Changing Welfare Policies and (Long-term) Care Relations

Transcription

1 Changing Welfare Policies and (Long-term) Care Relations 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 Centre for Social Policy Research University of Bremen

2 Contents I. 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? Prof. Dr. Heinz Rothgang 2

3 Contents I. 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? Prof. Dr. Heinz Rothgang 3

4 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 Prof. Dr. Heinz Rothgang 4

5 Contents I. 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? Prof. Dr. Heinz Rothgang 5

6 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 are 1. 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 gesamtgesellschaftliche Aufgabe moral obligation to care decreases Prof. Dr. Heinz Rothgang 6

7 II. Action theory: Care-giving as a make or buy decision (1/3) Source: Eurofamcare Final Conference Prof. Dr. Heinz Rothgang 7

8 I.2 Action theory: Care-giving as a make or buy decision (2/3) Tabelle 1: Regressionsmodelle: Pflegearrangements stationär ambulant Geld Konstante 54,50 *** 27,24 *** 18,26 *** Vollstationäre Heimplätze je 100 1,71 *** -0,35 *** -1,36 *** Personen älter 75 Jahre Beschäftigte in amb. Diensten in -1,84 *** 4,19 *** -2,34 *** VZÄ je 100 Personen älter 75 Jahre 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 Quelle: GEK-Pflegereport 2009 Prof. Dr. Heinz Rothgang 8

9 I.2 Action theory: Care-giving as a make or buy decision (3/3) selber gepflegt nur organisiert nicht beteiligt 100% 90% 80% 8% 8% 20% 26% 24% 25% 40% 33% 70% 20% 15% 6% 11% 60% 0% 10% 50% 40% 30% 20% 83% 60% 59% 70% 64% 60% 47% 10% 0% trad.us-milieu neues US-Milieu kons.ms-milieu gesellsch.mitte liberales MS-Milieu konserv.bürgerl.milieu liberales bürg.milieu Befragte, bei denen ein naher Angehöriger pflegebedürftig wurde(ist) (n=306) Blinkert / Klie Annabergstudie 2006 Prof. Dr. Heinz Rothgang 9

10 II. Action theory: Care arrangements (% of all cases) Vollstationäre Pflege Ambulante Pflegedienste Ausschließlich durch Angehörige Quelle: BARMER GEK Pflegereport 2010 Prof. Dr. Heinz Rothgang 10

11 II. Action theory: nursing home beds per population Quelle: GEK Pflegereport 2009 Prof. Dr. Heinz Rothgang 11

12 II. Action theory: Regional variation in nursing home rates (1/2) Nursing homes rates in level I Nursing home rates in level II Prof. Dr. Heinz Rothgang 12

13 II. Action theory: Regional variation in nursing home rates (2/2) Nursing homes rates in level III Average daily rate in nursing homes Prof. Dr. Heinz Rothgang 13

14 Contents I. 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? Prof. Dr. Heinz Rothgang 14

15 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 Prof. Dr. Heinz Rothgang 15

16 III. The need of long-term care as a social risk Share of LTCI beneficiaries among those who died in Only 2.6% of the total population is in need of long-term care ,2 40,3 41,6 61,9 Männer 43,5 Frauen 64, , ,7 Among the elderly (65+) the risk is at about 10% 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 Jahr Long-term care is not a fringe risk, but a social risk that should be addressed Insufficient coverage is an issue for social policy Prof. Dr. Heinz Rothgang 16

17 Contents I. 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 1. Some figures 2. Typologies 3. The role of women V. Welfare state policies in long-term care VI. Who cares? VII. The political issue: How to guarantee future care-giving? Prof. Dr. Heinz Rothgang 17

18 IV. Welfare State arrangements: expenditures Prof. Dr. Heinz Rothgang 18

19 IV. Welfare State arrangements: public-private expenditure mix Prof. Dr. Heinz Rothgang 19

20 IV. Welfare State arrangements: expenditures to arrangements Prof. Dr. Heinz Rothgang 20

21 IV. Welfare State arrangements: Care Arrangements Prof. Dr. Heinz Rothgang 21

22 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 Prof. Dr. Heinz Rothgang 22

23 IV. Welfare State arrangements: Typologies Typology of some EU countries Type of welfare state Sozialdemocratic Separate LTCI system Bismarck-Type LTC financing system No separate LTCI system Beveridge-Type Type A Denmark, Finnland, Sweden Conservative Type B Austria, Germany, Luxembourg, Netherlands b Type C Belgium, France, a Italy Liberal Type D United Kingdom, Ireland Rudimentary Type E: Spanien, Portugal, Griechenland Prof. Dr. Heinz Rothgang 11 23

