Health Care in Germany

by Christina Geyer on August 18, 2009 · 55 comments

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:

Read more of my health care series:

What are your thoughts on the German system?


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{ 52 comments… read them below or add one }

1 Lilacspecs August 18, 2009 at 3:53 pm

Belgian healthcare, from what I know if it (which isn’t a ton, but certainly enough to know the basics) is set up very similar to German healthcare.
I was going to write about it for you but I really don’t know enough of the ins and outs to put together a comprehensive summary. All I know is that for both Hans and I we pay a fraction of what I used to pay in the U.S. just for myself and more things are covered here.
.-= Lilacspecs´s last blog ..Het Achterhuis, the diary of Anne Frank =-.

2 Juliette August 18, 2009 at 4:55 pm

Just a note: People working for the German government who qualify for “privat” insurance aren’t required to take it. In fact, there is a percentage of people who qualify for privat but refuse to take it on issue of principle (ie they say privat patients have an unfair advantage over ‘public’ insurance).

For us, as my husband works for the government, it was actually considerably cheaper for pay for the partial private coverage than it would have been to pay for public. Strange, but true!
.-= Juliette´s last blog ..End tables: Take 2 =-.

3 Stacy August 18, 2009 at 7:02 pm

Christina, you just moved me a lot closer to being willing to entertain a “public option” policy. My reservations vis a vis the proposals floating around over here (since there still isn’t an actual bill on the table) are more or less as follows:

1) Multiple Democrats are on record as favoring single-payer, while as you describe it, one of the key features of the German system is competitive field with multiple public and private insurers. Whatever the US goes with _must_ reduce overall cost, or nothing else is going to matter. Single payer means monopoly, and no monopoly in history has ever reduced costs.

2) It’s possible for bureaucracies to function well, but I think a couple of the necessary conditions are a high level of social trust and relatively low corruption in government. The US is in bad shape on both of those fronts these days. Both major political parties have a high level of corruption, and factional feelings are strong in the population (or it seems like it lately)

So, I suspect that Germany’s system works well for Germany, but wouldn’t necessarily translate in the US. Definitely food for thought, though. Despite what some are saying, pretty much everyone agrees that the system needs reform, just not on what reform is needed.

4 Christina Geyer August 18, 2009 at 9:17 pm

@lilacspecs: You could just write about your own experiences with health care. I’d love to hear a little about what you think of the health care in Belgium.

@juliette: My husband is also a Beamter (one of the government workers that is partially covered), so we’re in the same situation. It is much cheaper for us to take private insurance for the part not reimbursed by the government than it is to pay in to the public system. If there weren’t such a big difference, I would have been more than happy to stay publicly insured. Submitting all the paperwork for reimbursements is a serious pain!

@Stacy: Wow, I worked hard on this and it’s cool that I’ve affected someone’s opinion!

5 Sabine August 18, 2009 at 10:09 pm

Thanks a lot for your post.

Just two small comments:
one on the waiting room times: I encountered more or less everything between 0 minutes and 3 hours or more. What I heard from friends and family: patients with private insurance might have to wait a little shorter. And more importantly they also can schedule an appointment in much shorter time (mainly applies to specialists like orthopedists).

two on losing the health insurance when losing the job: the insurance is connected to your job as your employer pays half of your contribution. When you lose your job, depending on your situation, you do not exactly lose your insurance, but depending on your situation, it might change who pays for it. As compared to other countries (e.g. Italy or Spain) where the public health insurance is independent of your job.

I might be able to contribute something on the Dutch health insurance system, but so far my experiences are not very extensive.

6 Isabella August 18, 2009 at 10:30 pm

I love this! Wonderful! Thanks so much for taking the time to put this together. So very helpful and informative!

7 Marilena August 19, 2009 at 2:28 am

Thanks this is very interesting. So a doctor usually either works at a hospital or has his own office? So what happened if your doctor decides that you need an MRI or CAT scan? Who chooses where you would have that done? How long would you have to wait? I am asking specifically about those because in Italy there is usually a long wait for those test?
Thank

8 rositta August 19, 2009 at 5:21 am

Christina, well put together post. I have seen the German system in operation and wish that our Canadian system would be like that. This country is so fixated on a public system (which is going broke) that we’re all going to die waiting for care. The only things we can pay for are drugs, dental and chiropractic treatments. The wait time for an MRI is roughly eight months in my city…ciao
.-= rositta´s last blog ..Were We’ve Been =-.

