Journal of Asian Women’s Studies Vol. 18

Research Paper

Conditions and Challenges of Germany’s Long-term Care Insurance:
Care Policies and Inequalities
based on Gender, Socio-economic Class and Ethnicity
Hildegard THEOBALD
University of Vechta

Abstract
With the introduction of the Long-term Care Insurance in Germany, a universal
coverage scheme was established on the national level. Despite the universalisticorientation and clearly-defined care rights of this law, unequal care arrangements haveemerged depending on gender, socio-economic class, living situation and ethnicity. The
emergent care patterns are explained based on a conceptual approach to the impact ofcare policy designs on the construction of formal and informal care work as determinedby life situations. Assessments and the use of types of benefits, care arrangement
patterns, informal care-giving and the emergence of migrant carers within the family
context provide the empirical basis for the analysis. The findings show that universal
coverage on a medium level and the offer of cash benefits and services interact withsocial, economic and cultural factors of the life situations of beneficiaries and informal
carers, and result in the unequal patterns of care arrangements.
Key words: Long-term Care Insurance, Universalism, Cash benefit, Inequalities, Germany

1. Introduction
Following a drawn-out debate in 1995/96, Long-Term Care Insurance (LTCI) was
introduced in Germany on a national level to guarantee universal public support in asituation of care dependency. Before the introduction of LTCI the risk of caredependency was covered only after means-testing, in accordance with the Federal law
on Social Assistance dating from the 1960s. A serious shortcoming in this law was thatthe middle classes, above all, were left without social protection in a situation of caredependency. It often resulted either in an increasing dependency on the care and/or
economic support of their children, or in a situation of impoverishment due to the highprivate costs of residential care. Increasing social assistance costs at municipal levels,

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however, provided the main incentive for the establishment of the new pillar within theGerman social insurance system (Ostner, 1998; Campell and Morgan, 2005).
The introduction of the LTCI in Germany and the Federal Care Allowance System
in Austria in 2003 marked a starting-point for the establishment of universal long-termcare schemes in further continental European countries, such as Luxembourg or
Flanders and even further afield in Japan and, more recently, in Spain and South Korea(See Theobald and Kern, 2009). The new long-term care schemes re-defined public
responsibility, the role of informal family care and the interplay with the market.
Common features that define the new schemes include universalism, clearly definedrisk situations and benefits, a re-organisation of public funding systems and an
expansion of care service provision mainly related to the introduction of care markets.
A more detailed comparison reveals major differences between the long-term careschemes, which concern the type of benefits available, e.g. the provision of careservices and/or cash benefits, the level of support and the (re)organisation of nationalregional-local interplay with regard to the policy process and implementation. In
contrast to Germany, politicians in Japan, for example, voted for services only as typeof benefit to promote the expansion of a care infrastructure and to avoid an emphasis on
the mainly female informal care provision.
Since the introduction of the LTCI in Germany intense research activities –statistics, quantitative and qualitative studies – on the (changing) situation of thebeneficiaries, informal and formal care have revealed strengths but also significant
weaknesses in the institutional design of the insurance and the mode of its
implementation. On one hand, the insurance led to a marked increase of the population
covered in a situation of care dependency, even including the middle-classes. It is also
related to an expansion of home-based and residential service provision and changes
with regard to the quality of care services. On the other hand, in contrast, significant
deficits have become visible related mainly to a lack of comprehensive care service
support for older female adults living on their own and to burdened family carers due tothe reliance on mainly female family care. A detailed analysis of the deficits brings
about different outcomes for different social groups, depending on the intersection ofgender, socio-economic class and ethnicity.
Research shows that despite the idea of universalism, the LTCI is related to a wide
range of unequal resource allocations from the perspective of the beneficiaries and theinformal family carers. The patterns, the related societal processes and theirinterrelationship to the care policies, are the focus of this article. It starts with thepremise that different dimensions of the institutional set up of LTCI – such as eligibility
criteria, levels of support, types of benefits and central, regional, local interplay – andtheir interaction with the social, economic and cultural factors of the life situations ofdifferent social groups causes the development of the group-oriented unequal patterns ofcare provision.
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In the following, in the second section the outline of significant features of theGerman LTCI and a conceptual-theoretical framework for the impact of care policies on
the development of care arrangements and outcomes provides a background for theempirical analysis. In the third section, the assumption will be scrutinized empiricallyon the basis of statistics and research studies. The empirical part discusses assessments,
eligibility criteria and the use of different types of benefits, care arrangement patterns,
the situation of informal carers and the emergence of migrant carers within the family
context. In the final concessionary section, I summarise the findings of the analysis and,based on this, discuss the on-going efforts to reform the LTCI.

2. Background(1) Basic Features of the Long-term Care Insurance
The LTCI in Germany aims to provide universal and need-related public support insituations of care dependency. In order to achieve this goal, eligibility criteria, careneeds and corresponding types and levels of benefits are clearly defined within anational law. The law defines three levels of increasing care dependency and assigns
them to three types of support – cash benefits, home-based care services and residential
care services (cf. table 1).
Beneficiaries are able to choose between the use of cash payments to organise careprovision privately or home-based care services and, in principle, also with relation to
institutional care provision. In addition, eligibility criteria and benefits are determined
for further support services, such as day centres, short-term care or low-threshold
services.
The insurance re-defined the role of the state, family and the market with regard to
funding and care provision and is based on four main principles.

