What if we sought inspiration from German health insurance?

French social security is going through turbulent times. One reform after another has failed to satisfy the insured population nor guarantee balancing the health system’s finances over the long term. And the challenge of population ageing remains to be met. And so, some people are suggesting a new approach known as the “Grand Social Security project” (“La Grande Sécu”[1])… Centralisation and state control would then be the keys to solving all the problems. Germany, so often held up as a model, has not gone down that route. Quite the contrary! This has been revealed in a recent study sponsored by Gerep, devoted to the German health insurance system, past and present. [1] “La Grande Sécu”, a project to reform first layer Public Health Insurance and second layer Complementary Health Insurance.

The German system ensures free choice and solidarity

Inherited from a long tradition—an eventful history detailed in the study—that dates back to the Middle Ages, the German health insurance system has evolved into an organization based on decentralized management, national solidarity, and freedom of choice for insured persons. Today, Germans can choose from more than 100 ‘statutory funds,’ historically linked to a company, region, or profession, which have now opened their services to everyone. These funds reimburse healthcare costs and collect contributions from gross salaries at a single rate set by the State. Contributions from all statutory funds are pooled into a ‘Health Fund,’ from which reimbursements to members are also made. There is a risk compensation mechanism, and the State may step in to cover deficits or specific expenses, such as children’s health insurance or family allowances. In this system, the diversity of players serves one purpose: ensuring service quality and controlling costs through competition.

Room for private insurance

In Germany, health insurance is compulsory. However, it is possible to opt for private insurance from the first Euro, i.e. be fully covered by private health insurance. This choice is open to civil servants, the liberal professions and employees earning more than 62,000 Euros a year. Surprisingly varied categories of people, once again inherited from the past! 8.7 million German insureds have chosen from around fifty private funds. These offer differentiated rates and personalised rules, as well as a few privileges. These funds are not increasing in number, as the range of care and cover offered by the statutory funds is considered satisfactory. However, 26 million insured persons have chosen to supplement their basic coverage with complementary private insurance, which allows them, for example, to obtain a single room when in hospital or 100% reimbursement of dental care, compared to 80% maximum in the statutory funds.

Enviable performance and ‘inspiring’ solutions

Healthcare expenditure is roughly equivalent in France and Germany: around 12.5% of GDP in 2020. In terms of copay, French policyholders are better off than Germans: according to the OECD, they are left to pay 9% of their healthcare costs compared to 13% in Germany. Yet, the level of satisfaction with the healthcare system is much higher in Germany. With hospital beds having become a subject of debate in our country, one figure can illustrate this difference: Germany has 34 beds per 100,000 inhabitants compared with only 16 in France.

Something that characterises the German system above all is its capacity to evolve smoothly, to adapt and to balance its budget. On the French side, social security is an issue that is much more fraught, often sparking national political quarrels, probably because the system is so centralised. In neighbouring Germany, insured persons’ free choice and competition between funds does not detract from the feeling that health and social protection are a common good: healthcare is satisfactory, solidarity is ensured and the social contract is respected. This undoubtedly stems from a decentralised pragmatic approach, which seeks concrete solutions to problems rather than spectacular reforms. For example, the premium rates charged by complementary insurers to pensioners in France (who no longer benefit from an employer’s contribution) is seen as justification for the “Grande Sécu” upheaval. In Germany, expenditure is kept stable, in most funds, by a mechanism involving contributions from pension funds. Quite simply… At a time, here in France, when major reforms are being prepared based on reports and studies, it may be enlightening and inspiring to take a look at the systems that work rather well and peacefully for our European neighbours.