What Germany can teach the world about healthy aging

It is mid-October in the small southern German town of Burladingen, and the harvest of the day is apples — hundreds of them. Their peeling and cutting requires all hands on deck. At large tables abutting a kitchen steaming with the scent of winter spices, knives clunk against cutting boards in a steady thrum of industry. The sounds of children playing in the nearby living room mingle with the workers’ lively chatter. 

It’s not a typical nursing home scene, but this is not a typical nursing home. This is Haus Fehlatal, one of 30 facilities owned by the German company BeneVit. For residents here, working together, being needed, is therapy. It is their hands doing most of the peeling and cutting, supervised by staff.

For founder Kaspar Pfister, the revolution started in a kitchen. After a career in civil service, he took a job leading a church organization that oversaw nursing homes, “mini-hospitals” full of people “lying in their beds waiting to die,” as he describes it through an interpreter. At one of the homes, a resident with dementia had been trying to break into the facility’s kitchen, which was off-limits, for months. Staff were becoming increasingly desperate.

His suggestion: Open the door. They did, and the resident walked in, picked up an apple, and left. That moment changed everything. “What kind of system do we have when very old people aren’t allowed to go into a kitchen?” he thought. “That’s where we started to just think differently.”

At Haus Fehlatal, residents’ daily work reminds them they live in a community with other people, and that they are not alone, says Pfister. It’s the last place most of them will live, but “they don't have time to think about that,” he says. “They have things to do.”

Before 1995, German eldercare looked much the way it does in the US: quality was wildly uneven, both in nursing homes and in home care settings, and many people couldn’t afford it. That year, the nation rolled out universal long-term care insurance—what it calls Pflegeversicherung—after forecasters began predicting a worldwide aging trend of seismic proportions.

Now, decades later, the differences between the countries are stark. While Germany faces similar demographic changes, workforce shortages, and financial strains as the US, its eldercare system has led to improved outcomes on key measures. Many German eldercare services reflect the latest science on healthy aging. It’s not that getting older isn’t hard in Germany—it just doesn’t hold the threat of economic ruin the way it does for so many Americans. 

BeneVit is just one of many companies quietly breaking new ground in the field Pflegeversicherung created. Facilities around the country, along with programs designed to keep people from needing them in the first place, hold lessons for the rest of the world, especially the US, on facing the rising tide of aging populations.  

"Germans like to plan ahead"

Decades of medical progress have led to longer lifespans. That’s leading to big changes in population dynamics worldwide: Over the next quarter-century, the global population of adults over 80 is expected to triple. That plus low fertility rates means most countries will soon have far more older people needing care than they will have younger people who are able to provide it. Eldercare costs are rising steeply.

These changes and their economic consequences were predictable, says Benjamin Veghte, a social policy scholar who has studied both German and American long-term care insurance programs. “Germans like to plan ahead,” he says, and by the 1990s, “they saw demographic shifts coming.” 

At the core of Pflegeversicherung is the requirement that all German residents be covered by some form of insurance to pay for the assistance they might need due to age or disability. It works a bit like Social Security does in the US: workers pay 3 to 4 percent of their paychecks into the insurance fund, and the fund disburses monthly payments to every resident who needs care, scaled according to their level of disability. About 90 percent of the population is covered by the government’s plan (a few have private insurance).

Long-term insurance payouts may go directly to the resident and be used to pay either a family member or a hired worker to provide home-based care. Alternately, the money may go to a facility where the resident lives to help defray the costs of their care. 

It’s not perfect. The payment rarely covers all the care a person needs, but it provides a scaffolding for iteration, innovation, and improvement, says Veghte. “It’s light-years better than our system,” he says, referring to the United States. What’s more, the system incentivizes providers to compete for clients by guaranteeing them the same payout for every person who needs a certain level of care. Without the need to compete on costs, they compete on services and lifestyle offerings. 

Take BeneVit, which appeals to its largely rural clientele by integrating homemaking and family into the fabric of everyday life. Each of the company’s 27 homes is designed much the way student housing is, says Pfister, with four wings, each of which houses fourteen private rooms. In every wing, the rooms converge on an open-plan kitchen facing a dining room filled with large, round tables. Each also has a living room where residents can relax and watch a fire crackle behind the glass doors of a wood stove. Families can take part in caring for their loved ones who live in the home in exchange for a substantial discount. Pfister calls the concept “Stambulant” — a combination of the German words for inpatient and outpatient.