9 Moe C. Larry August 19, 2009 at 8:59 pm

100 million Americans underinsured or uninsured? Right.
I lived in Germany too, and it was far from the paradise you are talking about. The first thing I look for is the infant mortality rate measured the same in both countries, because it is not. The second thing I look for is are the populations the same, because they are not. We have a much more diverse population than Germany with many times the number of residents that come from a third world nation. So it looks like you fail on just the basics, so why waste my time reading propaganda?

10 Christina Geyer August 19, 2009 at 10:38 pm

@sabine: I made some points about the treatment of private patients in my next post. I’d love to hear any thoughts you have on the Dutch system.

@marilena: Doctors either have private practices or work in a hospital, so the obgyn you see during pregnancy is not the one that will be there for the delivery in the hospital. The wait for an MRI or CT scan can be anything between a day and a month or two. It probably depends a lot on what it’s being requested for. And you choose where you get it done, the doctor just gives you names and addresses of places that can do it.

@rositta: Wow, that’s hard to believe. It seems the UK and North America have some serious health care problems (although I think Canada and the UK are still better on average than the US).

@Moe C Larry: If it’s such a waste of your time, why bother even commenting? You could have contributed to the conversation by actually spelling out the issues you had with health care in Germany. You’ve left it completely open. It’s up to our imaginations to figure how it isn’t the “paradise” I supposedly describe (and it isn’t a paradise, it has its problems, I’ll be happy to go into more detail on those in Friday’s follow up post).

So where do my numbers come from?

  • How was infant mortality measured? – See pages 25-26 of the Indicator Compendium report (pages 28-29 in the Acrobat reader) by the World Health Organization, “Infant mortality rate is the probability of a child born in a specific year or period
    dying before reaching the age of one… For developed countries where civil registration is complete, IMR is computed directly from data of the civil registry if the data of the year to be estimated is available.
    ” They are measured the same way.
  • 100 million Americans uninsured or underinsured – Commonwealth Fund Report – Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families—Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007
  • Finally, your point on the US being more diverse than Germany is true, but how does that make me fail on the basics? I’m describing the health care system in Germany. How would the demographic makeup of the US contribute in ANY way to a discussion on how health care works in Germany? It is completely relevant to a discussion on health care in the US, but that’s not what I’m doing here. I don’t think I’m the one who just failed on the basics.

A side note to you, Moe C[urly] Larry: A stooge is generally defined as a person that is under the control of another. Nice one.

11 Maria August 19, 2009 at 11:42 pm

One thing to add– When I was pregnant in Germany, I was able to have my doctor and midwife deliver The Boy in a private hospital. It was covered by my public insurance except for the midwife, whom I paid 300 Euro to stay with me the entire labor. I was able to have her for pre and post natal care too. I’m not sure why or how the doctor was able to do that other than he was in a private practice with two partners and somehow could be there. The midwife had privileges there too. Probably not normal though…
.-= Maria´s last blog ..Fitness is Important =-.

12 geoff August 20, 2009 at 12:11 am

You probably saw that I put a brief resume of my experiences on my blog.
I just hope your excellent summary gets sent round a few forums in the US.
.-= geoff´s last blog ..Health Care in Germany–My Experiences =-.

13 Christina Geyer August 20, 2009 at 12:31 am

@maria: I think that is unusual.

@geoff: I really hope so, it would be great to help people realize it’s not scary at all.

14 ClintJCL August 20, 2009 at 1:35 am

Excellent post, Christina!
.-= ClintJCL´s last blog ..links for 2009-08-19 =-.

15 J August 20, 2009 at 4:35 pm

This is an excellent post! I have been fighting ignorance and fear with my family & friends when it comes to the proposed health care changes in the U.S., and the misinformation and lies about existing universal coverage programs is driving me crazy! I hope you don’t mind if I link to you from my blog.
.-= J´s last blog ..B’s first day of kindergarten =-.

16 Hayley August 21, 2009 at 10:48 pm

I came over from J’s blog…thanks so much for outlining some of the differences, I, like J am tired of explaining that healthcare doesn’t have to be the big bad wolf the ‘right’ is making it out to be. I was born in New Zealand and have lived all over the UK and Europe and now reside in the USA. When in NZ & UK I received exceptionally good care under the NHS from each respective country. I cared for a little boy in London with massive heart issues and he was under the care of one of the top cardiac surgeons in the world…did any of us ever see a bill, an EOB? All this talk about Death Panels reminds me of how things are actually managed through Insurance companies. My BIL almost died as a result of being taken to a hospital in florida that said they accepted his insurance but after arriving they made him wait SIX hours while they decided to admit him because they weren’t sure if they could accept his insurance? (sad that my sister had to call the hospital en route to ask in the first place)…after six hours they transferred him to another hospital, his appendix burst on the way there. He was an employee of the State. Sad huh.