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Table 1. Care dependency: Levels and Benefits
Care dependency levels
Types of benefits

Considerable (I)

Substantial (II)Most substantial (III)2008€ 215.00€ 420.00€ 675.00

January 2010

€ 225.00€ 430.00€ 685.00

January 2012

€ 235.00€ 440.00€ 700.00€ 420.00€ 980.00€ 1,470.00€ 440.00€ 1,040.00€ 1,510.00€ 450.00€ 1,100.00€ 1,550.00

Cash payments (per month.)
July

Care services: home based(per month)
July

2008

January 2010
January 2012(€ 1,918.00)(extraordinary high need of care)
Care services: residential(per month)
July

2008

€ 1,023.00€ 1,279.00€ 1,470.00(€ 1,750.00)

January 2010

No increase

No increase€ 1,510,00(€ 1,825,00)

January 2012

No increase

No increase(extraordinary high need of care)€ 1,550.00(€ 1,918.00)

Source: MDK Bayern (2008).

(a) Universalism and medium support
Within the framework of the LTCI the whole population is insured, albeit divided
between the social LTCI (approx. 90% of the population) and mandatory private
insurance (approx. 10%). The benefits are meant to cover basic care needs and have to
be complemented, either with informal family care, private economic means or withmeans-tested social security assistance. The insurance benefits are strictly related to thelevel of care dependency, i.e. the economic and family situation of the beneficiaries are
not taken into account.
(b) Priority of domestic care
The law aims at maintaining domestic care by supporting either informal care orhome-based care provision. Cash payments are intended to strengthen informal care, inparticular from the family or wider social networks. Home-based care services areintended to provide expertise or unburden family carers, but not to substitute informalfamily care. Domestic care should be given priority in order to delay the use ofresidential care services for as long as possible.

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Journal of Asian Women’s Studies Vol. 18(c) Care market: Demand as basis for an expansion of care services
The care services on offer before the introduction of LCTI were strongly
underdeveloped – both quantitatively and qualitatively. It was widely expected that the
introduction of the insurance and an opening-up of a care market for non-profit and forprofit care providers on equal terms would give impulses to a quantitative andqualitative development of the care infrastructure. The development of care services
was to be driven by users’ demands.
(d) National-regional-local interplay
By national law eligibility criteria and benefits are clearly defined to secure equal
universal support, while a wide range of actors on regional and local levels are
responsible for the implementation. The main responsibility for defining the mode ofcooperation between the further social and political actors according to regional
conditions was assigned to the Federal States (Bundesländer).
With the establishment of the LTCI, former state-supported structures were notabolished but significantly redefined. Now, the Federal Law of Social assistance steps
in after a means-test when the individual or the family are unable to provide thecomplementary care provision not covered by the insurance. The law also comes into
force in situations where care needs fall below the LTCI threshold, or when domestic
assistance only is required, which is not granted by LTCI. Laws and regulations related
to the elder assistance system entail the establishment of local social services, e.g.
transport services by municipalities to promote social integration for older adults.
Considerable room for discretion has resulted in wide differences in local service
structures, which have even been reduced since the introduction of the insurance(Bönker et al, 2009).
(2) Conceptual Part: Social Policy Design and the Issue of Equality
Since the 1980s gendered welfare state research has criticised the orientation of(international comparative) welfare state research on socio-economic class, the related
issue of social inequality and the neglect of the impact on gender inequalities. Based on
feminist criticism, research gradually arrived at a consensus that different types ofinequalities and their intersection are socially constructed and must therefore be taken
into account in any comprehensive analysis of welfare state policies and outcomes (Seee.g. Esping-Andersen, 1999; Daly, 2000; Korpi, 2000).
In the course of the scientific debate, social care was identified as an area where
gender, social and – increasingly, even ethnic – inequality meet. Research into theconcept of “social care” has revealed the widespread care activity of women and its
relationship to gender (in)equality. Since the 1990s, the inclusion of care work provided
by home helpers or migrant workers in US research prove that social care is also related5

