Nursing care insurance at its limit: What a reform should achieve

Statutory long-term care insurance turned 30 this year – but the challenges could hardly be greater. Expenditures exceed revenues, and the number of benefit recipients is increasing year after year: currently from 5.2 million and, depending on forecasts, up to 5.9 million in 2027 (Federal Statistical Office 2025). If long-term care insurance is not fundamentally reformed and restructured, it threatens collapse in the foreseeable future, thus also threatening social peace.

In its coalition agreement, the future German government announced that it would address the structural and long-term challenges of long-term care insurance with a major care reform. The goal is to ensure the sustainable financing of long-term care insurance, strengthen outpatient and home care, and simplify and reduce bureaucracy in accessing services for those in need of care and their families.

A federal-state working group at ministerial level, with the participation of municipal associations, is to develop the foundations of the reform by the end of 2025. It took six years for long-term care insurance to be passed 30 years ago. One can therefore be skeptical about the extent to which the new federal government intends to have developed the reform proposals in just a few months.

Due to financial constraints in long-term care insurance, the contribution rate was raised again at the beginning of 2025, rising to 4.2 percent for those without children and 2.6 percent for parents with five or more children. However, this provides only limited time. A deficit of billions remains, and financial developments are worrying. Economists expect contributions to continue rising by the fall at the latest, as otherwise many long-term care insurance funds face insolvency and will require financial support.

The social security contribution rate is already 42 percent. This limit should not be exceeded for a long time. Continuously increasing social security contributions is therefore not a solution. The question arises as to how to either increase revenue (in other ways) or limit expenditures.

Full nursing care insurance?

Generally, incomes have developed positively in recent years. The contribution assessment ceiling could therefore be raised across the board for everyone. Some experts propose a comprehensive long-term care insurance system: This would cover care-related costs entirely through social insurance—and be designed as a public insurance system that would include everyone regardless of their insurance status and take into account all types of income up to the contribution assessment ceiling (Rothgang 2025).

Even though the proportion of healthy years increases with age, the likelihood of needing care increases with age. While increasingly complex therapies are becoming possible, what is medically and technically feasible is not always sensible. For example, if the life expectancy gained is minimal or the quality of life cannot be improved for the remaining time. This is where we reach ethical limits, and a societal debate is urgently needed about how we want to be (medically) cared for at the end of life, whether curative or palliative.

The primary goal of every individual must be to stay healthy for as long as possible in order to be able to live a self-determined and independent life. This requires a political framework with laws for prevention and health promotion, as well as structural measures to improve health literacy in society and from childhood onward. Future health and care reforms should incorporate corresponding measures into the catalog of services. Care can play a key role here. What is needed is less doctor-centered and more care-centered care, which is also more cost-effective.

Financing from tax revenues

In addition, long-term care insurance must be purged of non-insurance-related benefits. These include, for example, pension contributions for family caregivers, free co-insurance, pandemic-related additional costs, and contributions for recipients of citizen's allowance. These should be financed through tax revenue rather than through social long-term care insurance. The establishment and expansion of caring communities and support structures in self-help, neighborhood, and volunteer settings are also urgently needed and should be financed through tax revenue.

Likewise, the financing of nursing training and nursing studies in outpatient and long-term care must no longer be borne by benefit recipients. In the future, funding must be provided from tax revenue, similar to medical studies. This will significantly reduce the financial burden on long-term care insurance and those in need of care.

With the reform of long-term care insurance, the responsibilities of lay caregivers, assistants, and professional caregivers for nursing care must be regulated more clearly than before. The binding nature of the reserved duties for professional caregivers under the Nursing Professions Act (Section 4) must be clearly regulated by law (professional law/professional code of conduct) and reflected in the benefits law, as must the management of the care process. Professional caregivers must be clearly differentiated from lay caregivers, nursing assistants, and support tasks through the regulation of authority and responsibility.

Introduce a nursing classification system!

Extended roles such as Advanced Practice Nursing and CHNs can play a crucial role in both counseling and care management. To ensure that those in need of care, as well as their relatives and friends, can provide care independently for as long as possible, even in complex situations, support and guidance from professional nursing professionals are essential.

The reform of long-term care insurance requires the introduction of a nursing classification system and terminology to systematically justify nursing services. This will promote the expansion of digital and AI-supported applications and platforms. A uniform terminology supports quality assurance and facilitates interdisciplinary collaboration. Furthermore, it serves as a basis for documentation, reimbursement, and research.

The challenges are enormous, and it requires the combined expertise of all involved, as well as a willingness to tackle reforms across party lines and beyond the legislative framework. Professional nursing, as a key service provider and stakeholder in the system, must be involved! There is no time to lose.