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How sick is Germany’s healthcare system?
Photo: DPA

How sick is Germany’s healthcare system?

Published: 10 May 2010 18:13 GMT+02:00
Updated: 10 May 2010 18:13 GMT+02:00

The phrase “healthcare reform” entered the politicians’ lexicon of stock ideas a long time ago: no matter what country you live in, the system that provides medical care seems to be in constant refurbishment. Perpetual adaptation and improvement is a good thing in principle, but as governments keep on discovering, a new healthcare policy is not easy to agree on, never mind convert into actual change. Compromises between political parties, labour unions and powerful lobby groups for the likes of pharmaceutical companies and doctors hold back change. Any particular nation’s old problems tend to persist, like a cold you can’t shake.

Germany’s niggling cough is its two-tier health insurance system. It remains one of the few developed countries where you can opt out of the state system altogether and insure yourself completely privately. About 10 percent of the population – mostly the self-employed or those with high salaries – are privately insured, while the 90 percent have to muster healthcare for the whole nation.

On top of this, the chronically ill, who incur the biggest costs, have trouble getting private insurance, so the 90 percent who pay into the state system also pay for the most expensive cases. “That’s why we don’t need to be surprised that the social contribution system doesn’t work,” says Rene Bormann, a health policy spokesman for the Friedrich-Ebert-Stiftung, a think tank associated with the SPD. Bormann believes in the German state insurance system (which is made up of a patchwork of statutory insurers or gesetzliche Krankenkassen) - at least in principle. He particularly believes in the principle that employer and employee share health insurance costs. “I think it’s important that the employer also contributes, because then he has the motivation to form work conditions accordingly,” he says. “That’s a very important central point, and I think we should hold onto that.”

New plan, same problem

Unsurprisingly, Bormann is unimpressed with the kind of reform the new health minister Philipp Rösler, a pro-business Free Democrat, has in mind. Like every other idea so far, Rösler’s plan conspicuously fails to address the inherent unfairness of the public-private schism. In fact, his Kopfpauschale idea – a monthly flat-rate fee paid regardless of income – is more likely to widen the gap between rich and poor among state patients, and continues to protect private insurance companies from intervention. “To start with, I find the idea that the receptionist or the canteen lady downstairs pays the same as me a bit difficult,” says Bormann.

As Rösler’s Kopfpauschale was presented to parliament in February, the leftist opposition lined up its responses. The most withering came from SPD health spokesman Karl Lauterbach, a veteran health policy enthusiast and conservative antagonist. Lauterbach’s research assistant Olaf Rotthaus spelt out the main point: “The central aim has to be getting over the divided insurance system,” he says. “We need insurance from everyone, for everyone, for everything. That means a unified contribution system for private and state patients. That would be the most effective measure.”

The political battle lines make sense. The SPD’s alternative to the FDP’s notion is nicely egalitarian, but it’s hard to avoid pointing out that Germany’s unfair two-tier system, so roundly blamed by Rotthaus, survived almost a whole decade of SPD health ministership: during Ulla Schmidt’s tenure from 2001 to 2009, piecemeal reforms failed to make the system either fairer or more efficient.

Chronically expensive

Inefficiency is as big a problem as injustice. Keeping Germany healthy is chronically expensive: this country has the fourth highest health expenses in the world and the compulsory individual fees, be they state or private, carry on rising faster than inflation.

The average state health insurance contribution is €500 a month, which is split between employee and employer – while the self-employed pay everything themselves, unless they’re lucky enough to be in the Künstlersozialkasse for freelancers in creative professions But both state and private health insurance companies have increased their premiums in recent months as rising unemployment has put more pressure on the welfare state.

Yet however much the contributions grow, they never seem to be enough for Germany’s ravenous healthcare system. It demands vast sacrifices, and in the past few years, the government has been forced to inject more and more tax money into the system: from 2008 to 2009, its contribution to the newly devised Gesundheitsfond (“health fund”) – a centralized pot into which everyone’s healthcare contributions are paid – doubled from €1.5 billion a year to €3 billion. The idea that healthcare should be at least partially funded by tax money is a central plank of more left-minded policy – the notion that everyone contributes and everyone gets basic healthcare, and that competitive capitalist model isn’t necessarily the most effective way to keep people alive.

In Europe, Britain’s National Health Service, for all its flaws, is still the model example of an entirely tax-financed system. The last round of German reforms, brought about during the SPD-CDU coalition government in 2007, was a gesture in this direction. Even Rösler’s new plan requires a significant tax contribution, as low earners would receive an extra health allowance which would have to be financed by tax money. But Bormann is not convinced such a system would work in Germany.

