German system values health care as a right

Roman Deininger

is a political reporter for the Suddeutsche Zeitung in Munich, one of Germany's two leading daily newspapers, and is visiting The Philadelphia Inquirer on an Arthur F. Burns Fellowship.

I was in an American hospital's emergency room only once, and then I was not the patient. A friend of mine from Malaysia was, and he received excellent care. But I have to admit this is not what I primarily remember from that night. Instead what springs to mind is that the first thing this frightened patient was asked by the hospital staff wasn't how he was doing. It was how he intended to pay.

For me, as a German, this was a culture shock. The scene nurtured a feeling - grossly unfair as it is to countless dedicated professionals - that the U.S. health-care system was more about money than health. You hear terrible stories (told not only by polemics like Michael Moore) about commercial insurers weeding out customers they deem unprofitable. Stories about people getting sick, losing their job because they are sick, losing their insurance because they lost their job, and losing their life because they lost their insurance.

This couldn't happen in Germany. Don't get me wrong: Our health-care model is full of flaws and in constant need of reform, and of course it's also about making money. But the drive for profits is held in check by one overarching principle: solidarity.

I know this sounds a bit like "socialism," but it isn't. And I understand the conservative philosophy feeding the American distrust toward public health insurance. However, if there is to be an honest discussion about universal health care - as provided by nearly every industrialized nation - we must dispel the myth that it infringes on individual rights.

The German model, the world's first national system, dating back to 1883, is based on the conviction that every person should have a basic protection at any given time in his life, and that this should be guaranteed by the collective sharing of risks. Therefore, health care is financed by individuals on the basis of what they can afford to contribute while being available to everyone on equal terms. Ninety percent of Germans participate in the public system; 10 percent have private insurance.

We're not talking about "socialized medicine." The system, once almost self-sufficient, is supervised by government but not run by it. America's Medicare and veterans health plans, already in place (and working neatly), are much closer to being socialized than the German model.

Yes, the state co-finances the whole structure - for example, by covering children for free from general revenues. Yes, the state collects the premiums as taxes (15.5 percent of income, with employers and employees contributing roughly half). And yes, the state redistributes the money to insurers and on to doctors and drug companies. But the insurers don't work for the government, and neither do doctors. They're making autonomous decisions regarding patients' health.

There are more than 200 insurance funds in Germany. They are nonprofit, but independent and competing for customers from the risk pool. Granted, competition is lame compared with the United States, but there is enough to give people choices.

But first things first: In Germany, health insurance is mandatory. Only a minimal part of the population - 0.1 percent - goes uncovered (mostly illegal residents and homeless, but some self-employed, too). In the United States, this number is close to 15 percent. Those too poor to afford health care in Germany have it subsidized by the state. Almost no one is in danger of being ruined financially by medical bills.

And it's safe to say that in general the German system delivers more at significantly less cost than the U.S. system. Life expectancy is longer, child mortality lower, and the number of doctors higher (3.5 per 1,000 people, compared with 2.4 in the United States). Germany spends around 10 percent of GDP on health care, while the United States is up to 16 percent.

Why is it cheaper? With an aging population and the development of new drugs and treatments, costs are exploding in Germany, too. But even in the private sector, stricter laws prevent corporate profits from skyrocketing immorally. A focus on prevention helps save money otherwise needed for the potentially more expensive care after a late diagnosis. Moreover, doctors are reasonably protected against excess demands in malpractice lawsuits. Government regulation, the German example shows, can be a force for good in health care.

And Germans like it that way. According to a current survey by the prestigious Allensbach Institute, 80 percent rate their system as "very good" or "good." Yes, there are some complaints, but this is partly because we are spoiled: We are used to walking into a doctor's office and being seen that day. Waiting days for an appointment or sitting in a doctor's office for an hour challenges our patience.

Rising costs have led to certain fees. Visits to general practitioners used to be free, but we now pay $13 for the first visit of every quarter. Patients kick in for trips to health resorts that used to cost them nothing. Also, to control expenses, doctors must heed a prescription-drug budget set by the insurance funds.

But this does not mean services are rationed. Budgets are tailored to the specific patients a doctor treats, and the doctor can argue for using a certain drug, even if that process is much too bureaucratic. There are injustices: Some patients have to settle for second-best drugs, at least for a while. But no one, including the elderly, is left out in the cold. I know people well into their 80s who got hip replacements, and quickly.

Nevertheless, Germans are worried about the emerging class gap in health care. The wealthy can opt out of the public system and get private insurance instead, and more and more do (nobody who can afford otherwise can be forced into the public plan). They'll get better and extra services for their money: practically no waiting time, tests right away, or a single room in the hospital.

You can also stay with public insurance and supplement your plan with some private services. I, for example, pay for the right to be treated by the top doctor - I had serious knee surgery once and want to be able to consult the best specialist if the problem recurs.

So overall, the German system provides fairly high-standard coverage for everyone and at the same time offers consumers a good measure of choice. That's reassuring. But what I like most about the German system is that coverage is a right. People die from diseases, but they shouldn't die from the diseases that cripple their health-care system.