Some Aspects of Long-Term Care in Germany Professor Konrad Obermann MD PhD Rome, May 2019

Obermann: LTC in Germany Key issues 1. History and (ethical) principles 2. Demography 3. Financing 4. Finding and retaining qualified staff Obermann: LTC in Germany

Clear ethical foundations in imperial message 帝国诏书打下了明确的伦理基础 The development of social security in an industrializing country 工业化国家社会保险的发展 Clear ethical foundations in imperial message 帝国诏书打下了明确的伦理基础 Message of Kaiser Wilhelm I to the Reichstag November 1881: “Already in February of this year We voiced our conviction that the healing of the social damage cannot only be sought through the repression of social riots, but equally on the positive promotion of the welfare of the workers. We consider it our Imperial obligation to again recommend warmly this task to the Reichstag, and we would look back with much greater satisfaction to all the success with which God has obviously blessed Our government, if we were to raise awareness on this issue and bring the fatherland new and permanent guarantees of its internal peace and to help those in need with greater security and efficiency of the assistance to which they are entitled. ... For such assistance it is a difficult task to find the right ways and means, but also one of the highest responsibilities of any community, based on the moral foundations of the Christianity. The close connection to real life forces of this nation and the merging of the latter in the form of corporate co-operatives under state protection and state support will, as we hope, make the solution of tasks possible that the state alone to the same extent could not provide. Obermann: LTC in Germany

Obermann: LTC in Germany The development of social security in an industrializing country 工业化国家社会保险的发展 1881年11月德国皇帝威廉一世致国会的诏书： “今年二月份，我们已经明确阐述过：要抚平社会创伤不能只靠镇压社会动乱，而同样要增进工人福利。我们认为，将这项举措推荐给国会是帝国的责任；我们应该增强人们对这个问题的重视，从而为祖国内部稳定提供新的永久保障，并对困难的人群给与更有效的援助，这样，日后我们会更高兴地对上帝赐予我国政府的巨大成功。...... 找到正确的援助方式和来源不是一项容易的任务，然而，根据基督教的道德基础，完成这项任务是每个群体的最高责任之一。我国政府与劳动人民联系紧密；我们希望在国家保护和支持下，劳动资源与法人组织相结合，能承担这个由国家独自出力无法完成的任务。” Obermann: LTC in Germany

1995: Long term care insurance The development of social security in an industrializing country 工业化国家社会保险的发展 Development of the “five pillars” of security 社会保障 “五大支柱”的发展 1871: Second German Reich founded: tendency towards centralism, unification, administration 1871年：建立了德意志第二帝国：趋向集中化、一体化、行政化 1926: Unemployment insurance (initially for soldiers): 1926：失业保险（最初为了士兵） 1995: Long term care insurance 1995：长期看护险 1889: Old Age Pension 1889：养老保险 1880 1900 1920 1940 1960 1980 1870 1890 1910 1930 1950 1970 1990 1883: Health insurance: 1883：医疗保险 1885: Accident insurance (paid in full by employers) 1885：意外保险（完全由雇主支付） 1900: BGB (citizens‘ code of law): 1900：BGB(民法典) Obermann: LTC in Germany

Economic principles in post-war Germany The Social market economy (Alfred Müller Armack) “A system which allowed business and finance to operate under the conditions of free market trading yet which worked within the legislative framework of industrial democracy at plant, company and industry level and within a statutory social security scheme seemed to enjoy the best of both worlds.” (Nigel Reeves, 1995, 213) Obermann: LTC in Germany

The Social Market Economy Free market trading The industrial harmony Laws of Co-determination Monetary policy of the Bundesbank (Federal Bank of Germany) Extensive social security scheme Obermann: LTC in Germany

LTC introduced in 1995 in response to financial problems Up until 1994 the local councils were responsible for financing LTC Serious financial difficulties were envisaged for the future Long discussion about whether to have another column of “pay-as-you-go” or a “capital-based financing” Obermann: LTC in Germany

LTC was attached to social health insurance Eligibility: when ill or disabled (Core: the definition “in need of care”, changed in 2017) Weighted results leads to grading (grade 1-5) Care allowance – home care (in kind) – residential care Benefit levels vary accordingly: from EUR 125 / month (grade 1, care allowance) to EUR 2005 / months (grade 5 – residential care) Obermann: LTC in Germany

