Alan Stolier, MD/




It’s somewhat incredulous that Otto von Bismarck (“Iron Chancellor”) who was quoted as saying that German unification would require “iron and blood” is the same man who wanted to help ordinary people deal with illness. In 1883, his Sickness Insurance Law was the world’s first national healthcare system. “Americans who buy health insurance through their employer with premiums withheld from the paycheck are using the Bismarck model…”


All 82 million citizens, as well as guest workers (legal or not), are guaranteed medical care. Doctors, dentists, chiropractors, physical therapists, psychiatrists, opticians, all prescriptions, nursing homes, health club memberships and even the occasional spa visit are covered. The is no queue. In fact, Germans spend less time waiting than Americans. Patients can choose any doctor or hospital and insurance must pay. There are more than 200 insurance companies! “Most importantly prices for insurance are fixed”.

These insurance plans or sickness funds (Krankenkassen) are private. They are all nonprofit and “have about one-third the administrative expenses of the U.S. companies.  Likewise, the general practitioners are also in private practice. German hospitals are mainly charity or municipal.   There is, however, a growing private sector with private insurance where plans negotiate prices with clinics and hospitals. There is little government input into how medicine is practiced, generally less than in the U.S. Premiums for indigent patients are paid by the government. Most important, participation is mandatory! Government unemployment also automatically covers insurance premiums, no matter how long the hunt for work requires.

The price Germany pays for this expansive system is high, higher than most other European nations. It pays 11.3% of its GDP on healthcare (U.S. 17.9%). To pay for its system, Germany imposes strict controls on payments to doctors and hospitals. Yet medical education is generally free, so there is no student debt. Malpractice insurance runs about $1400 per year for general practitioners. Germany, like France, utilizes a universal smart card (die elektronischen Gesundheitskarte) which reduces paperwork and administrative costs.

universal smart card (die elektronischen Gesundheitskarte)

German’s can sign up for any sickness fund in the country and can change at almost any time. The premium will remain unchanged. Nonetheless, there is intense competition among these nonprofit plans. Some offer beyond the basic benefits, like Asian therapies, free neonatal nursing care in the home or longer stays in the spa. Beginning in 2006, German patients began paying copays when visiting a doctor’s office or hospital. This generally runs about 13$ per quarter. Once the $13 is met, visits are fee until the end of the quarter. Executive pay is generally linked to the size of the coverage pool. Interestingly the richest families are excused from the mandate to sign up. There are private insurances available and private hospitals catering to this group. This amounts to about 7% of the population.

As previously noted by Tsung-Mei Cheng, “No matter how good the health care is in a particular country, people will complain about it.” In this case, physicians have been frequently complaining about the fees they receive from the sickness funds. Similarly, the government and the sickness funds are concerned about the relentless increase in cost. Many healthcare reforms have been made in recent years, but the basic model of private health insurance remains. At over 130 years old, the German system is the oldest on the planet and is unlikely to end anytime soon.

Links to earlier segments:

Part 3: France: https://www.breastcarenetwork.com/news/healthcare-systems-around-the-world-part-3/

Part 2: Healthcare models: https://www.breastcarenetwork.com/news/healthcare-systems-around-the-world-2

Part 1: Introduction: https://www.breastcarenetwork.com/news/healthcare-systems-around-the-world/

Leave A Comment