Social rights and employment rights related to family care: Family care regimes in Europe

Journal of Aging Studies 29 (2014) 66–77

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Social rights and employment rights related to family care: Family care regimes in Europe Patricia Frericks a,1, Per H. Jensen b,2, Birgit Pfau-Effinger a,⁎ a b

Hamburg University, Allende-Platz 1, 20146 Hamburg, Germany Centre for Comparative Welfare Studies, Aalborg University, Fibigerstraede 19220 Aalborg East, Denmark

a r t i c l e

i n f o

Article history: Received 1 June 2013 Received in revised form 28 October 2013 Accepted 5 December 2013 Available online 7 February 2014 Keywords: Family caregivers Welfare states Gender Social risks Care work

a b s t r a c t In early welfare states, social rights predominantly derived from formal employment relations. Within the past two decades, however, some European countries have opened these social institutions to care work also. Cash-for-care and social entitlements for periods of at-home family caregiving have changed the characteristics of informal care work that family members traditionally provide to older relatives. Formerly based on unpaid kinship relations, it has changed towards new paid and more formalized forms of care work by family members. But it can be assumed that long-term care work by family members is constructed differently across welfare states. The paper is guided by the following research question: How do welfare-state policies differ in the degree to which their policies towards family care for senior citizens create social risks for the caring family members? We use the conceptual framework of “family care regimes” as our analytical framework for the comparative research. To do this, we compare care policies towards older care-needy people in the welfare states of the Netherlands, Germany and Denmark. The findings show that a common feature in all three countries is that the situation of family carers is to some degree being formalized: in all three countries a frail senior citizen can chose a family member as the care provider, and the welfare states support the family care providers. Still, the legal situation as well as the quality and level of social rights for family caregivers differ considerably among the three countries. It is shown that the institutional framework for senior care by family members in Germany and the Netherlands represents a family care regime that supports semi-formal family care, and that in Denmark it can be classified as a family care regime that supports formal family care. We show that these different types of family care regimes differ considerably in the social risks they pose to family carers. © 2013 Elsevier Inc. All rights reserved.

Introduction The care of older people in need of care has changed substantially in post-industrial societies. This social phenomenon is partly accompanied by policy reforms rearranging ⁎ Corresponding author. Tel.: +49 40 42838 3810. E-mail addresses: [email protected] (P. Frericks), [email protected] (P.H. Jensen), pfau-effi[email protected] (B. Pfau-Effinger). 1 Tel.: +49 40 42838 2463. 2 Tel.: +45 99 40 81 70. 0890-4065/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jaging.2013.12.002

care provision, the rights of frail senior citizens to receive care, and the rights of family members when they provide care for their relatives in need. In this paper we analyze the latter aspect in a comparative manner to answer the question whether there are different family care regimes in Europe. In industrial society the care of older people was mainly provided by women and in a completely unpaid, informal way. In reaction to the “graying” of society and the increase in women's integration into the labor market, many countries have considerably expanded financial support and public provision in the field of care for senior citizens since the

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1990s (Kröger & Sipilä, 2005). European welfare states have supported the formalization of senior care so that today formally employed care workers provide this care to a considerable extent in many countries. Concurrently, new welfare-state policies have strengthened the role of economic principles and of “choice” in this policy field by introducing or strengthening care markets and cash-for-care systems (Bode, 2008; Da Roit & Le Bihan, 2011; Rostgaard, 2006; Rummery, 2009; Theobald, 2011, Ungerson & Yeandle, 2006; Vabø, 2006). As a consequence, long-term care has in part been formalized and recognized with pay and social security. While the welfare states of industrial societies had established social rights only in connection with social security for employed people, the welfare states of post-industrial society have also established social rights for, on the one hand, senior citizens to receive care, and on the other hand for family members to give care (see Knijn & Kremer, 1997).3 In concrete terms welfare states have, to very different degrees, started to support family members who provide care for their frail relatives, and introduced or extended social rights to caring family members by introducing pay for their care work, elements of social security and care leave options. Geissler and Pfau-Effinger (2005) have conceptualized this transformation of unpaid, informal care done by (mostly female) spouses or adult children of the frail senior adults, into forms of family care which are partly financially supported or provided with social rights by state programs, as a “semi-formalization” of family care. In this case, care work is legally regulated and formalized in this respect, without having the character of formal gainful employment. For example, no clear employer and employee roles and no employment contract are provided, but equally it is not declared as ‘self-employment’. ‘Formal’ care work is based on formal employment. ‘Informal’ care work, on the other hand, means that care work takes place in a family context, on the basis of family or other social networks or on the basis of informal employment contracts, without formal registration. The aim of this paper is to analyze the ways in which welfare-state policies towards long-term care are framing family care in a comparative perspective. The paper is guided by the following research question: How do welfare-state policies differ in the degree to which their policies towards family care for senior citizens create social risks for the caring family members? We use the conceptual framework of “family care regimes” as our analytical framework for the comparative research. With “family care regime” we mean the manner in which care policies of a welfare state frame the care work of caring family members (Pfau-Effinger, Jensen, & Och, 2011). We will show that the generosity of social rights and welfare-state support related to family care for senior relatives and the degree of formalization of family care differ substantially in the institutional designs of different European welfare states. We moreover show that the degree to which social risks are related to family care depends, firstly, on the degree of generosity of care policies, and secondly, on how social rights are orchestrated in the context of family care regimes. We take three countries for the analysis: the 3 In welfare-state research, the concept of “social rights” means the rights that individual social citizens are guaranteed by the welfare state; see Marshall (1964).