Journal of Asian Women’s Studies Vol. 18

to socio-economic class and ethnicity (cf. Graham, 1991). In Europe, the increasing
influx of migrant carers has fostered a debate on the emergence of new divisions basedon ethnicity in the female-dominated activity (See e.g. Ehrenreich and Hochschild,
2002; Lutz, 2008).
While at the beginning of the debate the intersection of different inequalities wereanalysed from the perspective of informal carers or paid carers within the family context,
the unequal situation of the care recipients has gradually come to the fore (See Theobald,
1998; Burau et al, 2007). Both the impact of social policy designs on the situation ofcare users and informal carers and their interrelationship, as well as the underlying
processes are the focus of this article. I start with the assumption that institutional
designs of care policies impact decisively on the emerging patterns of inequality related
to care provision from the perspectives of the informal carers and the care recipients.
Second, the impact of institutional designs is mediated by factors of life situations
related to gender, socio-economic class and ethnicity that set construction processes ofcare arrangements in train and result in corresponding patterns of arrangements. The
article goes on to examine institutional designs, the processes and the outcomes fromthe perspective of the care users and informal carers in greater detail.
Daly’s conceptual approach (Daly, 2000) offers a starting-point for the analysis of
the impact of care policies on the intersection of gender and socio-economic inequalities
within the area of elder care. In her approach she distinguishes between structures,
societal processes and outcomes. Structures are defined as institutional designs of social
policies, e.g. the risks covered and the construction of entitlements. As one fundamental
process she teases out the construction of formal and informal care activities across theprivate-public border. Outcomes are defined as the distribution of resources and thecorresponding stratifications from the perspective of the carers and care recipients. The
basic concepts of structure, processes and outcome will be elaborated according to thespecificity of the area of elder care.
Based on findings within elder care research four dimensions of care policy
designs – eligibility criteria, levels of support, types of benefits and central, regional,
local interplay – can be defined as being decisive for the process of construction offormal and informal care activities and their relationship to emerging patterns ofinequalities (Theobald, 2008). Eligibility criteria generally determine access to benefits.
The range of care risks covered, e.g. basic nursing care, household services, institutionalcare, and the level of care needs, serve to define eligibility criteria. In some countries,
further eligibility criteria may also include economic circumstances – ascertained bymeans testing – or the family situation (Anttonen et al, 2003).
Österle defines goals determining the level of support and related them to policy
outcomes (Österle, 2001). The first goal of care policies “guaranteeing minimum
standards” aims to prevent care recipients falling into poverty and provides only aminimum level of public support. The second goal “supporting living standards” grants
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a higher level of public support to prevent older adults from big drops in their individualliving standards. The third goal, “reducing vertical and horizontal inequality,” takes
vertical differences in income or horizontal differences between the care recipients andthe healthy into account.
The new definition of public responsibility for financing care support since the1990s corresponds to the increasing establishment of a mix of different types of benefits,
mainly cash benefits, care services or leave schemes. Daly and Lewis (2000) describe
the new balance between cash transfers and services as a major trend in the area ofsocial care, where the mixture differs between and within welfare states. As a result, theboundary between formal care (provided by public, voluntary or commercialorganisations) and informal care (by family members, relatives, friends and neighbours)
has become an area of conflict, re-negotiation and newly-developed forms ofcooperation. The shift from service provision to cash benefits is justified with thepromotion of more choice for the service users, an acknowledgement of informal careprovision (carried out mainly by women) and the goal of cost-efficiency, i.e. with theaim of lowering costs (Ungerson, 1997; Daly and Lewis, 1998).
Recent research in the area of elder care has revealed the impact of the type of
benefits – cash benefits or care services – on the situation for both informal and paidcarers within the family context, as well as for care recipients. In a range of westerncountries, the provision of cash payments for informal family care has led to anincreasing inequality among women based on socio-economic class or migrantbackground (See e.g. Burau et al, 2007). In addition, the provision of unregulated cash
benefits proves to be related to the emergence of migrant carers within the family
framework, e.g. in Italy, Austria or Germany (Ungerson, 2005; Simonazzi, 2009,
Theobald, 2009).
Traditionally, elder care policies were developed and implemented at local levels,
but the increasing public responsibility within the areas is related to the development ofcountry-specific interplay between central and local relations (Anttonen et al, 2003).
Thus, political institutions in the field of elder care policies stretch simultaneously
across local, regional and national levels. The devolution in some countries of theexecutive power and responsibility to the municipalities or regions was intended toenable local authorities to adapt care services to the individual needs and to the risk
structure in the local area (Glendinning, 1998). Despite the advantages, this emphasis on
local level responsibility raises the question of equity and citizenship. For example in
Sweden, social care rights are defined in greater detail at local levels, which results invery different support structures on the municipal level (Rauch, 2005). Glendinning(1998) argues that the devolution of responsibility makes the overarching regulatory
frameworks even more important if elderly people are to have equal access tocitizenship-based services.

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According to Daly’s framework, structures, i.e. care policy designs, cause societal
processes. Societal processes, i.e. the construction of formal and informal care work,strongly influence outcomes and thus the available care resources and stratifications
among care recipients and carers (Daly, 2000). The processes and outcomes, however,are not only influenced by policy designs but are also mediated by resources of the carerecipients and of the informal carers, respectively. Despite public support, in all western
European countries families provide the bulk of care provision. Thus, elder carearrangements mostly include both formal care services and informal family care. Three
dimensions of social care are relevant for the analysis of the construction of care
activities across the formal-informal borders: the definition of the type of care work as
formal or informal, the costs of social care, and its embeddedness in a normative
framework of family and public responsibilities (Daly and Lewis, 1998). Thus, theimpact of care policy designs on the construction of formal and informal care ismediated by available family and social informal support and private economic means
embedded in norms on public and private responsibilities.
Against the conceptual background the design of Germany’s LTCI can be
described as providing a medium level of support based on the principle of universalism,
which has to be complemented by family or further private resources. Cash benefits andcare services are offered related to the principle of freedom of choice for the
beneficiaries. There is an emphasis on clearly-defined eligibility criteria and benefits on
the national level, which together with implementation on the regional or local levels
are intended to secure legal certainty and equitable care throughout the country insituations of care-dependency. In the following empirical sections the impact of theinstitutional designs on the development of care arrangements will be analysed. Above
all, I examine assessments and access to benefits, the construction and mix of formal
and informal care in different life situations and the corresponding outcomes fordifferent social groups.

