Health ministry · Long-term care
Nursing and long-term care: a system under strain
More people need care, fewer people of working age can provide it, and the insurance that pays for it is running deficits. Carsten Linnemann has warned that without fundamental reform the system will collapse in the 2030s. His first major bill, adopted by the cabinet on 30 September 2026, is meant to buy time for that reform.
- Benefit recipients (SPV)
- 6.01m · end 2025 (BMG)
- People in need of care
- 5.7m · Dec 2023 (Destatis)
- Contribution rate
- 3.6% · childless 4.2% (2026)
- SPV balance 2025
- −€0.49bn (BMG)
- Care reform (PNOG)
- Cabinet bill, 30 Sep 2026
Who needs care, and where
Two official counts, measured differently: Destatis counts people in need of care; the BMG counts recipients of insurance benefits.
Cared for at home, by relatives, home care services or both · December 2023 · Destatis, Pflegestatistik
Women among the 5.7 million people in need of care · December 2023 · Destatis, Pflegestatistik
Share of all health expenditure spent on nursing and care services (€135.9bn) · 2024 · Destatis
Benefit recipients of social long-term care insurance
SourceFederal Ministry of Health, Pflegeversicherung facts and figures (Jul 2026). Including private long-term care insurance: 6.43 million at the end of 2025.
The number of recipients has more than doubled in ten years. Ageing is only part of the reason. In 2017 Germany replaced the old, largely physical definition of care need with five care grades (Pflegegrade) that also cover cognitive and mental impairment, such as dementia. This brought many people into the system for the first time, especially at the lower grades.
The figures also show the backbone of care in Germany: families. Most people in need of care live at home, and many receive no professional service at all, only the care allowance (Pflegegeld) paid to them and passed on to relatives. Any reform that weakened family carers would shift the burden onto a professional workforce that is already short. This is why Linnemann’s statement on carers’ pensions drew attention.
Destatis expects updated figures in its next care statistics, for 2025, around December 2026.
The workforce gap to 2049
The Destatis nursing staff projection (Pflegekräftevorausberechnung) measures the gap that population ageing alone would open.
The two scenarios differ in how many people take up nursing. The trend variant assumes the recent rise in nursing employment continues. The status-quo variant assumes it does not. Even the more optimistic case leaves a gap of more than a quarter of a million. On the demand side, ageing is unavoidable: one in five people was 67 or older in 2024, and Destatis projects one in four by 2035. A large part of today’s nursing workforce is itself close to retirement.
Hospitals employed 553,400 nursing staff in 2024 (Destatis), and outpatient and residential care services about 1.26 million people in 2023. Across the whole health sector, about 6.2 million people worked at the end of 2024, three-quarters of them women. A Destatis update extending the projection to 2070 has been published but is not used here, so that the figures above come from one consistent release.
Training, pay, staffing and professional standing
Recruiting more people into nursing and keeping them there: the measures already in place, most of them inherited.
Generalist training
Since 2020 the Nursing Professions Act (Pflegeberufegesetz) has replaced separate training for general, paediatric and geriatric nursing with a common three-year training leading to the qualification Pflegefachfrau/Pflegefachmann, with options to specialise. Training is free of tuition fees and paid. Degree programmes in nursing have been strengthened, and students now also receive a training allowance.
Wider powers for nurses
The act on extending nurses’ powers and reducing bureaucracy in nursing (Gesetz zur Befugniserweiterung und Entbürokratisierung in der Pflege) passed the Bundestag on 6 November 2025 and came into force on 1 January 2026. Qualified nurses may now carry out certain medical tasks on their own responsibility that were previously reserved for doctors. Care services with good inspection results are inspected every two years instead of annually (BMG).
Nursing assistant training
A nationally uniform training for nursing assistants (Pflegefachassistenz) replaces the Länder’s different programmes. The Bundestag passed it in October 2025, and according to the BMG it takes effect on 1 January 2027.
Pay: the collective-agreement rule
Since September 2022, care facilities have only been able to bill long-term care insurance if they pay their staff at least in line with collective agreements. This has raised pay in the long-term care sector, which historically lagged behind hospitals. It has also raised costs, and therefore residents’ own payments and insurance spending.
Staffing standards
In residential care, a scientifically based staffing method has been introduced in stages since July 2023, with a greater role for assistants. In hospitals, a nursing staff assessment tool (PPR 2.0) is being introduced. Nurses’ organisations call both necessary but say that without more staff, standards cannot be met in practice.
Recruitment and retention
Recognising foreign qualifications, bringing part-time staff back to more hours and keeping experienced nurses in the job are the most-discussed levers. Linnemann’s principle that nurses should have time for patients, not forms, points to reducing documentation. Beyond that, no new workforce bill has been announced since 29 July 2026.
Long-term care insurance: a partial cover in deficit
Social long-term care insurance (soziale Pflegeversicherung, SPV) was introduced in 1995 as the fifth pillar of social insurance.
Unlike health insurance, long-term care insurance was designed from the start as partial cover. It pays fixed amounts per care grade. People in need of care pay the rest themselves, including in care homes, where they also pay for board, lodging and a share of investment costs. If their own money is not enough, municipal social assistance steps in. Rising wages in care have pushed up residents’ own payments, a recurring political issue.