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Netherlands, Germany and Denmark. These three welfare states represent different welfare regime types. Denmark, in Esping-Andersen's welfare regime typology, is classified as a state-centered, social democratic welfare regime, whereas Germany is classified as conservative, family-centered welfare regime (Esping-Andersen, 1990). The place of the Netherlands in the welfare regime typology is highly contested: it is variously called hybrid, liberal, social–democratic or conservative depending on the particular author's analysis (Arts & Gelissen, 2002). In assessing cross-national differences in the situation of caring relatives, we start with the observation that several European welfare states have started to introduce a mixture of social rights and work-related rights into the legal framework of care work performed by family members for their senior relatives (Pfau-Effinger et al., 2011). Accordingly, we include into our analytical framework factors that include the degree of family members' legal rights in their care work with regard to the amount of pay, conditions on the eligibility for pay, protection against dismissal, and the level of social security rights with respect to unemployment, pensions, and sickness provisions. We moreover analyze the degree to which the legal framework of care by family members includes a right to take care leave from regular employment and the conditions connected with such leave. In a second step we explore how far social risks which may be caused by family care regimes include current and future income risks due to income insecurity, poverty and social security gaps. We also analyze whether family members have real options to give care or not. New welfare-state policies towards family care and social risks — state of the art Comparative research on the development of welfare-state policies towards long-term care for seniors has thus far rather neglected how new policies are framing family care for older people. For several decades and up to now, the informal and unpaid nature of care within the family has been a central subject of feminist theory and research (England, 2005; Orloff, 2009). However at the same time, the transformation of welfare-state policies towards family care and the consequences for the shift in the main features of family care have taken place nearly unnoticed. Typical for the discourse is that authors usually treat family care as a type of work that is unpaid and informal, and that family care contributes to women's marginalization on the labor market, in sharp contrast to the paid and formal nature of care that is provided in formal employment — which they see as the main road to gender equality. The main focus of research on welfare-state policies towards the care of senior citizens is therefore also on the “familializing”/“de-familizing” role of welfare-state policies on long-term senior care, that is, on the degree to which welfare states support the formalization of care for senior citizens (Esping-Andersen, 1999; Leitner, 2003; Lister, 1995). Most current research neglects the fact that the way in which welfare states are shaping family care has substantially changed its main features, in that several European welfare states have restructured the care of senior citizens performed by their relatives as legally paid and provided with elements of social security. As a consequence, there is very little research about how welfare states are legally framing family care of

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senior citizens, and the degree to which these policies create social risks to the family caregivers. Some researchers have analyzed policies towards family care in the context of cashfor-care systems, i.e. options that provide older people in need of care with money allowances to pay for it, potentially including family care (Da Roit & Le Bihan, 2011). That research, however, has focused on the concrete working conditions, or on the work–family balance of women caregivers. But welfare states are re-framing family care through different types of programs, not only cash-for-care. A systematic analysis of the ways welfare states are legally re-framing the care provided by family members is thus lacking. Ungerson (2004) has already conducted international comparative research into the ways the “commodification of care” has developed in European countries, and the type and funding of pay that family caregivers receive. She found that welfare regimes support the commodification of informal family care to different degrees, and that the funding regimes of the various welfare states differ in their labor–market impacts. She did not focus, however, on the ways in which care policies are framing family care as work. Family care was analyzed by Pfau-Effinger et al. (2011). They have analyzed how welfare state policies towards long-term care for senior citizens construct elder citizens as ‘care consumers’ who can select a specific type of care on the basis of ‘free choice’ on ‘care markets’, and how welfare state institutions construct family care in this context.

Social risks related to new forms of family care — state of the art In the industrial society of many European countries the working class was divided into male breadwinners and female housewives. Men were integrated into the factory system as “productive” workers; women were assigned to “reproductive” and care work in the household. Men in this context had the role of the “male breadwinners” responsible for providing an income not only for themselves, but also for their wives and children. The social risks to these male breadwinners centered on the interruption of earnings in old age, unemployment, work injury and sickness (Esping-Andersen, 1990). These risks were met by many welfare states with “social rights” offering wage-earners compensatory payments such as unemployment benefits in case of loss of income. Feminists have stressed that women as housewives differed from men with regard to their social risks. The main basis of women's specific risks was that their work in the private household was hidden and unpaid, while men's work in formal employment was visible and paid.4 Accordingly, social security for women as housewives was based on the social rights of their husbands and was related to their husband's employment income. Consequently, social risks resulting from their social position as housewives and informal caregivers were primarily related to the social risks of their husbands, and to the loss or lack of a male breadwinner in case of non-marriage, divorce or death of their spouses. Therefore these women were in a particularly dependent and risky situation compared to that of men. It is important to understand these particular social risks, in the “golden age” of

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For a summary see England, 2005; Fraser & Honneth, 2003.

the housewife marriage, as social risks that mainly resulted from the unrecognized and therefore unpaid nature of their housework and care of children and senior relatives. As part of the shift to a post-industrial society and in reaction to cultural change, women have on a massive scale entered the labor market. The family has developed into a two-income unit, and the modern lifestyle of families is usually based on two incomes. In addition, the unit for the accrual of social rights is shifting from the family to the individual, with social rights derived from individual labor–market participation in particular (Frericks, 2011). If a family member takes on the care of an older relative, this can cause substantial social risks, which Taylor-Gooby (2004) has characterized as “new social risks”. This is because care obligations towards family members may involve (part-time or fulltime) exit from the labor market, which in turn constitutes a potential loss in income and a decrease in social security entitlements, and which may threaten the welfare of the individual as well as that of the family (Ebbinghaus, 2005; Frericks, Maier, & De Graaf, 2006, 2008; Kohli & Rein, 1991; OECD, 2011). However, it is a contested issue whether these risks are really “new” for women. Reasons for taking on the care of a frail senior relative differ. It may be caused by a lack of older people's social rights to public or publicly financed care. It can also be based on cultural values, if family solidarity is a strong cultural value and people believe that family care is the “best” type of care (Eichler & Pfau-Effinger, 2009; Fersch & Jensen, 2011). However, if family members decide to care for their frail elderly relative, the level of generosity of welfare-state policies towards family care is crucial for the degree to which family carers are exposed to social risks. With the new care policies, the nature of the care work of family members has in part changed. Family care has partly been recognized as “work” by the institutions of the welfare state, and provided with pay and social security (Geissler & Pfau-Effinger, 2005; Pfau-Effinger, Jensen, & Flaquer, 2009). While in the past informal forms of family care brought substantial social risks, welfare policies promoting new, more formalized forms of family care might more or less reduce these risks. It is therefore an important question to what degree welfare states with differing designs of care policies have reduced social risks for family carers who provide care during the work week instead of working in formal employment or in addition to a part-time job. Since it is primarily women who have historically been continuously responsible for domestic care, their social risks are of major interest. Cross-national analyses of the ways welfare state institutions frame family care and social rights and of how they determine the level of social risks of caring relatives have until now hardly been attempted (Frericks, 2011; Pfau-Effinger, 2012). Varieties of family care regimes in the Netherlands, Germany and Denmark In this part we present a comparative analysis of the family care regimes in the welfare states of the Netherlands, Germany and Denmark. We analyze the legal framework regulating the care of senior citizens and how it shapes family care in this context. Then we explore the institutional framework for the family-based care of senior citizens. We understand family care as a specific type of work that relatives provide instead of or in