On a personal level, my experiences have also been not so rosy….as a sufferer of multiple miscarriages I was on vacation in Aspen, Colorado when I felt ill, I called a local Dr and she agreed to see me. She told me I was miscarrying and needed to go to hospital to prevent massive hemmoraging, she called ahead to tell them I was coming. Surgery was performed within hours and I was released. But due to the fact that the DR had called ahead to warn this small hospital to call in an anesthesiologist the Insurance company coded the procedure as ‘elective’ so my husband and I were stuck with a $6000 bill and we had INSURANCE! I fI had not recieved the surgery I could have bleed to death…gee, I guess the meaning of ‘elective’ has changed…perhaps it’s my accent?

The system is a mess over here. I’m tired of people yelling from the rooftops that the US has the best of the best of everything…when in most cases they have never ventured far enough to experience or witness any other systems.

What are people so scared of? If one more person compares Obama to Hitler I am going to gag!
.-= Hayley´s last blog .. =-.

17 cliff1976 August 22, 2009 at 11:32 am

I’m tired of people yelling from the rooftops that the US has the best of the best of everything…when in most cases they have never ventured far enough to experience or witness any other systems.

Thank you, Hayley — I agree completely. It embarrasses me, as a willing or unwilling representative of the USA living in Germany, when locals come back from a vacation to Florida or the Rocky Mountains and tell me how much some aspects of the USA (OMG!) — rightly or wrongly — aren’t the best (cell tower coverage, environmental issues, immigration questionnaires at the airport, whatever). I think there are some serious gaps in common understanding originating on both sides. Germans gripe about immigration practices at the airport, but only watched 9/11 on TV. Americans, like you said, need to spend some time outside the U.S. experiencing other countries before boasting about whatever aspects of their own country. Otherwise we’re just so many hooligans coasting (for how much longer?) on the greatness of generations before us.
.-= cliff1976´s last blog ..Buttermilk Biscuits =-.

18 Christina Geyer August 22, 2009 at 9:22 pm

@Clint: Thanks!

@j: Absolutely not, please, link away. I want to spread the word that there’s nothing to fear about universal health care.

@hayley: Your experiences there in the US are terrible! I’m sorry you and your family had to go through those things. I really don’t understand the belief that criticizing the US health care system is an attack on the US. Being patriotic about a broken health care system doesn’t make it better. Why are the people who want to reform the system called unpatriotic when we just want to make it great, something to really be proud of.

@cliff: Here here. Agree completely with you.

19 daisey0907 August 23, 2009 at 3:21 pm

Actually, the best option would be competition and less government regulations. The ability to buy insurance a la carte and across state lines would be key to my solution.

Really, the state of Delaware required that insurance companies cover hair plugs!!! What! So everyone who gets health insurance in Delaware has to pay for hair plug coverage even if they never use it. AH, government policies at their best!

We pay for our own insurance and I have been without insurance. And I still do not support the public option in that bill especially there are already public options available to the needy!

20 Sha August 24, 2009 at 8:40 am

Daisey: And what sort of public option do the working impoverished have? Most times they make too much to get on any sort of federal aid, private insurance is too expensive and if they are lucky enough to work for corporate employer, they don’t work enough hours to get insurance. The problem is most people seem to forget about those who work and make below the line of poverty.

21 Christina Geyer August 24, 2009 at 9:43 am

@daisey: Because deregulation worked so well with the banking industry, right? I also went through the Delaware Title 18 Insurance Code and could not find a section requiring insurance companies to pay for hair plugs. I did find Chapter 314, requiring them to pay for hair prostheses for people who have suffered hair loss due to alopecia areata, which seems fair to me. I’m guessing this amendment was twisted into coverage for hair plugs in whatever news source you learned that tidbit from. If I’m wrong, please point me to the appropriate section of Delaware’s insurance code.

@Sha: Very good point.