“I’m not really sure if financing through tax is always the right idea,” he says. “In the last few years, there have been many efforts to raise the contribution from tax money. And in the following year, all of a sudden the state budget didn’t look so good, and everyone said the contribution was too high. It’s a risky business.” Bormann has a better idea: “If we widened the income base from which we got healthcare contributions - for example, if we included capital income - we’d get significantly more money.”

Coming back to Rösler’s plan, Bormann says, “On the whole, I don’t think the Kopfpauschale idea gets us closer to our aims. It’ll create additional and disproportionate bureaucracy. I think we should keep the system we have in place now and try to optimise it.”

Private is not always best

Peter Sawicki, head of the Institute for Quality Efficiency in Healthcare, a government-appointed body that examines new medical services and drugs, recently got himself into trouble over his expenses and was dismissed by the new government. But he was also seen as an official who protected the consumer against avaricious pharmaceutical giants, and a few people believe the business-friendly government expedited his departure to clear away an inconvenient troublemaker.

His views are certainly obstructive to the pharmaceutical industry: “I think the market forces are often suspended for pharmaceuticals – supply and demand don’t determine the prices – and with the huge amount of money they get, they win influence,” Sawicki says. “There needs to be an independent body that decides whether a new medication has additional patient-relevant benefit. If it doesn’t, then it shouldn’t be reimbursed at all, and if it does, then you should have to negotiate about the price.”

Sawicki has a simple solution to Germany’s healthcare problems. “There should be a general, compulsory basic insurance for everyone. After that, people should be able to voluntarily insure themselves to get additional services – for example, for single rooms or treatment by the head doctor. Some party, – I don’t know which one - should back such a sensible scheme, and go into an election with it.”

Bormann, along with the SPD, wants some kind of merger of state and private health insurance. Exactly how this can be achieved is difficult to define: Rotthaus ominously talks about Germany needing “a third way beyond radical market values and state medicine”. But it seems even well-earning Germans are beginning to notice the pitfalls of going private – an apparently privileged situation much-coveted among the middle classes. “I was on private insurance for about a year – they have their tricks,” says Ralf, a Berlin musician. “They were able to charge me for care that they denied anyway!” These are probably the “radical market values” that Rotthaus mentioned.

But there is another problem with private insurance: it encourages massive waste of medical resources. Some doctors are reported to be able to earn 50 percent of their income from the 10 percent of their patients they treat privately. Often the only difference in the treatment is that they don’t keep private patients for as long in the waiting room. Private patients also get appointments quicker from many specialists. Some clinics and hospitals even have special appointment hotlines for privately insured patients.

A recent article in Stern magazine exposed the massive temptations doctors come under to over-treat private patients. Mike, a 33-year-old privately insured Berliner hurt his knee while playing squash. “I said ‘privat versichert’ and it was of course no problem getting an appointment with a ‘booked out’ orthopedic specialist pretty much right away. The problem was escaping his over-zealous care. First he prescribed me expensive knee braces, custom shoe inserts, then physiotherapy. Soon, it was surgery – which he would be performing himself at a private clinic…” A second doctor said the operation was unnecessary. Mike resumed his weekly squash game. His knee got better, “by itself.”

Many commentators note that doctors with privately insured patients are the most privileged salesmen – they have the instant confidence of the customer, and the customers have the comfort of feeling that their money is being spent on them.

On top of this, it is very difficult to return to the state system once you have gone private, as Ralf found. “They’ll raise your premiums substantially once you’re no longer entitled to public healthcare,” he says. To return to a state insurer, you’ll have to get a proper professional contract with employee status, or else go on welfare (Hartz IV) so that the job centre pays for your insurance.

The situation can sometimes be quite precarious for expats. Sarah is a non-EU national working as a freelance English teacher in Berlin, which means she finds it difficult to get state coverage in the first place. “So as far as I understand it, right now private is my only choice,” says the 39-year-old New Zealander. “Unfortunately, the premiums are slanted towards the needs and budgets of high-income earners, and I can’t afford it.”

Due to a Kafkaesque quirk of bureaucracy, Sarah’s just lost her insurance coverage. “They asked me to supply a date of entry stamp from my passport or a copy of travel tickets. Of course, there is no such thing as travel tickets any more, and I only keep such things after I travel if I can claim it as tax deductible. I sent the insurance company a photocopy of my first entry into the EU, which was actually near on 10 years ago, and explained that that was my first entry and that I had no other stamps because of the EU no-stamping policy. So they cancelled my insurance because of that, saying it was too old.” At the moment, she is completely uninsured.