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combination with their own waged work in formal employment (Daly & Lewis, 2000; England, 2005; Ward-Griffin & Marshall, 2003). Accordingly, in our measurement of the particular social risks that may be caused for the family caregiver, we apply the theoretical concept of the “family care regimes” which is a conceptual framework for the comparative analysis of the institutional framework for senior citizen care provided by family members (Pfau-Effinger et al., 2011). This conceptual framework takes into consideration that many welfare states have linked work-related and social rights with the care performed by family members. Accordingly, we analyze the type of work contract and the contract partners that the law establishes for family carers. Then, we analyze the conditions of pay, social security and job-security for family carers. Finally, we identify the social risks the family carers might face resulting from the institutional framework of the different national family care regimes, both in the actual care situation as well as in the long run, including income levels, income risks and the degree of social security. German welfare-state policies towards the care of senior citizens; the family care regime in Germany Until the early 1990s, the care of older people in the then-existing West-German state, as well as in the former East-German state (despite its orientation to a dual-earner family model), was essentially organized as unpaid family care. Care in residential homes played a secondary role. With the “Long-Term Care Insurance Act” (SGB IX) implemented in 1995 and 1996, the German welfare state defined care for senior citizens as a task for the central state. The law established a new “social insurance” that finances a universal basic care provision for those in need of care on the basis of contributions from everyone in gainful employment. It also introduced new universal social rights: the right of senior citizens to receive a basic care provision from agencies or in residential care facilities free of charge, and the social right of caregiving family members to get pay and some elements of social security. A main goal of the law was to make it possible for old people in need of care to live a self-determined life in their own household. Currently, 67.3% of those in old age who receive care allowances in the context of the Long-Term Care Insurance live in their own homes (Statistisches Bundesamt, 2013). Welfare-state policies towards long-term care of seniors On the basis of SGB XI, senior citizens who live at home can avoid dependence on family care through opting for ambulant professional care. According to SGB XI, senior citizens have the right to receive care if they can prove that they have a physical need for it through illness or disability (Section 14 Abs. 1 SGB XI). On the basis of a qualificatory test, the degree of their care need is fixed. They can choose between various providers of care: service agencies run by local authorities or non-profit organizations, as well as commercial providers. They can also opt for care from family members such as spouses, partners, daughters and sons, or social networks, if these are willing to be their caregivers. All these types of care are paid for by the long-term care insurance. The degree of individual care need determines the amount of care hours per week. Payment – the “care allowance” – is made by the care insurance to the service

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agency if the care receiver has opted for care by an agency. The amount paid by the care insurance differs as to which of three “care levels” the person in need of care has been assigned, i.e. according to the extent of that person's requirements (SGB XI). If a family member provides the care however, the care allowance amount is considerably lower than that paid for comparable care from an agency. The care insurance does not pay for all the care that a senior citizen needs, but rather mainly only for physical care, at least on the lowest of the three care levels. The reason for this is that it is expected that the elderly themselves or a family member provides some or most of the household work. Altogether, it can be said that people who have senior relatives in need of care in a private household are more or less “freed” by the provisions of the law from performing the actual physical care, but are expected to do or organize some of the housework. The majority of senior citizens who live in private households and who receive care allowances receive their care however exclusively from family members, whereas care done by agencies, or the combination of both types of care, is less common (Statistisches Bundesamt, 2013).

The institutional framework of family care in the German welfare state Family care in Germany is based on the social right of any relative of a frail senior person (who must qualify for care on a health status test required by the German Care Insurance) to provide it. In this regard, it is a universal right in Germany to personally give family care. The amounts paid to family members for delivering care are legally fixed. They depend on the care level of the care recipient and range from €225 per month (care level 1) to €430 per month (care level 2) and up to €685 per month (care level 3). At each level the caring family members are expected to deliver care for a specific number of hours per week. The pay corresponds to 4 to 5 Euros per hour. The care relationship is based on a contract between the care insurance and the carer, which however regulates only the minimum number of hours the family member should give care in one of the three care-level categories mentioned above, the main tasks performed, and the standardized pay for this care. The allowance, however, is paid to the care recipient, and there is little control over whether he or she actually forwards the money to the caregiver. Family members who provide care for a relative at least 14 h per week in the framework of the Care Insurance Law (care level 2) have the option to build up pension rights in the public pension system for the time periods in which they provide long-term care. The contributions are paid by the care insurance. They are also covered by insurance against accidents at the workplace. They can pay voluntary contributions to the health insurance, which are however rather high in that case (except if they are married to a male breadwinner, since they are then already covered). They may also pay voluntary contributions to the unemployment insurance so that they are eligible for unemployment benefits after the family care has ended. However, the contribution amounts that people have to pay if they decide on voluntary health and unemployment insurance are so high that it

