Germany's Social Long-term Care Insurance: Design, Implementation and Evaluation

Across all industrialized countries, issues surrounding population ageing have captured the attention of policymakers. Among its manifold ramifications, disability-related poverty and the projected growth in public funding of long-term care demand close attention. Comparative studies have revealed distinct policy approaches to long-term care across different countries, but a shared interest in market-oriented policy design and cost containment. In Germany, legislation on mandatory and universal dependency care insurance came into force recently. The 1994 Dependency Insurance Act responded to limited market insurance against the financial risk of long-term care, deficiencies in servicing long-term care dependants and the fiscal crisis of German communities, which had to provide social assistance to a growing number of destitute care clients. The new social long-term care insurance scheme adopts basic features of existing German social insurance schemes even as it challenges the country's social insurance legacy in terms of cost containment strategies and consumer-directed provision. After three years of operation, the new programme is technically in place and financially healthy. However, critics point to its tight screening procedures, persistent shortages in the supply of formal care, and fraud. Equity issues, quality of care and consumer direction have also drawn critical attention. A variety of scenarios for programme improvement are conceivable. Coverage could be extended and payments offered to family caregivers. A comprehensive "cash and counselling" concept should be developed. Finally, programme efficiency depends on public accountability and quality auditing. Choice should be informed by ongoing research into long-term care and the broader impacts of long-term care policy.     

Balancing Long-term Care in Japan

This article discusses Japan's long-term care (LTC) from the perspective of balancing the provision and financing of care. Specifically, this article provides an overview of the long-term care insurance (LTCI) system in Japan and analyzes the current state of Japan's LTC with current statistical data as to whether the supply meets the demand for care by frail elders and their families.     

Curbing the demographic “drifting dune” in long-term care insurance financing: The case of Germany

Long-term care provision and financing are becoming increasingly important matters in all ageing economies. Therefore, a major challenge for policy makers is to strike a balance between adequate care and sustainable financing. In this study, we evaluate the proposal of a so-called sustainability factor in German long-term care insurance. Considering changes in the beneficiary-contributor ratio, it aims for a rule-based consideration of demographic dynamics to alleviate pressure on long-term care financing. Using the framework of generational accounting, we demonstrate that this proposal could have a relieving effect on finances, depending on the share of involvement of current and future generations. It may offer an option for pay-as-you-go long-term care insurance systems worldwide that need to curb the impact of ageing societies. Therefore, this article addresses policy makers tasked with designing a sustainable financing model for long-term care insurance. It demonstrates that the sustainability factor represents a step towards sustainable finances and, thus, it might be one component of a more comprehensive reform package.     

Comparing long-term care systems: A multi-dimensional,actor-centred typology

Like other fields of social policy, the organization of long-term care (LTC) varies temporally and geographically. The present article aims to advance the comparison of LTC systems worldwide by proposing a conceptual framework to analyse variation, putting a special focus on analysing the role of public and private actor types. In a precluding literature review of existing LTC typologies, we find that there are various promising classification approaches, but with an overwhelming concentration on European countries and often constructed in-transparently and superficially. Building on the concept of the care/welfare mix, we develop a multi-dimensional, actor-centred typology of LTC systems. In doing so, we employ the methodological procedure of theoretically constructing a typological attribute space. We argue that three dimensions, that is service provision, financing and regulation, are crucial for differentiating types. Furthermore, we chose an actor-centred approach, asking who bears the main responsibility in each dimension. Five relevant types of corporate actors are distinguished: state, societal actors, private for-profit actors, private individual actors, and global actors. Finally, we present and discuss the resulting attribute space and further illustrated the typology's use by exemplarily classifying three countries.     

COMMUNITY-BASED SERVICES AND THE FRAGMENTATION OF PROVISION: A CASE STUDY OF HOME AND COMMUNITY CARE SERVICES IN A SUBURBAN COMMUNITY