Ralf, Sarah, Sawicki, Rotthaus and Bormann all have a clear view of the central predicament, but that doesn’t mean the solution is simple. “The money sometimes goes into the wrong channels,” Bormann says. “And it’s sometimes a bit of a problem that we always see health as just a question of costs. After all, the healthcare sector is also a huge part of the economy that sustains hundreds of thousands of jobs – and there is a lot of unused economic potential in certain areas. It’s often a question of financing this. We just have to find a way of financing it fairly.”

Exberliner (editor@exberliner.com)

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Your comments about this article

20:22 May 10, 2010 by jillesvangurp
I moved here last year from Finland and am originally from the Netherlands. In finland, health insurance is really simple: you pay what amounted to 60 euros per month for me and you get a so-called kela card that you use to identify yourself with in hospitals and health care centers. That's it. 60 euro. Full coverage against the basics. The annual cost for health insurance in the Netherlands is around 1200 euro for the so called base insurance, which as the name suggests covers the essentials.

When I joined here in Germany I was in for a shock. First I had to choose between private and public, a system that was abandoned a few years ago in the Netherlands. Secondly, my health insurance bills are about 9 times as high, with no obvious advantages in terms of coverage. I suspect a mix of inefficiency and the pharmaceutical industry milking the government through price fixing and other practices. 9 times as high: somebody is getting rich here without working for it.
22:02 May 10, 2010 by slawek
How to organize the funding for the health system is not really the major problem.

In some regions you have to wait for 6 months to see a specialist. In my region it's only six weeks, but there isn't more time than 10 minutes to talk the doctor. More complex anamnesis is simply impossible, which means you'll end up in the ER at some point and after that in a hospital, because no med. practice has the time to look after you. The hospital will try to get rid of you as soon as possible, but you'll get a whole 1h when seeing a doctor there, so further misdiagnosis is less likely.

Basically, the system tries to save money by waiting until people become seriously sick. If they don't the health care wins, if they do the costs multiply and multiply. How can this be effective? This is the actual question.
22:32 May 10, 2010 by derExDeutsche
@jillesvangrup

'I suspect a mix of inefficiency and the pharmaceutical industry milking the government through price fixing and other practices. 9 times as high: somebody is getting rich here without working for it.'

What? 'like the Yeti and the Loch Ness, Govt' Inefficiency is a myth.'

It is Free Market Competition that is the True Evil of European Society. Prices need to fixed, and the rest made 'free'.

Really? Are you sure it isn't the Govt. that's been corrupt, more so than the Evil Free Market?

do you really think the Govt. STILL doesn't have enough control to make everything all better?

And just because the initial Coverage rates are lower elsewhere, does not mean that Govt. is not extracting the costs from somewhere else... follow the wild goose chase back to.... your wallet.

So instead of Big Pharma Paying off your Politicians, now your tax laws are? PLUS the GOVT. owns the Industry? Nice job if you can convince your lemming public

its for 'the people, waah. and anybody that doesn't agree is a Racist'. eiyayei

are you sure Obama isn't a Germanic name?
01:23 May 11, 2010 by Logic Guy
Well, the first thing I would recommend, is that the government ban toxic chemicals from foods. The true role of government is to protect everyday citizens from greedy and unethical companies.

A soiety educated in healthy nutrition alone would revent most,(90%) of major health care to begin with. Therefore, in the grand scheme of things, health care in Germany could EASILY be much better.

Actually, most things are easy to accomplish. Life is only difficult when people lack the basic know-how.
05:21 May 11, 2010 by derExDeutsche
@ Logic Guy

The true role of Govt is not to 'Protect the People'. It is to ensure the Freedom of the People.

And from what you are telling me, it is the Govt.s role to be our collective 'Mutti'.

Where will the Govt stop at 'Protecting' the people? No more 'Schweinsbraten'? Too much fat? No more 'Spezi'? Too much sugar. After all, YOU the Tax Payer are paying for those people who are overweight and toothless. So, the Govt. MUST do something about all those Evil Evil people making Money outside of the Govt, right? right.
08:29 May 11, 2010 by Talonx
@ derExDeutsch

&

@ Slawek

Quit talking out your #sses. Read the following two articles both of which have been endorsed by the WHO and than try to make your idiotic arguments.