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would consume most of the pay they receive for giving the family care. Family members who care for senior relatives do not have any of the employment rights usually connected with an employment contract, such as protection against unfair dismissal. The care relationship can end at any time, for example when the care recipient moves into any kind of care-home, dies, or just decides on a different caregiver. Although the person in need of care is bound to the family care or agency care for at least six months, this does not mean that she or he is obliged to maintain the care relationship with a specific person during that time. Caregiving family members also have a right to four weeks' leave from the care situation in case they become sick, or for vacations, but they do not receive pay for this time off. During these four weeks, if taken, the Care Insurance pays for substitute care from another family member or from a care agency. The vacation time is reduced by one day for each day the caregiver is sick and cannot work. This means that only caring relatives who do not claim sick-time have the full right to four weeks' unpaid vacation. Independently of SGB XI, there are three different state programs for elderly care leave from regularly-held jobs. People who temporarily care for an older family member can take unpaid care leave from their employer. During this leave their job is protected; dismissal is not possible. The “Care Vacation” (Pflegefreistellung) was introduced 2008 and is a maximum of ten working days and can be paid leave if this is permitted by collective bargaining agreements. The “Care-Time” (Pflegezeit) was introduced 2008 and offers employees in firms of more than 15 employees the possibility to take leave for the care of a frail older relative for a period of six months. In 2012 the German Government introduced the “Family Care-Time” (Familienpflegezeit). It offers part-time leave for a maximum of two years on the basis of a 50% reduction of employment working time. During the part-time leave the employee receives 75% of their existing salary. After the employee returns to fulltime employment in her or his firm, their salary is reduced to 75% until the balance is paid off. Employed people who want to care for senior relatives can also reduce their usual working hours over a longer period (up to several years) in the context of the “Law on Part-time and Fixed-Term Employment” (Teilzeit- und Befristungsgesetz), if they have been employed by the firm for at least six months, if the employer does not object for economic reasons, and if the firm has more than 15 employees. Social risks related to family care work in the German family care regime Care in the context of SGB XI does not require a regular contract. It constitutes a relatively precarious, semi-formal form of care work paying hourly wages. The pay for the care is low, and even in case of full-time care, only slightly above the poverty line, and clearly below the level of pay in formal employment. Also, there is a relatively high degree of income insecurity, since the care relationship may end at any time. Time off for sickness or vacation is guaranteed for up to four weeks, but is unpaid. This means a high risk of income loss, particularly for those caring family members who may have given up or interrupted their regular job in the employment

system in order to provide the care. Family members who care regularly at Care Levels 2 and 3 make pension contributions. They can also be included in the health insurance and in the unemployment insurance if they pay voluntary contributions. However, these contributions are so high that it can be expected that most people who care for a family member do not take this option. Given that three out of four family carers are women it is highly likely that they are dependent on income support from a male breadwinner during the time in which they care for a senior family member and afterward if they are unemployed (Statistisches Bundesamt, 2013). The law therefore also contributes to the persistence of gender inequality. The fact that family carers can take leave from their regular jobs which are then formally protected for the period, hardly balances the related social risks. The way in which care policies in the German welfare state construct the care situation of family caregivers therefore creates particular social risks. How the care relationship is legally framed causes distinctly contradictory interests within the family, i.e. between the elderly person who receives the care and the “worker” who delivers it. The family caregiver is legally in a relatively weak and precarious position. However, compared with the traditional situation of informal care in the context of the housewife marriage, there is a clear reduction in social risks to family caregivers in that they have the right to care leave while their job is protected, they can receive some pay for the care, and are entitled to at least some pension rights. Dutch welfare-state policies towards care of senior citizens; the family care regime in the Netherlands In the Netherlands, publicly financed non-profit organizations have traditionally supplied care to senior citizens in need of care. Up to the 1990s much of the elderly care was delivered in residential care facilities. In addition, a great number of volunteers organized and supplied at-home care (Lyon, 2010). Welfare-state policies towards care for the frail elderly changed in 1995 when the so-called Personal Budget (Persoonsgebonden budget, PGB) was introduced. This measure entitles people in need of care to get a specific amount of money to “buy” the individually chosen type of care on “care markets”. In 1997, an option was introduced for frail older people in need of care (the “budget holders”) to pay also informal carers and family members by means of the Personal Budget, after being emphatically demanded by informal carers' organizations (Kremer, 2006). But the care-needy person has to contribute additional, individually calculated payments in amounts depending on family formation, income level and age (Rijksoverheid, 2013a,b). Welfare-state policies towards family care for senior citizens The Dutch welfare-state support for frail senior citizens comprises household support on the one hand, as indicated by the Law on Social Support (WMO), and physical care on the other hand, as indicated by the Law on Special Health Costs (AWBZ). For our analysis, public support for household tasks is practically irrelevant since most municipalities, which are responsible for implementing this law, do not allow budget holders to pay a family member for it (PGB,

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2012). The Law on Special Health Costs, institutionalized on the national level however, is crucial for understanding the framing of family care. A person who has been indicated as in need of a well-defined care supply can opt for a Personal Budget which is calculated to the care needs in terms of hours and kind. And although it has not been a legal right but rather a policy instrument, until 2010 requests were generally approved.5 We first outline how senior citizens in need of care can use the Personal Budget to pay a family caregiver and, secondly, what leave options employees have if they decide to care for an elderly relative, before we reflect on the social risks related to family care in the Netherlands. For two reasons, family members of senior relatives in need of care are not really “freed” from the duty to provide care in the Netherlands. Firstly, there is a structural lack of care homes and long waiting lists. Secondly, family members are expected to provide both some part of the household work and some of the physical care without remuneration. The majority of senior citizens who live in private households are cared for exclusively by a family member, whether they receive a Personal Budget or not (De Boer, Grootegoed, & Timmermans, 2010). The institutional framework of family care in the Dutch welfare state A family caregiver can have one of two different types of contract with the relative for whom she or he cares: the “Care-Agreement” (zorgovereenkomsten or overeenkomst van opdracht) or the “Employment-Agreement” (arbeidsovereenkomst). Neither of these were originally designed for contracting family members; consequently they involve many obstacles to doing so. The “Care-Agreement” (zorgovereenkomsten or overeenkomst van opdracht) The policy instrument of the Personal Budget imposes several thresholds on a family member to be formally engaged as a carer of a senior citizen relative. If budget holders want to pay their caring relative for their care work, they have to prove that the amount of care they will receive from the family member is more than the care that family members already provide “on average” (SVB, 2012). This means that caring relatives are expected to supply a list of care tasks they already perform without pay. These care tasks are listed (in the protocol gebruikelijke zorg) and include all forms of personal hygiene (washing, toothbrushing), dressing, helping with eating and drinking and going to the toilet (De Boer et al., 2010; Sociale Zekerheid, 2012). The consequence of this is that family members can be paid for only a small part of their factually delivered care (in fact, the care allowance is given for only 5% of all informal care), and the amount of pay from personal budgets can only in very limited cases (e.g. very intensive care situations) compensate for the carer's income losses (De Boer et al., 2010; Decruynaere, 2010). In addition, 5 Recent policy reforms, although partly undone after a government change in 2012, will change caring family members' rights since Personal Budgets will be conceded only to a tremendously restricted number of people with the highest level of care need, see MinVWS (2011); SVB (2012).