22 Snooker August 24, 2009 at 11:37 am

Excellent series Christina, thank you for the work involved.
I too will be giving you the linky/linky to pass this information along to as many Americans as I can.
.-= Snooker´s last blog ..Random Tuesday – Philosophical Edition =-.

23 Hayley August 24, 2009 at 11:12 pm

I think a lot of people get their information from the ‘fake’ news, um I meant to say FOX news. Clearly stellar reporting at it’s finest. That’s why I get my news a la BBC.
.-= Hayley´s last blog .. =-.

24 Christine Potthast September 26, 2009 at 2:28 pm

Hi Christina!
Thank you for this excellent post. I am from Germany and have lived in Houston, Texas for 20 years. My children are growing up here and for me, this is home. What has surprised me this summer was the viciousness over the ongoing healthcare debate. At times, I find it startling how people are arguing with each other and I have wondered why we are not looking more to the experiences of other nations? Scandinavian countries, for example, have very good healthcare. Although, I have done no research on the statistics, I can confirm that German healthcare is at a very high level. In fact, when we visited this summer, we had to consult a doctor. We got an appointment within two days although we are not regular patients. I wish we could discuss this more rationally, learn from others and combine the best of several system. –
I will post the information you gathered on my facebook page. Thanks again. Christine Potthast

25 mikeinreality October 8, 2009 at 12:51 pm

Hey,

So I live in Germany and have for several years. First, I have to say, the health care is not better than what I had back in NYC but that is just my perspective. For example, twice in Germany, I had a doctor that smoked while reviewing me. In NY, I always got great care, however, I was one of the lucky 250 million insured in America.

Granted, as a system overall, Germany’s concept has its advantages; however, certain terminal illness patients will not be given life prolonging drugs/all options and that part annoys me about the German system. It is similar to dialysis treatment in the UK in that sense. In other words, they only experiment on medicine they deem appropriate. Again, these cons still outweigh other cons of the American system but they are also as you said, far from perfect. I think it is important for must people to realize that the German system is very, very, very far from perfect and just ask your average German. They will only mention it in terms of being superior to the American system because well it is but they know how bad it is too.

Lastly, not to spit venom on your post because your heart is in the right place but many of your figures are off, sorry to be the one to point it out. For example, when weighing a pro and con in an attempt to measure two things then the two things need to be apples to apples in order to give statistical significance. In other words, most of your figures do not account for a weighted average, a standard deviation, or a universal measuring point to better defend your argument. This is likely because you lack the necessary knowledge, skills and ability to actually tackle such daunting tasks like health care comparisons. What I am saying is: A. when looking for a better system then America, there are many other EU countries that highlight health care strengths far greater than Germany’s.; and B., You should probably just stick to your day job.

26 Christina Geyer October 9, 2009 at 7:17 pm

@mikeinfantasyland: First, you really should get some new doctors, cause the ones you’re visiting sound like quacks, and quacks exist in every country. I would also agree that my health care in the US was excellent, and my health care here is just as good. The point is not that medical treatment is better here, the point is that everyone can be insured without overall treatment levels suffering.

I would have to disagree that terminally ill patients don’t receive life prolonging treatments. They do. They might not receive ALL options covered, but they can certainly pay privately for any procedure or drug that they desire. In the US, I ‘m pretty sure that insurance companies are not approving ALL life extending treatments and procedures to patients. Nicht wahr? With people living longer and medical care becoming more advanced and expensive, not everyone can receive every option without bankrupting a society. The cost of a treatment needs to be weighed against the resulting gains in quality of life and/or longevity.

I disagree that only “experiments” that are “deemed appropriate” (by the German health insurance system? Your argument did not make this clear, so I’ll have to assume) are taking place, universities and research institutes here do medical research paid for by German and EU science grants (not by health insurance or the German medical system), and one of my best friends has incurable cancer and has already taken part in two studies (she also receives plenty of life extending treatments and has for years).

As to the average German, maybe you’re hanging out with a bunch of outliers, because I don’t know a single German who is so pessimistic about their health care. I’d say the majority see problems and room for improvement, but I don’t think they view it so severely.

While I agree that there are European countries with better health systems than Germany, I am a blogger who writes about life in Germany, so I chose to write about the German system.

I’m wondering what exactly you would like me to take the weighted mean of? Because there is no variable listed above where I could imagine that would apply. What do you want the standard deviation of?