Although the use of non-government organisations to provide assistance has long been part of Australian welfare history, the principles of community-based provision have only recently been adopted as part of the mainstream philosphy of service provision. This article examines the association between the expansion of community-based provision and the fragmentation of service provision using information drawn from a study of the provision of long-term care for a group of primarily elderly people through the Home and Community Care Program (HACC) and related provisions in a suburban community. The account focuses on the structure of formal service provisions, identifying organisational features which directly affect the operation of the system of local services, fragmenting the assistance made available. First, the organisations providing care are all of relatively recent origin and their operation continues to reflect many of the characteristics associated with their initial establishment. Second, the organisations involved are essentially hybrid bodies, being the product of both national/State programs and local initiatives. A number of tensions and conflicts arising from this characteristic are discussed. Third, service providing agencies tend to be highly specialised, with the consequence that the main division of labour is between, rather than within, organisations. Finally, the system of funding and administration has tended to orient agencies vertically, towards the source of funding, limiting their flexibility and capacity to develop horizontal patterns of cooperation with other services in the local area. Overall, the emergent system of services appears to be characterised by a large number of small organisations organised under a range of different auspice bodies, struggling to preserve their own autonomy and to operate within an insecure and continually changing policy environment. Recognising that reforms are likely, a number of broad alternatives to privatisation arc canvassed in the final section of the article.     

Compulsory intergenerational family solidarity shaping choices between work and care: Perceptions of informal female carers and local policymakers in Estonia

Estonians are obliged by law to provide maintenance for family members who are unable to cope by themselves. As a result, 80% of fragile older people receive informal care. Whether this is because the carers themselves feel solidarity and choose informal caring or because they lack alternatives is the question. We applied the cultural approach for explaining the construction of compulsory family solidarity in care provision to older people through the perceptions of informal carers and policy actors. Our interest is in how filial norms framed by individual responsibilities of care provision required by law can influence (i) informal carers’ perceptions concerning their choices between work and care and (ii) impact policy actors’ perceptions concerning eldercare service provision. Analysing the empirical data produced during focus groups with female carers and interviews with policy actors, we demonstrate the triple‐fold pressure to informal caregiving as an expression of compulsory family solidarity. Key Practitioner Message: ? The article demonstrates how the national Family Law Act constitutes a compulsory requirement of family solidarity in society; ? The compulsory family solidarity norm influences local‐level policymaking and inhibits the development of formal care services for older people; ? Informal carers’ choices between work and care are shaped by their personal filial norms, familialistic policymaking, and pressure exerted by older people.     

Long-term Care in China: Issues and Prospects

One of the major socioeconomic challenges China faces is the rapid aging of its population. China is now an aging society, even though it is still regarded as a middle-income economy. Coupled with the market-driven reform of social services and rapid erosion of family support, the provision of affordable and accessible social care services to older people has already become an urgent issue for the government to address. Looking into the future, the formulation of a sustainable position on long-term care (LTC) will increasingly become the major focus of social policy. This article sets out the background to the demographic shifts resulting in the emerging need for LTC in China. It analyzes the issues facing LTC services and reviews their prospects, including the structure, operation, financing, and interfacing of residential and community-based home care services.     

Electoral Politics, Ideology and American Social Policy

This article addresses the politics of social policy in the context of the 2004 American presidential election. It examines the divisions in American society and their distinctive agendas. It also explores the record of the Bush administration on key social policy issues and shows how it relates to the broader conservative tradition as well as to the Clinton administration's reform of welfare. Finally, it examines the election results. The article argues that the Bush administration has a distinctive agenda on social policy issues and that its approach is likely to reduce further the role of the social government in the provision of social policy, by emphasizing market forces and philanthropy as well as cutting taxes. It also notes, however, that the Bush administration has taken a strong stance on traditional moral values and that its opposition to abortion and homosexuality is an important part of its political strategy.     

Social Care in Old Age: More Than a Funding Problem

There is currently a debate about the future funding of long-term care for old people. Welcome as it is, there is a risk that the focus on finance will obscure equally important questions about who should provide the care and what models of care should be chosen. Many years of research and innovation in the care of the elderly have shown that the effective and efficient provision of simple care services is very difficult to achieve. Social care is at once everyday and peculiarly complex. Some essential characteristics of social care are described which make it unlikely that a solution to the funding problem will improve either the allocation or the outcomes of long-term care.     

