Long-term care: only the optimists survive
by Jozef Pacolet (KU Leuven - HIVA)
Tomáš Szalay and Michaela Laktišová provide a state-of-the art overview of the challenges for the very old but only recently discovered long-term care. It reminds me of some of our pioneering studies on services for the elderly and social protection for the elderly in Europe. We discovered, or learned, at that time that it took twenty years to discuss in a country like Germany that an explicit new branch of social security should be created, along the same lines of the rest of the social security and under the roof of the health insurance. Since then a new table on long-term care provisions was inserted in the European ‘MISSOC tables’ on social protection, and more and more statistics were provided at OECD and European levels. Among others, in the European studies on the cost of ageing (published since 2009), the present and future evolution of long-term care insurance was documented. More recently a chapter on long-term care is going to be introduced in the European regulations on the coordination of social security systems and, finally, the icing on the cake is that a ‘principle’ or right on long-term care is included in the European Pillar of Social Rights.
The wording of the ‘long-term care’ principle is surprising even: “Everyone has the right to affordable long-term care services of good quality, in particular home-care and community-based services”, Surprising, since it gives the impression that only home care should be prioritized. Probably all studies on long-term care come to the conclusion that people want to stay as long as possible at home, but in reality, when that is no longer possible, residential care is needed and needs to be of good quality, and requires even the bulk of the budget. Both systems, informal and formal, at home and in institutions, need to be of high quality.
But identifying it and distinguishing it, does not imply that it needs to be separated. Szalay and Laktišová correctly underline the need for an holistic approach of needs and the support provided. The latter is composed of informal and formal care.
And making it more visible nowadays does not imply that it did not exist before. The need for long-term care is a very basic provision, including the support for persons with a handicap, but is now becoming more important because of the needs of an ageing population. Looking at the basic statistics for Slovakia in the European Commission Ageing report 2018, the demographic challenge is enormous, but not problematic. The fertility rate is indeed one of the lowest, but it will converge later again to European averages and the ageing is the most outspoken between now, where Slovakia can only be described as a relatively young country with only 14.7 of the population above 65, and the future where it will increase substantially to 31%. The total population is even to decline in the future, from 5.4 million nowadays to 4.9 million in 2070.
But who knows how demography will evolve. I remember that in the eighties, Belgium expected a decline of the population from 10 million to some 8.5 million. Then in the early 2000s, a stagnation of the population was announced around 11 million and now an increase is announced up until 13 million in 2060. But all the time the mantra of the heralds of the unaffordability and unsustainability of the welfare state because of the cost of ageing remained the same. That is of course contradictory and our conclusion is that with declining, stable or increasing populations, the social security remains feasible if properly managed and if the political desire to maintain that system remains.
Since 1995 we ask national experts every five years to document for their country the evolution of the welfare state, especially in the field of pensions, healthcare and long-term care (see https://hiva.kuleuven.be/nl/onderzoek/thema/verzorgingsstaat/p/The-State-of-the-Welfare-State-in-EU-overview/Overviewanno1992). We concluded that a common growth path of economic progress and social progress is possible, hand in hand, at different speeds perhaps, at different levels, with different institutions, with different societal plans… but ultimately going in the same direction. For example we compared formal and informal care in Belgium with some southern countries where the so called ‘family model’ was prevailing. We discovered that professional care is looked for when it’s affordable. Relatively early, Spain introduced an explicit long-term care insurance (2006), only eleven years later than Germany. Since then, we have read on many occasions how professional home care is emerging in countries where there is not a well-developed formal care system with for, instance, low-paid posted workers. Those services are needed and desired by the population and should be properly developed. Remarkable as well, is how quickly things are changing. Slovakia became member of the EU in 2004, but already in 2009 it introduced the Euro, only 10 years after the start of the Euro. Why should social development not catch up also?
It took twenty years of political debate before the explicit long-term care insurance was created in Germany, in 1995. Since then other countries followed (e.g. Luxembourg, Spain) while it other countries they are included in existing systems of healthcare and social care.
