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Development of the Health Care System in Germany
Nearly everyone residing in Germany is guaranteed access to high-quality
comprehensive health care. Statutory health insurance (Gesetzliche Krankenversicherung--GKV)
has provided an organizational framework for the delivery of public health
care and has shaped the roles of payers, insurance or sickness funds,
and providers, physicians, and hospitals since the Health Insurance Act
was adopted in 1883. In 1885 the GKV provided medical protection for 26
percent of the lower-paid segments of the labor force, or 10 percent of
the population. As with social insurance, health insurance coverage was
gradually extended by including ever more occupational groups in the plan
and by steadily raising the income ceiling. Those earning less than the
ceiling were required to participate in the insurance program. In 1995
the income ceiling was an annual income of about DM70,00 in the old Länder
and DM57,600 in the new Länder.
In 1901 transport and office workers came to be covered by public health
insurance, followed in 1911 by agricultural and forestry workers and domestic
servants, and in 1914 by civil servants. Coverage was extended to the
unemployed in 1918, to seamen in 1927, and to all dependents in 1930.
In 1941 legislation was passed that allowed workers whose incomes had
risen above the income ceiling for compulsory membership to continue their
insurance on a voluntary basis. The same year, coverage was extended to
all retired Germans. Salespeople came under the plan in 1966, self-employed
agricultural workers in 1972, and students and the disabled in 1975.
The 1883 health insurance law did not address the relationship between
sickness funds and doctors. The funds had full authority to determine
which doctors became participating doctors and to set the rules and conditions
under which they did so. These rules and conditions were laid down in
individual contracts. Doctors, who had grown increasingly dissatisfied
with these contracts and their limited access to the practice of medicine
with the sickness funds, mobilized and founded a professional association
(Hartmannbund) in 1900 and even went on strike several times. In 1913
doctors and sickness funds established a system of collective bargaining
to determine the distribution of licenses and doctors' remuneration. This
approach is still practiced, although the system has undergone many modifications
since 1913.
The formation of two German states in the second half of the 1940s resulted
in two different German health systems. In East Germany, a centralized
state-run system was put in place, and physicians became state employees.
In West Germany, the prewar system was reestablished. It was supervised
by the government but was not government run. According to the Basic Law
of l949, Germany's constitution, the federal government has exclusive
authority in public health insurance matters and sets broad policy in
relation to the GKV. The government's authority applies in particular
to benefits, eligibility, compulsory membership, covered risks (physical,
emotional, mental, curative, and preventive), income maintenance during
temporary illness, employer-employee contributions to the GKV, and other
central issues. However, except for the funding of some benefits and the
planning and financing of hospitals, the responsibility for administering
and providing health care has been delegated to non-state entities, including
national and regional associations of health care providers, Land
hospital associations, nonprofit insurance funds, private insurance
companies, and voluntary organizations.
Portability of coverage, eligibility, and benefits are independent of
any regional and/or local reinterpretations by either insurers, politicians,
administrators, or health care providers. Universal coverage is honored
by any medical office or hospital. Check-ins at doctors' offices, hospitals,
and specialized facilities are simple, and individuals receive immediate
medical attention. No one in need of care can be turned away without running
a risk of violating the code of medical ethics or Land hospital
laws.
The health care system has achieved a high degree of equity and justice,
despite its fragmented federal organization: no single group is in a position
to dictate the terms of service delivery, reimbursement, remuneration,
quality of care, or any other important concerns. The right to health
care is regarded as sacrosanct. Universality of coverage, comprehensive
benefits, the principle of the healthy paying for the sick, and a redistributive
element in the financing of health care have been endorsed by all political
parties and are secured in the Basic Law.
By the mid-1990s, health care benefits provided through the GKV were
extensive and included ambulatory care (care provided by office-based
physicians), choice of office-based physicians, hospital care, full pay
to mothers (from six weeks before to eight weeks after childbirth), extensive
home help, health checkups, sick leave to care for relatives, rehabilitation
and physical therapy, medical appliances (such as artificial limbs), drugs,
and stays of up to one month in health spas every few years. Persons who
are unable to work because of illness receive full pay for six weeks,
then 80 percent of their income for up to seventy-eight weeks. In an attempt
to contain costs, beginning in the 1980s some of these benefits required
co-payments by the insured. Although these fees were generally very low,
some co-payments were substantial. For example, insured patients paid
half the cost of dentures, although most other dental care was paid by
health insurance.
The system has managed these achievements relatively economically. In
1992 about 8.1 percent of the gross domestic product went into medical
care, or US$1,232 per capita, compared with 12.1 percent of GDP and US$2,354
per capita in the United States. Even so, Germany devoted about one-third
of its overall social budget to health care, an amount surpassed only
by retirement payments.
The German health care community has made a serious and sustained effort
to control the growth of health costs since the mid-1970s. The steep rise
in health expenditures in the first half of the 1970s prompted the passage
of the Health Insurance Cost Containment Act of 1977. The law established
an advisory board, the Concerted Action in Health Care, to suggest non-binding
guidelines for health care costs. Chaired by the federal minister for
health, its sixty members represent the most important interest groups
having a stake in health care. The board has contributed to slowing the
growth of health care costs, but further legislation has been necessary.
Modest co-payments for medications, dental treatment, hospitalization,
and other items were introduced in 1982 for members of sickness funds.
These payments were further increased by the Health Care Reform Act of
1989 (Gesundheitsreformgesetz--GRG) and again by the Health Care Structural
Reform Act (Gesundheitsstrukturgesetz--GSG) of 1993. The GSG also introduced
new regulatory instruments to monitor more closely access to medical practice,
to reorganize sickness-funds governance, and to control medication costs
and prospective hospital payments. In addition, it proposed measures to
overcome the separation between ambulatory medical care and hospital care
that prevailed in the former FRG.
* Development of
the Health Care System
* Health Insurance
* Health Care Providers
* Remuneration
of Health Care Providers
* Current Health Care
Issues
- Population
- Immigration
- Women In Society
- Marriage
- Fertility
- Mortality
- Age-Gender Distribution
- Social Structure
- Health Care
- Religion
- Urbanization
- Geography (lands,
topography and climate)
- Society (population,
religion, marriage, urbanization, social structure, immigration)
- Education (elementary,
junior, senior, vocational, higher)
- Economy (the Economic
Miracle, financial system, Bundesbank, business culture)
- Politics (government,
the Chancellor, the President, parties, Bundestag)
- Mass Media (newspapers,
radio and TV)
- Armed Forces (army,
navy, air forces, police)
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