April/May 2014
Even with “Obamacare”, there are still major differences between the American and German healthcare systems, says former German Minister of Health, Daniel Bahr
By Katja Ridderbusch
A conversation between a German and an American about healthcare often goes like this: “Everyone should have health insurance,” says the German. “We don’t want European socialized medicine,” replies the American. That’s usually where the discussion ends. Not for Daniel Bahr. The former German federal minister of health in February joined the Center for American Progress as a visiting fellow. The Washington-based think tank advises the Obama administration on healthcare and other policy matters.
Bahr has been labeled a “socialist” quite a few times since his arrival in the United States. “That’s somewhat ironic,” he says, laughing. After all, he’s a member of the Free Democratic Party, which is the most market-oriented political party in Germany.
“I guess we just have different ideas of freedom. Some Americans think that mandating health insurance is limiting their freedom.” In his opinion, however, not having health insurance restricts an individual’s freedom, as it can result in bankruptcy and be an existential threat. “It’s a risk so big it needs to be spread and shared.”
Bahr finds himself explaining a lot these days. That, for example, there’s no such thing as European style healthcare, since every country in Europe has its own insurance system, and most vary considerably. While Great Britain has a publicly funded “National Health Service”, the German healthcare system is more market-oriented. It offers a wide range of choices – and freedoms, for that matter: the freedom to choose an insurance, a doctor, a hospital, or a therapy.
Spreading the risk is one of the principles that the German healthcare system was established upon 131 years ago. Federal law requires all Germans to have health insurance, but does not provide coverage directly. About 85 percent of the population purchase heavily regulated, non-profit insurances called statutory health insurance. Insurance premiums for Germany’s statutory scheme are based on the individual’s income. A person pays roughly 8 percent of their gross income into the insurance, while the employer contributes about the same amount.
Only 10 percent buy private insurances, mostly civil servants and self-employed. Also, individuals who make more than $74,000 per year can opt-out of the statutory health insurance and purchase private insurance, which is also regulated, but more flexible, more expensive and offers better elective services, like a single hospital room or treatment by the chief physician. The remaining 5 percent fall under specialty insurance schemes.
All insurances cover comprehensive medical care. Still, healthcare spending in Germany accounts for only 11 percent of the GDP, while it is 17 percent in the U.S., the highest in the industrialized world. At the same time, more than 15 percent of Americans remain uninsured.
“That’s what stunned me when I first came to the United States, and it still bothers me: that so many people have no coverage,” says Dr. Bernd Wollschlaeger. He’s a family physician in Miami, Fla. German born, he studied medicine in Germany, Israel and the U.S., before settling in Florida in 1991. In his private practice, Wollschlaeger sees both insured and uninsured patients. He’s in favor of the Affordable Care Act (ACA), called “Obamacare” by its friends and foes.
The reform has brought the U.S. healthcare system a step closer to most European healthcare schemes - by establishing an insurance mandate, prohibiting insurance companies from denying patients based on pre-existing conditions, and allowing parents to insure their children under their plan until they’re 26. Still, Wollschlaeger says, there are more differences than similarities.
One major difference is regulation. In Germany, doctors’ fees and drug prices are heavily regulated. There’s also a cap on the amount of physicians who can open a practice in a certain area. “In America, you can have a gazillion dermatologists and plastic surgeons in one area, and no family doctor,” says Wollschlaeger, “as long as the market provides the economic incentive.” In a place like Miami, it certainly does, “where the demand for Botox and other beauty treatments is high”.
Wollschlaeger doesn’t expect regulation in the U.S. to be ever as strong as it is in Germany. “Any type of government intervention is something Americans reject,” he says. “There lies the deep ideological divide between the European and the American approach to healthcare.” The physician agrees with Daniel Bahr that freedom has different meanings in both cultures. “Personally, I’d prefer to be healthy and maybe not so free.”
In the United States, the majority of individuals still receive health insurance through their employer. When they lose their job, they lose insurance. The ACA is now trying to fill that gap. In Germany, individuals can keep their insurance when they leave their job. “Linking health insurance with employment limits mobility,” says Jonathan Fox, an American-born professor of economics at the Free University of Berlin. “In the U.S., many people stay in jobs they would normally not be in, simply because of health insurance.” Fox calls this a waste of human capital.
Another difference: emergency care. While Americans tend to go to the E.R. for an acute illness or trauma, most Germans, unless it’s a major crisis, first turn to their family doctor. “One reason is that in Germany, emergency care is widely organized by the general practitioners themselves,” says Bahr. Primary care doctors work rotating shifts during nights and weekends. “Also, Germans traditionally have a long-standing relationship with their family doctor. Some statistics suggest that in Germany, people stay with their doctor longer than they do with their spouse.”
In the United States, the E.R. is also the last safety net for the uninsured, a mission quite different from German emergency departments. In addition to government insurance plans like Medicaid, indigent care in America is widely supported by corporate or private donations.
“The culture of giving is very different in Germany,” Bahr says. “You may find a few limited initiatives here and there, like a project to support a children’s cancer ward. But not donations on a large scale like in the U.S.” This is something Germans could learn from Americans, Bahr says.
However, he adds, “I don’t agree that the poor should have to depend, even in part, on charities.” Healthcare should be based on the principle of mutual solidarity, a social contract. “Everyone has to pay their contribution” he says. “But then, you don’t have to beg. You have the right to claim your benefits.” That, too, is what Germans would call freedom.
© The Atlantic Times / Katja Ridderbusch