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the policy measures differentiate between family members of the first degree (spouses, parents and children) and second degree (siblings, grandchildren and grandparents), as well as between family carers who live in the same household as the cared-for person and those who do not live in the household. By law only the first category of family carers is allowed to sign the Care-Agreement, by which is specified the care task and the pay for it; this implies extremely limited legal rights connected with their care work. The fact that the budget holder can get an allowance of only €250 per year for the informal carer (mantelzorgcompliment) clearly indicates that the law treats the informal care as a largely voluntary and morally motivated activity. Since the frail senior citizen entitled to a Personal Budget can offer the Care-Agreement only to the most closely related family members, but a better agreement (Employment-Agreement) to other family members, it is evident that not all family carers have the same access to public support. In the case of spouses or adult children caring for an elderly spouse/parent, the pay and social security are subjects to individual negotiation between the family member and the care recipient (PGB, 2012). In this type of contract the caregiver is conceptualized as a free-lancer, and the relationship between the care recipient and the carer is that of a client and a supplier. Accordingly, there is no fixed pay for these caring family members. Instead, the parties are free to agree on any kind of payment (Lundsgaard, 2006). Studies show that women, in the context of familial negotiations, have a rather weak bargaining position (Grootegoed, Knijn, & Da Roit, 2010). The Employment-Agreement (arbeidsovereenkomst) If the family care by contrast is based on the EmploymentAgreement between the care recipient and the family carer (possible only with non-cohabiting persons or more distant relatives), the pay and social rights accruing to the family caregiver are more generous than in the case of a CareAgreement: First of all, family caregivers younger than 65 have a right to the minimum wage for their care work. Also, the employer, i.e. the budget holder, has to guarantee the caring family member all social rights, including pay in case of sickness, health insurance, unemployment insurance and pension funds. This means that the law in this case creates an employment relationship which is similar to formal employment. While their pay and social rights in this case resemble those of formal employment, the employment rights of the family caregiver are very limited. Since the budget holder is the client or employer, and can at any time end the agreement, the family caregiver is not protected against dismissal. In addition, and in accordance with the above-mentioned regulation that the care recipient need only pays for the factual hours of care supplied, carers lose their care allowance on the day the care relationship ends. Thus the care relationship in the form of the Employment-Agreement is institutionally framed in a way disadvantageous to family carers of older relatives. The social rights of family caregivers in the context of the Personal Budget differ with the type of contract that the care-needy senior, as the budget holder, can or wants to offer the caregiver. The different agreements result in divergent levels of social security rights in terms of unemployment,

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pensions, occupational disability and sickness. Closer family members or those who cohabit with the relative for whom they care do not have the option of the EmploymentAgreement. Therefore these groups are confronted with very low levels of pay and social security and do not have medical insurance. If the caring relative gets sick, the budget holder does not need to pay him or her during illness, nor does the SVB (the social insurance funds) have to cover their loss of income during illness. The SVB pays during illness only those carers who have an Employment-Agreement (SVB, 2012). Close and cohabiting family members also do not have – differently from more distant caring relatives – any right to payment during vacation (or vacation allowance), and the seniors receiving care need not pay social insurance contributions for them (PGB, 2012). Basic pensions are related to residency and are therefore not affected. However, additional pension contributions – exempted here – are essential to building up sufficient pension rights for old age (Frericks, 2011). Finally, it should also be underscored that entitlement to the PGB in general is not guaranteed, since the amount of social expenditure in this field is subject to short-term government budget decisions. In fact, difficulties in the national finances allowed no new Personal Budgets to be claimed during the second half of 2010, and conditions for getting them have been made even more restrictive since then (Rijksoverheid, 2013a). Apart from Personal Budget-based care, there are options for relatives' taking paid leave from employment with job security,6 but these are restricted to some few days in case of emergency, up to some weeks in case of care leave. Unpaid leave options exist for longer leave periods. One can purchase, with some tax privilege, additional leave time (IKAP-regeling). In addition, the law allows employees to reduce their working hours without financial compensation as long as this does not put the firm into difficulties (Wet aanpassing arbeidsduur). An exception is the regulation for civil servants, who after a minimum of 5 years continuous employment, and from the age of 57, may reduce working hours without much loss to their gross income (Pasregeling). Unpaid leave is an option for family members to care for a relative if they have contributed to a “Life Course Savings Scheme” (LCSS, levensloopregeling7). This opportunity was introduced in 2006 and allows employees to put aside some of their gross income for (unpaid) periods of leave (Maier, De Graaf, & Frericks, 2007). In that case the leave is financed by the saved wages and is not supported by public means. This regulation is the most comprehensive for long-term care since one can take up to two years of leave.

Social risks to caring relatives resulting from care work Altogether in the Dutch welfare state, family caregiving perpetuates substantial social risks. These are different for close family members (spouses and children) and other family members, and for co-habiting and non-cohabiting family members. 6

For an overview, see EC-HRM (2011). It will be replaced by the Vitality Scheme (Vitaliteitsregeling) as of 2014, which in terms of care leave is comparable to the LCSS. 7

First and above all, caring family members face different forms of income risks. The actual income earned during care periods is insecure and may end at any time. In addition, the income levels are low. Although the Personal Budget does not pay very much below that which older people would have to spend for long-term care performed by an agency, caring relatives might be paid much less than carers earn in formal employment in a service agency, and they have to do many care tasks without pay. In addition, family carers who are close relatives or live together with the relative for whom they care usually do not have any right to social security. Income risks also concern future income since people who care for older frail family members (mantelzorgers) face a variety of employment risks. These result from the reduction in working time in their formal employment (Mantelzorgwijziger, 2011; Rademakers & Van den Wijngaart, 2005). Job protection for a longer period (up to two years) is only given if leave is taken within the policy instrument of the Life-Course Savings Scheme (LCSS), which is however unfavorable to women. The main providers of care to older relatives (whether paid from a PGB allowance or not) are however women (De Boer et al., 2010). For them, “a prolonged period of leave can lead to subsequent unemployment as the person's skills or human capital may gradually deteriorate” (Kremer, 2006; Lundsgaard, 2006; Lyon, 2010). Caring relatives also have to face lower social security entitlements (e.g. sickness, unemployment, pensions and other periods of non-labor–market activity) and their social rights are reduced in comparison to those in formal employment. This is particularly the case for spouses and children who act as family carers, and carers who cohabit with seniors getting the care. In addition, the caregiving relative's situation hardly profits from even newer policy instruments such as the Life-Course Savings Scheme (LCSS, see Frericks, 2011; Maier et al., 2007). When leave is taken within LCSS, the financial situation of caregiving relatives is indeed better than it would have been in previous times: Employees can save part of their income for later periods of leave, including care leave. With this option they have the legal right to “buy themselves out of work” for up to two years without losing their job. A main shortcoming, however, is that this regulation requires wage-related saving and is, thereby, gendered. Gender gaps in wages, the quality of employment contracts (and the employer's contribution), employment level and working hours make it much more difficult for women (and rather impossible for those who are actual carers) to save for leave, all of which is well documented in the Netherlands. And those women who either reduce their work time (and thereby their wages) in order to supply care, or who take the leave for purposes of caregiving that they had “saved” within the Life-Course Savings Scheme, are then not able to afford the more “luxury” social rights which are possible with the LCSS, such as early retirement, leave for leisure or further education. This is due to the “amalgamation of social protection” in the Dutch welfare state (Frericks, 2011): all the various kinds of leave are regulated within one program, and apart from childcare (which is publicly supported) no difference is made as to the reason for leave-taking. In addition, to live on less than 100% of wages as a means to increase the period of leave is hardly possible for those on lower incomes, as from part-time work.