3. Empirical Part
(1) Benefits and Assessments: The Impact of Gender, Socio-economic Class andEthnicity
The introduction of LTCI based on the principle of universalism led to a significant
increase in the number of beneficiaries (who had hitherto received benefits according to
the Federal Law on Social Assistance), from approx. 563,000 in 1994 to approx. 2.5
million care dependent people receiving LTCI benefits in 2007 (Eisen and Mager, 1999;
Statistisches Bundesamt, 2009). In 2007, 11.3% of adults 65 years or older received
benefits, whereof 2.8% chose home-based care services, 4.2% cash payments and8

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further 4.0% institutional care services (Statistisches Bundesamt, 2009). In addition,according to a representative survey in 2002 approx. 3 million citizens aged 70 years orolder stood in need of some form of assistance with housekeeping, of which approx. 2%
received benefits according to the Federal Law on Social Assistance (approx. 0.5% of
adults 70 +) (Schneekloth, 2006).
Since the introduction of LTCI a (falling) majority of beneficiaries has preferredcash benefits to home-based care services; from 82% in 1995 to 68% in 2005 (Evers,
1997; Statistisches Bundesamt, 2007). Overall, from 1999-2005 we find an increase of
beneficiaries living in residential care from 27.7% to 31.8% and receiving home-basedcare services from 21.3% to 22.2%. While the use of home-based care was still
increasing in 2007 (to 22.4%), the proportion of beneficiaries using residential care fellslightly to 31.6% (Statistisches Bundesamt, 2001, 2003, 2005, 2007, 2009). The take-up
rates of long-term care benefits and the type of benefit selected differ markedly between
different groups in society based on the criteria age, gender, socio-economic class andethnicity.
The take-up rates of benefits are commensurate with gender and age and thecorresponding health status. The risk of care dependency is strongly related to age, thus
in 2007 54% of the beneficiaries were 80 years and older. In addition, in the same year,
68% of the beneficiaries were women (Statistisches Bundesamt, 2009). Theinterrelationship of care dependency and age and gender can be explained by the healthstatus – with a poorer health status in older age and health differences between men andwomen. The higher level of care-dependency among women is not a German
phenomenon. A study in 12 European countries clearly confirmed the development of a
specific profile of morbidity related to a higher risk of care dependency (Stiehr andSpindler, 2006).
The gender-oriented patterns of family status and living-situation in old age arealso correlated to gendered patterns of benefit use; above all to cash benefits andinstitutionalised care. While men more often opt for cash benefits – 54.9% for men
versus 41.7% for women in 2007 – women are more likely to “choose” residential careservices, 33.7% versus 21.9% (Statistisches Bundesamt, 2009). Above all, women in
old age living on their own move more often into residential care facilities if they reacha high level of care dependency. In contrast, men are more likely to be cohabiting andare more often cared for by wives or partners (Theobald, 2004; See section below oncare arrangements)
Besides gender and age, adherence to certain socio-economic classes and ethnic
groups impact significantly on both the take-up rates and the selected types of benefits,
as well as on the results of assessment procedures. In general, due to their poorer healthstatus, citizens on lower-socio-economic strata are more often care-dependent(Theobald, 2004; Borchert and Rothgang, 2008). In 2006, the proportion of caredependent members of the social long-term care insurances doubled the proportion
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within the framework of the private long-term care insurances (Bundesministerium fürGesundheit, 2007). In Germany, compared to the social long-term care insurances,private long-term care insurances typically insure people from the higher socioeconomic strata.
The differences are not caused by a more favourable assessment procedure forapplicants of the social long-term care insurances. Within the framework of the social
long-term care insurances applications are more often rejected than within theframework of the private long-term care insurances (Bundesministerium für Gesundheit,2007). Furthermore, beneficiaries within the framework of the private insurances are
more often assigned to higher levels of care dependency; i.e. to care dependency level
two instead of one with regard to home-based care and to care-dependency level threecompared to level two with regard to residential care. There is no convincing
explanation for the differences. While the eligibility criteria are comparable in both
frameworks, assessments for the private insurances are carried out by private firms andthose for the social insurance by the medical departments of the health insurance funds.
One explanation may be the positive economic situation of the private insurances
related to a surplus between contributions and expenditure and, by contrast, the difficult
economic situation of the social long-term care insurances related to a deficit.
Furthermore, studies in daily care provision found that members of the lower socioeconomic classes more often opt for cash payments instead of services, while membersof the (upper) middle-classes tend to use more home-based or institutional services(Blinkert and Klie, 1999; Heusinger and Klünder, 2005 for a detailed explanation See
section 3.3 below).
Labour migrants recruited from the 1950s to the beginning of the 1970s onwards
are increasingly reaching age groups with higher risks of care dependency (BaykaraKrumme and Hoff, 2006). Above all qualitative studies reveal features of different
patterns of service use in migrant groups (for further details see section 3.3. below). An
analysis of the assessment reports in one region, where applicants with a Turkish
migrant background are compared to German applicants proved the role of migrant
status on the results of the assessments and the types of benefits selected (See Okken etal, 2008). First, the analysis showed that the applications of the migrant group are more
often rejected and that they are more often assigned to care dependency level one only.
Second, the Turkish migrant group voted more often for cash benefits than the Germangroup (91% to 42%) and less often for home-based services (9% to 29%), and hardly
ever for institutionalised services (1% to 29%). The significant group differences are
partially related to the group-specific impact of age and gender. In the German group,
gender and old age is related to an increasing use of home-based and institutional
services (See above). This impact could not be found for the migrant group (for a
detailed explanation see section 3.3 below).