The five pillars of the German social security system 德国社会保障体系的五大支柱 Special systems特殊系统 for farmers 农民 for miners / seamen 矿工/航海员 for state servants 公务员 (“Beamte”) for soldiers 士兵 for pensioners (SHI) 退休人员 German Social Security System德国社会保障体系 Statutory Health Insurance (SHI) 法定医疗保险 Pension Insurance 养老保险 Unemployment Insurance 失业保险 Long-term Care Insurance 长期护理保险 Accident Insurance 意外保险 SHI - Social Health Insurance 社会医疗保险 OAP - Old Age Pension 养老保险 AI – Accident Insurance 意外保险 Statutory unemployment insurance  insures employees' livelihood in case of unemployment, Statutory pension insurance insures members in old age as well as in case of reduced earning incapacity and upon an employees' death insures his survivors as well, Statutory health insurance  supports maintenance and restoration of good health and eases the financial consequences of illness, Statutory accident insurance  helps an employee regain his earning ability after a (work-related) accident, Statutory long-term care insurance  provides financial support for those dependent on care and assistance from others. Legal Basis: Social Code Books (SGB) 法律基础： 社会法典（SGB） SGB V SGB VI SGB II/III SGB XI SGB VII Obermann: LTC in Germany

Structures and principles of social security 社会保险的结构和原则 Solidarity and Subsidiarity 团结和权利自主 Solidarity: Western / Christian concept of the stronger ones supporting the weaker ones (e.g. young – old; rich – poor; without children – with children; healthy - sick) 团结原则：西方／基督教概念中，强者应该帮助弱者（例如年轻人－老年人；富人 －穷人; 没有孩子的人－有孩子的人；健康人－病人） Subsidiarity: the most local and smallest of all available institutions, if possible, take care of a problem (family – community – regional state – federal state) 辅助性原则：可能的话，问题尽量通过最地方的和最小的责任机构进行处理 (家庭——社区——州——国家） Obermann: LTC in Germany

Long-term care insurance: € 37 bn Complex financing structure 复杂的融资结构 Social Security System major part of public spending 社会保险系统是主要的公共支出 GNP Germany: € 3,210bn (2017) 2017年德国国民生产总值：3.21万亿欧元 Social insurance system: € 579 bn (2017) 社会保障体系：5.79千亿欧元(2017) Combined state budgets: € 920bn (2017) (federal, states, communities) 国家总预算：9.2千亿欧元（联邦，各州，地区） Old age insurance: € 304 bn 养老保险：3.04千亿欧元 Federal budget: € 329 bn (2017) 联邦政府预算：3.29千亿欧元（2017） Social health insurance: € 228 bn 社会医疗保险：2.28千亿欧元 of which spending on old age pensions: € 100 bn 其中在养老保险的支出为：1千亿欧元 Accident insurance: € 13 bn 意外保险：130亿欧元 of which spending on defense: € 37 bn 其中在国防费用的支出为：370亿欧元 Long-term care insurance: € 37 bn 长期看护险：370亿欧元 Unemployment insurance: € 27bn 失业保险：270亿欧元 Obermann: LTC in Germany

Obermann: LTC in Germany Financing LTC 2.55% of gross income (2.8% if no children) Managed by the SHI schemes (currently: 117) Grade of care formally assessed by the independent Medical Review Board of the Statutory Health Insurance Funds (MDK) Some control and corruption issues (organised crime in ambulatory and in-kind care) Co-payment on average about EUR 580 / month (individually set by the institution) Obermann: LTC in Germany

Oral contraception available Challenge 1: Demography 1910 2016 Post-war (WW II) Post-war (WW I) Reunification Oral contraception available World War II Franco-German War 1870/1 Obermann: LTC in Germany

Challenge 2: Demography

Challenge 3: Coordination LTC Use of IT Data protection Prevention Management Single window Paying for AAL SHI OAP LTC Long-term Care SHI Social Health Insurance OAP Old Age Pension AAL Ambient Assisted Living Obermann: LTC in Germany

A number of sensible legal changes – but the overall strategic direction is missing 2009 PSG I Erstes Pflegestärkungsgesetz: Improved services, better focus on dementia care, ambulatory flat-sharing 2015 PSG II Zweites Pflegestärkungsgesetz: New definition of “need for care”; move from 3 levels of care to 5 grades of care External evaluation of residential home care (“Pflege TÜV”) 2016 PSG III Drittes Pflegestärkungsgesetz: Improved local coordination; fighting fraud and corruption In addition 2002 Pflegeleistungs-Ergänzungsgesetz: improved care allowance; testing innovative models 2012 Pflege-Neuausrichtungs-Gesetz: better services for dementia patient; private co-insurance for LTC Obermann: LTC in Germany

One thing is for sure: German Angst will not help “The Last German”

Obermann: LTC in Germany Thank you! info@konrad-obermann.de Obermann: LTC in Germany

Obermann: LTC in Germany https://www.medhochzwei-verlag.de/Shop/ProduktDetail/the-german-health-care-system-978-3-86216-293-2 Obermann: LTC in Germany