Care: The only thing that is exploding is the cost of care

In one fell swoop, hundreds of thousands more people in need of care – it sounds as if the Federal Minister of Health Karl Lauterbach (SPD) is really surprised that in an ageing society there are more and more people who are considered to be in need of care. “In recent years the number of people in need of care has risen explosively,” said the minister in an interview with the Editorial Network GermanyFor demographic reasons, only an increase of around 50,000 people was expected in 2023. But the actual increase is over 360,000. “Such a strong increase in such a short time should give us pause for thought,” says Lauterbach. It is not yet clear exactly why this is the case.

Are there really so many more people in need of care in Germany all of a sudden? A look at the care statistics and the figures from the medical service of the health insurance companies shows that the forecast does not deviate that much from the actual figures. In 2021, around five million people in Germany were in need of care, now there are almost 5.6 million. In fact, according to the umbrella association of health insurance companies, there were only around 35,000 more people in need of care last year than in previous years. According to the MDK, the nursing care insurance assessors had to process 160,000 more initial applications last year than in the previous year. Overall, the number of initial applications rose to 1.35 million.

In general, the risk of needing care increases with age. The Federal Statistical Office has calculated how the number of people needing care could develop by 2055. Two scenarios were used. The first scenario was based on the pure ageing effect on the basis of previous care rates. However, this is probably not entirely realistic. The 2017 care reform redefined the need for care. Since then, it has been much easier to have a care level recognized, and care rates have therefore increased. The second scenario therefore expects increasing care rates, which now appear to be occurring.

Nevertheless, the health minister speculates about all sorts of possible explanations. Is it due to a possible catch-up effect since the corona pandemic? Perhaps hundreds of thousands of very old people, out of fear of being infected with the corona virus, refrained from applying for a care level and postponed the necessary assessment by the medical service of the health insurance companies until it was no longer possible? This will be investigated, promises the minister, who also considers it conceivable that the first baby boomers will already be in need of care. The health minister speaks of a “sandwich effect”. For the first time, there are two generations that are relying on care at the same time. Care are dependent on: “The baby boomers and their parents.” That sounds dramatic, as if the collapse is not far away.

Experts are not surprised by the increase

However, many experts find Lauterbach’s explanations implausible, not only because the baby boomers are still too young to be in need of care to any significant extent. A catch-up effect due to postponed assessments by the medical service is also rather unlikely. This is because these mostly took place over the phone during the pandemic. “The figures were to be expected given the previous development of the need for care and are not influenced solely by demographics,” says nursing scientist Daniel Tucman from the German Institute for Applied Nursing Research in Cologne.

He refers to the care statistics published every two years by Lauterbach’s ministry, according to which more than five million people in Germany will have a care level by 2023. Tucman cannot understand why the health minister assumes an increase of only around 50,000 people per year. In recent years, the statistics have often shown an increase of over 200,000 people affected. “The only recent explosive increase in the number of people in need of care was due to the adjustment of the definition of need for care with the 2017 reform. But at that time, no one raised the alarm at the political level,” says Tucman.

Bremen nursing researcher Heinz Rothgang is also not surprised by the increasing number of people in need of care. Realistically, an increase of around 300,000 people affected per year must be expected. In his opinion, the fact that there are now over 360,000 could have something to do with the corona pandemic. On the one hand, many people have postponed applying for a care level, but it is also conceivable that many people are suffering from long Covid and other consequences of the pandemic. There is no evidence of this so far.

However, long-Covid initiatives such as the Long Covid Germany Association of Sufferers state that by the end of 2021, a good half a million people had already contracted myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Experts believe it is quite conceivable that some of them have now received a care level. Above all, however, Rothgang still sees the increase in numbers as an effect of the 2017 care reform. The number of 50,000 cases assumed by the Minister of Health is based solely on demographics, but ignores the fact that many more people can now be classified as needing care, usually with care level 1, which, however, does not have a major impact on care costs.

Cologne-based care expert Tucman explains the increase as follows: “A large proportion of those in need of care have care level 1 or 2, so the impairment of independence is still comparatively low. But because more types of restrictions on independence have been taken into account since 2017, many more people are also receiving a care level than before.” Tucman observes that a societal rethink is taking place. “Many older people and their relatives are better informed today and naturally use the Internet. Many know what they are entitled to and they make use of their rights,” the nursing scientist suspects.

Care costs are rising rapidly

Nursing researcher Rothgang considers the sandwich effect cited by Lauterbach, with people in need of care in two generations, to be implausible. There may be some baby boomers who are already in need of care, but there is not yet a relevant number in this generation. Both he and Tucman therefore assume that the health minister is raising the alarm for political reasons.

Nursing insurance is at its limit, and a further increase in contributions is urgently needed to refinance the rising costs of nursing care – due to demographic aging, but also the shortage of skilled workers and attempts to make the nursing profession more attractive through wage increases. Even today, many people can hardly afford the personal contribution. According to the Association of Substitute Health Insurance Funds (Vdek), the private contribution for a place in a nursing home is on average 2,576 euros per month. Because of this increase in costs, Lauterbach has campaigned for a limit on the personal contribution; since the beginning of the year, those in need of care have been given greater relief, and nursing insurance funds now cover 15 percent of the personal contribution in the first year in the home, 30 percent in the second year, 50 percent in the third year, and 75 percent of the monthly personal contribution for a stay of four years or more. The benefits for home care have also been improved.

It is therefore not the number of people in need of care that is likely to rise sharply, but rather the costs of nursing care insurance. Rothgang suspects that Lauterbach underestimated the consequences of this reform. “It could be that people are acting so surprised now in order to distract from this misjudgment,” he says. A comprehensive financial reform in nursing care is therefore long overdue. But it is unlikely that this will happen before the next federal election. Although an inter-ministerial working group has been set up in the Federal Ministry of Health, the experts’ assessments differ widely. The group’s work is therefore a good basis for a major nursing care reform in the next legislative period, said Lauterbach. By then at the latest, a reform of nursing care insurance with a view to demographics will be long overdue.