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The patterns of rejections and assignments related to socio-economic class andethnicity call for further investigation into the assessment process within both social andprivate long-term care insurances. The use of different types of benefits – with regard togender, socio-economic class and ethnicity – will be explained further by a moredetailed analysis of the development of care arrangement patterns and the situation of
informal carers.
(2) Patterns of Care Arrangements: Family Care, Public and Private Services
The German law on LTCI focuses on the priority of domestic care and especiallyaims to support and maintain informal family care (See above section 2.1). The general
patterns of care provision confirm the family-oriented care strategy. A representativeinquiry in 2002 revealed that 92% of the beneficiaries living at home were receiving
support from family members, while only 38% were using publicly supported homebased care services. In addition to the take-up rates, the amount of care provision also
differed significantly. While publicly financed care services – depending on the level ofcare dependency – delivered between 0.5 to 1.8 hours a day, informal family careamounted to 5 hours a day on average (Schneekloth, 2006; Schneekloth and Wahl,2006).
While households with the heaviest care burdens draw on public services more
often, the majority of highly-burdened households organise support privately either on
the basis of family or social networks or by using private services (Runde et al, 2003).
Public home-based services are mainly used for the provision of basic nursing care
(Statistisches Bundesamt, 2009). In a representative inquiry in 2002, 23% of the longterm care insurance beneficiaries purchased private services and 11% received support
from voluntary workers, e.g. visiting services. However, approx., 42% of informal
carers stated that they were very burdened by care provision and about 60% demanded
more comprehensive support (Runde et al, 2003).
Cash benefits are mainly used to pay a nominal sum for informal care, in particular
to children or neighbours or, more rarely, used to buy domestic services on a grey
market. Related to spousal care cash payments are viewed as a part of the householdincome (Evers, 1997; Heusinger and Klünder, 2005). Private services are more often
purchased by recipients of public services to complement professional care services,while only 9% among the cash benefits recipients used private services in 2002
(Schneekloth, 2006). In a qualitative study, informal carers receiving cash paymentscomplained about the low level of payments, which was, however, not followed by areduction of informal care. Cash payments or pension points that could be granted incertain defined care situations only rarely offer an incentive for family carers to reduceor interrupt employment (for a more detailed explanation See section 3.3). Cashpayments only provide an incentive to carry out informal care-giving for informal carers
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in difficult life situations, for example, unemployed neighbours (Heusinger and Klünder,
2005; Schneider and Reyes, 2007).
A representative inquiry in 2002 into the attitudes related to the mix of informal
and formal care provision outlined a trend towards the recommendation of professional
services. 30% of informal carers and care recipients recommended informal family care
only, while 39% recommended a mix of informal care and professional services. A
further 20% voted for assisted living facilities and 4% for institutionalised services.
Even among the recipients of cash payments about 60% recommended a mix of formal
and informal care provision. Here, clear differences can be detected between carerecipients and informal family carers, with care recipients preferring more informal,
family care provision only (Runde et al, 2003). The general patterns of formal andinformal care provision outlined here differ significantly depending on gender, family
status, socio-economic class and ethnicity, which will be explained from the perspectiveof informal care provision – a decisive element in the family-oriented care system inGermany.
(3) Informal Care Provision: Inequalities Related to Gender, Living Situation, Socioeconomic Class and Ethnicity
Informal care provision is still a female dominated area. In a representative survey
15% of women and 8% of men aged 40-85 years report that they provide long-term carein private households. The gendered pattern changes when the family status of theinformal carers and the age group is considered. While the gender difference declines
for the older age-groups, mainly due to the spousal care, it increases with regard toparental care for the age-group 40-54 years. With 51% of all care relations care for theparents is the most dominant care support, while 18% of the informal carers provide
care for a partner (Künemund, 2006).
Representative statistics on informal family care for LTCI beneficiaries only foundchanging gender patterns in care provision. The female share among main informal
carers was 73% in 2002, and thus already a reduction compared with a female share of
83% in 1991 (Schneekloth, 2006). 60% of the main carers were 55 years or older withan average age of 59 years and were either partners (28%) or daughters/daughters-inlaw (32%) of the care recipient. While the inroads made by men is mainly related tocare of a spouse even the proportion of sons acting as a main informal carer increased
between 1991 and 2002 from 3% to 10%. Since the introduction of LTCI, careprovision for the parents and the spouse or partner is seen less as a social duty, but
based on more positive feelings or reciprocity (Runde et al, 2003). Even the mode ofcare provision differs significantly between male and female main informal carers. Male
carers can be found sharing care arrangements with other informal and formal carers, inparticular care services which usually take care of bodily needs. The increase of sons as
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informal carers can be explained either by male unemployment but also by the impactof the long-term care insurance and the availability of publicly supported care services(Schneekloth and Wahl, 2006).
In addition to gender, the living situation, socio-economic status and ethnicity
influence care arrangement patterns. The use of different types of benefits – either cash
payments or services – can be viewed as an initial indicator. Care services are more
often used by beneficiaries who live on their own with precarious social and family
support, older adults on higher socio-economic strata and are more likely to be German
nationals than migrant populations (Blinkert and Klie, 1999; Klie and Blinkert, 2002;
Heusinger and Klünder, 2005; Baykara-Krumme and Hoff, 2006; Okken et al, 2008).
The differences will be explained by group-specific social, family, economic andcultural resources. The care arrangements are not related to a balanced care situation,
where one type of support is substituted for another. On the contrary, it may indicate alack of care provision and an overburdening situation for some groups of informal
carers. In a representative study in 2002 14% of care recipients reported a lack of careservices and a further 12% a shortage of domestic support (Schneekloth, 2006).
The introduction of the LTCI has increased the number of care recipients who canremain in their own homes; while 40.9% of insurance beneficiaries were living in theirchildren’s households in 1997 this figure had dropped to 35.1% in 2002 (Runde et al,2003) Despite changing living situations, representative statistics confirm a situation of
intense contact and support between children and parents who often live near one
another (Künemund 2006). In a situation of precarious family or social support,
however, living alone often equates with inadequate or lack of care provision because
publicly provided home-based care is not able to compensate for the lack of informalcare provision where high levels of care-dependency exist (Blinkert and Klie 2006).
Long-term care statistics reveal that especially older women living on their own with ahigh level of care dependency more often move to residential care facilities (Theobald,2004).
An indicator for the impact of socio-economic class on care provision is the grouprelated use of cash benefits and care services, where the (upper) middle-class opt
significantly more often for services instead of cash payments. Several research projects
into the impact of socio-economic class reveal a complex pattern of class-related
economic and cultural factors that influence the construction of care arrangements(Blinkert and Klie, 1999; Klie and Blinkert, 2002; Heusinger and Klünder, 2005).
Economic factors are related firstly to the (private) costs for the purchase of careservices, which are developing embedded in the design of the long-term care insurance.
Within the framework of the long-term care insurance, the level of care-dependency andthe type of care provision determine the amount of public support, while the economic
situation of the care recipient is not considered. Only below a certain income threshold
are beneficiaries eligible for additional social support within the framework of social
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assistance. The economic burden related to the purchase of services differs dependingon the income situation. Statistics show that the use of privately paid home-based
services is related to the income of the beneficiaries. In a representative study on
average 8% of the beneficiaries stated that they buy privately home-based care services;
this proportion rises to 18.6% for beneficiaries with an income of € 2500 or more. Only
4.9% of all beneficiaries, however, have an income of € 2500 or more (Runde et al,2003). In the main, beneficiaries either complement the granted services with informal,
family care or they reduce the level of support; only 5% receive social assistancebenefits in addition (Runde et al, 2003; Bundesministerium für Gesundheit, 2007).
Secondly, economic factors are related to opportunity costs when informal carers
interrupt or reduce their employment. In 2002, 10% of informal carers had interrupted
employment and a further 11% had reduced their working hours in order to meet theircaring responsibilities. Fully 51% of the main informal carers in employment age had
not been gainfully employed before (Schneekloth, 2006). The combination of informalcare-giving and employment is strongly influenced by socio-economic class, i.e. boththe employment status before the advent of care dependency and the impact of informalcare provision. For example, while 44.9% of blue-collar workers had not been gainfully
employed at the advent of care dependency, the comparable figure for high-qualified
white-collar workers is 27.1% and 20% for high-qualified self-employed workers.
Furthermore, only 32.2% of the employed blue-collar workers continued in employment
without any changes compared to 45.0% of the high-qualified self-employed workers(Runde et al, 2003).
The class differences are also related to cultural factors, which, in turn, are related
to parental care (See Heusinger and Klünder, 2005). While the role of the family
members in care provision is emphasised in all socio-economic classes in Germany,
expectations differ widely as to what care tasks should be conducted by offspring differ.
Despite an emphasis on the responsibility of the family, the upper middle-classes, inparticular, would not expect their offspring to take over all care tasks. The use of
professional home-based services and, under certain circumstances, the move toresidential care, is accepted. Also, in the (lower) middle-classes paid assistance might
be called upon to unburden informal carers (mainly offspring), but assistance is more
likely to be sought in grey market services. Families at the lower end of the socioeconomic scale expect free provision of care and are more unwilling to accept a move toresidential care. Cultural factors also affect access to information on public support. The
complex public support structure in Germany – related to a care market with a wide
range of providers and with care provided within the framework of the LTCI, but also atmunicipal levels – impedes service use, in particular for lower socio-economic classes.
It may be related to a highly burdened situation of the informal carer, dependent on
available further family and social support.

