healthcare in germany healthcare in germany germany has a universal multi-payer health care system paid for by a combination of statutory health insurance (gesetzliche krankenversicherung) and private health insurance (private krankenversicherung). life expectancy development in germany by sex the turnover of the national health sector was about us$368.78 billion (€287.3 billion) in 2010, equivalent to 11.6 percent of gross domestic product (gdp) and about us$4,505 (€3,510) per capita. according to the world health organization, germany's health care system was 77% government-funded and 23% privately funded as of 2004. in 2004 germany ranked thirtieth in the world in life expectancy (78 years for men). it was tied for eighth place in the number of practicing physicians, at 3.3 per 1,000 persons. it also had very low infant mortality rate (4.7 per 1,000 live births). in 2001 total spending on health amounted to 10.8 percent of gross domestic product. according to the euro health consumer index, which placed it in seventh position in its 2015 survey, germany has long had the most restriction-free and consumer-oriented healthcare system in europe. patients are allowed to seek almost any type of care they wish whenever they want it. in 2017, the governmental health system in germany kept a record reserve of more than €18 billion which made it one of the healthiest healthcare systems in the world at the time. history the university medical center freiburg 1883 germany has the world's oldest national social health insurance system, with origins dating back to otto von bismarck's social legislation, which included the health insurance bill of 1883, accident insurance bill of 1884, and old age and disability insurance bill of 1889. bismarck stressed the importance of three key principles; solidarity, the government is responsible for ensuring access by those who need it, subsidiarity, policies are implemented with the smallest political and administrative influence, and corporatism, the government representative bodies in health care professions set out procedures they deem feasible. mandatory health insurance originally applied only to low-income workers and certain government employees, but has gradually expanded to cover the great majority of the population. 1883–1970 unemployment insurance was introduced in 1927. in 1932, the berlin treaty (1926) expired and germany's modern healthcare system started shortly after the expiration of berlin treaty. 1935, gerhard domagk discovers sulfonamides. in 1956, laws on statutory health insurance (shi) for pensioners come into effect. new laws came in effect in 1972 to help finance and manage hospitals. in 1974 shi covered students, artists, farmers and disabled living shelters. between 1977 and 1983 several cost laws were enacted. long-term care insurance (pflegeversicherung) was introduced in 1995. 1976–present since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries. the commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. in 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. capitated care, such as that provided by u.s. health maintenance organizations, has been considered as a cost-containment mechanism but would require consent of regional medical associations, and has not materialized. copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. the average length of hospital stay in germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the u.s. (5 to 6 days). the difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. drug costs have increased substantially, rising nearly 60% from 1991 through 2005. despite attempts to contain costs, overall health care expenditures rose to 10.7% of gdp in 2005, comparable to other western european nations, but substantially less than that spent in the u.s. (nearly 16% of gdp). as of 2009, the system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. approximately 92% of the population are covered by a 'statutory health insurance' plan, which provides a standardized level of coverage through any one of approximately 1,100 public or private sickness funds. standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. higher-income workers sometimes choose to pay a tax and opt-out of the standard plan, in favor of 'private' insurance. the latter's premiums are not linked to income level but instead to health status. historically, the level of provider reimbursement for specific services is determined through negotiations between regional physicians' associations and sickness funds. regulation the german healthcare system is regulated by the federal joint committee (gemeinsamer bundesausschuss), a public health organization authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine decisions regarding healthcare in germany. the federal joint committee consists of 13 members, who are entitled to vote on these binding regulations. the members composed of legal representatives of the public health insurances, the hospitals, the doctors and dentists and three impartial members. also, there are five representatives of the patients with an advisory role who are not allowed to vote. the german law about the public health insurance (fünftes sozialgesetzbuch) sets the framework agreement for the committee. one of the most important tasks is to decide which treatments and performances the insurances have to pay for by law. the principle about these decisions is that every treatment and performance has to be required, economic, sufficient and appropriate. health insurance german health care spending (red) as a percentage of gdp for 1970 to 2015 compared with other nations since 2009, health insurance has been compulsory for the whole population in germany, when coverage was expanded from the majority of the population to everyone. as of 2021, salaried workers and employees who make less than €64,350 per year or €5,362.50 per month are automatically enrolled into one of currently around 105 public non-profit "sickness funds" (krankenkassen). the fund has a common rate for all members, and is paid for with joint employer-employee contributions. the employer pays half of the contribution, and the employee pays the other half. insured persons can also choose optional plans that include higher deductibles and are therefore cheaper. plans that include high reimbursements if