What is healthcare like in Germany?

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What better argument for universal health care can you make than that of Germany? By far one of the most successful systems, it has had some form of universal health care for almost 130 years, and is currently one of the most successful health care systems in the world. It is again, a mixture of public and private funding, with employers providing most of the funding for health care by paying into one of several hundred “sickness funds” that provide health care funding to their employees. Germany is widely regarded as having excellent access, short wait times, care with the best technology and pharmaceuticals available, and this again while spending 10.7% of GDP (US 16%) with per capita spending of ~3.3k USD (approximately half of that in the US).

The German health care wikipedia entry is a good starting point, and it’s always fun to try to translate German web pages and try to make sense of Google translations. But I’ve found several good articles describing the system including several articles in the MSM like this NYT piece which refers to Americans as having an “… immature, asocial mentality [that] is rare in the rest of the world,” one for travelers, and one for those looking for German jobs. The consensus seems to be that Germany rocks when it comes to health care.

Let’s talk about how it performs and how it works.


I know I’m starting to sound like a broken record, but as usual, the universal system blows the US out of the water in terms of cost and performance. A survey of health satisfaction comparing the US and several other countries, including Germany, showed that they are superior in many measures of patient satisfaction and provision of care.

Germans enjoy the shortest wait times for elective procedures, short ER wait times rivaled only by the Netherlands, and are the most likely to get a doctor’s appointment within one day’s notice. Depsite this the Germans seem to be the hardest on their system, with many thinking it could be better and needing significant reforms. In performance and outcomes data it’s better than the US in almost every regard but about middle-of-the-road compared to most other universal systems studied.

Their system works almost entirely through funding of “sickness funds” through employers, with a small contingent of private funding (about 10% of people) from those who are self-employed or make enough money to opt out of the system. The system is still one-tiered, despite the option of buying insurance that provides more amenities, all Germans have access to the same health care from mostly public hospitals, and public and private clinics. From the age of 18 to 65 all Germans are required to have insurance and employers match funds provided by employees. Private insurance can be bought, one can self-refer to specialists (unusual in most universal systems), and fee-for-service does exist though rare. The sickness funds are non-profit, and independent of the government, but highly-regulated funds that are incentivised to pay for chronically ill and sick patients. The large number of funds allow a great amount of choice for individual subscribers.

Germany to me doesn’t sound like they have a perfect system, but it is an enduring one, and one that outperforms the US. Again, the key we’re seeing among these successful systems based on private insurance is a high degree of regulation designed to prevent the sick from being screwed out of the system and better sharing of risk.

Comments

  1. #1 rob
    May 27, 2009

    what are ya? a communist? if god meant for the u.s. of a to have a good healthcare system he would have added an 11th commandment. you can have my health care system when you pry it out of my cold, dead hands!

    (which, may not be that far off considering our system here…)

    but seriously, it really gets me down when i hear about europe’s health care systems.

  2. #2 perceval
    May 27, 2009

    Still no comments? Well, as a German who is now living in the UK, let me weigh in.

    Germans have been through several reform attempts in the past 10-20 years; it’s well known that the current system has giant funding gaps. When I left Germany almost nine years ago, patients could go straight to specialists. The primary care provider as gatekeeper model was not really implemented very thoroughly (and people would be up in arms about it). Women routinely saw (and still see) an ob/gyn for their checkups and also in pregnancy, while children see dedicated paediatricians. In the UK, all this is handled by GPs.

    In Germany, people who are with one of the private insurers are perceived to be treated better, more quickly, and with more appropriate / expensive medication than people who are in one of the state-mandated insurance schemes. Many people have additional insurance for hospital stays to ensure preferential treatment and better rooms. The big problem is that once you’ve gone “private”, it’s very difficult to switch back. Also, while normal insurance will include your children for free, private insurance won’t. Private
    insurers appear to price their products like American insurance companies.

    Overall, provision in Germany is better. For German children, regular check-ups are recommended, which have been phased out by the UK system. Doctors are frustrated by low pay after a long training phase, lack of jobs, a system that rewards procedural over cognitive medicine (sounds familiar), and persistent underfunding.

    I suspect that the German system will become more like the UK system in an attempt to cover costs. It’s no accident that quite a few German doctors have defected to the UK for better pay and better working conditions …

  3. #3 VonMises
    May 27, 2009

    It seems that your analysis cherry picked to a certain extent, perhaps only looking at people not sick.

    http://www.cato.org/pub_display.php?pub_id=8483

  4. #4 MarkH
    May 28, 2009

    VonMises,
    It’s hard to tell in what context you refer to my analyst cherry-picking, as it’s just a survey in general of patients in other countries. However, you cite Cato, a denialist organization. They deny global warming, they are rabidly against any form of universal healthcare, they are libertarian ideologues and frankly I simply do not trust them as a source of information, period.