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Denmark's policies towards senior-citizen care; its family care regime The Danish public sector has a deep historic involvement in elder care. The creation of the first public residential care facilities began in the 1920s. These were supplemented in 1958 with the offer of at-home care, and elderly care in general has been a universal right in Denmark since 1968. Anyone with a need for care has the right to state help that is comprehensive and free of charge (Nielsen & Andersen, 2006; Szebehely, 2005). The massive involvement of the welfare state in elderly care has meant that family members are so to speak “freed” from the necessity to care for their senior family members if these are in need of care. However, reform initiatives in 2002 made free choice the key organizing principle in this area of welfare (Fersch & Jensen, 2011; Rostgaard, 2006). Seniors requiring care can now choose between three types of provider: public providers, private providers (primarily private, for-profit businesses), or allowing a relative, neighbor or friend/acquaintance to assume responsibility for their care. Welfare-state policy towards the care of senior citizens Publicly operated and financed formal forms of care have become predominant in Denmark, and care is a universal social right (Andersen & Jensen, 2011). The operational, financial and administrative responsibility for the care of the elderly lies with the relatively autonomous municipalities, which have extensive authority to define the level of municipal services (quality and coverage) (Nielsen & Andersen, 2006). The care services offered by the municipality are in the form of residential care facilities or else assistance in the recipient's own home (at-home care). At-home care is provided in the form of personal assistance, care and help with practical tasks in the home, such as cleaning, shopping etc. As operationally responsible, the municipality runs residential homes and nursing homes, and provides professional care staff and practical help in the senior citizens' own homes (Fersch & Jensen, 2011). Care performed by family members is an option, but nobody is forced to opt for family care. If no one is able or willing to provide the care that an elder relative requires, the municipality is obligated to step in. The institutional framework of family care in the Danish welfare state The Social Service Act (SSA) allows a person who has been granted publicly-funded home care to choose a person to provide this help, e.g. a relative, neighbor or friend/acquaintance. Those opting for this must further choose between three alternatives: First, “ordinary” home help, when the municipality functions as employer (SSA article 94a); second, “ordinary” home help, when the elderly person functions as employer (SSA article 94b), and third, “extraordinary” home help, i.e. at-home help targeted at elderly citizens with significant and permanent reduced physical and mental capabilities (SSA articles 95–96). In practice, the SSA articles 95–96 are the alternative to comprehensive care in residential facilities. In all three options, a written employment contract ensures details such as the payment arrangement, work to be carried out, working hours and work conditions. Wage

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levels are determined on the basis of collective agreements between the FOA (The Care and Service Union — Fag og Arbejde) and the association of municipalities — “Local Government Denmark”. An hourly wage amounts to about €17, while weekly work hours are given by the magnitude of help the elderly person is entitled to receive. If the senior citizen is granted four hours of help per week by the municipality, the weekly working hours will thus be four hours per week. As an employee, the caregiver is entitled to all social rights (e.g. access to health insurance, unemployment benefits, sick pay, vacations, pension and work accident coverage). The caregiver is also covered by the ordinary rules for the termination of employment. In the event of the death of the senior citizen, the caregiver must be offered work elsewhere for the same number of hours per week until the contract terminates. Although an elderly person eligible for assistance or support is entitled to appoint a person to carry out the home help work, this person, i.e. the caregiver, does not have an unconditional right to reduce working hours at their ordinary employer in order to care for the elderly relative.8 In such cases the caregiver may be forced to work double, carrying out the home help in addition to ordinary employment. People past retirement age (65 or older), however, can be employed as caregivers under the same conditions as those under age 65. Section 94a stipulates that a senior citizen entitled to home help has the right to choose a person who is subsequently employed by the municipality. This means that the caregiver becomes a public employee. As employer, the municipalities assume all relevant responsibilities with regard to the delivery of care. The municipality must ensure that the person in question is capable of providing the help that has been granted funding. If necessary the municipality can require the caregiver to participate in courses or training. If the caregiver becomes sick or goes on vacation, for instance, the municipality is responsible for finding a substitute caregiver. As employer the municipality also makes sure that the home of the care receiver complies with work environment laws etc.9 Sections 95–96 are referred to as “citizen-regulated personal assistance” (Borgerstyret Personlig Assistance). It is an unconditional legal entitlement for seniors to employ care if they are granted funding for more than 20 h of weekly home care. If the care granted is less than 20 h per week, the individual municipality is not obligated to pay the citizenregulated personal assistance, but often does so, especially in cases in which the senior in question requires special assistance. Under this option the senior citizen functions as employer. Not only are the care recipients allowed to choose whom they want to provide them help, but are also free to make the agreement with the employee as to when and how the help is to be provided.10 The municipality sets the amount that the senior citizen can receive under the presumption that the caregiver will be paid in line with collective wage 8

Such a right only becomes relevant when a close relative is dying. According to Section 94b, the municipality can, if this is the wish of the care receiver, transfer the role as employer to the senior citizen. “Local Government Denmark” is opposed to Section 94b, and as this option is not compulsory, very few municipalities actually make use of it. 10 The following review of Section 94 builds on the following sources: Socialministeriet, 2011a, b; Andersen & Jensen, 2011; Aalborg Kommune 2011a, b. 9

