One guide to rule them all — Health insurance in Germany — Part 2.1
This is the part 2.1 of our ongoing quest to dive deep into the German health insurance world. You can find part 1, where we talked about the history of health insurance in Germany, here.
Part 2.1 is the start of the public health insurance section, which we will spend most of our time on. Specifically part 2.1 take a closer look at the organisational structure of public health insurance and who gets to make the decisions.
If you are ready, follow us on this (magical ?) journey.
Health insurance: The two systems
As you have realised by now (if you read the first part), health care in Germany has a long history and it is always intertwined with the current political zeitgeist. That means that the answers to questions such as “what is covered”, “what treatments are included”, “who should be enrolled”, “how much it should cost” and “who should pay for it” naturally change over time.
The fact of the matter is that we currently have two systems in place that are vastly different in price structure, coverage and accessibility: private health insurance aka PKV and public health insurance aka GKV.
The part you are reading now will focus on the GKV, Part 3 will tackle the PKV. Those parts are divided into subsections to a) give them more structure and to b) enable the reader to skip parts she is not interested in.
Public health insurance
The GKV has become such a behemoth and constant presence in the communal German mind, that it has become complicated to have an unbiased, fact-based discussion with almost anyone about it. This section will try to build the ground for that, we want to deliver facts and figures as objectively as possible and answer the question: what is the GKV?
However, we also want people to actually read this guide and ideally find it somewhat interesting. We will not deliver every single number and state every single benefit and treatment but rather resort to a general overview and point to the places where more comprehensive information can be found.
This section will be divided into a few subsections that tackle the diverse topic that GKV represents:
· Structure: How is the GKV build up and who makes the decisions?
· Eligibility: Who gets to be in the GKV and why?
· Benefits: What do you get from being in the GKV and how much do you have to pay?
· Challenges: What does the future hold for the GKV?
You are currently reading part 2.1 of the entire guide, which looks at the structure of the GKV and how it is made up. Shall we?
The Structure of the public health insurance
To understand the structure and build-up of the GKV, one has to inevitably look at the circumstances of its inception. The GKV has a strong social character as it is supposed to give everybody equal access to health insurance for a premium that is reflective of the persons income. High income equals high premiums, low income equals low premiums, but the benefits stay the same (more on that in the following parts). It is a pillar of modern German society and is supposed to level the playing field and stand for what modern Germany wants to represent: a mutually supportive society.
But this would not be Germany if the actual goals of the GKV were not written into law.
Legal anchoring
The goals of the GKV are stated in “§ 1 Fünftes Buch Sozialgesetzbuch”, stated here in the original:
“Die Krankenversicherung als Solidargemeinschaft hat die Aufgabe, die Gesundheit der Versicherten zu erhalten, wiederherzustellen oder ihren Gesundheitszustand zu bessern. Das umfasst auch die Förderung der gesundheitlichen Eigenkompetenz und Eigenverantwortung der Versicherten. Die Versicherten sind für ihre Gesundheit mitverantwortlich; sie sollen durch eine gesundheitsbewußte Lebensführung, durch frühzeitige Beteiligung an gesundheitlichen Vorsorgemaßnahmen sowie durch aktive Mitwirkung an Krankenbehandlung und Rehabilitation dazu beitragen, den Eintritt von Krankheit und Behinderung zu vermeiden oder ihre Folgen zu überwinden. Die Krankenkassen haben den Versicherten dabei durch Aufklärung, Beratung und Leistungen zu helfen und auf gesunde Lebensverhältnisse hinzuwirken.“
The first sentence is the centrepiece and can be translated to:
“Health insurance as a mutually supportive society / organization based on solidarity has the task of maintaining, restoring or improving the health of the insured persons.”
In addition to that, there are other tasks such as providing information and consultation, rehabilitation and stating that the people are grown-ups and should also be responsible for their own health.
Furthermore, the benefits / treatments of the GKV ought to be “ausreichend, zweckmäßig und wirtschaftlich”, meaning they ought to be sufficient, appropriate and economical[1]. Those three small words have a very strong political and actual power as they are the guideline each treatment is measured against.
To make a very candid example: should there be a cure for cancer but it costs 1 € billion, the GKV would not be supposed to pay for the treatment because it would not be economical.
The carriers
The GKV does not have a single entity that provides health insurance but can rather be seen as a decentralized system of various carriers and providers that offer health insurance to the general public. There are currently six different types of GKV carriers (“Krankenkassen”) with a total number of 110 separate organisations:
· 11 Allgemeine Ortskrankenkassen (AOK)= „General local health insurance carrier”
· 85 Betriebskrankenkassen (BKK)= „(former) company health insurance carrier”
· 6 Innungskrankenkassen (IK)= „guild health insurance carrier“
· 6 Ersatzkassen (EK) = „substitute health insurance carrier”
· 1 Sozialversicherung für Landwirtschaft, Forsten und Gartenbau = a carrier for people working in agriculture, forrestry and landscaping
· 1 Deutsche Rentenversicherung Knappschaft-Bahn-See = „guild pension insurance train and sea“
The differences are rather historically and geographically now. The last two carriers emerged from other organisations representing their respective workforces. The figure below shows you how many people are insured in what type of carrier[2].