no medical services are used are also possible. in addition, insured persons can forego certain services with some health insurance companies and choose cheaper plans. self-employed workers and those who are unemployed without benefits must pay the entire contribution themselves. provider payment is negotiated in complex corporatist social bargaining among specified self-governed bodies (e.g. physicians' associations) at the level of federal states (länder). the sickness funds are mandated to provide a unique and broad benefit package and cannot refuse membership or otherwise discriminate on an actuarial basis. social welfare beneficiaries are also enrolled in statutory health insurance, and municipalities pay contributions on their behalf. besides the statutory health insurance (gesetzliche krankenversicherung), which covers the vast majority of residents, some residents can instead choose private health insurance: those with a yearly income above €64,350 (2022, unchanged from 2021), students and civil servants. about 11% of the population has private health insurance. most civil servants benefit from a tax-funded government employee benefit scheme that covers a percentage of the costs, and cover the rest of the costs with a private insurance contract. recently, private insurers provide various types of supplementary coverage as an add upon of the shi benefit package (e.g. for glasses, coverage abroad and additional dental care or more sophisticated dentures). health insurance in germany is split in several parts. the largest part of 89% of the population is covered by statutory public health insurance funds, regulated under by the sozialgesetzbuch v (sgb v), which defines the general criteria of coverage, which are translated into benefit packages by the federal joint committee. the remaining 11% opt for private health insurance, including government employees. public health insurance contributions are based on the worker's salary. private insurers charge risk-related contributions. this may result in substantial savings for younger individuals in good health. with age, private contributions tend to rise and a number of individuals formerly cancelled their private insurance plan in order to return to statutory health insurance; this option is now only possible for beneficiaries under 55 years. reimbursement for outpatient care was previously on a fee-for-service basis but has changed into basic capitation according to the number of patients seen during one quarter, with a capped overall spending for outpatient treatments and region. moreover, regional panel physician associations regulate number of physicians allowed to accept statutory health insurance in a given area. co-payments, which exist for medicines and other items are relatively low compared to other countries. insurance systems total health spending per capita, in us$ ppp-adjusted, of germany compared amongst various other developed countries germany has a universal system with two main types of health insurance. germans are offered three mandatory health benefits, which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance. accident insurance for working accidents (arbeitsunfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace. long-term care insurance (pflegeversicherung) is covered half and half by employer and employee and covers cases in which a person is not able to manage their daily routine (provision of food, cleaning of apartment, personal hygiene, etc.). it is about 2% of a yearly salaried income or pension, with employers matching the contribution of the employee. there are two separate types of health insurance: public health insurance (gesetzliche krankenversicherung) and private insurance (private krankenversicherung). both systems struggle with the increasing cost of medical treatment and the changing demography. about 87.5% of the persons with health insurance are members of the public system, while 12.5% are covered by private insurance (as of 2006). in 2013 a state funded private care insurance was introduced (private pflegeversicherung). insurance contracts that fit certain criteria are subsidized by €60 per year. it is expected that the number of contracts will grow from 400,000 by end of 2013 to over a million within the next few years. these contracts have been criticized by consumer rights foundations. insuring organizations the german federal legislature has reduced the number of public health insurance organizations from 1209 in 1991 down to 123 in 2015. the public health insurance organizations (krankenkassen) are the ersatzkassen (ek), allgemeine ortskrankenkassen (aok), betriebskrankenkassen (bkk), innungskrankenkassen (ikk), knappschaft (kbs), and the landwirtschaftliche krankenkasse (lkk). as long as a person has the right to choose health insurance, they can join any insurance that is willing to include them. public health insurance organizations in january 2019 numbers number of members including retired persons open on federal level open on state level not open all public insurance organisations 109 72.8 m 43 46 29 betriebskrankenkassen 84 10.9 m 33 32 28 allgemeine ortskrankenkassen 11 26.5 m 0 11 0 landwirtschaftliche krankenkassen 1 0.6 m 0 0 1 ersatzkassen 6 28.0 m 6 0 0 innungskrankenkassen 6 5.2 m 3 3 0 knappschaft 1 1.6 m 1 0 0 public insurance ambulance vehicle of german red cross near hannover regular salaried employees must have public health insurance unless their income exceeds €64,350 per year (2021). this is referred to as the compulsory insurance limit (versicherungspflichtgrenze). if their income exceeds that amount, they can choose to have private health insurance instead. freelancers and self-employed persons can have public or private insurance, regardless of their income. public health insurers are not forced to accept self-employed persons, which can create difficulties for foreign freelancers, who can get refused by both public and private health insurers. since health insurance coverage is a requirement for their residence permit, they can be forced to leave the country. in the public system, the premium is set by the federal ministry of health based on a fixed set of covered services as described in the german social law (sozialgesetzbuch – sgb), which limits those services to "economically viable, sufficient, necessary and