Dr. Clif Cleaveland

Commentary

Several years ago, our granddaughter, who was 5 years old at the time and residing with her family in Germany, sustained severe burns in an accident. The health needs of her family were covered by a state-regulated health plan that provided her with superb acute and convalescent care.

Her family did not have to pay any deductibles or co-payments. Her experience was my first acquaintance with a health- care system for which I have maintained great respect.

Germany boasts one of the world’s oldest, government-sponsored health systems. Even before unification of separate states under Chancellor Bismarck, the idea of a societal role in health benefits had been established by craft guilds. Dating from medieval times, the guils extended various illness and injury benefits to their members.

The 1883 Health Insurance Act provided medical benefits for the poorest 25 percent of the German population. Subsequent years saw gradual extension of coverage to higher income groups. Reunification of East and West Germany in 1996 presented a major challenge to the health system. Rising costs of technology and an aging population stress Germany’s current health system.

Germany spends slightly more than 10 percent of its GD on health care. Each resident must participate in either a public or a private plan. Regulation of the program is shared between the central government and 16 states.

Ninety percent of Germans are covered by state-regulated plans. Approximately 8 percent of an employee’s gross income is matched by a like amount from his or her employer. Large companies may offer an in-house plan to employees, but most citizens prefer making a selection from the 250 state-regulated sickness plans. A small quarterly payment (approximately $15 dollars) covers unlimited visits to a primary care physician who participates in the selected health plan. Subspecialty services require a similar additional quarterly payment.

The plans cover physician services, hospital and convalescent care, 90 percent of prescription drug costs, and some dental services. The government pays for coverage for poor and unemployed persons. Children are covered under the plans at no additional cost to their families until they reach 18 years of age. Home health care services following illness are especially generous.

Self-employed persons and people earning more than the U.S. equivalent of $72,000 per year must purchase coverage from one of more than 50 private health insurance providers. Physicians in these plans may charge more than colleagues in the state-regulated plans. Physicians and hospitals bill people in the private plans directly. Patients are then reimbursed by their plan. Private companies determine the fee schedules for providers.

At retirement, the state takes over payment of premiums for those in state-regulated plans. Retirees in private plans must continue to purchase coverage.

The majority of Germany’s hospitals are either publicly owned or private, non-profit institutions. Twenty percent of hospitals are private, for-profit enterprises. Federal and state governments share in the construction and support of public hospitals. Church-sponsored hospitals may also receive subsidies from state and federal governments.

Germany’s health system continues to evolve. In 1995 long-term care was required. In 2002 the government launched programs for the management of chronic illnesses such as diabetes. Health plans received cash incentives to enroll persons with these conditions. In 2007 funding for children’s care shifted to government revenues. Direct-to-consumer advertising of prescription drugs was banned. Protocols were established to evaluate new technologies for cost-effectiveness. This information is then used to determine if a new therapy will be covered by health plans.

While accepting the principle of universal access to health services, many Germans complain about waiting times for elective surgery. Other complaints center upon restrictions in some dental services and access to new medications. Satisfaction with the overall system remains quite high.

Germany’s health care system blends wage-based and tax-based support. Citizens can select from a wide array of plans and can change plans without penalty. Payments to plans are equalized by law so that plans cannot monopolize young, healthier clients.

The public and private components do seem to create a two-tier system, which can create unfairness in access to services. For example, persons with private coverage may have shorter waits for service. The future of the private component of health care is actively debated.

For much less than our country spends for health care, Germany provides almost all its citizens with comprehensive care. Consumer choice is maintained. Each citizen can select a personal physician. The system remains open to change and improvement. Our political leaders should take note.

Contact Clif Cleaveland at cleaveland1000@comcast.net.

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