24 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. Prof. Dr. Heinz Rothgang 24

25 Contents I. 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 1. Normative Analysis 2. The Introduction of LTCI in Germany VI. Who cares? VII. The political issue: How to guarantee future care-giving? Prof. Dr. Heinz Rothgang 25

26 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 meanstested 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 Prof. Dr. Heinz Rothgang 26

27 V.1 Social insurance has advantages over private insurance Financing 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. Prof. Dr. Heinz Rothgang 27

28 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.? Prof. Dr. Heinz Rothgang 28

29 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. Prof. Dr. Heinz Rothgang 29

30 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. Prof. Dr. Heinz Rothgang 30

31 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 Prof. Dr. Heinz Rothgang 31

32 Contents I. 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? 1. Care-giving today 2. Care-giving past developments 3. Care-giving the future VII. The political issue: How to guarantee future care-giving? Prof. Dr. Heinz Rothgang 32

33 VI.1 Care-giving today Prof. Dr. Heinz Rothgang 33

34 VI.1 Care-giving today Main Carer of Dependent People in Private Households Share in % Change Sex Male Female Relation of Carer to Dependent Person Husband or (Male) Partner Wife or (Female) Partner Mother Father Daughter Son Daughter-in-law Son-in-law Other Relative Neighbor / Friends Residence of Main Carer Co-resident Separate Household Sources: Schneekloth and Potthoff, 1993, 126; Schneekloth and Mueller, 2000, 52; and Schneekloth and Leven, 2003: 19. Prof. Dr. Heinz Rothgang 34

35 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 Prof. Dr. Heinz Rothgang 35

36 VI.2 Care-giving past developments (2/3) Number of Providers Capacities of formal care Extramural Care Employees Whole time equivalents Number of Nursing homes Intramural Care Number of beds in nursing homes , ,782 56,914 8, , , ,567 57,524 9, , , ,897 57,510 9, , , ,307 56,354 10, , , ,162 62,405 11, , ,1 3,1 1,1 3,5 4, ,2 6,0 0,0 6,3 5, ,4 6,7-2,0 7,0 6, ,0 10,2 10,7 5,8 5, ,6 28,5 9,6 24,5 23,8 Source: Statistisches Bundesamt 2008b: 25. Prof. Dr. Heinz Rothgang 36

37 VI.2 Care-giving past developments (3/3) Type of benefits chosen ,3 58,1 55,9 Nursing home care combination 54,2 53,0 52,3 52,0 51,5 51,0 50,6 50,3 49,9 49,6 49,0 cash benefits in kind benefits ,1 25,4 26,3 26,8 27,5 27,9 28,3 28,7 29,2 29,5 29,6 29,8 29,5 29, ,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, Year Source: own calculations based on data published by the Federal Ministry of Health Prof. Dr. Heinz Rothgang 37

38 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. Prof. Dr. Heinz Rothgang 38

39 VI.3 Care-giving the Future Prof. Dr. Heinz Rothgang 39

40 VI.3 Care-giving the Future Entwicklung des Pflegepotenzials je Pflegebedürftigem in NRW bis Index Partnerpflegepotenzial je Pfegebed. Kinderpflegepotenzial Szenario 2 Kinderpflegepotenzial Szenario 3 Pflegepotenzial gesamt Szenario 2 Pflegepotenzial gesamt Szenario Abbildung 3: Entwicklung der Indizes für das häusliche Pflegepotenzial je Pflegebedürftigem in Nordrhein-Westfalen 2002 bis 2040 im Szenarienvergleich Quelle: Rothgang Prof. Dr. Heinz Rothgang 40

41 VI.3 Care-giving the Future Status quo 2/3 of all dependent persons are care for in private households Every 2nd dependent person is cared for without formal care Future Relative care potential, i.e. potential informal caregiver per dependent persons, is going to half by 2040 Informal care is the backbone of caregiving 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 formal care (working together with families) case management Growing Expenditure Prof. Dr. Heinz Rothgang 41

42 Contents I. 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? Prof. Dr. Heinz Rothgang 42

43 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. Prof. Dr. Heinz Rothgang 43

44 The end Thank you for your attention! Contact: 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 Prof. Dr. Heinz Rothgang 44