Health Care in Germany -- a Matter of Class?

When Peter Stegman calls to set up a doctor's appointment, he usually gets what he wants. The 37-year-old Berlin resident who works in the mobile phone industry is insured privately, and if he wants an appointment on the next day, he almost always gets it.

"You just get treated better when you have private insurance than if you have the public kind," he said. "The service is better and you have more choice."

Before coming to Germany from Finland two years ago, he investigated the country's insurance system and was told that if he could afford it, private insurance was the best option, since people on the public plans get lower priority with many doctors.

"They have problems getting appointments quickly; it takes a lot more time," he said.

Second-class service

Anecdotal evidence abounds about difference in service between those insured under private health care plans in Germany and those with the state system. The newspaper Bild conducted a test of 100 doctor's offices around Germany, calling each to set up appointments.

In each case, one caller would claim to have private insurance, another to be insured under the public system. In the majority of cases, the privately insured individual got appointments much sooner than did publicly insured pretend patients, if they got appointments at all.

"Private patients are preferred, publicly insured patients are brazenly turned away, just gotten rid of," Heinz Windisch, president of VKVD, an interest group for both privately and publicly insured individuals, told the newspaper.

All this has led to accusations that patients in the public system are second-class citizens, having to wait months for non-emergency doctor's appointments or procedures and paying ever more out of their own pockets as the list of covered treatments and medicines shrinks, all the while watching as their monthly health insurance contributions continue to rise.

Public vs. private

People who earn less than 46,800 euros ($54,850) per year are obligated to enroll in one of Germany's public health plans. Their contributions are determined by their income and range from 12.7 to 15.5 percent, half of which their employer pays.

In addition, patients must pay a 10 euro quarterly office fee, five to 10 euros for medicines, pay for shared rooms in hospitals and generally cover 50 percent of the cost of dental prostheses.

Private patients, on the other hand, generally have much more choice regarding doctors, have long lists of services covered, are not required to pay a quarterly office fee, and can receive medicines or eyeglasses without additional charges.

"Those who pay more in Germany get better service," said Kai A. Konrad, a professor specializing in health system economics at the Institute of Public Finance and Social Policy at Berlin's Free University. "They are like two different products."

But that dual system does not sit well with many, including Germany's Social Democratic Health Minister, Ulla Schmidt.

"Those who are publicly insured should not have to get the feeling that they are second-class citizens," she said.

She wants to do away with the system that allows doctors to charge different fees for the same services depending on whether a patient is publicly or privately insured. For example, a doctor conducting an ultra-sound test on a public patient can charge 17 euros. However, that same test conducted on a private patient can bring the doctor 58.97 euros. Therefore, from a purely economic standpoint, it is in the physician's interest to attract as many private patients as possible, and keep the number of public patients lower.

"Many doctor's offices in Germany are dependent on these higher fees," said Roland Stahl, a spokesman for the National Association of Statutory Health Insurance Physicians. "If they disappear, then about one-third of the medical practices in Germany would go under."

He says the quality of the health care itself is generally not dependent on what kind of insurance one has, although he admits the speed at which one gets to the see the doctor often is.

Which reform?

Reforming Germany's health care system is considered crucial by most politicians on both the left and the right. But what that reform should look like is a matter of much debate.

In the negotiations that led to the coalition government under Angela Merkel the topic was so divisive it was left off the table for now.

Health Minister Schmidt's plan for merging the fee schedules for both public and private patients has led to some accusations that she wants to do away with private insurance companies all together.

Indeed, on the left, the idea of a "citizen's insurance" -- an obligatory public plan for everybody -- has found some support, and her plan might move in that direction, although no one is seriously advocating abolishing private insurance yet.

Angela Merkel's conservative Christian Democrats (CDU) have called for a single, flat rate -- or "premium" -- for all members of the country's public plans, which are now calculated according to income level.

Bakery example

Health expert Konrad tries to illustrate the complicated issue of the two plans with a metaphor of an imaginary bakery. If this bakery were run by the Social Democrats, who advocate wealth redistribution, the cost of rolls would depend on the income level of the buyer. Low-income people would pay 20 cents per roll, those with higher incomes would pay 40 cents.

"The problem people have with this system is that people with lower incomes buy too many rolls and people with higher incomes buy too few," he said, explaining that the rolls in this illustration represent medical services. After a while, he says, the economic sustainability of the bakery (medical plan) comes into question.

Under the CDU's "premium" plan, all the rolls (medical services) would cost the same, no matter what the buyer's income is. Advocates here say that would encourage people to only buy however many rolls they actually needed to sate their hunger -- not too many, not too few. They also say such a plan would encourage competition between the plans and could drive down costs.

But this plan, which would do away with the redistribution aspect all together, is not completely feasible at this point, Konrad says.

"We don't think either plan is sustainable," said Stahl of the health insurance physicians' group. "We'll need a mix of these two when reform finally does come around, probably not before 2008."