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As already indicated in the analysis of the take-up rates of cash benefits or services,
ethnicity or migrant background strongly influence patterns of care arrangements (Seesection 3.1 above). The differences can be explained by a combination of economic,
social and cultural factors. An analysis of a representative study of the living situationof migrants without German citizenship indicates discrimination in several respects(Baykara-Krumme and Hoff, 2006). Life situations are characterised by lower incomes,
lower educational levels, below-average housing standards, and, although only slightly,
poorer states of health. The family situation is comparable to the situation of the control
group of German citizens characterised by dense intergenerational contacts, but withtwo differences. First, the proportion of the elderly, mainly the female widows, livingwith offspring is much higher than in the German sample. Second, on average thenumber of offspring in each family is higher than in the German sample.
A qualitative study on the long-term care situation in Turkish migrant families
revealed a strong emphasis on family responsibility even related to daughters (in laws),
which is based on cultural ideas and socio-structural resources (See Lorenz-Meyer andGrotheer, 2000). While home-based care was generally accepted, institutionalised care
was seen as something that should be avoided. Existing home-based care services andresidential care facilities in particular are only rarely adapted to the cultural ideas ofdifferent migrant groups. In a situation of limited availability of culturally-sensitive careservices, the provision of a cash payment to support family care tends to strengthen thecare-giving responsibilities of the daughters (in laws). The traditional assignment ofcare responsibilities to the daughters (in laws) will create increasing conflict with themore employment-oriented younger generation in the near future.
(4) The Emergence of 24-hour Care within the Family Context
The basic principle of Germany’s LTCI, namely to grant universal support on a
medium level, left a care gap that must be closed, either by informal care, privately paid
services or, after a means-test, with social assistance benefit. As figures on take-up rates
of cash benefits and hours of care provided by family members reveal, the care gap ismainly closed by family members and social networks. Moreover, apart from theprofessional care services, a grey market for domestic or care services has emerged.
On the grey care market two different types of care arrangements can be
distinguished. In a first pattern, assistance, mainly with household tasks, is provided byolder German women, housewives or migrants either already living in Germany or
recently arrived workers. The domestic workers do not live in but serve a number ofhouseholds for whom they work on an hourly basis (Gather et al, 2002). A grey market
for household tasks in Germany is widespread especially in the (upper) middle-classes,
but recently older adults have begun to buy more and more this type of service (Hank,
1998; Enste et al, 2009) As a second pattern, the increasing demand for more
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comprehensive care service provision has resulted in the emergence of 24-hour carearrangements provided by a live-in migrant worker.
According to estimates, about 100,000 migrant carers provide 24-hour care on arotational basis in about 50,000 households in Germany and concerns about 3-4% of
long-term care beneficiaries. Investigations into the situation of care users reveal the
relationship between a certain care and social situation (See Lutz, 2009; Neuhaus et al,2009). 24-hour care arrangements are used mainly by severely care-dependent older
adults with a high level of functional or cognitive impairment and a comprehensive
need of surveillance, basic nursing care and household services. The arrangements are
typically used by older adults on higher income levels who live alone with limited
family support or care provision from offspring (Lutz, 2009; Neuhaus et al, 2009).
Families who pay migrant carers in Germany cite the lower costs for carecompared to 24-hour formal care provision or residential care, i.e. professional careservice providers would calculate € 3000-5000 per month. In contrast, a 24-hour carerorganised by an agency costs between € 1200 and € 2400. The costs are mainly coveredby the care users themselves. In a study, about half of the care users report they are able
to pay for the costs without any economic constraints and a further 26% with acceptableeconomic constraints (Neuhaus et al, 2009).
Other reasons for the attractiveness of such care arrangements are wishes to avoid
nursing-home admission and to relieve the burden on family carers. Migrant workers
typically provide both domestic services and care activities, while about half of the carerecipients use additional professional services. Despite this, the use of professional careservices has fallen (Neuhaus et al, 2009). In a representative inquiry in 2002, about 44%of the recipients of long-term care benefit or their family carers already considered it“acceptable in principle” for them to employ a migrant carer, and 2.4% stated that they
already employed a migrant carer (Runde et al, 2003).
Many of the migrant workers come from the most recent EU-member states in
Eastern Europe and arrive on short-term or tourist visas to offer their services on arotational pattern (Finotelli, 2008). The limited right of cross-border service provision
within the EU is widely used, which offers the legal possibility to provide service inanother EU-country for up to six months a year. In 2002, on a temporary basis (thatbecame permanent in 2005) a legal care worker recruitment scheme was implemented
to legally hire out domestic carers to families with care dependent members. The
regulations correspond to regular working-conditions in Germany, e.g. 38.5 hours aweek are defined as a fulltime-job, German labour laws and social security standards
have to be followed and the activities concern domestic work only. According to theauthority responsible for the placement 3,032 domestic workers were employed on thisbasis in 2007. The monthly costs lie between € 1500 and € 2000 a month, comparable tothe costs for a migrant carer via the agencies. Empirical research reveals that users viewthe regulations as too bureaucratic and as not corresponding to their own needs.
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Qualitative studies reveal that in reality, users often fail to comply with working-time
regulations and controls on the part of the responsible authorities are rare (Lutz, 2009).