Of the comparisons made at the beginning of my article, only the life expectancy calculations involve any statistical inference. The reporting of the number of hospital beds, the infant mortality, and the other variables within industrialized nations is fairly accurate, there is no estimation involved. If you bother to read the World Health Statistics Indicator Compendium (life expectancy is on p.28 of the report, p.30 in Acrobat), you will see the methodology used for life expectancy calculations. Life table data were used in weighted regression models, with later years being weighted more highly.

And what is the definition of a universal measuring point? Because in my 7 years of statistical education, I never came across that term. In fact, Google only came up with 4 occurrences across the whole world wide web (and two of those were on the same site).

Sure, the US and Germany are different, as are their health systems, but the methods of calculating these statistics were the same within each country. If you want to throw out the use of observational data and stick to controlled, double blind studies, you are going to have to pretty much throw out the sciences of epidemiology and demography.

And, by the way, this is me sticking to my day job.

27 real patriot October 20, 2009 at 1:34 pm

shame on YOU!!!! Germany is not a perfect place Ive been there. Germans have imigration problems with turkish peoples Germans commited the big atrosity of this century when they exturminated jews. Nothing good can come of such EVIL peoples.Are you an American? I have doubts. this is all propangist lies. you love barack HUSSEIN obama but they would have him gassed.

28 Maria October 20, 2009 at 4:12 pm

Perhaps “real patriot” should get the log out of his eye. Americans have committed our own atrocities– interment camps for Japanese, hanging of black people, murder of Arabs, death by burning, electrocution, and lethal injection, torture– we are far from being morally elite to any one or any nation. Our past is sketchy at best. Germany may not be perfect, but they aren’t the devil either– nor are they “evil.” Americans like “real patriot” embarrass our nation and are anything but real patriots.

29 Jentry October 20, 2009 at 6:04 pm

Well said Maria! To add to what Maria said, the US also has it’s issues with immigration. I’m from Texas and there is a pretty big problem with illegal immigrants there. And to reiterate what Maria said, American history is not as happy and cheery as you might like it to be. We have had our share of “evil people” in our history. (Oh, and by the way, Hitler was Austrian…just a little tidbit for ya there.)

Have you ever heard of Audi, Porsche, BMW, Volkswagon, Heidi Klum, Brahms, Mozart, Richard Wagner, Roland Emmerich. Nietzsche, Albert Einstein, Dirk Nowitzki, just to name a few??? Yeah, nothing good ever comes from Germany….
.-= Jentry´s last blog ..Smiling Baby =-.

30 yourprobablywrong November 2, 2009 at 3:01 pm

http://www.dw-world.de/dw/article/0,,4546042,00.html

I am not going to agree or disagree with anything said but I do think you only perceive the German system better because you come from a land that has no viable medical options. At the end of the day, I would also say Germany’s system is not so great, hence why they are trying to make so many changes to it. Just because it is better than America does not mean much.

31 Michael November 4, 2009 at 11:58 pm

Hello Christina,

Thanks for posting your viewpoints and experiences regarding the German healthcare system and sharing them here.
I also have a few additional questions I hope you’ll have the answers for.
Are abortions covered under the German healthcare system, and if so are there any restrictions currently in place for them?
Do German medical personnel have the option to opt-out of procedures or treatments which they feel are not ethical or immoral?
I could not find any information regarding these two issues as it relates to the current German system.
These are two BIG issues currently being debated in the proposed US legislation.

Danke!

32 Christina Geyer November 8, 2009 at 11:05 am

@michael: 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.

Here is an informative page about abortions in Germany (in German): http://www.netdoktor.de/Gesund-Leben/Schwangerschaft+Geburt/Schwangerschafts-abbruch/Schwangerschaftsabbruch-353.html

33 Nelson January 24, 2010 at 1:37 am

Christina,

I am working on a paper about the German healthcare system and I am having some problems finding information about care given to illegal aliens/non-German citizens. Can you shed some light on this for me? If a Turkish beggar showed up at a hospital with a cough would they turn them away? Would a hospital deliver a baby for a pregnant transient? As I’m sure you know in the U.S. pretty much anyone can go to an emergency room for treatment and not get turned away (Millions and Millions of dollars are spent delivering babies of illegal immigrants each month here in Texas). Any information or personal experience you can relay would help. Thanks!