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agreements. Documentation of the payment of wages is provided to the municipality, and unused funding for wages is returned to the municipality. To support the capacity of the senior citizen as employer, the municipality is responsible for continuously providing information to the senior citizen about employment law issues, including rules about working environment, vacation, sick pay and maternity leave. The senior's home is regarded as the workplace, and the senior citizen must therefore comply with work environment laws. The senior citizen can face penalties if it is found that the work is not taking place in compliance with them. As an employer, the senior citizen must also pay contributions to a work-related pension fund, vacation pay and other obligatory social insurances such as worker's compensation. In short, the senior citizen as the employer is responsible for ensuring that the caregiver enjoys the same working conditions and social rights as they would in ordinary jobs.11 Even though the care performed by family members has thus the status of a formal employment relationship with all the rights of standard employment, relatively few people in Denmark exercise the family care option. In the City of Aalborg, for example, where 8463 persons receive home care, there are only around 60–65 persons who make use of this opportunity to provide care for their frail senior relatives. A disproportionate share of this number are ethnic minorities, that is, persons presumably subscribing to more traditional family values than is the norm in Danish society.

Social risks resulting from the care work of family members Family care in Denmark in the context of the Social Services Act resembles waged work as we know it from the ordinary labor market. Still, care work provided by family members remains associated with some social risks, even if these are clearly less serious in the Danish family care regime than in the family care regimes of Germany and the Netherlands. Being a family caregiver is usually a part-time job, and mainly women are inclined to enter into a care employment relationship in order to care for a family member. On average, the work load in a family care employment relationship is about 3.7 h per week. If a fulltime working woman does not want to give up her career but nonetheless wishes to enter into a care–employment relationship, she must choose between two options: either work overtime, or reduce her ordinary working time by the amount of the care-work load. This might result in some income loss and reductions in social rights, especially for women earning high wages, as caregiving is relatively poorly paid work. Reducing one's working hours from fulltime to part-time work requires the consent of one's employer. Thus, if family caregivers are unwilling to work overtime or unable to reduce their working hours with their present employer, two options remain: take a new part-time job compatible with 11 These employer responsibilities, however, can be transferred to a relative, an association or a private business. In such cases, cash does not change hands between the care–receiver and caregiver, but rather between the caregiver and the municipality or between the municipality and the business or association that the senior citizen has employed as supervisor/ employer.

family care, or give up working on the “ordinary” labor market and engage only in caregiving work, which could result in a dramatic loss of income and social security rights, an option thus particularly risky to women. Though the Danish welfare-state policies provide rather generous support for care undertaken by family members, family care remains uncommon. Ethnic Danes are more likely to opt for the regular labor market rather than for caring for their elderly relatives. Currently, ethnic minorities are pretty much the only people exercising the options made available by the institutional framework. Conclusion The aim of this paper is to shed light on the way welfare states institutionally frame the working conditions and social security for family caregivers and to analyze the social risks related to this framework in the contemporary welfare states Netherlands, Germany and Denmark. A common feature in all three countries is that the situation of family carers is to some degree being formalized: in all three countries a frail senior citizen can chose a family member as the care provider, and the welfare states support the family care providers. Still, the legal situation as well as the quality and level of social citizenship for family caregivers all differ considerably among the three countries. They therefore represent three different family care regimes. The Danish family care regime builds on a high degree of formalization of care for the frail relative. The family care situation can be characterized as a formal work situation based on a normal employment contract and comprehensive legal regulation. The care work is paid in accordance with collective agreements; i.e. family care wages are equivalent to those of a “standard employment relationship”. Also, caregiver relatives have the same social security and employment rights as people who are formally employed — social security benefits, health care, pension, sick-leave, and paid vacation. The German and the Dutch family care regimes are based on semi-formal care work performed by family members. Those who care for frail older relatives can under certain circumstances get pay and some elements of social security for the work. In Germany this is based on a social right to give family care, to which is entitled any relative of a frail older person who qualifies for it after criteria of the German Care Insurance. In this sense there is a universal right in Germany to give family care. Also, the concrete amount of pay for care is fixed by state law. Moreover, family caregivers have the right to long-term care leave, considered to be part-time employment, for up to several years. However, the level of pay is clearly below that of standard employment in Germany. Also, only some groups of family carers are eligible for pension entitlements, and the inclusion in health and unemployment insurance is only possible on the basis of high voluntary contributions, or, in the case of health insurance, within the framework of the traditional male breadwinner relationship. In the Netherlands, family members' social rights to give care are very limited. Paid leave from employment and related job security are restricted to very short periods of several days. Family members can take unpaid leave to care for a relative if they have contributed to the “Life Course Savings Scheme” (soon to be replaced by the “Vitality Scheme”). In that case, the

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leave is financed by saved wages; it is not publicly funded. Since 1997 it has been possible to pay a family member from the so-called Personal Budget that the frail elderly may receive in case of care indication. However, the different types of prescribed contracts with family members mean that there is no uniform individual social right to publicly defined support for family care work. The pay is therefore subject to individual negotiation within the family. The legal differentiation between different groups of family carers is accompanied by particularly low levels of pay and social rights, but high levels of care obligation for close family members and those who live in the same household as the care recipient. To care for an elder relative is not an unconditional right unless family members engaged in waged work in formal employment have the right to leave their job for elderly care purposes. Paradoxically, in Denmark, where female employment rates are very high, the formal provision for leave for elderly care does not exist at all in the employment system, so the probability of actually making use of the family care options is perhaps slight. Leave from a job there is a matter of negotiation with the employer if the family carers are regularly employed, whereas such rights do exist in Germany and to a very limited degree also in the Netherlands. Also the institutionally constructed relationship between the elderly person in need of care and the family carer differs markedly among the three countries. In the Dutch and German welfare states, the elderly person in need of care has the role of an employer or purchaser who largely defines the work situation of the caregiver. This leads to a strong and problematic dependency of the caregiver on the care recipient in the care relationship. In Denmark, the care recipient and the family carer are embedded in different systems. The municipality is the employer of the family carer and pays this person for the family care on the basis of a formal contract. It is thus the municipality which regulates the working conditions of the caregiver. The care recipient receives the family's care if she or he chooses, but this does not create any direct employer– employee relationship between them. The situation is different in Germany, where the law creates an employer–employee relationship between the care recipient and the family carer, though the working conditions, pay and social security are fixed by law. In the Netherlands the institutional framing of family care creates two different relationships between the cared-for person and the family carer, in that the closest family members like the spouses or children of the care recipient, or other relatives who live in the same household with him or her, have a relationship dependent on the good will of the cared-for person. Other relatives have a kind of employer–employee relationship with the care recipient. What are the consequences in terms of social risks connected with family care in the three welfare states? Table 1 summarizes the wage and work conditions in the family care regimes of the Netherlands, Germany and Denmark such as the duration and amount of pay as well as conditions of eligibility for pay; the level of social security rights of caring persons related to unemployment, pensions and sickness; the existence of a right to leave regular employment; and the conditions connected with taking care leave. As can be seen, the German and the Dutch welfare state support a semi-formal form of family care, while the Danish welfare state supports a formal form of family care. In addition, the degree of generosity