  5. #5 LanceR, JSG
    May 28, 2009

    Classic denialist tripe from Cato:

    American men are more likely to be diagnosed with prostate cancer than men in other countries, but we’re less likely to die of it.

    Correct me if I’m wrong, I’m not an oncologist. But isn’t Prostate cancer one of those where most men die *with* it, not *from* it?

    The usual “‘Murrican research roxxors! Da US is the place to be if yer sick!” without commenting on your ability to *pay*. Sure, if you have the money you can get great healthcare here. If you don’t, you’re screwed. Even with insurance, a serious medical condition can be a crisis.

    Anecdote, not data: last year I got pneumonia that rapidly progressed to a collapsed lung with empyema. I required a thoracotomy to clear the goo and reinflate the lung. A week in the hospital, six weeks off work, and the “copays” and “deductibles” and “not covered” expenses damn near put me into bankruptcy. The bill from the hospital alone was $45,000 (before insurance).

    So, the Cato denialist think-tank can blather on about American research (mostly paid with tax money) and “rah-rah we’re the best” until the heat-death of the universe. But that doesn’t mean diddly-squat to those who can’t pay for those wonder treatments.

    Of course, all this is going to be ignored by someone who chooses “vonmises” as a pseudonym. Libertarians always ignore anything that might challenge their preconceptions. Or their ability to do anything they want.

  6. #6 darmowe ebooki
    May 28, 2009

    Welcome. I think that yes it is. This blog is so interesting that you spend most of his reading of his time. Waiting for the next entries. Yours.

  7. #7 Luna_the_cat
    May 29, 2009

    So how does Germany handle healthcare for the unemployed?

  8. #8 Lin
    May 29, 2009

    Luna, the unemployed in Germany keep their insurance and are eligible for government assistance.

    Perceval is right to point to the various reform efforts in Germany. The latest reform has been going into effect over the last couple of years and right now the results are not looking too great. Now the system has massive funding holes, in part because of the world economic issues but also because of the new structure for payments implemented this year.

    It was a reform that no one really seemed to like from the start, except the Chancellor and the Health Minister.(That it’s a coalition government was probably one part of the problem.) This is an election year in Germany, so we shall see whether health care complaints play a role.

  9. #9 Brian
    May 31, 2009

    You mention nothing of the costliness. “Drug costs have increased substantially, rising nearly 60% from 1991 through 2005.” Hmmm….are you in DENIAL?

  10. #10 Frau Jones
    June 12, 2009

    I am an American living in Germany. I can not speak of the ins and outs of the system as far as who is paying what. I just know that I have never had such affordable, fast, comprehensive health care. I’m having issues taken care of that have largely been swept under the rug by my physicians at home. Fairly simple issues, really. My prescription drugs are unbelievably cheaper. So, for a decently healthy person, I can say that a simple comparison based on my experience with doctor visits, specialist visits, and prescription drugs, the German system far out-performs the American system. But, I suppose there will always be complaining by those who are native to a country and it’s previous symptoms. However, if we look at it in a relative light–and everything is relative–there is not much to complain about from what I see.

  11. #11 Frau Jones
    June 12, 2009

    I should also add that, though I am a teacher, I am eligible for the student rate, which is very, very cheap.

  12. #12 czarna lista allegro
    June 26, 2009

    Good job! Im glad to read that

  13. #13 Dave Edmnds
    September 12, 2009

    How does Germany handle healthcare for illegal aliens?

  14. #14 Anne
    September 13, 2009

    Hi,

    as a German I can answer that last question.

    Illegal aliens are and stay illegal in Germany, meaning that if they wish to stay unapprehended here, they either have to go without medical help or pay for it in cash. It is possible to pay directly cash and it is not as expensive usually for minor stuff. So many do just that.

    However, just as in the USA anyone can get free treatment in an ER at any hospital. They may not and they will not send you away if you arrive there with an acute sickness regardless of nationality. If the procedure involves high costs and a protracted stay you will at the very least get a bill and they will try to collect it, too.

    This means that one has to provide a valid ID card. If none can be procured then the police will be asked to verify the identity of the patient. Which usually means taking custody of an illegal alien after the hospital releases him or her. During the time that it takes to consider the alien’s case (e.g. whether he might apply for asylum and stay or is to be repatriated) health insurance is then provided by the state, just as for welfare recipients.

    One has to know that there is zero tolerance in Germany regarding illegal aliens, they will always be repatriated if there are no valid reasons for asylum. In conjunction with the fact that every inhabitant of Germany has to be able to identify him/herself via a valid ID document, it is practically impossible to buy something on credit (which also requires an ID).

    In everyday life that means that most illegal aliens go without medical help for as long as they can. They also have only a very constricted amount of possible jobs available to them (menial, low-paid work mostly) and have huge problems with normal day-to-day life. It’s these days practically impossible to rent a flat or even hotel room without an ID for example. So the number of illegal aliens living outside of state institutions in Germany is very, very low. It’s nowhere near the state of things in the USA. The vast majority of socalled illegal aliens already are in state custody, contained there until their court or eviction procedure is through. E.g. 2006 there were roughly 21,000 official aliens demanding asylum in Germany (population thereof 84,000,000), which gives you an idea on how minor that problem is here. If there are more than a few hundred or possible a couple thousand illegal aliens living in Germany outside of the system I’d be very astonished.