Of course one size does not fit all. But when I read the most recent overview of long-term care in Slovakia (Gerbery D. & Bednárik R., 2018) we can see that home care services are mentioned, residential care is mentioned, the care allowance for the informal care is mentioned and care budgets for a personal assistant exist. The complete list of entitlements that we call ‘representative’ for mature welfare states is in place. Of course the level of those entitlements, the number of users, the quality standards (initiatives have been announced) and working conditions can differ substantially. But Slovakia is, for the moment, a ‘young country’: only 14.7% of the population is older than 65. So the country has time to improve standards and expand the level of utilization of long-term care in the coming decades.
By doing so, it creates new jobs and further economic development in industries of the future, health and social care. And if more or the workforce can be kept working at home, a bigger workforce will be available. A relatively big part of Slovakians work abroad. The report of Gerbery & Bednárik mentions that already some 34,000 Slovakian women are working abroad in health and social assistance. Regaining and retaining this workforce by offering decent working conditions at home is the most important challenge. The 2017 report on EU Mobility confirms the relatively high number of healthcare (10,053) and social care (5,743) workers working abroad (E. Fries, a.o., 2018, p. 226). But the total number of persons at working age (20-64) that permanently moved abroad is estimated in that latest report at 189,000 persons (Ibidem, p. 170) , the majority to the Czech Republic, Austria and Germany. That number equals 7.5% of the number of persons employed in Slovakia. Furthermore, there are 156,000 frontier workers or 6.2% of the total number of persons at working age. On top of that comes the number of posted workers, estimated at 55,538 persons to one other member state and 19,471 to more than one member state. In total: 75,009 or 3% of the number of employed persons (De Wispelaere, Pacolet, 2017). Summing up: 16.6% of the workforce that could have been employed in Slovakia, are now benefiting from the free movement of workers within the EU.
On several occasions we invited Claude Rolin, MP in the European Parliament, to conferences on posting and mobility of workers and he reminded the audience that the ambition of the European economic integration was also to create jobs and economic progress in the new Member States of the EU, to contribute to the regional economic development. Job creation in the long-term care services can contribute to that. Further development of the welfare state is not part of the problem, it is part of the solution. That is why we are optimistic about the future development of long-term care and the fairy tale of social security.
The ‘Central European fairy tale of the ‘Three Grosschen fairy tale’ reveals the principle of solidarity that is included in social security of the Bismarck type, where the active contribute for the inactive. It insures against the risks of life, from ‘craddle to grave’. We call this fairy tale a ‘superior technical device of social insurance and solidarity’.
[Jozef Pacolet is Emeritus Professor with formal duties at HIVA/Catholic University of Leuven.]
- De Wispelaere F. & Pacolet J. (2017), Posting of workers, Report on A1 Portable Documents issued in 2016, European Commission, Network Statistics FMSSFE
- European Commission (2018), The 2018 Ageing Report. Economic and budgetary projections for the 28 EU Member States (2016-2070). European Economy Institutional Paer 079|2018.
- Fries-Tersch E., Tugran T., Rossi L., & Bradley H., (Second edition September 2018), 2017 annual report on intra-EU labour mobility, European Commission and Network Statistics FMSSFE
- Gerbery D. & Bednárik (2018), ESPN Thematic Report on challenges in long-term care – Slovakia. Brussels: European Commission – Directorate-General for Employment, Social Affairs and Inclusion.
- Pacolet, J. (ed.), (2015). L'état de l'état-providence dans l''UE anno 1992 et 20 ans plus tard. Revue Belge de Sécurité Sociale; 2015; Vol. 57; iss. 4; pp. 637 – 818
- Pacolet J. & De Wispelaere F. (2018), ESPN Thematic Report on challenges in long-term care – Belgium. Brussels: European Commission – Directorate-General for Employment, Social Affairs and Inclusion.
- Pacolet, J. De Wispelaere, F.(2015), The State of the Welfare State, Fifth Conference, Leuven, see: https://hiva.kuleuven.be/nl/onderzoek/thema/verzorgingsstaat/p/The-State-of-the-Welfare-State-in-EU-overview/Overviewanno1992)
- Radvanský M. (2015), State of welfare state in Slovakia, Slovak Academy of Sciences, paper presented on the fifth conference on ‚The State of the Welfare State‘, Leuven