Healt care reform controlling spending and increasing efficiency:

>> http://www.oecd.org/dataoecd/26/28/33717721.pdf > http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2007/May/Mirror--Mirror-on-the-Wall--An-International-Update-on-the-Comparative-Performance-of-American-Healt.aspx
09:30 May 11, 2010 by rugbycoach
`On top of this, the chronically ill, who incur the biggest costs, have trouble getting private insurance, so the 90 percent who pay into the state system also pay for the most expensive cases.´ well erm er yes. So they should its a massive massive pot. Whats wrong with that?, should the high earners therefore pay for the sickest people? Its a fair system in Germany just that the system isnt run very well...
10:46 May 11, 2010 by mrsams
It's not a surprise, health care is only one of the systems here in Germany where we work so much and pay to help for the needy and to those who intentionally want a free ride for the benefits without contributing anything.We ( hard working tax payers )are been taken advantage from the people ( a certain group)inside germany also outside are doing it.
11:54 May 11, 2010 by Hebbellover
@ derExDeutsche excellent points and couldn't agree with you more. Of course the government has a role, however being the sole provider of anything gives the government a monopoly unlike what the kings of old had!
16:23 May 11, 2010 by Der Grenadier aus Aachen
The whole approach of evaluating national insurance schemes based on cost is faulty notion.

If we are a nation of good people, never mind a Christian nation, with values of egalitarianism, a greater common good, protection of the individual, and a value for life, then one can not consider cost when it comes to health care. Caring for your neighbor is far more important than any amount of money.

We should pay what that costs. To give everyone excellent health care. To let everyone, and anyone, enjoy their lives on God's earth for as long as they are able. I don't care if that costs me 40% in taxes, or 50%, or 60% or 70%, or 80%. I don't care if I am left with barely a penny after all my toils and bills are said and done.

If you should speak any other way, you are speaking out of selfishness.
18:25 May 11, 2010 by derExDeutsche
@Der Grenadier aus Aachen

Wow! Spoken like a TRUE Communist!

And we all know that Communism is for 'The People'. No one else, just 'the People'. Wonderful. Will anybody ever learn that this type of rhetoric is what brought us the USSR and Communist China? They HAD all the best intentions 'For the people', and if you didn't agree, you were a SELFISH/RACIST.

Will anybody ever learn that a Monopoly on Power corrupts?
20:35 May 11, 2010 by Der Grenadier aus Aachen
@derExDeutsche

I'm not a communist. Certain things just shouldn't be controlled by market forces; that's not an attack on capitalism at all, that's just a matter of seeing things for what they are.

Also, my motivations aren't political; they're religious. I considered myself to be speaking as a Christian, and I didn't imply racism in any of it.

And yes, sometimes do bad things out of good intentions.

Other than that, I don't see any actual correlation between what I said, and what you responded. So, if you'd like to come back with something relevant to the issue that argues a point, please do so. Otherwise, keep your aggressive comments about my character to yourself.
20:48 May 11, 2010 by Hebbellover
@Der Grenadier aus Aachen

since when does your christian god force you to comply? Last time I read his plan was optional, sounds to me like you want forced compliance.
22:11 May 11, 2010 by derExDeutsche
ok @ @Der Grenadier aus Aachen

'I don't care if I am left with barely a penny after all my toils and bills are said and done.

If you should speak any other way, you are speaking out of selfishness. '

Enlighten me, how is this different than Communism?

Am I not an 'Enemy of the People', comrade? Should not measures be taken?
22:31 May 11, 2010 by slawek
@Talonx I don't need any secondary sources from you, my report is first hand.

First of all, please learn to distinguish between observation made by someone and an argument. Only then decide if, whom or what to call idiotic.

If you have nothing to add to a bottom-up view on the matter, why make the ill guided mistake to cite some top-down sources to prove me wrong.
22:52 May 11, 2010 by Zlik
American Heathcare Does Bangup job too. Their on Drugs.
23:33 May 11, 2010 by Logic Guy
Well, all 6.7 billion of us would like as much freedom as possible. However, a nation without an effective government is a nation that will always struggle and therefore never reach full potential.

In a democracy, the goal is to achieve a perfect balance between indivudual rights and civilized law.

This extraordinary condition has never been achieved by America, Germany or any other democracy. It is nonetheless possible.
00:12 May 12, 2010 by Talonx
@ Slawek

Your observation is painted with a few faulty assumptions -- 1.) assumptions that the waiting times you report are abnormally long, 2.) assumptions that the amount of time you get to see the doctor on average is abnormally short. This is simply not the case. You'll find much worse waiting times in the U.S. and Australia, and many clinics where you never even get to see a doctor (this is especially the case in the U.S.).

