relation of Carer to Dependent Person Husband or (Male) Partner 24 20 Wife or (Female) Partner 13 12

28 - 9

Mother 14 11 12 - 2 Father 0 2 2 + 2 Daughter 26 23 26 0 Son 3 5 10 + 7 Daughter-in-law 9 10 6 - 3 Son-in-law 1 0 - 1 Other Relative 6 10 9 + 3 Neighbor / Friends 4 7 8 + 4

Residence of Main Carer Co-resident 78 73 62 - 16 Separate Household 22 27 38 + 16

Sources: Schneekloth and Potthoff, 1993, 126; Schneekloth and Mueller, 2000, 52; and Schneekloth and Leven, 2003: 19.


VI.2 Care-giving – past developments (1/3)• Introduction of LTCI triggered expansion of formal sector,

particularly in nursing home care intended effect

• There are huge regional differences in utilizing formal care not intended

• LTCI aims to favour family care over (formal) community care over nursing home care

• There are several measures favouring home care, e.g.– Cash benefits for family care– Pension benefits for informal care-givers– Higher benefits for home care (in level I and II)

• Nevertheless, there has been a trend towards formal care, though the rate of the shift is declining


Capacities of formal care

Extramural Care Intramural Care Number of Providers

Employees Whole time equivalents

Number of Nursing homes

Number of beds in nursing

homes 1999 10,820 183,782 56,914 8,859 645,456 2001 10,594 189,567 57,524 9,165 674,292 2003 10,619 200,897 57,510 9,743 713,195 2005 10,977 214,307 56,354 10,424 757,186 2007 11,529 236,162 62,405 11,029 799,059

1999-2001 -2,1 3,1 1,1 3,5 4,5

2001-2003 0,2 6,0 0,0 6,3 5,8

2003-2005 3,4 6,7 -2,0 7,0 6,2

2005-2007 5,0 10,2 10,7 5,8 5,5

1999-2007 6,6 28,5 9,6 24,5 23,8

Source: Statistisches Bundesamt 2008b: 25.

VI.2 Care-giving – past developments (2/3)


VI.2 Care-giving – past developments (3/3)

Source: own calculations based on data published by the Federal Ministry of Health

Type of benefits chosen

23,125,4 26,3 26,8 27,5 27,9 28,3 28,7 29,2 29,5 29,6 29,8 29,5 29,0

61,358,1

55,9 54,2 53,0 52,3 52,0 51,5 51,0 50,6 50,3 49,9 49,6 49,0

8,8 9,4 10,0 10,6 10,7 11,0 10,9 10,8 10,8 10,8 10,7 11,0 12,0 13,5

6,9 7,1 7,8 8,4 8,9 8,8 8,8 9,0 9,0 9,1 9,3 9,3 8,9 8,5

0

10

20

30

40

50

60

70

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Year

Nursing home care cash benefitscombination in kind benefits


VI.3 Care-giving – the Future• There are good reasons to assume a continuation of this

trend– Demography: Decreasing share of informal caregivers per

dependent elderly– Socio-structural change: Increasing share of 1-person households

among elderly; children live further away – Increase female labour market participation higher opportunity costs of family care-giving

– Declining “duty to care” felt by families

• On the other hand the reservoir of professional care-givers is not growing respectively.


VI.3 Care-giving – the Future


VI.3 Care-giving – the FutureEntwicklung des Pflegepotenzials je Pflegebedürftigem in NRW - 2002 bis 2040

40

50

60

70

80

90

100

110

2002 2005 2010 2015 2020 2025 2030 2035 2040

Inde

x

Partnerpflegepotenzial je Pfegebed.Kinderpflegepotenzial Szenario 2Kinderpflegepotenzial Szenario 3Pflegepotenzial gesamt Szenario 2Pflegepotenzial gesamt Szenario 3

Abbildung 3: Entwicklung der Indizes für das häusliche Pflegepotenzial je Pflegebedürftigem in Nordrhein-Westfalen 2002 bis 2040 im SzenarienvergleichQuelle: Rothgang 2004.


VI.3 Care-giving – the FutureStatus quo

Future

2/3 of all dependent persons are care for in private households

Every 2nd dependent person is cared for without formal care

Informal care is the backbone of care-giving

Relative care potential, i.e. potential informal caregiver per dependent persons, is going to half by 2040

Informal care is going to decline

A new balance of care-giving (‚mixed care arrangements‘) has to be found

• support for informal care-givers

• new role for formalcare (workingtogether with families)

• case management

Growing Expen-diture







VI. Who cares?



VII. How to guarantee future care-giving?• How to finance LTC?

• How to stabilize informal care?– 2008 reform: counselling, case and care management, additional

benefits for people with dementia, work leave for care-giving– Actual debates

• Reforming the entitlement (new “Pflegebedürftigkeitsbegriff”)• Improve possibilities to combine care-giving and work

• How to find enough professional care-givers– Improving recruitment, retention, and return after childbirth by

• Improving the image of the profession• Improving working conditions and pay

• In order to find the right policy better theories about the care relation and what makes people care might be helpful.


The end

Thank you for your attention!

Contact: [email protected]

See also:

Rothgang, Heinz (2010): Social Insurance for Long-Term Care: An Evaluation of the German Model, in: Social Policy and Administration, Vol. 44, No. 4, August 2010, pp. 436–460

Documents

Changing Welfare Policies and (Long-term) Care … Changing Welfare Policies and (Long-term) Care Relations ... 80% 90% 100% t r ad.U S - M i l u n s ili e ... fare state Separate