Radical Institutional Change and Incremental Transformation: Long-Term Care Insurance in Germany

Abstract

The introduction of the Long-term Care Insurance in 1995/1996 in Germany brought about a fundamental change of long-term care policies related to social rights, mode of funding and care provision. Before its introduction, long-term care was defined as the responsibility of (mainly female) family members with public support only available after a means-test. Based on the introduction of a mandatory (social) insurance scheme, the new long-term care policy combined principles of universalism, basic funding and an emphasis on family responsibility. Within the framework of the new long-term care policy, the roles of informal, family and professional care, the conditions for the development of the care infrastructure and the responsibilities of significant political actors on the central, regional and local levels as well as insurance funds and care provider associations were thus redefined. While the basic principles are still valid, reform effects and new societal developments required gradual adaptations in different respects. In this chapter, two types of developments—radical change and incremental transformation—are analyzed. Processes of radical change are analyzed through the examples of the system of funding and the definition of social rights, where clearly defined regulations on a federal level were introduced after intense debates (with only minor changes made since). Second, reform strategies related to the restructuring of care provision are examined to reveal processes of incremental step-by-step change. This study looks at processes of policy development as shaped by the interplay of actors, ideas, interests and institutions; and the rationale for and content of the policies as well as their effects.