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2012 Conference Presentation

Markets/regulationPolicy Germany

6 September 2012

Disruptive institutional change and gradual transformation: long term care Insurance in Germany

Hildegard Theobald, University of Vechta, Germany
Sarah Hampel, University of Vechta, Germany


With the introduction of Long-term Care Insurance (LTCI) Germany fundamentally restructured its long-term approach related to eligibility criteria and benefits, mode of funding as well as care provision. In contrast, since the introduction of LTCI only gradual transformations of the policy scheme can be found.

The paper exemplarily examines both types of institutional change – radical change as well as gradual transformation – related to LTCI. The analysis reveals the interrelationship of the content of policy changes and processes of policy-development, i.e. the interplay of actors, ideas and interests embedded in a distinct institutional framework. The research was conducted as a part of a European project, which compared processes of policy development in selected European countries. Conceptually, it is based on a new-institutionalist approach on policy development. Empirically, it includes document analysis, representative statistics and a literature review.

The establishment of LTCI radically changed the institutional design of the prevalent residual, tax-based long-term care approach on the local level. However, despite the introduction of a national insurance scheme corresponding to German social policy tradition, the design of LTCI differed significantly from the insurance-based health care scheme. The empirical analysis reveals the significant role of two basic ideas and their combination – universalist coverage and cost containment – in the course of policy-making and finally their impact on the design of the policy scheme. The combination of both goals led to the construction of a new type of universalism, distinct principles of funding and the expansion of a market-oriented care infrastructure with considerable effects on care users, informal carers and care workers.

Since the introduction of LTCI, only small changes of the policy scheme can be found related to eligibility criteria and benefits, while gradual transformations of regulations aimed to promote the development of an efficient and high quality care infrastructure. The analysis contributes, first, to an understanding of the preconditions, process and effects of two types of policy change – radical institutional change and gradual transformation. Based on this, it reveals opportunities and difficulties related to policy changes, e.g. in particular the role of dominant ideas. Second, the analysis of the combination of two dominant ideas or goals in the course of the policy process – universalism and cost containment – shows their significant impact on the construction of policy design and in addition the (mainly negative) consequences for care users and care workers.


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