34 Horace Hicks January 26, 2010 at 10:14 pm

Christine,
Thanks for your posting, although I think there are a number of points that should be further pursued. How many non-paying patients are regular users of the German System? What is the range of actual monthly payment from the Euro 400 monthly to the highest, and what is the average cost of private insurance? I worked in Germany for 30 years and was fortunate enough to be a Private Patient as my time was much better spent getting in and out and back to working as opposed to the long waits for the masses. I just read that the average number of medical visits for everyone in the German system (Die Welt) was just over 18 per person and that of the 4th positioned US at just over 4. This translated to 45 visits per day per Doc in Germany, leaving precious little time for each. So if three Private Patients per day showed up with a 30 minute visit each, it cuts the Doc time tremendously. With a smaller number of Docs per capita in the US, if the number of visits even doubled to 8 per person, including the 40-50Million non-peyers, the system would be on the verge of collapse, overnight.

There are a ton of pros and cons to each system, but the overall society is a major factor in the function/non-function arguments.

35 Christina Geyer January 27, 2010 at 2:30 am

@nelson: Here’s a link I found: http://www.dw-world.de/dw/article/0,,4056861,00.html. Basically, anyone with an emergency is treated, with or without insurance, but they may be reported to immigration, although doctors groups disagree with reporting immigration status.

@horace: Thanks for commenting. You ask some good questions, and I will do some more research on them when I’m able to spend more time on the computer (my condition, HG, doesn’t allow me to look at a computer screen for long at the moment).

A couple points though, I spent about 5 years as a public patient and never had long waits to get an appointment, and have been a private patient for almost 3 years now, and don’t feel I’m getting substantially better treatment than I did before. I get a couple more tests performed and our pediatrician and a surgeon I visited once had seperate waiting rooms (we aren’t paying for private hospital rooms or treatment by department heads). I would very gladly go back into the public system, because the prepaying and submitting bills is a hassle, but my husband is a Beamter (permanent gov’t employee) and I stated in the post why they need private insurance.

Also, assuming the 45 patients per day number is true, and assuming the doctor is seeing patients 7-8 hours a day, that still gives 6 patients seen per hour, or 10 minutes per patient. Personally, in my almost 8 years in Germany, I haven’t felt like I was getting less time with a doctor in Germany than I did in the US (I’ve lived in 4 different cities ranging from the northeast to the southeast of Germany). Additionally, stopping by to get a prescription refill, without ever seeing the doctor, counts as a doctor visit (that’s how it’s charged on the bills I submit to insurance). So people requiring medication for chronic conditions would up the number of visits without taking up more than a second of the doctor’s time needed for him/her to sign the prescription.

I agree that society plays a major factor in how healthcare functions, but as you say, Americans go to the doctor much less frequently than Germans. I don’t think this would change substantially if Americans had universal health care. Going to the doctor takes time. With the information so readily available on the internet and so many medications available over the counter, I doubt Americans would suddenly start going to the doctor in droves. Living in Germany hasn’t increased the frequency I, or anyone other American I know, visits the doctor. We only go when we absolutely need to. Although I’m sure there are exception to this, I think, for the most part, people’s behavior would not really change.

Something Germany has done to decrease visits is to charge public patients 10 Euro per quarter to see a doctor. That amount could be increased or a per visit charge could be implemented if doctors were overwhelmed. Given that Americans are used to copays, while Germans are not, I think this idea would not be a problem at all in the US.

When I can, I will look into finding statistics on insurance in Germany. Thanks again for bringing up these important issues.

36 CPB February 8, 2010 at 12:16 pm

I disagree with the statement. “the quality is world class” I have lived here for 3 years and every time I go to see the doctor I get the feeling like they never have enough time to listen to problems or questions. I have been to 5 different doctors looking for one that is actually interested and have not found one yet.

37 Christina G February 8, 2010 at 5:57 pm

@CPB: I think we need to keep things in context. There is variance in every country’s medical system. The US included. Not every doctor in the US is “world class”, but “world class” medical care is available in the US. A random GP in the US is very unlikely to be equivalent to a top medical researcher in the US. The same is true about Germany. The doctors at the top institutes are just as good whether you are in Germany, the US, or the UK.

I remember when I first moved to the relatively poor area of Durham, NC, and had to find a GP to replace the one I had in the relatively rich northern Virginia suburbs, struggling to find a suitable doctor. I was pretty shocked at some of the doctors there. In my three years there, I went from doctor to doctor, never settling on a GP. When you move someplace new, it can take a while to find a doctor you can trust and can build a relationship with. If you find someone right away, I’d say count yourself lucky.

