GERMANY

In the German health care system, decision-making powers are traditionally shared between national (federal) and state (Land) levels, with much power delegated to self-governing bodies. It provides universal coverage for a wide range of benefits. Since 2009, health insurance has been mandatory for all citizens and permanent residents, through either statutory or private health insurance. A total of 70 million people or 85% of the population are covered by statutory health insurance in one of 132 sickness funds in early 2014. Another 11% are covered by substitutive private health insurance. ( Bismarck Group of Health Systems ).

Characteristics of the system are free choice of providers and unrestricted access to all care levels. A key feature of the health care delivery system in Germany is the clear institutional separation between public health services, ambulatory care and hospital (inpatient) care. This has increasingly been perceived as a barrier to change and so provisions for integrated care are being introduced with the aim of improving cooperation between ambulatory physicians and hospitals. Germany invests a substantial amount of its resources on health care: 11.4% of gross domestic product in 2012, which is one of the highest levels in the European Union. In international terms, the German health care system has a generous benefit basket, one of the highest levels of capacity as well as relatively low cost-sharing. However, the German health care system still needs improvement in some areas, such as the quality of care. In addition, the division into statutory and private health insurance remains one of the largest challenges for the German health care system, as it leads to inequalities.

A fundamental facet of the German political system – and the health care system in particular – is the sharing of decision-making powers between the Länder, the federal government and civil society organizations. In health care, the federal and Länder governments traditionally delegate powers to membership-based (with mandatory participation), self-regulated organizations of payers and providers, known as “corporatist bodies”. In the statutory health insurance (Gesetzliche Krankenversicherung (SHI)) system, these are, in particular, sickness funds and their associations together with associations of physicians accredited to treat patients covered by SHI. These corporatist bodies constitute the self-regulated structures that operate the financing and delivery of benefits covered by SHI, with the Federal Joint Committee (Gemeinsamer Bundesausschuss) being the most important decision-making body. The Social Code Book (Sozialgesetzbuch (SGB)) provides regulatory frameworks; SGB V has details decided for SHI. Since 2009, health insurance has been mandatory for all citizens and permanent residents, either through SHI or private health insurance (PHI).

SHI covers 85% of the population – either mandatorily or voluntarily. Cover through PHI is mandatory for certain professional groups (e.g. civil servants), while for others it can be an alternative to SHI under certain conditions (e.g. the self-employed and employees above a certain income threshold). In 2012, the percentage of the population having cover through such PHI was 11%. PHI can also provide complementary cover for people with SHI, such as for dental care. Additionally, 4% of the population is covered by sector-specific governmental schemes (e.g. for the military). People covered by SHI have free choice of sickness funds, and are all entitled to a comprehensive range of benefits. Germany invests a substantial amount of its resources in health care. ( HSiT )