16 August, 2014

German vs. American Health Insurance

Here we go again, another health-related post. Given the frequency of my recent doctor's appointments, this is on my mind a lot and is the most logical thing for the write about at the moment. This time, I'll do my best to give an overview of the differences and similarities between health insurance in Germany and the United States.

Typical German health insurance card

In both countries there are public and private health insurance options, but there are several differences regarding who has access to each system and how and what each one provides. 

In the United States, public insurance is only available to a small percentage of the population, namely the very poor, some children, the disabled, and the elderly. (Click HERE for a breakdown of the percentage of Americans on public and private insurance.) I believe there are also health insurance programs for military members and veterans but I don't know much about these. (If any Americans reading this know more about these programs, please feel free to contribute in the comments.) Although these programs are supposed to guarantee health care for those most in need, the reality leaves something to be desired. One huge problem with public health insurance in America is that many doctors don't accept it. The reimbursement rates from the public insurance are often so low that it is not worth the doctor's time to accept publicly insured patients. That, and the fact that most people don't qualify for it, makes public insurance almost useless as an option for most people. 

However, it's not useless for everyone. Arguably the most successful of the American public insurance programs is the program for the elderly, known as Medicare. Medicare provides a high level of benefits for elderly patients, and according to surveys it has a higher satisfaction rate than private insurance plans (click HERE for more info). Even amid this praise for Medicare, there are people in the government who want to cut benefits or privatize the program, which would open the door to major changes in favor of the private provider(s) and which would almost certainly reduce the quality of the program. I personally think Medicare should be expanded and offered to everyone in America, not just to the elderly.  

Public insurance in Germany is much more common than in the United States. Every German citizen is required to participate in the public health insurance system unless he or she works in one of several professions (I'll get to this point later) or makes above a certain amount of money. And even if you make above this set amount of income, you can still keep your public insurance if you want; this income threshold is simply the point at which you are given a choice and can leave the public insurance system if you wish. 

The public insurance in Germany is administered by a total of 132 different providers (or Kassen in German), but I believe the benefits are relatively comparable across the board. You can go to any doctor you want; no need to worry about who accepts which insurance or whether the doctor you want to see is in the right "network" (a frustrating reality of the American health care system). All doctors accept all insurances here, public or private. To have public insurance you have to pay a fee each month, but it is cheaper than a private insurance premium. And instead of going to a private company that is focused on making a profit, the money goes into a pool which is then used to cover the care of everyone insured by that provider. The public Kassen pay doctors less than the private insurance companies, but since all doctors accept all insurances you (usually) don't have to worry about being turned away from a doctor because of your insurance. 

Now for private insurance. Private health insurance is the most common type of insurance in the United States and is often provided by employers as a benefit of working for the company. That is how most people expect to be insured, but in recent years it has become harder to find a job that provides such benefits so many people have to buy their own private insurance, which can be very expensive, or go without insurance. Most private insurances have co-pays (a set charge you have to pay each time you go to the doctor, ranging anywhere from $10 to $50 or more), deductibles (the amount of money you have to pay out of pocket before the insurance will start to pay for anything, which can range into hundreds or thousands of dollars), and limits on how much the insurance will pay for a particular procedure. Even people with private insurance can end up paying a lot of money out of pocket after the insurance coverage for a procedure or treatment plan has been exhausted. 

Private insurance in Germany tends to pay for everything (although not always) and can even get you some special treatment such as a private hospital room or better quality materials. Since private patients (those who pay for themselves or who have private insurance) pay a higher rate for everything or can pay for things that the public Kassen don't cover, it can be better for both the doctors' wallets and the patients. Having private insurance can sometimes convince a busy doctor to take you on as a patient, even when he or she is not currently taking new patients, because the doctor knows there is more money at stake. However, private insurance is expensive, even more so than in the United States, so if you don't have a lot of money to throw around you may not have that option. And keep in mind that having private insurance is only an option if you make above a certain amount of income anyway. 

And then there are people for whom private insurance is the only option, meaning they are excluded from the public insurance system altogether. Contrary to my common sense, this group includes government employees, teachers (who are also technically government employees), and people who own their own businesses. The brother-in-law of a friend of mine owns his own business and therefore has to buy private insurance, and he pays something like 1000 euros (more than $1300) per month for himself and his family (5 people total).

Although having private insurance in Germany can be a benefit, it comes with its own set of expenses and drawbacks. One super annoying thing about having private insurance in Germany is the billing. With public insurance, as soon as you leave the doctor's office you are all done and your bill is paid by the Kasse. With private insurance, you have to pay all your bills first yourself and then send the receipts to the insurance company to get reimbursed. I have private Au pair insurance here (which covers less than most private insurance but works in a similar way) and that is the thing that drives me crazy the most about going to the doctor: I have to either pay my bill before I leave the office or wait weeks for the office to send me a bill, which I then have to pay with my limited funds and then send to the insurance company and wait again for them to reimburse me. It is very frustrating and it's the last thing I want to worry about when I'm in the midst of health problems.

In general, I like the German system better. I like that the public insurance is available to almost everyone and that it's accepted by all doctors. Personally I don't think private insurance should be allowed, because it creates two tiers of patients: the normal publicly insured patients and the richer privately insured patients who can get preferential treatment. Besides this one issue, though, I think the German system is more egalitarian and provides a better basic level of health care for the entire population.

I see many more problems with the American system. The Affordable Care Act, also known as Obamacare, that was passed a few years ago helped matters some, but essentially all it did was create more regulations for private insurance companies so that they can't completely screw people over anymore. For example, insurance companies now cannot charge women more for health insurance than men of the same age, they cannot deny people insurance because of a pre-existing medical condition and they are required to spend a certain percentage of their revenue on actual health care and not on, say, higher executive bonuses. Obamacare didn't expand the public insurance system very much, and there are still many people who fall through the gap between public and private insurance: they aren't poor/young/old/disabled enough to qualify for public insurance but they don't make enough money to be able to afford private insurance. And since health care in the United States is so expensive (click HERE for an article with some truly astonishing examples of inflated prices for health care in America), not having health insurance can set you up for bankruptcy and financial ruin if you get sick or have an accident. Millions of Americans go bankrupt every year because of medical bills, even people who have health insurance. That would never happen in Germany, or anywhere else in the developed world, for that matter. As of 2013, medical bills were the most common cause of bankruptcies in the United States, a statistic that I find humiliating. (For more info, click HERE.)

And even with these horribly sobering statistics, there are still lawmakers out there who want to undermine or dismantle the existing public health care systems in America. Many politicians hate Obamacare simply because it was Obama who put it in place. Instead of advocating for universal health care, which is what Obama actually wanted to do in the first place, these clueless politicians are urging people to start "medical savings accounts" where they can save up their own money in case of an accident or injury. This is a ridiculous proposition; when a single night in an American hospital can cost anywhere from $4,000 to $12,500 (2,985 to 9,330 euros), how can anyone who doesn't have the money to pay for health insurance possibly be expected to save up enough money to cover all eventualities?

Health care is a complicated system, and understandably there are flaws with any system. But the complexity of the issue is no excuse for the failings of the American health care system. It's a disgrace that the richest country on Earth can't provide quality health care to all of its residents. People die every single day in America because they can't afford health care, and many people who survive are drowning in debt as a result of health problems they could not possibly have prepared themselves for. It's about time that the United States looked to its peers for solutions. There are successful systems out there right now (see Canada and most of Western Europe) and there's no excuse for the US to continue along the overly expensive, inegalitarian and unhealthy path it's currently on. But I guess universal health care would infringe on our American freedoms, right?

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