Nursing reform | Well-entrenched injustice

A seniors' residence makes many things possible, including indoor animal-assisted therapies, like here in Bückeburg. Photo: dpa/Boris Roessler The federal government says savings must be made on care and it must be set up differently, i.e. less expensively. The main reason given for savings is the increasing proportion of older people in the population and therefore those in need of care at some point - and the corresponding decreasing proportion of those who pay into the nursing care fund. But vagueness and overly “generous” rules for support services should also disappear.

However, the first step of a corresponding reform, which has now been passed as a cabinet decision, only applies to the social nursing care insurance (SPV), in which 89 percent of the population is insured, in absolute numbers that is 74.6 million people. In addition, private nursing care insurance (PPV) exists somewhat in the slipstream of attention. The remaining ten percent are insured against the ailments of old age, i.e. up to 9.2 million people, characterized, among other things, by significantly higher incomes.

A balance between private and social care insurance is difficult - if you don't want it politically.

Also similar to health insurance, the “better risks” can also be found in private nursing care insurance: This means that the rate of those in need of care here was 4.5 percent in 2024, while for SPV it was 8.1 percent. According to experts, the difference is permanent and structural, which in turn suggests a risk-structural balance. This would also be justified because those with private insurance make use of structures that are financed at the expense of the vast majority, such as training and wage increases for employees.

There are currently only a few legal mechanisms that lead to payments from the PPV into the overall system. The first seems self-evident, namely that contributions are paid to the statutory pension and unemployment insurance for nursing staff, even for those in need of care who are privately insured. The PPV also contributes to funding for advisory structures or model projects for all insured people.

However, actual compensation is a difficult task, similar to the dual health insurance system. Chancellor Friedrich Merz (CDU) himself somewhat carelessly called out the imbalance between the two systems and, because it was perceived as unfair, announced something like changes, or at least that the issue would be addressed, at least for care. The Nursing Structural Commission is now supposed to complete this in just under four months by the end of January.

Risk-structural compensation is also the main option discussed for accessing private individuals' reserves. A simulation from the private sector Iges Institute for a step-by-step approach in such a case dates back to 2024. A carryover of 250 million euros was planned for the first year, at that time a maximum of one sixth of the PPV's contributory income. The value could rise to up to two billion euros annually over the course of a few years.

A second possibility could be that insured persons who switch from the PPV to the SPV take part of their retirement provisions with them in the future. The Federal Ministry of Labor had calculated a possible annual amount of 500 million euros for this because there is a lot of movement in this direction.

There have been calls for compensation for a long time, including from former Federal Health Minister Karl Lauterbach (SPD) and the German Patient Protection Foundation. Nevertheless, the hurdles are high. There are already reports that assess access to private funding as an inadmissible interference with the fundamental right to property and the principle of the protection of legitimate expectations. In addition, a financial equalization, as described above, could be classified as a special levy without adequate consideration - and would therefore fail before the Constitutional Court.

It should also be taken into account that private companies would be deprived of a central business area (namely the legally required basic coverage for those with private health insurance in the care sector) and thus professional freedom would be restricted, just as property protection is anchored in the Basic Law. In both cases this means that the intervention must be proportionate and serve the common good. However, expropriations are common practice in this country, namely as part of infrastructure projects. In addition to the overriding public interest, there needs to be a formal law, proportionality and adequate compensation.

However, it is only logical that the private health insurance association rejects any financial compensation and classifies it as unconstitutional and has also announced that it will go to the Federal Constitutional Court. Of course, this would particularly apply to the most radical solution to system stabilization: the merger of both systems into a solidarity-based employment or citizens' insurance. This has been demanded for years by parts of the SPD, social associations and trade unions, among others. The capital of the PPV would have to be transferred to a community fund in a legally secure manner; that would be one of the challenges. But here too, expensive “compensation” for the virtually expropriated PPV would probably be difficult to avoid.

It seems obvious that Merz was already aware that financial compensation is difficult or impossible - if you don't want it politically. Then the Union could only raise its shoulders in regret at Easter, when the cabinet decision for the second part of the reform is to be presented: “Our system” simply does not allow that. Unless the federal government sets up a special care and health fund.

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