The German Health Care System
Reinhard Busse, M.D. M.P.H.
Professor of Health Care Management
Berlin University of Technology & Charité – University Medicine Berlin
Who is covered?
Public (“social”) health insurance (SHI) is compulsory for people
earning up to around €48,000 per year, including dependents who are
included in the insurance.
This applies to around 75% of the population.
Individuals with earnings above €48,000 per year (around 20% of the
population) are currently not required to be covered. If they wish, they
can remain in the publicly-financed scheme on a voluntary basis (and
75% of them do), they can purchase private health insurance, or they
can theoretically be uninsured. The publicly-financed scheme covers
about 88% of the population. In total, 10% of the population are covered
by private health insurance, with civil servants and self-employed being
the largest groups (both of which are excluded from SHI). Less than 1%
of the population has no insurance coverage. From 2009, health
insurance will be mandatory, depending on previous insurance and/or
job status either in the social or in the private health insurance scheme.
What is covered?
The SHI benefits package covers preventive services; inpatient
and outpatient hospital care; physician services; mental health care;
dental care; prescription drugs; medical aids; rehabilitation; and sick
leave compensation. Since 1995, long-term care is covered by a separate
insurance scheme, which is mandatory for the whole population.
Traditionally, the SHI scheme has imposed few cost-
sharing provisions (mainly for pharmaceuticals and dental care).
However, in 2004 co-payments were introduced for visits by adults
aged 18 years and older to physicians and dentists (€10 each for the first
visit per quarter or subsequent visits without referral); other co-
payments were made more uniform: €5 to €10 per pack of outpatient
medications (except if the price is at least 30% below the so-called
reference price, i.e. the maximum reimbursable amount for drugs of
equivalent effectiveness, which is the case for more than 12,000 drugs),
€10 per inpatient day (up to 28 days per year), and €5 to €10 for
prescribed medical aids. For dental prostheses, patients receive a lump
sum which on average covers 50% of costs. In total, out-of-pocket
payments accounted for 13.8% of total health expenditure in 2005.
Cost-sharing is generally limited to 2% of household
income. For additional family members, part of the household income is
excluded from this calculation. For the chronically ill, the cost-sharing
limit is 1%. A directive sets out the conditions for qualifying as
chronically ill; since 2008 it is also necessary to demonstrate that the
person has received counselling on screening measures prior to the
How is the health system financed?