You don’t say where you are located, but I would suggest if you’re in a rural or suburban area, try going to the nearest city. In a city, try going to a doctor in the richer residential or business areas. If you live in Berlin, Frankfurt or Munich, try visiting one of the doctors that have registered with the US Consulate as English-speaking. They’ve actively gone out and are trying to recruit American patients, so they’ve generally had experience dealing with us and our cultural expectations towards medicine. I had a lot of luck picking doctors off the Berlin list when I lived there. Good luck!
.-= Christina G´s last blog ..Back to Deutschland =-.

38 Stanley Johnson March 22, 2010 at 3:12 pm

Thanks for your great blob onb health care in Germnay. I lived in Germany for many years and have not been able to describe German health care as brilliantly as you did.
Do you have a blog on Long Term Care – Pflegeversicherung or are you planning to write about it?

39 yoursiteseemstosuck March 25, 2010 at 11:31 pm

What experience do you have that is relevant to medicine that makes you so comfortable even pretending to speak about this stuff as if you know it? Or are you just a typical blogger who speaks with no idea because that is how you sound. As a very liberal person, I probably agree with your points but find your approach obnoxious.

40 Christina Geyer March 26, 2010 at 12:25 am

@yoursite: Speaking of obnoxious approaches… LOL. Reading comprehension is not your strong suit, eh? You “probably” agree with my points, but you’re not sure? Did you read the post? It doesn’t sound like it.

As I’ve stated quite a few times in the comments and also on my About page, I am a trained statistician who has worked in health research (studies on genetic and environmental factors in healthy aging and clinical trials of cancer treatments) and in the pharmaceutical industry (clinical trial planning, analysis, and working on FDA and BfR submissions) in both Germany and the USA. My husband also contributed substantially to this post, in addition to having been a paramedic in Germany in his youth, he is a cancer researcher and professor in the medical school here in Regensburg and also spent time as a visiting professor at Duke University in the USA.

41 Christina Geyer March 26, 2010 at 12:34 am

@stanley: I don’t currently have a post about Long Term Care. I will look into writing one when time allows. Thanks for commenting!

42 rositta March 26, 2010 at 1:01 am

You know Christina, now that health care reform has passed in the U.S. you will get all sorts of nasties coming out of the woodwork. I’m not sure they got it right actually and I wish Canada were more like Germany…ciao
.-= rositta´s last blog ..The End Of The Rainbow =-.

43 Pat March 27, 2010 at 11:16 am

Don’t sweat the trolls, Christina. I bet you a million dollars if you had written a post trashing German health care they would be commenting how awesome it was and not asking about your qualifications. I’m sure none of them question views that agree with them. We all have a right to have an opinion about a subject and if you have a blog you can write about it on your blog. If I don’t agree with something I just move on instead of making a jackass of myself. And the stupid thing on their part is that you are totally qualified to have an educated experienced opinion on health care!

44 YOU LIE March 27, 2010 at 11:01 pm

so were supose to beleive some random anonimus blogger that claims to no somthing? you can calim ur a docter or lawyer or statsician but that dont make it tru. someone making up numers out of theair and telling lies on them doesnt make an exprt if you like it so much in europ you should stay and not push entitlment progams for lazyass blacks and illegal mexicns on harworking americans

45 Jentry March 29, 2010 at 6:11 pm

Ok, I wasn’t going to get into this, but I feel I must since some people seem to not be able to read (or spell). First off Mr. “You Lie”, I think you need to go back to a certain government program, namely school, to learn how to spell. That being said, yeah. I think you need to educate yourself on what the bill is actually about. Are you going to deny sick children health coverage? Yeah, I didn’t think so. Oh, and to stereotype blacks as lazy and all hispanics as illegal are like me calling you en effing redneck. Yeah, you don’t know these people in need of health care. They are hard working Americans, yet the cost of health care in the US is insanely expensive that they simply can’t afford it…especially if you have a pre-existing condition. If you have a pre-existing condition you are just screwed. So, Mr. “You Lie”, educate yourself on what exactly this health care bill is going to do (yes, even for you you effing redneck) and please learn to spell. Oh, and everyone is allowed to speak their opinion, and having a blog is one of those ways in which you can do this. Christina is highly educated on this subject and had a very highly educated opinion on this matter, so it might be good to just process a bit of what she has to say…but you probably won’t. I’ll let you get back to your Fox News and Rush Limbaugh now…

46 Agreetodisagree July 9, 2010 at 10:22 pm

What’s weird is that you seem to attack people with different views on this blog. Perhaps, that is the nature of being a blogger but still I think such an offensive is lame. Also, to whoever was calling out the spelling errors, that one read like a non native speaker to me, so cut him/her some slack.

