Germany

In the 1880s, Otto von Bismarck introduced a series of bills as part of the social legislation that signified the beginning of the development of first health care system in modern history. Now, over a century later, state health insurance still provides universal health care for the German population.

Recent History of Health Care in Germany

In 1883, Bismarck's Health Insurance Bill was the beginning of the social health insurance system that formed the blueprint for universal health care systems across the globe. Originally, the series of social legislation that included health care and old age pensions was introduced ironically in a response to Bismarck's growing concern over the spread of socialism. The "Iron Chancellor" ( nickname given to Bismarck due to his diplomacy of realpolitik- pragmatic, no-nonsense approach to politics) decided to win the approval of the working class by building up a welfare state and thus stem the growth of the socialist movement.

After WW1, and the consequential medical crisis it inflicted on Germany, the Weimar Republic introduced reforms to build on and continue to ensure the assurance of a universal health care system. Weimar Germany remained until 1933 when Hitler seized power. Under Hitler's rule, even though public health insurance remained, the government held the reigns over managers of insurance-schemes, enforcing a regime of strict control. His autocratic power led to the abuse of the health care system in Germany, culminating with the euthanasia of tens of thousands of institutionalised patients as part of his heinous agenda to murder millions of people.

When WW2 ended and Germany split into two states, both continued with state-run health care services, however West Germany reverted towards the more liberal system of the Weimar period, decentralising control, thus providing a more generous range and volume of services. As a result after the reunification of Germany in 1990, the health system in eastern Germany was transformed to be put in line, on financial and organisational basis, with the system in former West Germany.

Statutory Health Insurance

For citizens and permanent residents, health insurance is compulsory. The system is funded primarily through tax premiums paid by insured employees and their employers, split roughly 50:50. These sickness funds are paid through non-governmental bodies, that are autonomous but generally not-for-profit. The government also covers recipients of welfare. Overall, these health insurance schemes cover around 90% of the population and provide a fairly comprehensive array of services.

Despite being statutory, the government has little place in delivery. Regulation is largely delegated to self-governing bodies, collectively making up the Federal Joint Committee (G-BA). The G-BA was established under the Statutory Health Modernisation Act (2004) and since has been at the forefront of the self-governance of Germany's health system. However the G-BA works under the supervision of the Federal Ministry of Health.

Private Health Insurance

The percentage of the population who receive their primary coverage from substitutive private insurance is approximately 10%. Private health insurance is often attractive to young professionals, who earn a good income, such that insurers can offer them premiums which cover a wider range of services for the right price that might convince them to opt out of statutory health insurance.

Substitutive private health insurance is also necessary for those who were not covered by statutory health insurance, the largest groups being civil servants (although they are refunded in part by their employer) and people who are self-employed. Private health insurance is substitutive because the government still regulates providers in order to prevent premiums increasing considerably with age. This is in the hope to avoid dire consequences if the claimer's income decreases.

References:

• BMJ, German health care: a bit of Bismarck plus more science (https://www.bmj.com/bmj/section-pdf/186059?path=/bmj/337/7679/Analysis.full.pdf)
• PubMed Health, Health care in Germany: The German health care system (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0078019/)
• The Common Wealth Fund, The German Health Care System (https://international.commonwealthfund.org/countries/germany/)
• German Culture, Development of the Health Care System in Germany (http://germanculture.com.ua/germany-facts/health-care-system-in-germany/)
• The Lancet, Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition (https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31280-1.pdf)
• Smithsonian, Bismarck Tried to End Socialism’s Grip—By Offering Government Healthcare (https://www.smithsonianmag.com/history/bismarck-tried-end-socialisms-grip-offering-government-healthcare-180964064/)
• Pacific Standard, Nazis and Health Care (https://psmag.com/news/nazis-and-health-care-3483)
• Foundation for Economic Education, National Health Care: Medicine in Germany, 1918-1945 (https://fee.org/articles/national-health-care-medicine-in-germany-1918-1945/)
• NCBI, Reform of health care in Germany (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193657/)
• Germeinsamer Bundesausschuss, The Federal Joint Committee: Who we are and what we do (http://www.english.g-ba.de/structure/)
• The Commonwealth Fund, The German Health Care System (https://www.commonwealthfund.org/sites/default/files/documents/___media_files_resources_2008_health_care_system_profiles_germany_country_profile_2008_2_pdf.pdf)

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Emilia Chen, Oxford