4. Conclusion: Conditions, Challenges and Reform Efforts
Long-term Care Insurance (LTCI) was introduced in Germany in 1995/96 toprovide universal coverage in situations of care dependency. According to the Germansocial insurance tradition, social rights, i.e. care needs and corresponding benefits –were clearly defined within the law on the national level. Despite the principle ofuniversalism and the strict definition of social rights on a national level, the law resulted
in unequal assessment results and unequal care situations for beneficiaries and informal
carers, depending on gender, living situation and family status, as well as on socioeconomic class and ethnicity. Using Daly’s basic concept on structure, processes andoutcomes as a starting-point, a conceptual framework was created to examine theimpact of care policy designs on the outcomes (Daly, 2000). In the conceptual part, thestructure, i.e. decisive dimensions of care policy designs are defined, such as eligibility
criteria, levels of support, types of benefits and central, regional, and local interplay.
The empirical part clarifies the factors of the life situations that impact on the process ofconstruction of formal and informal care arrangements. The findings reveal careresources and stratifications in group-related care arrangement patterns.
The principle of universalism based on public funding on a medium level, which
requires further resources (economic, social or family resources) and the non-adaptationof the level of public support to the income or family situation, build the starting point
for the construction of the unequal care arrangements. Moreover, cultural factors –normative values, as well as access to information – influence the care strategies indifferent life situations. The findings show a significant impact of gender on theprocesses and outcomes, which, however, have to be differentiated for different groups
based on socio-economic status, living situation and migrant background.
Both care dependency and informal care-giving are gendered phenomenon.
Women are more often exposed to the risk of care dependency themselves, while at thesame time they carry out the bulk of informal family care. Moreover, the care situation,
as well as patterns of care provision differ significantly between women and men. Dueto their living situations, men are more often cared for by their partners, while womenare more often dependent on care from their offspring or on formal care provision. In
particular, in a situation of high care dependency, professional home-based care cannot
compensate for a lack of informal family care and women move more often than men
into residential care facilities. Despite the female dominance in informal care provision,
men are increasingly taking over spousal care-giving and – less significantly – parental