Incentivizing family involvement likely has positive effects on residents’ quality of life. Studies suggest that worldwide, nursing home residents with moderate dementia experience less distress, more social engagement, and even improved cognition when their families visit more often. An independent 2023 review showed residents in one of Benevit’s nursing homes felt they had more autonomy and a higher quality of life than those in traditional nursing homes. 

Reducing the need for long-term care in the community

One of the best ways to reduce the cost of eldercare is to reduce people's need for it.

Like many countries, Germany is prioritizing strategies to stave off decline and preserve independence for longer. This usually means preventing chronic conditions from developing and managing them aggressively when they do. Within this model, cholesterol-lowering medication is prevention; exercise is prevention.

But in Germany, prevention manifests in other less-obvious forms, many of them aimed at reducing or delaying people’s need for Pflegeversicherung funds.

In a low-slung building in a suburb of Frankfurt, Frédéric Lauscher guides me through a large, light-filled room filled with neat lines of chairs, past clusters of cafe tables and a wall-spanning bookshelf stacked with board games and books. We’re inside a community center run by the Frankfurter Verband für Alten, a non-profit organization Lauscher leads that operates care homes, day programs, and home care services for seniors. 

“This is prevention,” Lauscher says. Not a dose of a pharmaceutical or a certain number of leg lifts, but an easily accessible community of people and activities to stimulate the mind and body. It’s a place that gives people reasons to leave home. Lauscher quotes the Austrian geriatrician and psychologist Erwin Böhm: “You have to move your soul before you move your leg.”

The structure we’re in is one of about 30 similar centers scattered all over Frankfurt, which together offer 120 programs daily – everything from yoga to chess to film clubs to language lessons. It also provides help and advice to community members for navigating the country’s extensive eldercare bureaucracy. 

The centers are all built to be especially welcoming to elderly people and are located within steps of the organization’s care homes, but the programming is open to residents of all ages. “The nursing home, it's kind of a ghetto of old people with problems,” Lauscher says. Environments that silo older adults are often the opposite of normal life, and lack chance encounters and conversations with neighbors. Normal life is stimulating; typical nursing home life, not as much, says Lauscher. 

Research backs him up: Studies of intergenerational programs show that a range of activities that put young and old in contact—everything from horticulture work, to digital skills workshops, to all-ages dance classes—led to better general health and well-being. What’s more, both the older and younger adults who participated in the studies saw benefits.

Lauscher resists describing the setup as utopian. “I don’t know,” he shrugs. “We like it.” 

The World Health Organization has championed the notion of age-friendly cities, which strive for inclusion of older populations, as a means of prevention and promoting healthy aging. While Frankfurt is not a member of the network, it seems to naturally hew to many of its priorities. The neighborhood we’re in is one of 15 purpose-built to maximize people’s access to social services. On a walking tour, Lauscher hustles me past housing for low-income families, people with physical disabilities, and independently living seniors, pointing out an age- and disability-inclusive gym and the nearby public transit station. 

Frankfurt residents who do need to live in one of Frankfurter Verband’s nursing homes find that these, too, have innovated to meet the local population’s needs: In this most diverse of German cities, the organization’s facilities focus on providing care to groups of seniors sometimes ignored by mainstream German culture. At the entrance to the Julie Roger Haus, an LGBTQ-inclusive nursing home, a poster displays pictures of residents carousing at burlesque nights, gay pride celebrations, and costume balls. At another of its facilities that specializes in care for Muslim seniors, residents have access to halal meals, receive care from providers who speak their language, and celebrate holidays in alignment with the Islamic calendar. 

Lauscher says these niches are an example of how Pflegeversicherung encourages providers to stretch to meet the needs of their local populations: “We all have to find ways how, with the same money, we can do something special,” he says. “That’s the main motor of innovation.”