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is high in the Danish family care regime, moderate in the German family care regime and low in the family care regime of the Netherlands in terms of income and income security, as well as the degree of social security related to family care. As a consequence, new social risks connected with family care are relatively low in Denmark, moderate in Germany, and high in the Netherlands. Social risks in relation to the caregiving of family members for their older relatives are low in Denmark primarily because the income risks during care periods and afterwards are much lower than in the other two countries. While the weekly work hours in the care relationship are relatively few, it is in principle possible to combine formal labor–market participation and paid care work in Denmark, while in the other two countries the combination of formal and semi-formal work is much less supported by the care regime, so that part-time employment, interruption or early exit due to elderly care is very common among Dutch and German relatives. In Germany these social risks are moderate. On the one hand, there is a universal social right to care for senior family members in need of care if these qualify on the test of the long-term care insurance. Also, caring family members have the right to receive a fixed amount of pay from the care insurance, varying with the amount of care they are expected to give. On the other hand, Germany is also characterized by problematic regulations for caring relatives. The pay is clearly below level of standard employment and so are social rights. The German state provides social (pension) rights only for caring family members with higher amounts of care hours. In the Netherlands the social risks to caring family members are still more pronounced than Germany's, in part because caring relatives do not get any pay if they are spouses or children of the care recipient. The closest family caregivers are expected to carry out a considerable amount of care tasks free of charge — care supplied by those relatives is not comprehended in terms of work but as moral obligation within kinship relations. Also, social risks for caring relatives are high because they only get access to some social rights via the “employer”, i.e. the “budget holder”, and not via the state as in the other two countries because – different to Denmark and Germany – regulations in the Netherlands distinguish between cohabiting/closest relatives and more distant family caregivers. Also, as women are the primary family carers in the Netherlands, they must often reduce, interrupt or stop working to be able to supply care for an elderly family member in need. The Dutch and German family care regimes tend to maintain gender inequalities and thereby gendered social risks. This has special bearing on the Netherlands, where the LCSS is less advantageous for women than for men (and the future Vitality Scheme will not reduce these disadvantages). The gender inequality issue is less pronounced in Denmark where new social risks are also low. It should also be considered that social risks to caregiving family members are probably greater when they have little or no choice in caring personally for a senior relative in need of it. In Denmark, the public supply of care for older people and the related social rights are comprehensive and generous, so that family members are free to decide or not to care themselves for a frail senior relative. This is somewhat different in Germany, where publicly paid care for senior citizens is more or less restricted to direct physical care, and household work is mostly

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Table 1 Differences in family care regimes and social risks.

Forms of family care which are mainly supported by welfare state programs Degree of generosity of welfare state policies towards family care Duration and amount of pay for family care, and conditions of eligibility for pay Level of social security rights of the caring relative Caring relative's right to leave regular employment or reduce working time, and job protection Legal rights of caring relatives within the care relationship (e.g. protection against dismissal, etc.) Family members' option to decide against personally caring for a senior relative Degree of social risk associated with family care Current income risks due to low pay and incomplete social security Future income risks from loss of employed status and related loss or reduction of social security entitlements

German welfare state

Dutch welfare state

Danish welfare state

Semi-formal care work by family carer

Semi-formal care work by family carer

Medium

Low

Formal care employment of family carer High

Medium but clearly below level of standard employment

Low for close or cohabiting family members, medium (up to minimum wage) for other relatives Low for close or cohabiting family members, medium for other relatives

High, i.e. based on standard employment

Low (medium in case of participation in the LCSS)

Low

Low

Low

High

Low

Medium

High

Medium

Low

High

Low (up to minimum level of employment) High (medium)

Medium

High (medium)

Low

Medium, with right to pension insurance, but below level of standard employment High

not included, so that family members are expected to provide for free at least some additional care-related work. In the Netherlands, there is a structural lack of care homes and family members are expected to provide most care without remuneration. Seniors in need of care can buy it from agencies on the market if entitled to a Personal Budget (PGB). However, the share of the care that they can purchase is legally limited since the state expects family members to provide a substantial part of the needed care. Therefore policies only to a relatively low degree offer people the option to be “freed” from the responsibility of family senior care. Consequently among the three countries the social risks are highest in the Netherlands not only because social security and employment conditions there for family-based care are the worst, but also because of the practical lack of an option for families to decide against family caregiving. In contrast, social risks are lowest in Denmark because family care is organized on the basis of the working conditions and social security standards of formal employment, and anyone also has the real option to choose not to care personally for a senior relative. Before pointing to Denmark's as the path to follow, however, it should be noted that care leave there is not a social right, which is probably one major reason why so few people in that country make use of their option to provide care personally at home. References Aalborg Kommune (2011a). Ansættelsesvilkår for udpegede hjælpere ansat efter servicelovens § 94. Aalborg. Aalborg Kommune (2011b). Brugerhåndbog for BPA ordninger efter servicelovens § 95. Aalborg. Andersen, J. G., & Jensen, P. H. (2011). Ældreudfordringen: tilbagetrækning, pensioner og ældrepleje. In I. H. Møller, & J. E. Larsen (Eds.), SocialpolitikKøbenhavn: Hans Reitzels Forlag.

High, at level of standard employment

Low

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