German unification started 30 years ago with a peaceful, joyous night as East Germans crossed freely into the west for the first time in decades. But German unification is far from done. East Germans lag behind in many key economic and social outcomes. There are large and important health differences, for example, at older ages, when people need more care and when health care costs are more widespread and particularly large. The gaps in health outcomes between east and west are not surprising, given the different industrial histories between the two Germanys leading up to unification. The differences in long-term care provisions, though, reflect more recent and persistent gaps in economic opportunities across the newly unified Germany.
The German experience holds clear implications for the US. The population ages and needs more long-term support and services. Policymakers and advocacy organizations consider expanding long-term care insurance and paid family leave, but those are not enough to address unequal health needs and access to services as the German case shows.
An annual report for the health insurance company DAK, co-authored by the long-term care expert Professor Thomas Klie, illustrates stark differences in health outcomes among the population needing long-term care between East and West Germany. East German long-term care recipients are younger than those in the West. The average age of entrants into the long-term care system is 75 years or younger in the East, below the Germany-wide average of 77.3 years and also below the average entry age of 78.9 years in Bavaria, the highest of any German Land.
Not surprisingly, East Germans in long-term care also die much earlier than their counterparts in the west. On average, long-term care recipients in East Germany die before age 79 years and in Brandenburg, the state surrounding Berlin, they pass away before age 76. In comparison, West Germans in long-term care in Bavaria and Baden-Wuerttemberg in the south west die on average at 83.8 years. These differences reflect differences in life expectancies between East and West Germany as East Germans often die younger than West Germans.
The costs of those in long-term care vary in important ways between East and West Germany. For the years from 2014 to 2016, the average annual health insurance costs were 15,880 euro in Brandenburg, the highest average of any part of Germany, compared to a low of 11,485 in Bremen in the northwest.
These differences reflect greater health care needs of East German care recipients. Long-term care costs after all were on average lower than in the East than in the West. And care recipients in the East were also by and large more likely to need hospitalization than those in the west.
There exist two key differences between East and West Germany. People in East Germany suffer from more health issues, requiring more costly health care. At the same time, the long-term care responsibilities fall more on family members in the East, in part because of fewer care facilities, especially in more rural areas, and a lack of paid caregivers.
East Germany has seen tremendous improvements in health outcomes since the fall of the Wall. Yet East Germans, especially men, often still lag behind their western counterparts, for instance, with respect to heart disease, death from lung cancer and seeking out psychiatric treatments.
These differences in health outcomes reflect several factors, including the legacy of massive, industrial pollution prior to unification. In fact, air and water pollution were so severe, particularly in the mining and manufacturing southern part of East Germany, that they in part contributed to the opposition that ultimately brought down the East German government and the Wall. One of the biggest polluters was uranium mining in Thuringia and Saxony, which spread radioactive contamination in the surrounding communities.
I experienced this pollution firsthand. In early 1990 before unification, I worked in banking, establishing branch offices for a West German bank in Thuringia and Saxony. The air reeked of coal, billowing out of ubiquitous smoke stacks, East German cars and the chimneys of private residences. Local ponds near chemical factories shimmered an alluring yet unnatural silver. And many older miners already had to leave their jobs in uranium mining due to severe health issues. Anybody who visited the industrial southeastern part of the country right after the Wall fell could see the environmental hazard and imagine the long-term consequences that are now showing up in long-term care data.
Long-term care services also look different in the East. East Germans receive a lot more care from their family members than those in West Germany. For instance, 60.5% of care recipients receive care from family members in Mecklenburg-Vorpommern on the Baltic Sea. In comparison, only 38.7% of care recipients in Hamburg got help from their family members. Similarly, care recipients in East Germany tend to be more likely to receive home-based care services than is common in most areas in West Germany.
The reliance on families for long-term care in East Germany in part reflects the lack of paid caregivers. East German regions have lost populations as people have moved west. This population decline is expected to continue in the next two decades, worsening the caregiving shortage. And average pay in the East is below that of West German workers, making it harder to attract people into care professions.
The German East-West gaps in health outcomes and long-term care services hold important lessons for an aging U.S. society. Strong growth, low unemployment and widespread social insurance are not enough to even erase systematic differences over an entire generation. This is important to keep in mind. Long-term care insurance is gaining traction as Washington state just started its own program. Several presidential candidates have also started to focus on long-term care. For instance, Sen. Warren has proposed that health insurance will include long-term care benefits. And several Democratic contenders have proposed to expand paid family leave. And AARP has written model legislation to offer caregivers a tax credits. More support for family caregivers is a good first step. But the German experience shows that addressing the challenges of an aging population will also require more support for paid caregivers, more equitable access to health care providers in rural areas, among other considerations.