There’s still more to do. Next year, construction will finish on a pilot project interspersing affordable housing units in between residents’ rooms on one wing of a Frankfurter Verband care home, making it more of a multi-generational community. Lauscher knows there will be some challenges: Occasional nursing home smells in common areas are unavoidable. But he’s encouraged by how well the concept has worked in the Netherlands, where housing college students within a nursing home has made life more affordable for its younger residents, and more fun for its older ones. He’s confident it’s worth the effort to give Frankfurt’s elderly space in a community that could give them better lives.

Are older Germans better off than Americans?

Does all this innovation make aging measurably better? According to a 2024 Commonwealth Fund report, older Americans have more chronic health conditions than Germans. But it’s not clear if those differences are due to eldercare insurance or Germany’s health insurance system, which is separate. 

One of the data points that most plainly shows the individual impact of this eldercare system is financial: Insurance keeps many more elderly Germans out of poverty than their American counterparts.

Getting older in Germany is not inflected with the kind of precarity that defines aging in the US. A recent study by an economic policy institute at the Hans Boeckler Foundation found that in 2019 and 2020, poverty rates were more than twice as high in Americans over 65 (23 percent) as they were among Germans of the same age (11 percent).

To receive government assistance for age-related care in the US, a middle class person must deplete their assets—often selling the home they live in—enough to qualify for Medicaid, the federal health and care insurance program for low-income people. “We just wait ‘til you have bankrupted yourself, essentially impoverished yourself, and then we say, ‘Okay, now we're going to help you,’” says Veghte. Only three to four percent of Americans have long-term care insurance because both costs and the bar for eligibility are high. Furthermore, many plans have been unable to deliver what they promised to their policyholders: In fact, many companies that once offered these plans have collapsed due to their inability to provide the benefits they’d initially guaranteed their policyholders.

Meanwhile, support from the German long-term care insurance plan kicks in the moment a person needs care, regardless of income and assets. Although German seniors and their adult children are expected to make out-of-pocket contributions to their care if they have enough assets, seniors’ own homes don’t count toward the calculation—and their children only contribute if they make a lot of money.

Older Germans can generally feel secure “in terms of what could happen in a year, or in five years,” regardless of their income bracket, says Hans-Werner Wahl, a gerontologist at Heidelberg University who studies attitudes toward aging. Concerns about, for example, “‘How long can I make it in my apartment?’” are just less intense in Germany than in the U.S, Wahl says. “it's quite clear that Germany is better off and more secure,” he says. “I'm proud that we have this system.”

Even this system is under strain

For many years, Germany’s long-term care insurance program was considered a paragon. Moreover, its supply and demand were about even, which meant it could meet the needs of its residents. But rapid social changes have created some challenges. As the nation’s population ages rapidly, the pot of long-term care insurance fund reserves is quickly being drained. The nation’s nursing and caregiving workforce is much too small to meet the needs of all the seniors who require it, and as a result, some nursing homes struggle to offer high-quality care. And the entire enterprise only works because elderly people’s families – usually women – assume so much of the caregiving responsibility.

With the system facing more strain, adaptation is going to be necessary, says Anna Brückner, a policy advisor at BAGSO, the German National Association of Senior Citizens' Organizations. The early years of the system saw a boom in new companies and ideas. Her big question now is whether the system can flex enough to innovate further. 

Still, as it stands today, the program works in the sense that it’s affordable and it provides equitable coverage, says Veghte. That makes it a good model for US policymakers to consider when seeking fixes to the US long-term care insurance problem.

In fact, when Washington State policymakers decided in 2014 that they wanted to create a statewide long-term care insurance program, they modeled it on the German system. Veghte now directs that program, called the Washington Cares Fund, and he says it, too, is imperfect – but it’s a starting point for asking questions about how to improve its design to better meet the needs of the people it serves.

Before I leave Burladingen, Pfister and I sit down to a lunch served by several residents wearing burgundy aprons bearing the words Glucklich-macher—“happiness maker.” Over fire-roasted pork with spätzle, he tells me everything would go much faster if the employees did all the cooking and washing rather than supervising residents in the work. But for residents, unloading the dishwasher is a fall-prevention activity, and setting a table is light exercise. And in any case, the real point of these tasks is to give people purpose.

The residents’ homemaking, however unhurried, is proof to each person that they have value, and that they’re living in community, Pfister says. That, as much as any physical or cognitive reward, is central to their well-being. “If there's still meaning in their lives, then death is not something to fear anymore,” he says.