The most incisive guide to issues facing the American family today . . . An invaluable resource for anyone wishing to stay on the cutting edge of research on family trends.

-W. Bradford Wilcox
Associate Professor of Sociology, University of Virginia 

Wedded to the State for Health Care

Bryce J. Christensen and Nicole M. King

As policymakers in the bloated welfare states of Western Europe wrestle with the impossibility of sustaining current levels of state-provided medical care for a rapidly aging population, many realize that they must increasingly substitute the informal, non-monetized care typically provided by spouse and family for the formal care paid for through government programs. But some Western Europeans resist this financially imperative shift in responsibility for care—even as runaway medical expenditures for formal medical care push their governments to the edge of insolvency. According to a new Dutch study, one group resisting this much-needed shift is Western Europe’s growing phalanx of never-marrieds, who apparently believe it is the government’s responsibility to meet their medical needs.

Affiliated with Erasmus University in Rotterdam and the Netherlands Institute for Health Services Research, the authors of the new study begin their inquiry aware that “Western countries are confronted with cutbacks in formal health care spending” at the very time that these countries are experiencing challenging “demographic developments, such as the rapid increase of elderly persons or persons with a chronic disease, and developments in the labour market, such as a scarcity of health care personnel.” They therefore do not wonder that policymakers in many of these countries are trying to effect a “shift in responsibility for care from the government to the general public.” To make that shift, of course it is “essential” for policymakers to find “a sufficient number of informal caregivers like family, friends or neighbors [who] are willing and able to lend care.”

People’s willingness to accept the burden of providing informal care, the researchers explain, depends on “feelings of obligations, intergenerational affection, filial responsibility and moral duty.” Though some sense of obligation or moral duty may motivate friends or neighbors to provide care, the researchers repeatedly refer to the one set of social bonds within which individuals are most likely to give informal care to those in need: the bonds of the family. It thus makes sense that when the researchers speak of “cultural factors” affecting individuals’ willingness to provide care, they immediately examine “strength of family ties . . . and norms on family responsibility.” 

Consequently, although the researchers seem to anticipate a role for friends and neighbors in providing informal care such as providing “emotional support [and] practical assistance with transport,” they acknowledge that when informal care takes the form of “nursing care tasks,” it is “usually . . . only provided to close family member[s],” typically by “a partner or a child.” (In referring to a partner rather than a spouse, the authors betray the political skittishness about marriage now so prevalent among academics that relatively few will affirm that wedlock defines the normative foundation for family life.) 

Obliquely acknowledging traditional gender roles in the family, the researchers remark that “females . . . often are caregivers lending care to parents(-in-law) . . . [suffering from] physical health problems or dementia.” Family caregiving, they further note, can also mean “provid[ing] care to [a] partner [or] child.” And the understanding that it is typically daughters, wives, and mothers providing such care explains why the researchers express concern about how the potential for informal care for the elderly may be affected by “demographic figures and expected societal changes, . . . [affecting] the number of women in a country and their employment participation rate.”

Given the political challenge of shifting greater obligations onto such informal caregivers, the authors of the new study have good reason to ask “whether the general public, who might become caregivers in the future . . . [hold views that] align with the shift to more informal caregiving.”

Addressing this issue in their own country of the Netherlands, the researchers want to assess “views on the responsibility for care [provided by] the general public versus the government.” To this end, the researchers parse data collected in 2015 from 1,097 individuals participating in a survey conducted as part of the Dutch Health Care Consumer Panel.  

These data confirm some commonsense expectations: For instance, Dutch adults already carrying heavy family-care responsibilities “consider the government more responsible for personal or nursing care” than do peers not so burdened. Also unsurprising are findings indicating that “persons with lower income and those who perform paid work part-time perceived the government more responsible than the general public for personal or nursing care than [did] others.”  

But at a time when marriage rates run astoundingly low throughout Western Europe and the United States, so accounting for an unprecedented multiplication of single-person households, no finding deserves more attention than this: as a group, persons who have never been married are distinctively committed to the idea that the government should provide care to the elderly and chronically ill and are distinctively unwilling to provide informal care to the elderly and chronically ill themselves.  While the researchers found that almost two-thirds (62%) of adults in their survey who were married or in registered partnerships expressed a “willingness to provide informal care in the future,” they found that less than one-fourth (23%) of those who had never been married expressed such willingness. (The effect of wedlock in fostering willingness to provide informal care would probably appear even more dramatic if the researchers had not—in politically correct fashion—lumped together in their analysis those in real marriages and those in the registered partnerships that serve as dubious surrogates.)

Exposed to the immense political pressures within modern academe against any normative understanding of marriage, the authors of the new study remain remarkably taciturn about the implications of this yawning marital gap in willingness to provide informal care to the elderly and chronically ill. But unless aging Western nations can rediscover and reaffirm wedlock, that gap will devilishly complicate the task of any policymaker trying to contain national medical costs by relying more on family-based informal care and less on government-provided formal care.


(R. J. Hoefman, T.M. Meulenkamp, and J.D. De Jong, “Who Is Responsible for Providing Care? Investigating the Role of Care Tasks and Past Experiences in a Cross-Sectional Survey in the Netherlands,” BMC Health Services Research 17 [2017]: 477, Web.)