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care. Compared to women, informal male carers are far more likely to be embedded in a
network of further informal and formal care provision.
On the basis of a different economic life situation and normative values, socioeconomic class and migrant background interfere with the general gendered pattern.
Owing to the combination of high private costs for complementary care services and thelow labour market participation rates of women with a low or medium vocational
training, beneficiaries in the lower socio-economic strata opt more often for cash
payments instead of home-based services. The availability of a cash payment and thenormative values “to provide long-term care” without any costs strengthen the informalcare strategy. In Germany, the living situation of labour migrants in old age ischaracterised by a low income level, a low level of vocational training and a strongemphasis on family care responsibility, and thus resemble the living situation of themembers of lower socio-economic strata. Moreover, home-based and, in particular,
residential care services are only rarely adapted to the needs of the migrant population.
Economic, social and normative factors therefore strengthen the preference for cash
payments. The opening-up of a care market related to a wide range of service providers,the uncoordinated offer of local services and information policies impede the use of
supporting services. The low level of service uptake often results in an overburdenedcare situation, depending on further family and social resources.
Since the introduction of the LTCI several reform efforts have been undertaken to
improve the service use, diversify the care infrastructure and increase the amount, i.e.
the hours of care provision for older adults with low levels of family or social support.
- In 2002, the Complementary Nursing Act was drawn up to relieve the informal carersof beneficiaries with dementia and simultaneously to give more space to create newelements in the care infrastructure. According to the law, beneficiaries suffering fromdementia may apply for an additional benefit of up to € 460 per annum to alleviate
the burden of the informal carers. “Payable” low-threshold offers that unburdenfamily carers ought to be created based on co-operation between professional carers
and voluntary workers. The benefits are only rarely used: in 2006 17.5% of eligible
beneficiaries have applied for the additional benefit (Sauer and Wißmann, 2007). In
order to increase the take-up rates, the amount was increased with the reform of 2008
to € 1200 and € 2400 per annum in very difficult cases and access to this benefit was
facilitated.
- Semi-residential care services have been established to unburden family carers. With
1% among the beneficiaries using short-term care and 1.5% attending a day care
centre, semi-residential care services are only rarely used (Statistisches Bundesamt,2009). The private costs related to service use have been put forward as one argument
for the negligible use. Since the reform in 2008, an additional benefit can be granted
for the use of day care facilities in certain situations, i.e. if it is necessary to maintaindomestic care due to the need of supervision, when the care situation deteriorates
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rapidly or to enable (part-time) employment of the family carer. The last point can beseen as an acknowledgement of changing labour market strategy, which requires thatwomen be continuously employed during the life course. On the other hand, two
unpaid leave schemes were introduced with the most recent reform in 2008. One
scheme grants an unpaid ten days leave to organise or adapt care arrangements. A
second scheme allows an interruption of employment or the take-up of part-timework on an unpaid basis for up to six months, which again promotes female informalcare work.
- A care budget was introduced between 2004-2008 based on a model-project.
Participants received the amount of money for home-based care services as apersonal budget, i.e. a cash payment, to purchase freely different legal care ordomestic services in addition to registered professional care service offers. The aimof the personal budget is to give beneficiaries more leeway to decide on different
types of support, thus strengthening their positions as customers. The evaluation of
the project shows that beneficiaries buy more assistance via legal, but low-prize
services, such as domestic workers, meals on wheels, etc. Related to this type of paid
assistance, the available paid caring time increased from an average of one hour to
ten hours per week (Blinkert and Klie, 2006; Klie, 2007).
- The bottom-up strategy of the German middle-classes to employ (often) illegally
migrant carers can be interpreted as a further strategy to create more flexible and“payable” care provision (See above). The development inspired a political debate on
the regularisation of migrant carers working within the family context. At the centreof the public debate are the low costs of the care provision for the families and thefact that migrant workers benefit too, owing to wage differentials between the
countries.
- In big cities such as Berlin, related to home-based services, culturally sensitive careoffers have been established. Here, mainly self-employed nurses with migrantbackgrounds offer home-based care services (Theobald, 2004). The employment ofcarers with a migrant background can be viewed as a further strategy to create moreculturally sensitive care services.
- The establishment of a sound information structure aims to support an adequate
service use. The reform of the LTCI in 2008 entails the development of“Pflegestützpunkte” (local single information points), to provide adequate andaccessible information services and case and care management services at one local
office. Since 2009, there is an individual right to information, even including freecontinuous case management services for all (potential) LTCI beneficiaries.
The reform efforts to increase service use, to provide the insured with more paidcare time, to diversify the care infrastructure or to improve information services havebeen conducted under the premise of cost-containment. From the perspective of the careusers and informal carers only a limited success can be ascertained, whereby the effects
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Journal of Asian Women’s Studies Vol. 18of the most recent reform in 2008 have not yet been evaluated. From the perspective of
the paid carers, however, the strategies aim to limit the costs of care provision and tocreate more “payable” care services, which is often related to precarious working
situations for carers who provide low-paid, partly illegal, up to 24-hour care. Despite
the strategies, the now more “affordable” paid care services are more likely to beoriented towards the life-situations of the middle-classes and offer no solution to theburdened informal carers of lower socio-economic or migrant backgrounds.

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