This is the first post in a series on universal health care, addressing the concerns that have been brought up in the current debate on health care reform in the US. This post describes the German health care system.
How do health statistics compare between Germany and the US?
Looking at the World Health Organization’s Core Health Indicators, Germany has better numbers than the US in most health care related statistics. Here are some highlights:
- Life expectancy at birth, for both sexes combined, is 80 years in Germany and 78 in the US
- Healthy life expectancy at birth, for both sexes combined, is 72 years in Germany, 69 years in the US
- Infant mortality rate (per 1000 births) for Germany is 4.0, the US is 7.0
- Hospital beds (per 10000 people) is 83 in Germany and 32 in the US
- Physician density (per 10000 people) is 34 in Germany and 26 in the US
- Total expenditure on health as percentage of GDP for Germany is 10.7%, the US is 15.2%
- and Per capita expenditure on health is $3250 in Germany and $6350 in the US
What kind of health care system does Germany have?
Germany has universal health coverage for all qualifying residents. In fact, it has the oldest universal health care system in the world, whose origins date from Otto von Bismarck’s social legislation of the 1880s. The German government does not insure people, instead it requires by law that residents have health coverage and has a multi-payer health insurance system. There two types of insurance providers: Public “statutory funds” and Private.
Statutory health insurance funds are non-profit and not run by the government. They must provide coverage following tight government regulations. The statutory insurance premium is based on a percentage of salary which varies depending on the fund you choose, but is typically around 15% of your gross monthly salary, or €570 a month, whichever is lower, with employees and employers contributing about half each. Some lower income workers can qualify to pay a lower percentage of salary.
Family members earning less than €400 a month are covered by the statutory funds at no additional cost. Approximately 72 million people are covered by the public statutory funds (Germany’s population in 2009 was a little over 82 million people). The statutory funds are also funded in part by taxes to support the coverage of people who have never been employed or paid into the system.
Some people can opt out of the public statutory funds and be covered by private “for-profit” insurance companies. Not everyone can do this, you must make over €50,000 a year or be self-employed. Some government employees, called Beamter, are reimbursed for part of their medical costs and must take out private insurance policies to cover whatever the government does not reimburse. The private insurance companies decide on the premiums, so younger, healthier people will have lower premiums than older people with pre-existing conditions. The premiums are locked in when you join, although the premium may increase if health costs in general increase. Family members can be covered, but each must pay an additional premium. Only about 10% of the German population (about 8.5 million people) is covered by private insurance.
Does the German government provide health care?
No. Doctors are not employees of the German government. Doctors outside of hospitals are in private practices and considered self-employed. For doctors in hospitals, it depends on the hospital ownership. Out of Germany’s 2,030 hospitals, 790 are publicly owned, while 820 are private non-profits, and 420 are private for-profit. This competition helps to keep hospital costs down and quality of care high.
Are there long waits and rationed care?
Here’s a chart from a Commonwealth Fund study of wait times between Australia, Canada, Germany, New Zealand, the UK and the US:
The German Health Ministry’s page also says wait times are lower in Germany than elsewhere. My experiences agree, I have no reason to believe that wait times aren’t lower here than elsewhere. Wait times for appointments and operations, in my experience, have been the same or less than in the US, and I hear similar things from other people. I did find waiting room times at doctors offices (but not hospitals) to be long in the former East Germany (2-3 hours sometimes), but it was also common in the former East that appointments weren’t given and you just showed up and waited when you needed to be seen, so you had same day care at least. In the state of Bavaria, I’ve hardly ever had to wait more than 20-30 minutes in a waiting room and appointments are usually for the same day, and if not, they are rarely more than a week away.
Necessary treatments are given to all patients, public and private. There are some limits made on doctors, for example orthopedists have a limited number of physical therapy sessions they can give out each quarter (per statutory fund), so for all but the most seriously affected patients, doctors might only prescribe eight physical therapy sessions per quarter, saving leftover sessions for the most in-need patients. The statutory funds might also cover 1000 screenings per month, the doctor will do more screenings if needed, but anything beyond the limits set by the funds needs to be paid for by the patient or the doctor, but is almost always paid by the doctor. Politicians have even advised that if your doctor asks you to pay for a test or procedure, you should switch doctors. However stroke or accident victims, for example, would receive all the physical therapy that they need. This is sometimes also partially paid for by retirement funds.
If something is not covered by a patient’s public or private insurance, they can always pay for it out of pocket.
Doctors regularly make housecalls to patients who can’t travel or when care is needed outside of normal office hours. You don’t need to go through your primary care physician to see a specialist, you can make appointments directly, and you can get as many opinions as you want.
This all sounds great, but it must cost a fortune, right?