Lastly, I have lived in the States and Germany, and I can not say the German care is better. I have had private and state in Munich and thought both were pale in comparison to America’s care.

That does not mean I am republican or against universal health care or whatever. In fact, just the opposite, I think the German care so terrible, one of the worst I have ever had, and I have even lived in West Africa, which has actually great free health care (Ghana). Ok, ok, well its not there for everyone and has its weakness of course, its Ghana.

My point is, the German care is terrible because they attempt to satisfy both a large corporate interest with insurance companies and maintain the superior social state, however, all the while weaking the structure of that state and level of care.

Germany Health is not as good on average as America, that is just a fact. Now, if you wanted to say, Germany health care is more available to the average person then I would agree, because it is, of course. I can not though in anyway agree with the level of care being good here.

I have never felt like the doctors were interested in my concern. They were distance, not thorough and seemed to prescribe things too fast, too easy just to bill an extra item and make money because they could not do it any other way. Not to mention, the doctor’s in Germany have long wait times and almost never take appointments without private insurance, and give priority to such people because they can make more money through private insurance carriers. Basically, they also seem to just give you useless treatment, all in the name of making a buck. I have read your blog and talked with many German friends before and after I chose to respond, and I still strong believe you sadly mistake and no offense, but drinking a little to much of the local kool-aid.

And to any of the obvious would be grammar police on your blog, which there seem to be a few. Whatever, this is a blog comment, so in my Kerouac-esk stream o consciousness bothers you then maybe you should spend more time reading things that are not the ramblings/opinions of random strangers through an internet blog.

47 Agreetodisagree July 9, 2010 at 10:23 pm

One other thing, I do mean to say because I don’t want that last one to come of rude because I do really like your blog and mostly I like your comments that don’t require me to do a million steps to respond. Good work, just not on this article.

48 Christina Geyer July 10, 2010 at 10:42 pm

@agreetodisagree: I suppose, if we are judging health systems based only on personal experience, rather than on health statistics, then as your name states, we will have to just agree to disagree. My experiences, both as a public and a private patient here in Germany, have been quite the opposite of yours.

49 Christine Potthast October 24, 2010 at 3:07 pm

Christina,
Your article is excellent. It is very well researched and portraying the healthcare situation in Germany better than anything I have read before. I am sorry to come across it a few months after initially reading it only to find some really nasty comments, that are unsubstantiated and rather geared at disrupting a fruitful discussion than at finding answers. – Don’t worry, your research speaks for itself. – Of course, as in any place of the world, you will have doctors in Germany that you will like and there will be those you will not like. – Exams in medical school exams do not put personalities to the test. I have found great physicians in the US, and I have had bad experiences, two really bad experiences actually. In 1997, I almost died after surgery in the famous Houston Medical Center because the nurses in charge and the treating surgeon made a big mistake. Thanks to my neighbor who had stayed with me that night, I survived. She ran from one nurse to another until she finally found a nurse (on a different floor) that would understand my symptoms – and the alarm went off. I was saved last minute. – While I did not experience such a grave situation like that in growing up in Germany (I was younger of course), I came across some doctors I did not like at all but changing to someone else was never a problem. I will never understand why people in the US are so vehemently fighting against the idea that there could be healthcare for everyone. – A healthy population is not only happier but also more productive. Besides, we can all get sick, it can happen to any of us, anytime. I don’t understand the concept of making healthcare a privilege. -Thanks for your great blog, Christina. Positive accounts such as yours need to be spread in this country to open the eyes of those who cannot see it yet: Healthcare for all is not only possible, it means progress for the entire country.

50 Patrick October 29, 2010 at 7:46 am

I wish there was a comparison b/t the U.S. and Brazilian health care system. The economics of dissimilar, but the ethnic demographic are more similar then any other country in the world. This would then allow a better opportunity for case study of health outcomes.

51 Nancy October 18, 2012 at 7:47 pm

Could you please do a new blog post with updated health care stats? The first one is so helpful, and it would be interesting to see if there are any changes. Thanks!

52 Theressa Salisberry March 28, 2013 at 2:46 pm

Yeah ok Tom (yeah i know you), you have the guts to post such comments? At least respect the OP views!

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