title: The German Long-Term Care Insurance Program: Evolution and Recent Developments.
abstract: OBJECTIVE
  Since 1995, Germany has operated one of the longest-running public programs providing universal support for the cost of long term services and supports (LTSS). Its self-funding, social insurance approach provides basic supports to nearly all Germans. We discuss its design and development, including recent reforms expanding the program and ensuring its ongoing sustainability.
  
  
  METHODS
  The study reviews legislative and programmatic changes, using program data, as well as legislative documents and program reports.
  
  
  RESULTS
  The program is widely accepted among citizens and has achieved many of its original goals: ensuring access to LTSS and reducing reliance on the locally-funded safety-net social assistance program, which can be used to cover nursing home costs. It also strengthened the LTSS provider infrastructure and expanded access to home care. Recent reforms have addressed some of the program's key issues: the benefit's decreasing value, the eligibility and benefit structure that largely excluded cognitive impairment, and the program's longer-term financial sustainability-particularly its ability to sustain newly expanded benefits, which provide stronger protections to caregivers, index-link benefits, and more systematically incorporate cognitive impairment via a new assessment system. It has addressed financing issues by increasing premiums, introducing subsidies for the purchase of private insurance, and creating a "demographic reserve fund."
  
  
  CONCLUSIONS
  The reforms constitute a significant strengthening of the program, remarkable in an era of retrenchment. Overall, the program provides evidence for the financial viability of a social insurance model, although longer-term challenges may yet arise.
authors.affiliation: Associate Professor of Gerontology, and Fellow, Gerontology Institute, University of Massachusetts Boston.
authors.forename: Pamela
authors.initials: P
authors.lastname: Nadash
authors.affiliation: Senior Policy Analyst, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, District of Columbia.
authors.forename: Pamela
authors.initials: P
authors.lastname: Doty
authors.affiliation: Director, Aging Divison, Bundesministerium für Familie, Senioren, Frauen und Jugend, Berlin, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: von Schwanenflügel
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005858:Germany; D006291:Health Policy; D006801:Humans; D007341:Insurance; D007353:Insurance, Long-Term Care / Q000331:legislation & jurisprudence*; D008134:Long-Term Care; D008875:Middle Aged; D012943:Social Security / Q000331:legislation & jurisprudence* / Q000458:organization & administration