Access to the respective carriers used to be very restrictive and often simply based on your geographical location and job. If you lived in city X or had job Y, you had to go to carrier Z. Over the years, and especially during the liberal 1980’s / 1990’, competition was increased through several reforms. Simplified speaking, should you not belong to a group of people that has their own carrier (such as farmers), you have a free choice of carrier.
Going into too much detail here does not help the readability of this guide nor the goal we hope to achieve. If you are interested in (a lot) more details, we can recommend the Ministry of Health, the “Bundeszentrale für politische Bildung” or Krankenkassen.de for further readings.
The organisational structure
Health insurance and health care are complex and complicated so naturally lawmakers tried to make the organisational structure complicated too.
Germany is a federal state, meaning that each state (“Bundesland”) has a lot of freedom to do things as they please in their jurisdiction. That is not so much the case here, but the carriers are firstly organized on state level into state associations (“Landesverbände”).
Their job description shows many tasks, including the coordination of health policy positions and actions as well as the negotiation and conclusion of contracts with the actual service providers (e.g. insurance companies, hospitals, etc.).
The respective state ministry of health is responsible for the oversight of those organisations.
In addition to that, since 2007 the carriers pool together in a federal association, namely the “GKV-Spitzenverband”, the umbrella organisation of the public health insurance carriers[3]. The following figure shows its setup:
The various carriers meet every six years for a general assembly to, among other things, vote for the board of directors (“Verwaltungsrat”). The board has real power and a range of objectives and tasks such as health, care and socio-political questions of principle, questions of principle of supply development, the contract system and how the premiums are calculated and collected.
The board receives information and decision-making help from five committees (“Fachausschüsse”), which have a focus on specific fields.
Additionally, the board appoints the executives who lead the organisation. There are three executives that represent the organisation for a six-year term.
One important aspect regarding the organisational structure is self-government. The legislative (i.e. the government currently in power) establishes the legal framework and has the oversight but the public insurance system decides how to actually put the rules into practice.
It has a surprisingly democratic and social core. Ask any German about “Sozialwahlen” (social elections) and at best you will get a reaction that says: I have heard about it but I have absolutely no idea what it is. The mentioned board of directors has many employer representatives as well as representatives from the insured people themselves. Every six years around 90 % of Germans can vote for the employer and insured representation and therefore (semi-) actively shape the public insurance system.
Who gets to decide what treatment are covered?
If the umbrella organisation gets to put law and legal framework into action, who decides what the law and legal framework is? Simplified speaking, the government in power by passing said laws and providing said legal frameworks. Naturally, it is more complicated than that.
The following figure shows the structure of the entire official health care apparatus in Germany[4]:
The most interesting parts for us are the two central organisations: the ministry of health and the joint federal committee (“Gemeinsamer Bundesausschuss” or G-BA).
The ministry of health, among other things, introduces legislation that might be turned into law, thereby shaping health care. In addition to that, it has oversight of the G-BA.
The G-BA is the committee that ultimately decides which individual treatments are covered to what extent by the carriers (it also has other tasks which we will not go into at this point). It does so by issuing policy guidelines which are legally binding for the actors in the public health care system.
The decision-making body of the G-BA (the plenum) consists of 13 members with voting rights:
· 1 impartial chairman,
· 2 other impartial members,
· 5 representatives of the “GKV-Spitzenverband” and
· 5 representatives of the service providers (the “Federal Association of Statutory Health Insurance Dentists”, Federal Association of Statutory Health Insurance Doctors” and the “German Hospital Society”)
Additionally, it has members from “Accredited Patient Associations”, which do not have voting rights. The patients get to have a say but nobody needs to listen.
This is the central decision-making committee for public health care in Germany. It’s decisions shape the life’s of millions of people and billions of Euros and you can be very certain that 99 % of the population does not know that it exists or what people are part of it (if you want to belong to the good kind of 1 %, here you are).
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Thank you for reading! If you enjoyed part 2.1, you are bound to enjoy the rest of the series that we steadily publish here.
Visit us on www.versicherungsbuero-weiss.com for more information.
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Write us a message on facebook if you want to chat about insurances and other interesting things: https://www.facebook.com/ExpatSpecialist
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[1] https://www.sozialgesetzbuch-sgb.de/sgbv/12.html
[2] https://www.bundesgesundheitsministerium.de/themen/krankenversicherung/grundprinzipien/aufgaben-und-organisation-der-gkv.html
[3] https://www.gkv-spitzenverband.de/gkv_spitzenverband/der_verband/organisation/organisation.jsp
[4] https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/Publikationen/Ministerium/sonstiges/Poster_Das_Gesundheitssystem.pdf
