One of the typical hotspots in any political discourse between Americans and Germans is the topic of health care. Europeans firmly believe that a shocking percentage of Americans live without any access to health care, and Americans believe that the socialist Europeans pay their hard-earned cash to cure another (poorer) man’s illness. There is a bit of truth in both views, which is then ballooned by the media until it becomes impossible to understand how one country or the other can possibly survive on their current system.
For the purpose of discussion here, let us first differentiate between health insurance and health care. Health insurance is the system we pay into that should hopefully pay out in the event that we are ill and need financial support for treatment. Health care is the treatment of sick patients. While it is true that large numbers of Americans (about 16% of adults and 9% of children) don’t have health insurance, hospitals across the country offer health care to anyone who comes through their doors – for emergency care. And while Germany has universal health insurance, there are even people here who fall through the cracks and have no coverage.
There are some interesting effects of universal health insurance, and the German system is far from perfect. However, it offers access to good health care for the entire population – which has an incredible effect on social equality – and even includes preventive care. In the long term of course, preventive care is a far better investment for any insurer. Many of the public insurers also include options for reimbursement after attending fitness courses such as Pilates, as these courses tend to lessen the risk of back injury, etc.
Private health insurance, the only option for many Americans, is also available in Germany. Only those who earn above a certain income threshold (49,500 Euro in 2011) are eligible for opting out of the public system and buying private insurance, a fact that has ruffled my feathers of personal freedom. However, this method ensures that enough people are paying into the public scheme to keep it functional. Those earning above the opt-out threshold can choose to continue in the public insurance scheme, but even then they might discover penalties. For instance, public insurance was mandatory for me and yet when my children were born and I had no income for the first year while I stayed home with them, I still had health insurance but didn’t have to pay any insurance premiums. In contrast, a friend who was opting-in to the public system had to continue paying her insurance premiums after the birth of her children, despite having no income for a year. The private schemes also have pitfalls: in a family where one parent is privately insured, the children must be privately insured also. The private insurance premiums thus go up dramatically.
The biggest benefit of private health insurance in Germany is the preferential treatment these patients receive. Doctors are first and foremost there for healing sick patients, and doctors in Germany are no different. However, given that the average payment a doctor receives for a publicly-insured patient is around €35 per quarter (regardless of how many times the patient is seen), it is understandable that medical practices need private patients in order to maintain the business. The number of publicly-insured patients a doctor receives payment for is also capped – thus, if a doctor sees too many publicly-insured patients in a quarter, she will only receive a fraction of the €35 for the “extra” patients. The fact that private insurers are propping up the public system is obvious here.
Going to the doctor’s office in Germany is a very different experience than in the US. Because of the financial pressure, doctors don’t have much time to listen to their patients, and patient education is not popular. German doctors tend to be seen as, and act like, the gods of healing. In running a practice, it is in their best interest to diagnose and offer treatment to a patient as efficiently as possible. Patients who ask questions and want to understand more about their condition and treatment options are often cut short. Time for listening to patients is very limited, unless you are privately insured.
Alternative medicine, however, is incredibly popular and successful in Germany. Homeopathy is a standard course of treatment for many, and a significant portion of the population will seek care from a homeopath before seeing a doctor who practices Schulmedizin (school medicine). Given the lack of scientific proof about the effectiveness of homeopathic treatment, I have come to the conclusion that the reason it is so effective in Germany has to do with the insurance system. Homeopathic medicine is not covered by the public insurance schemes. Patients must pay the fees of a homeopathic practitioner, who then has the time to listen to the patient, provide education, and begin a psychological process of healing that many medical doctors in private practice can’t afford. Having your concerns, fears, symptoms, and background all understood and included in a treatment plan is probably a very significant factor in the healing process. Despite the lack of equality in insurance coverage that makes the US health care system unacceptable to many Europeans, this part of medical care is something that doctors in the US can still afford to provide to their patients. Many Americans arriving in Germany and visiting doctors will be disappointed and frustrated at turns until they understand this system. For my part, I switch doctors until I find ones that are willing to spend time talking to me even though I am only publicly insured.
The public insurance system in Germany is income-based. All participants pay around 15% of their salary, and their employer pays into it as well. There are plenty of public insurers to choose from and all offer different advantages. In addition, patients have a €10 copay per quarter, which can be automatically transferred to specialists via referral if necessary. For those Americans who are used to referrals being faxed to another doctor, get used to driving around and picking up your referrals. The best bet is to always pay your copay and get a referral from your family doctor (Hausarzt) at the start of the quarter – this saves the runaround and hassle if you are actually sick later on.
For the most part, the health care offered in Germany is high quality. It goes beyond the basic needs for survival and serves to build a healthy population. Throughout the phases of life, those in the public insurance system will at times be paying into a system they don’t use, and at other times be enjoying its hassle-free benefits. For those used to more personal freedom it can be frustrating to accept the restrictions of the public/private choices, and indeed to accept the concept of social solidarity on which it is based. However, the freedom within the system is much greater than with a US insurer. There are, for instance, no restrictions on which doctors you can visit and you don’t need permission to see a specialist, can choose your hospitals, etc. Provided you find doctors you trust and respect, you will certainly find the health care system manageable, and hopefully also find healing.