Contributions are 3.6% of gross earnings, and 4.2% for childless members over 23, since 1 January 2025 (BMG). Since 2023, members with several children under 25 have paid less. In 2025 the SPV took in €73.33 billion and spent €73.82 billion, a deficit of €0.49 billion.
Linnemann expects the gap to widen sharply. In his budget speech on 10 September 2026 he called the finances of the social long-term care insurance disastrous, citing an expected deficit of €8 billion in 2027 and more than €15 billion in 2028. These are his figures from the debate. The ministry has not published a detailed forecast.
„Wenn wir es nicht grundlegend umbauen, wird es in den Dreißigerjahren kollabieren.“
ContextThe BMG headlines the interview “Ohne Reform kollabiert das Pflegesystem” (“Without reform, the care system will collapse”). That is the ministry’s paraphrase, not his exact wording.
The Pflegeneuordnungsgesetz (PNOG)
Adopted by the federal cabinet on 30 September 2026. The bill now goes to the Bundestag and Bundesrat Proposed.
| Measure | Today | Under the bill | From |
|---|---|---|---|
| General contribution rate | 3.6% | 3.6% (unchanged) | — |
| Surcharge for childless members | 0.6 points (total 4.2%) | 0.9 points (total 4.5%, calculated) | 1 Jan 2027 |
| New surcharge linked to spouses/partners | — | 0.52% | 1 Jan 2028 |
| Contribution ceiling | As in health insurance | Raised by €300 per month, in line with health insurance | Per bill |
| Indexation of benefits | Ad hoc increases | Annual adjustment based on core inflation | 2029 |
| Pension credits for family carers | Paid by the SPV | Kept in full | — |
| Digitalisation of care | — | €1.6bn from the federal infrastructure fund plus €400m from the Länder | Per bill |
| Budget for children and young people in need of care | — | Up to €300 per month (max. €3,600 a year) for those up to age 25 | Per bill |
Source: Federal Ministry of Health, press release “Kabinett beschließt Pflegeneuordnungsgesetz”, 30 Sep 2026; Federal Government; ZDF FAQ. The 4.5% total for childless members is our own calculation (3.6% + 0.9 points). Existing care grades are protected, and a scientific advisory board is to review the assessment instrument.
„Wir machen keine Abstriche bei der Rente von pflegenden Angehörigen, denn sie sind die stillen Helden unserer Gesellschaft.“
The expert commission Under review
The bill is explicitly a bridge. A structural commission on long-term care starts work in October 2026, modelled on the finance commission for health insurance. Sources differ on its timetable. The Bundestag press service (hib 733/2026) reports that it must present results by March 2027 at the latest. Other reports mention proposals by January 2027, or a draft law “by Easter” with passage by 1 July 2027. We report all of these as stated and will update this page when the commission’s mandate is published.
Naming: ZDF refers to the bill as the “Pflegeordnungsgesetz”; the official title is Pflegeneuordnungsgesetz (PNOG).
Does the bill go far enough?
Arguments for and against the approach.
The case for the government’s approach
- The general rate stays at 3.6%, in line with his principle of limiting non-wage labour costs.
- The surcharge for the childless follows the Constitutional Court’s view that raising children is a contribution to the system in itself.
- Annual indexation from 2029 ends the pattern of benefits losing value between ad hoc reforms.
- Keeping carers’ pension credits protects the family care on which 86% of home care depends.
- The structural questions go to an expert commission rather than being decided in haste.
The critics’ case
- Higher surcharges raise revenue but do not address the gap between benefits and costs.
- Indexation only from 2029 leaves benefits losing real value until then.
- The deficits Linnemann himself names (€8bn in 2027, more than €15bn in 2028) are much larger than the extra revenue the bill raises.
- Nursing organisations, whose president had seen no signal of continuity in his appointment, want staffing and pay at the centre.
- Some argue for tax funding of tasks of society as a whole, such as carers’ pension credits.
The figures for the bill’s revenue effect were not available in the sources we checked, so this page does not quantify it. The final shape of long-term care reform depends on the commission’s report in 2027. See also demographic change and health financing.
Sources & further reading
- Federal Ministry of Health — Long-term care insurance, facts and figures (Jul 2026)
- Destatis — Pflegestatistik (people in need of care, 2023)
- Destatis — Nursing staff projection to 2049 (Jan 2024)
- Destatis — Expenditure on nursing and care services 2024 (Apr 2026)
- Destatis — Hospitals 2024 (nursing staff) (6 Nov 2025)
- Destatis — Health workforce 2024 (27 Jan 2026)
- Federal Ministry of Health — Cabinet adopts Pflegeneuordnungsgesetz (30 Sep 2026)
- Federal Government — Pflegeneuordnungsgesetz (Sep 2026)
- ZDF — FAQ on the care reform (Sep 2026)
- Federal Ministry of Health — FAZ interview (Sep 2026)
- Federal Government — Speech on the 2027 health budget (10 Sep 2026)
- German Bundestag, hib 733/2026 — Care commission (23 Sep 2026)
- Federal Ministry of Health — Act on extending nurses’ powers
- Federal Ministry of Health — Nursing assistant training act
- German Bundestag — Nursing assistant training passed (Oct 2025)