Health Care Reform in Germany

This past spring, Health Affairs, the premier health policy journal, had an interview with the German Minister of Health, Ulla Schmidt.  The interview focused on reforms to Germany’s health system instituted principally in 2007.  Minister Schmitt was asked what were the goals of the reforms. Her answer – she wanted to preserve the principles of social solidarity and affordability that had always been a part the German health system.

In comparison to health care in the United States, the Germans system could hardly be called a system in crises.  The per capita costs were about half of  what they were in this country $3,200 per person in Germany compared to $6,400 here.  But they did have too many uninsured – about 0.2% of the population.  The United States, by comparison has 15% uninsured. 

So the question is, What do Germans understand by social solidarity?  Minister Schmitt explained that everyone in Germany has guaranteed access to health care and everyone contributes to the financing based on their ability to pay.  Well, if that is social solidarity, where does affordability fit in?  For Minister Schmitt, if the entire system is not affordable, the social solidarity begins to break down.  

Too much of the health care debate in this country is muddled by ideology on both sides.  For many in this country, European health care sytems smack of “socialism.”  Yet, two of the defining characteristics of the German system are not real popular among progressives in this country.  The Germans have an individual mandate and they rely on insurance companies, although in Germany they give them a more accurate name, Krankenkassen, or Sickness Funds. 

Social Solidarity

But what I want to dwell on is this idea of an over-arching principle.  Even referring to an over-arching principal is an impressive starting point.  The words “social solidarity” say something about the values of the community, about people in a community looking out for one another; taking care of one another in times of need.  They are words that speak directly to the substance of health care.  What do people in health care do?  They take care of  one another.

You wouldn’t normally use words like social solidarity in other areas of human endeavor, for example auto manufacturing or banking.

So what words would we use to define an over arching principle guiding health care in this country.  Fragmented?  It is descriptive, but is it intentional?  Freedom of choice?  While much lip service is paid to those words, the reality is that in today’s managed care world, freedom of choice is constrained.  Perhaps more so than in many countries with “socialized” medicine.  In any system, there will be and, in fact, needs to be, a system of constrained choices.  And how can we salute “freedom of choice” while denying it to 55 million fellow Americans without health insurance. 

Free Market

No, the operative words can only be “free market”;  not even a “competitive market.”  In a competitive market, buyers and sellers operate (bad word choice) on a level playing field.  There is no level playing field in health care.  In a free market, there are no rules that winners don’t make.  

But what do the words “free market” really have to do with health care.  Do they have any special meaning in health care that logically makes one think of a healthier population, of people working to make and keep each other healthier?  When I mix the words “free market” with “health care”, I can’t help but come up with snake oil salesman.

During the last election, there were many yard and road-side signs that said, “Put America First” or “Country First.”  These messages don’t conjure images of social solidarity, they conjure images of self-centeredness – putting beliefs first, not people.  

I am reminded of the Peanuts character Linus, who once said, “I love mankind.  It’s people I can’t stand.”  We need signs that say “Americans First”, or “People First”, or “Country men, women and children first”.  And, please, I hope no one takes that last sentence as anti-immigrant.  I lived in Germany for two and half years.  I have experienced the health care systems in countries with social solidarity as the governing principle.  They treat foreigners better than we treat some of our fellow Americans.

How does “social solidarity” play out in Germany in more concrete terms.  One example jumps to the front.  Like this country, employers contribute to an employee’s health insurance costs.  So what happens when an employee becomes unemployed?  The state picks up the tab as part of the unemployment package of benefits.  But the insurance card does not change.  The former employee, now mere citizen, presents the same insurance card to the doctor or hospital.  The provider gets the same reimbursement as before.  Unlike this country, there is no separate state insurance benefit with separate, lower, provider reimbursements.  And they can do this and still spend half what we do for health care.

My Guiding Principal

For me, the over-arching principal is simplicity:  once and done enrollment; simplified provider reimbursements; integrated delivery systems that give patients choice without sacrificing care management; paymetns based on ability to pay.  With a simpler system, money can be spent on health care instead of in health care.  That may be a single payer system.  But as Germany seems to prove, you can have a more efficient system while maintaining multiple payers. 

Apologies to Patrick Henry

To some ideologues in this country words like social solidarity conjure un-American spectres like socialism.  With apologies to Patrick Henry, if that be socialism; make the most of it.  

It may be too much to think that a pro- active over-arching principle will precede meaningful health care reform in this country.  It is better to hope that meaningful health care reform will produce, as a by-product, something like social solidarity.  Maybe that is what the pundits are really afraid of.


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