"Religion is the finding thing": an evolving spirituality in late life

This paper discusses some important dimensions of faith and of the social contexts surrounding faith that are illustrative of continuity and growth in spirituality in the lives of older adults. Examples of an evolving spirituality emerge in the analysis of a recent qualitative research study that probed the nature of religious experience among thirty-one community-dwelling elders and fifteen elders residing in long-term care facilities. Face-to-face interviews with these forty-six older adults and with seven people who directed or assisted with formal and informal programs of faith comprise the empirical base for this paper. The seven people, I refer to them mnemonically as faithreps, worked in various ways in the long-term care settings to provide programs involving faith to older adults. The faithreps came from a range of educational and religious backgrounds and are not accurately or handily categorized. An evolving spirituality is shaped by the older person's links to the structural and the socio-relational contexts that have been created through interaction in the past as well as through interaction in the present. Moreover, the interaction of older adults and faithreps encourages spiritual growth because as social actors engaged with one another over a sustained period of time in an institutional setting, questions and dialogue about life and its meaning are regularly evoked. The social interactions that foster spiritual evolution may be an admixture of the secular and the sacred. Such socio-relational contexts were once part of the naturalistic settings of daily life among the old, but now must emerge through the efforts and planning of others. The salience of faith among present cohorts of older adults sensitizes us to the necessity of devoting more consideration to optimal ways of strengthening and building contexts that are conducive to the evolution of spirituality.     

Solidarity in Italy's policies towards the frail elderly: a value at stake

The Italian public policies towards the frail elderly are underdeveloped by both quantitative and qualitative standards. The bulk of care responsibilities lies on the family and the private provision of paid care is flourishing. The last decade was characterised by significant signs of improvement – an increase in the public resources committed to long-term care and the rising interest of politicians and scholars towards this issue – but the situation is still highly critical. In such a context several questions on solidarity arise regarding the degree to which this value is actually embedded in the public policies, what are the most relevant issues and how the main actors involved are concerned. The article aims to answer some of these questions, taking into consideration the points of view of the main actors: elderly people, carers and professionals.
In doing so, the article discusses the targets of the public services, differences in their provision across the country, the rise of the care allowance and the private provision of paid care. The article shows the problems regarding solidarity in the Italian policies towards the frail elderly and sets an agenda of issues to deal with in the next decade. How policy-makers will be able to manage these issues will determine whether and how the value of solidarity will shape Italy's long-term care policies in the future.     

A lesson learned from community-based integrated long-term care in Thailand

Abstract

Thailand is the second most rapidly ageing of the Association of Southeast Asian Nations (ASEAN) countries. With this rapid pace of population ageing, the demand for long-term care has increased. Due to lower fertility and migration of adult children, the availability of children as a main source of long-term care has been reduced. In order to retain the traditional lifestyle of ageing-in-place, community-based integrated long-term care has been implemented as an alternative approach in Thailand. The development of such community-based care and its challenges can be used as a lesson for other ASEAN countries in confronting ageing societies.     

Partnerships, Power and the "New" Politics of Community Participation in British Health Care

Multi–sectoral approaches to health improvement in its broadest sense have entailed an emphasis by the British government upon partnership working in and around community involvement in planning processes. New service planning and delivery organizations in the health service—primary care groups and primary care trusts—thus have to ensure that public and patient involvement strategies reflect a coordinated, if not integrated, multi–sectoral approach to such involvement. But how are these enforced partnership arrangements shaping the approach taken by primary care groups and trusts to the issue of public and patient involvement? More particularly, is the traditional dominance of health service managers and the medical profession in decision–making processes under challenge? This article draws on a study of primary care groups and trusts in three districts in order to gauge perceptions and calculations with regard to partnerships for involvement. Results appear to suggest that health service managers and practitioners continue to exercise considerable influence in comparison to that of patients and citizens. But, if the findings are viewed in the broader contexts of government managerialist strategies of surveillance and accountability and the growth of service–user and advocacy organizations, partnerships may offer significant scope for “lay” challenges to managerial and medical power.     

The Economic and Gender Consequences of South Africa's Home‐based Care Policy

South Africa's approach to care provision in the era of HIV/AIDS is home‐ and community‐based care, but in reality care for ill people in the home is provided on an unpaid basis, predominantly by women. But how much do they spend on this care work, in time and money? And what economic consequences does this policy have, particularly for poorer women? This article is based on findings from a study that focuses on unpaid care provision within the home for those in late‐stage HIV/AIDS in KwaZulu‐Natal, South Africa, and specifically on the costs of such provision. The findings show that female caregivers are bearing the bulk of the costs of care provision for ill people within the home on an unpaid basis. Home‐based care is cost‐effective for the provincial government but not for unpaid caregivers who are subsidizing the provincial economy. While hospital care for people with HIV/AIDS has been capped, home‐based care services have not been increased to a commensurate level. Unpaid caregivers and ill people within the home are largely disconnected from the health system. The analysis clearly shows that the home‐based care policy is not resulting in appropriate or sufficient support for these individuals in need and needs to be revised.     