Germany spends less as a percentage of GDP on health care than the US and less per person than the US, and all its residents have comprehensive health coverage. How can this be? Prevention, early treatment, and education go a long way towards lowering costs. Let’s take type II diabetes as an example. When it doesn’t cost anything to go to the doctor, you’re more likely to get regular checkups, at one of these checkups, the doctor might discover you’re pre-diabetic. You will be educated on the condition, on how to control it through diet, and the progression of the disease will be monitored. If you don’t have health care, or are under-insured, like many in the US (it’s estimated 100 million people in the US are uninsured or underinsured – that means you have insurance but can’t afford to see doctors because your co-pays and deductibles are too high), your condition may not be caught until it’s much more serious, requiring insulin, or even perhaps a hospital stay for a diabetic coma. Without proper followup and education, the condition can worsen to the point that amputation and extended hospital stays become necessary.
There are some health screenings that aren’t covered, and the timing and frequency of other screenings are set by the insurance companies, both public and private, but additional screenings can always be paid for by the patient out-of-pocket.
The government helps to keep costs low by negotiating prices with pharmaceutical companies and medical providers. Competition between the public and private insurances also helps, as does the fact that doctors and nurses make home visits. For easily treated conditions that occur outside normal business hours, a doctor will come to your home and treat you, saving the cost of a trip to the emergency room. Long term care is provided in the home when possible, with nurses stopping by daily when necessary, saving significantly over long hospital stays.
Costs to doctors for malpractice insurance is lower here as well, since payouts for lawsuits are lower in general and lawsuits are more difficult to bring to court.
The out of pocket costs to patients are also low. Public patients pay a €10 copay upon their first doctor visit a quarter. There is a small fee (I think €10 per quarter as well) for doctor home visits. Prescriptions cost €5 and are free for children.
Private patients must pay all bills out of pocket, but are then reimbursed by the insurance company and can receive refunds from insurance if they don’t require medical care in a given year.
Are abortions covered by health insurance in Germany?
Abortions are covered by insurance here when they are considered medically necessary or in cases where the pregnancy was the result of a crime (rape, incest), otherwise they are considered to be selective surgery and must be paid for by the patient. Social services do sometimes help with this payment for women who cannot afford it.
German medical personnel aren’t forced to perform any procedure they do not wish to perform.
Are illegal immigrants given medical treatment in Germany?
Germany is estimated to have about 1 million illegal immigrants. Because they do not have legal documents, they aren’t eligible for health insurance here. If they have an emergency however, they must be treated. The German government requires that illegal aliens be reported to authorities (this is not the case in many European countries), but many of Germany’s medical and social system personnel disagree with reporting personal information such as residency status.
What is the quality of care in Germany?
The quality is world class. In a 2000 WHO report, Germany’s health care system was ranked 25th in the world (the US was ranked 37th). Of course there is variation in the system, on a village level, you aren’t going to have the same care as in a top teaching hospital (similar to the difference between a small rural town in the US and Cedar Sinai Medical Center), but overall care is excellent here. Just like the US, rich oil sheiks also visit Germany for medical care, as do third world leaders, rich foreigners and celebrities (you might remember hearing on the news about how Farrah Fawcett came here for cancer treatment and U2 frontman Bono came here for back surgery).
Can you lose your insurance if you lose your job?
No, insurance isn’t connected to your job in that sense, only in the sense that your employer pays half of your insurance premium. If you change jobs, the new employer takes over the payment. If you are unemployed, you don’t need to pay, unemployment insurance funded by government taxes will cover you. You never lose your insurance coverage.
So you make the German system sound perfect, is it?
It’s not a perfect system, Germans find plenty to gripe about. Health coverage is good now, but there are going to be demographic problems here in Germany with an aging population and the low birth rate. These problems are things the US would actually not face nearly as severely were it to have such a system, as the birth rate and immigration rate is relatively high there.
German doctors complain about low pay and sometimes leave to practice in the US or the UK, where doctors make more and where a less hierarchical society means young doctors are more respected. But to be fair, college tuition in Germany is covered by taxes, so doctors come out of med school here free of debt, while doctors in the US often owe several hundred thousand dollars in student loans.
Drug distribution is also firmly in control of the powerful pharmacist union, so over-the-counter medications are still only available through pharmacies.
Also, many Germans feel everyone should be in the public system and it’s unfair that the wealthy can opt out into private insurances. I tend to agree with this and think everyone should pay in to the public statutory funds and private insurances can then be bought for additional coverage. But that is a debate for another day.
Christina Geyer has lived in Germany since 2002. She has worked as a clinical trial statistician, planning and analyzing data from pharmaceutical trials, in both the US and Germany and has also worked as a statistician in non-profit health care research in both countries.
For more information on health care systems in Germany and around the world, see:
- Bundesministerium für Gesundheit: Health Care System and Health Care Reform in Germany
- Wikipedia.com: Health in Germany
- Wikipedia.com: Universal health care
- New York Times Economix Blog: Health Reform Without a Public Plan: The German Model
- FiveThirtyEight.com: Not All Socialist Countries are Alike, a very simple explanation of the difference between Canada’s single-payer system and the UK’s national health care system.
Read more of my health care series:
- Health Care in the US and Germany: My Personal Experiences
- Health Care in Germany: Reader Experiences
- Universal Health Care around the World: Reader Experiences
- To my German readers: What do you think of your healthcare?
- The Takeaway’s Health Care Roundtables
- Universal Health Care: Taking on the Myths
What are your thoughts on the German system?