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Comparing Long-Term Care in Germany and the United States: What Can We Learn from Each Other?

Though one nation's policies rarely serve to answer another's problems, comparing experiences can help stimulate evidence-based debate and discussion. This AARP Public Policy Institute Issue Paper by Mary Jo Gibson and Donald L. Redfoot examines developments in the long-term care (LTC) systems in Germany and the United States to understand their impact on financing and coverage, consumer options and choice, family caregivers, the LTC workforce, and the quality of services. It also provides a brief overview of LTC reform proposals in both countries.

The German social insurance approach to LTC financing has addressed a number of problems by:

  • Providing universal coverage for services based on level of disability, not level of income;
  • Promoting consumer choice in types of services and settings;
  • Providing more support to family caregivers, who are the backbone of caregiving for older people with disabilities;
  • Relieving fiscal pressures on state (Land) governments, while maintaining overall spending on LTC at levels comparable to the U.S.
  • Developing more uniform standards of quality throughout the country.

The U.S. system has made important progress toward:

  • Shifting resources from institutional settings to home- and community-based settings in many state Medicaid programs;
  • Providing strong civil rights protections for persons with disabilities, including protections against unnecessary institutionalization;
  • Creating a national system of regulations and an extensive system of state-based monitoring that has resulted in quality improvements in some key areas; and
  • Spawning innovation through private financing in areas such as assisted living.

The increasing diversity of LTC services, settings, clients, and workers increase the challenges of assuring high quality in both countries. In addition, neither country will be able to meet the future demand for services without recruiting and retaining more professional and paraprofessional workers. Low wages, low prestige, and dangerous working conditions will have to improve to expand the pool of workers willing to do the difficult tasks associated with LTC. Both countries are likely to rely increasingly on foreign-born workers to provide care. (68 pages)

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