  15. #15 Anne
    September 13, 2009

    Hi again,

    regarding how we Germans see our healthcare system, it is not as positive as the outside view. Funnily our gripe is not with the system itself, but instead with the fact that it has been – by and large – much “americanized” over the past decades.

    It used to be that the only difference between private and public insurance was comfort of circumstantial treatment. A privately insured person would have to wait less, get a slightly better room at hospitals and have access to extraneous semi-medical or alternative medical procedures (e.g. Chinese medicine or acupuncture). At the base level, however, everything was of the same quality and ease.

    This has changed recently. We now have a class-separated medicine with only rich people able to afford certain procedures.

    E.g. I recently lost a tooth. I still have in my jaws a replacement implant some 2 decades old of top quality, fully clothed in ceramics (thus indistinguishable from natural teeth) and paid for in entirety by public insurance. Today the only solution which would be paid in entirety by public insurance would be a removable, all-steel bridge, no frills, and I’d still have to pay for a large part of the dentist’s work time. I couldn’t possibly finance an implant for that tooth instead and even a ceramic-steel composite bridge firmly cemented into my mouth would be way above my financial means. I have a normal, fulltime white-collar job of relatively good salary so as to give you an inkling where this places me. If I want the fixed composite bridge I will be in debts over that for several years.

    This can serve as an example of why Germans are getting angrier every instance about current socalled health system reforms, especially as it’s sold to us as a “betterment”. It isn’t.

    That’s not the end of it, there are loads of more serious cases, where this americanization of our health system involves life and death choices and especially the quality of life for people with severe illnesses.

    All recent reforms to our system have pushed it closer to the US system. This goes along with neo-liberal reforms in other parts of the former social welfare state of Germany and it is causing a considerable grumbling among people which soon may erupt into more outraged protests, or in other words, Germans are no longer happy with the system.

    While it has become clear to everyone that certain adaptions had to be made, there would have been several possible directions into which such changes could have been made. That of all of those such were chosen which lead to a “less socialized” (or in our view: less socially acceptable) health system has not been viewed positively.

  16. #16 dentist thornhill
    September 16, 2009

    The US needs to take note from other countries. The universal system is far superior than the US in terms of cost and performance. Health satisfaction comparing the US and several other countries, including Germany, showed that the later is far higher.

  17. #17 Candice Lovett
    October 24, 2009

    How is durable medical equipment paid for? What is the reimbursement? How receptive is Germany to having an American company sell to the patient?

  18. #18 EastCoaster
    December 17, 2009

    I’ve always wondered: how rich do you have to be to opt out of the system? Are we talking about billionaires who can self insure?

  19. #19 martin
    July 7, 2010

    Germany to me doesn’t sound like they have a perfect system, but it is an enduring one, and one that outperforms the US.

    Many countries have a better health system than US, not only Germany. US health system in 2010 is a mess!

  20. #20 Steven
    February 21, 2012

    As an Australian that has lived for over 15 years in Germany I can say that the German healthcare system has some very major issues. I would summerize these issues as:
    – overly expensive. 15% of income. That’s extorsion.
    – complicated (which worsens the cost factor)
    – class based (only self employed or wealthy may take private insurance)

    I personally think that the Australia model is the best that I am aware of as it does the following:
    – simple (paid for through one’s tax return/taxation as 2% of taxable income)
    – egalitarian (there is no minimum income as in Germay. There is the 2% medicare levy on income, regardless of how much or less one earns)
    – every taxpayer and family is covered.
    – flexible. If one wants extra benifits then one can get extra private insurance (e.g. private room in a hospital, alternative health)

    It should be noted that the SPD party is planning a Buergerversicherung (Citizen Insurance) for the next election. As a freelancer in Germany would welcome such
    as global insurance.

  21. #21 Jonathan
    May 12, 2012

    Nice post Steven. It does amaze me that the Australian system doesn’t get more publicity, but I guess that’s because it isn’t generating the sort of tax revenue that European politicians have a taste fore.

    A lot of you folks have rose-colored glasses about the universal health system. Too bad you don’t do some research on the history of health care in America, and associated issues such as tort and medical economics. Then you’d see exactly why the US system has gone to hell in a handbasket. You are just indulging in “grass is greener” type thinking.

    The German system is on a high roll right now. It won’t stay that way forever.

  22. #22 Wow
    May 14, 2012

    “but I guess that’s because it isn’t generating the sort of tax revenue that European politicians have a taste fore.”

    At least the European system produces enough tax revenue to pay for the common wealth. Such as, for example, spelling lessons in school.

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