Design limitations of long-term care insurance schemes: A comparative study of the situation in Spain

Social and demographic changes are gradually transforming the way Western societies cope with old‐age dependency, in particular the provision of long‐term care (LTC). In response to the need for formal care services and financing instruments, this study examines a range of both private and public insurance tools. As a general rule, LTC insurance is markedly underdeveloped. Furthermore, in southern European countries, the role of the public sector in LTC is unclear compared with its role in other, related welfare areas such as healthcare. The study examines the financing alternatives for LTC insurance, taking as its benchmark the Spanish LTC financing reform. It briefly examines some existing, publicly funded LTC financing tools and explores the potential role of private LTC insurance, arguing that it has an active part to play alongside compulsory mainstream insurance schemes and self‐insurance alternatives. As in other European countries, Spanish social attitudes show a preference for some kind of general entitlement to publicly funded schemes, although this preference is subject to significant regional heterogeneity.     

The Effects of Marketization of Long-term Care Services for Older Adults in Korea

To cope with the rapid increase in aging population, the South Korean government introduced new long-term care insurance in 2008 by using the market forces and mechanisms of competition and choice. The study explored the effect of the marketization of long-term care (LTC) services on the provision of services under the Korean long-term care insurance (LTCI) system. By adopting qualitative semi-structured in-depth interview methods, the experiences of 17 home visiting service provider managers were examined. The study results suggest that the marketization of LTC services faces several challenges. Some of the stakeholders in the field, such as home visiting service providers, care workers, and older clients, appear to employ unlawful activities or unprincipled behaviors to maximize their individual interests. The results also suggest that the unprincipled behavior, unlawful activities, and financial problems that service providers face contribute to low quality care services. Future studies should explore these issues using larger samples of service users and providers.     

Family support: past, present and future challenges

Section 17 of the 1989 Children Act incorporates a new legal framework for the delivery of services to support children in their own homes, and is a crucial part of the act, both in its own right, and in terms of its significance for other aspects of child care such as child protection activity. However, while "children in need" represents a new legal phraseology, the policy and professional issues addressed by the clause have a long history. This paper traces the evolution of the current approach to family support, and provides a brief account of its impact on policy and practice.     

Part of the Problem or Part of the Solution? The Role of Care Homes in Tackling Delayed Hospital Discharges

As part of current UK policies to reduce the number of delayedhospital discharges, a number of commentators have identifiedan alleged crisis in the care home market as one of key contributingfactors. With local authorities under pressure to cut costs,it is argued, the number of care homes is reducing, and delaysin hospital can often result. Behind this diagnosis is a seriesof assumptions about the role and nature of care home provision,the appropriateness of this form of service for many older people,and the need for more care homes to reduce the number of hospitaldelays. In order to explore and critique these assumptions,this paper reviews the role of care homes in tackling delayeddischarges, and argues the need for fewer and different carehome placements rather than more of this type of provision.     

Perceptions of Difference Between Aging and Disability Service Systems Consumers: Implications for Policy Initiatives to Rebalance Long-Term Care

This study explores service professionals' perceptions of how and why older adults and younger persons with disabilities are different consumers and clients within the long-term care service sector. Data are from 2004, early in the history of federal long-term care rebalancing initiatives, reflecting perceptions at that time. Findings suggest professionals working within aging, developmental disability, and physical disability service networks believe significant distinctions exist related to age of clients and nature of service required and how it is delivered. Overall need for greater professional and organizational capacity to support provision of service to both aging and disability populations is reported.     

Perceptions of difference between aging and disability service systems consumers: implications for policy initiatives to rebalance long-term care

This study explores service professionals' perceptions of how and why older adults and younger persons with disabilities are different consumers and clients within the long-term care service sector. Data are from 2004, early in the history of federal long-term care rebalancing initiatives, reflecting perceptions at that time. Findings suggest professionals working within aging, developmental disability, and physical disability service networks believe significant distinctions exist related to age of clients and nature of service required and how it is delivered. Overall need for greater professional and organizational capacity to support provision of service to both aging and disability populations is reported.