Healthcare systems comparison: Germany & the United States.

Recently, I have been following the U.S healthcare reform talks, with Biden becoming president, and I started seeing a lot of Americans in Germany talking about their experiences with the German healthcare system, usually praising it. Majority of these people are in their 20’s & 30’s , usually this is a healthy age group, and seem to have had wonderful experiences with the German system, and not so great with the American system.

It is no doubt that Germany’s healthcare system is superior to the American one, but I thought most people glamorize or romanticize some things about the German system, without talking about cons or how the system is paid for. My interest in the German healthcare system is that of a person living in Germany, but on the U.S healthcare system.

How does the German healthcare system work?

Germany has a multi-payer, universal healthcare coverage system. The government offers public healthcare coverage indirectly through sickness funds, and also allows people in Germany to get private insurance coverage. You however can only get private insurance coverage as your sole plan or added to your public health insurance if you make above approximately 60,000 euros per year, or you are self-employed. This means that majority of the people in Germany actually use public healthcare insurance, and seem to be content with it. For those who don’t qualify for public health insurance e.g international students – private insurance can be costly in the long run, since the premium you pay increases as you age. To qualify for public healthcare insurance in Germany, you need to be a tax payer with a German social security number.

Is the public healthcare insurance free in Germany?

No. It is paid for by payroll taxes that, you and your employer pay for, 50/50 every month. 14% of your income. However, for those who are unemployed, there is free public healthcare that covers medically necessary visits at no cost to you (e.g pregnancy). The government also covers the cost of children, so healthcare is essentially free for kids in Germany. This “free public healthcare is covered by social security tax”.

This German/Bismark healthcare coverage system works great at ensuring everyone is covered, to meet their basic healthcare needs.

It is also mandated to have healthcare insurance, and if you fail to provide proof, you are fined. Fines could go as high as 600 euros per month.

Healthcare services are funded through a progressive taxation that is based on a person’s need, so taking into account your health risk based on age etc. Long term care is covered through mandatory long term care insurance coverage.

On average Germany (a country of 84 million people), spends 11.7% of its GDP on healthcare.

How does the Unites states healthcare system work

The United States has a combination of health insurance from the government and then a private insurance market place, where people can purchase insurance from different private companies. Like Germany, majority of Americans are insured through their employer. The big difference is that the American citizen is offered healthcare insurance through a private company that their employer has chosen, without their input into what they would like. The only option you get is to choose a plan, from the 2 or 3 offered by that company. I personally paid around 300-400/mo before I got tricare (government insurance through military). Asking around (poll on Facebook), majority of single people range in the 200-600 USD/mo range and for families, just depends on how many people are in the family, but usually about 1000-1500 USD/mo for a family of 4.

For those who are unemployed, self-employed, or do not qualify for healthcare insurance through work, private insurance companies have either brokers that can help you navigate what coverage is best for you, or you can go through Obamacare – marketplace and choose a plan from a private company with no middle man.

On the other hand, 39% of Americans are covered through the government insurance. This includes medicare (18%), medicaid (17%) & tricare/VA (3.7%). Medicare is coverage for people over 65 yrs old who paid medicare taxes when they were working. Medicare is public healthcare from the government. There’s another branch, medicare advantage, that is exactly the same as the German Healthcare coverage system, where you have government healthcare and can also opt to get private insurance covering things that are not covered. Medicaid covers people who are low income, based on family size, income and the state you reside in. Some states offer better coverage than others. Tricare & VA cover military affiliated people.

Unlike Germany, it is not illegal to not carry healthcare insurance in majority of the states, and as of 2018, 8% of Americans are un-insured. If you live in California, Massachusetts, New Jersey, Rhode Island or Vermont, you are mandated to carry healthcare insurance or else you receive a fine.

When Obama care came into place in 2010, having healthcare insurance was mandated, until 2019, when Trump became president. People still opted to pay fines during that period because they couldn’t afford to pay the premiums, so paying the fine was cheaper.

The U.S ( with a population of 331 million people) spends more on healthcare than Germany by 6%.

What are the similarities in these 2 systems?

  1. Majority of people are insured through their employer
  2. In some states in the USA, just like Germany, it is mandated to have health insurance
  3. Quality of healthcare offered is actually very comparable – speaking from a healthcare provider perspective and comparing the treatment guidelines for most medical complains seen in the clinics or hospitals
  4. Both countries have universal healthcare for government employees & military.
  5. Visitors e.g international students are required to purchase private insurance. (more expensive in the u.s though & has very limited in network services or providers offered)
  6. In both countries, in case of an emergency, you can not be denied care. You will however pay the bill, which can be very high in the u.s depending on services offered.

What are the differences between these 2 systems?

  1. Cost: In Germany, the premiums people pay per month are lower (7% of their salary, with avg salary of 54,000 USD), compared to the U.S (approx 455/mo, with an average salary of 57,000 USD). In the U.S, there’s also added co-pays and medication co-pays as well that may increase this price. Cost highly depends on your insurance plan, while in Germany it is more uniform, you know what you are paying for, and co-pays are capped at a very low rate.
  2. Access: Higher in Germany. Germany ensures that everyone that lives here is covered one way or the other. The U.S does not, unless you live in the states with mandates. In the U.S, the more you can pay, the better your access to services.
  3. Free public healthcare covered by social security tax – In Germany, it covers medically necessary services like pregnancy & birth, acute illness etc for unemployed including refugees. Unemployed spouses and children fall under “free healthcare” too.

Reviews from patients about the German healthcare system

I usually assume anyone I saw at the U.S military hospital in Germany who complained about the German healthcare system, would mostly have had a bad experience and that is why they were here.

Most German citizens who qualify, use the U.S military hospital system as a back up to their German healthcare, for services they couldn’t get, or switch over completely because they like the American customer service and patient treatment from American healthcare workers.

This is an outlier, but I had a patient once tell me that she always comes to the American hospital because the German hospitals all have “foreign nurses who can’t speak German well”. This took me by surprise because here she was, in an American hospital full of immigrant workers, but I guess she couldn’t critique their language skills with the same level of spite, since she herself wasn’t as fluent either. This same patient was very condescending and difficult with nurses & aides.

I had a pregnant friend who was forced to use a German hospital and she had nothing bad to say about the services, but when she initially got there laboring, the hospital wouldn’t provide her care until she had a physical record of her medical care during pregnancy. Her husband had to leave her in the waiting room laboring, to go back to the hospital and get the records.

The German healthcare focuses on naturopathic medicine more. The treatment guidelines, treatments, procedures etc are very similar in both countries since the U.S & Germany both practice western medicine. However, there may be a cultural difference that maybe causes German practitioners to recommend less medications. As a healthcare provider in the U.S, I don’t necessarily feel like we all push medications on patients for everything, but I feel like the average American has an expectation to get medications when they go to the clinic or hospital for something. Generally, the American healthcare system practices more reactionary medicine and less preventive medicine. There is more education and emphasis to educate patients on the importance of preventative medicine, but people are still of the mentality that, “if it’s not broken, it doesn’t need fixing.” On the other hand, Germans may see the doctor more for preventative services because they know it is covered anyway.

References:

https://www.commonwealthfund.org/international-health-policy-center/countries/germany

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