Did you just want to throw some noise into the echo-chamber, or did you actually want to get involved in a discussion? Either way, your so called 'bottom-up view' is just as open to reasonably constructive criticism and deconstruction as any 'top-down view' is.
11:00 May 12, 2010 by michael4096
In some regions you have to wait for 6 months to see a specialist. In my region it's only six weeks,
Another person living in a different germany to me. A quick hands-up around the office showed that ~20 random people have never had to wait more than 6 days for a specialist. And, even that is when you choose a specific praxis - if it is an 'emergency' and any specialist will do, 2 - 3 days will do it.

Healthcare here is expensive, but in my experience it is very effective.
18:01 May 12, 2010 by michael4096
For those that probably don't understand some of the comments here. In germany, those earning over a given amount (~€70k) are given the choice (once a year) to take public or private insurance - however, if you choose private, you choose it forever.

Tradeoffs:

- public - for a family (1 to however many), proportion of salary to a fixed amount, stays same (fixed by law) proportion forever, gives standard healthcare

- private - for individuals, pay whatever the insurer says but you *must* have an insurer, gives whatever it gives above a legal minimum roughly the the same as the public

So, for those ambitious twenty somethings that don't believe that they will ever need it - private is far cheaper. Given a couple of decades, a wife, couple of kids and a dicky ticker, 'public' start sounding not so bad at all.

Put another way, compared to the us: what you get with a good job and a good salary is what everybody gets in germany. Superstars and others who don't want to think about such things get private. There is no equivalent to the 25% uninsured.

Not sure about poor Sarah. I know non-eu people on public, perhaps it depends on the work permit. Talking of which, I cannot believe that the german green card, which we must all have if we are not germans, cannot be used to solve her problem.
18:06 May 12, 2010 by michael4096
PS Getting laid off is not a problem. The Labour office continue to pay whatever your contributions were. However, if you take voluntary redundancy you might screw yourself.
22:53 May 12, 2010 by green idea factory
I suggest that Sarah (non-EU person mentioned in article) or others with similar issues contact Oliver at www.tetrateam.de. He should be able to help her with her insurance problem.
09:55 May 13, 2010 by Talonx
@ swimmer

Well said!

Finally, in answer to the articles question . . ., "how sick is Germany's healthcare system?", the answer is: NOT VERY.
13:55 May 13, 2010 by Prufrock2010
I am still waiting to hear a compelling argument in support of ANY health insurance system that exists to make a profit from people's illness. I've been waiting a long time. The silence is deafening.

Medical treatment is a right, not a privilege.
18:36 May 13, 2010 by Johnno
Pay extra for special care? Does this mean for example Spectacles?

The healthcare system doesn't pay anything for eye care except in very exceptional cases. Or pay extra for dental care? Most people have to do that now anyway since the limit of little more than 100 euros is a blot of what treatment costs.

Pay extra for medicines required as a chronically ill person? I require tablets, up to six a day, for whzich the Krankasse payment is laughable.

Oh, and they now require that I pay a regular extra top-up of my costsby bank transfer. I wonder how many have paid this?

In short - we pay more and more and we get less and less.
09:36 May 14, 2010 by Talonx
@ Johno

Right on, it isn't sick yet but it is getting there. The tendencies you note are the results of attempted profit maximization which runs directly counter to any form of health maximization. The more it is treated like some sort of potentially profitable business the worse those tendencies will be getting, that's why we need to get the FDP and CDU/CSU out of office and agitate for treating health along with schools like public institutions again.

Again, everyone on this board should really read this, http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2007/May/Mirror--Mirror-on-the-Wall--An-International-Update-on-the-Comparative-Performance-of-American-Healt.aspx
12:54 May 14, 2010 by Nova_pd
How sick is Germany´s healthcare system?"" I do agree with Talonx.

...Weiße Kittel, dunkle Geschäfte (Dina Michels), misuse of health care fund (Gesundheitsfonds), and the network between æquot;rzte and Pharmaindustrie, & unnecessary patient operation! Politicians of any parties are probably aware of this,but try to ignore it.

Kasse machen statt heilen, the Kopfpauschale and any reform for more % or additional cost, patients have no other way but to accept it.
13:11 May 15, 2010 by Ich
The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.

(Winston Churchill)
18:15 May 23, 2010 by Talonx
@ Ich

And for such idiotic views he was voted out.
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