Seventy percent of Americans
say the U.S.
health-care system is in a state of
crisis or that it has major
problems. That's why we're hearing a
lot about Medicare for all,
including some plans going as far
as banning private health insurance
companies altogether.
On page eight of the bill, it
says that we will no longer have
private insurance as we know it.
And that means that one hundred
and forty nine million Americans will
no longer be able to
have their current insurance.
That's in four years.
I don't think that's a bold idea.
I think it's a bad idea.
Problem. Senator Sanders, with that damn
bill that you wrote and that
Senator Warren backs, is that it
doesn't trust the American people.
I trust you to choose what
makes the most sense for you.
Not my way or the highway.
One country found a way to
provide universal health care coverage
while maintaining a competitive insurance
market that offers citizens
more choices: Germany. Here's
how they did it.
In 2017, U.S.
health care spending came
to around $10,200 U.S.
dollars per capita in Germany.
It was a little under $6,000.
Overall, Germany spent about 11.2
percent of its GDP on
health care, while the U.S.
spent 17.1
percent. Germany manages to cover
100 percent of its population.
In the United States, about 8.8
percent of the
population remains uninsured.
That comes to about 28 million
people with even more people
underinsured. Despite spending less, Germany
has better or comparable
health outcomes to
the United States.
Studies show that in Germany, there
were fewer deaths that could have
been prevented with proper
access to care.
In 2013, there were 83 avoidable
deaths out of every 100,000 people
in Germany, while the
United States had 112.
Life expectancy in Germany is 2.5
years higher than the United States,
and the infant mortality rate is
lower in Germany, with 3.3
deaths per 1,000 live births
as opposed to 5.8
deaths in the United States.
Additionally, the maternal mortality rate
in the United States is
more than 2 times
higher than in Germany.
So how does Germany manage to
have better health outcomes while
spending nearly half as much
as the United States?
Germany is a system that would
look familiar to Americans in that
everybody buys health insurance from a
private company and then the
doctors and the hospitals and the
labs are almost all private.
That's T.R. Reid, author of the
book "The Healing of America."
He traveled the world exploring different
health care systems and how
well they worked.
But it works better in
Germany for a couple reasons.
One is everybody is covered.
Everybody is required
to have insurance.
Everybody's in the system.
The insurance companies can't turn you
down because you had cancer
last year or something, they
have to take you.
They have to cover you.
Everybody has access to the same
treatment and all the doctors.
You can go to any doctor without
any limits set by the insurance
company.
In Germany, health insurance is
mandatory for all citizens and
permanent residents.
There are two different systems that
residents can turn to for
insurance. SHI, which stands for
statutory health insurance and PHI
or private health insurance.
German citizens are eligible for PHI if
they make more than a roughly
60,000 U.S.
dollars per year or if
they are self-employed .
Citizens making under that threshold
must pay into S.H.I.
S.H.I is made up of a network
of competing, not for profit private
health insurance funds known
as sickness funds.
In S.H.I., dependents are covered free
of charge and monthly costs
are capped around 840
euro per month.
Even though S.H.I sickness funds
are not government agencies, many
Germans think of them as part of
a public system because of heavy
regulation. Keith Tanner helps expats
navigate the German health care
system and he considers SHI
sickness funds quasi -public
organizations.
Basically, they have to
do what they're told.
They they are told by the government
in what range they can charge.
They they're told what health procedures
they can fund and they are
told by the government who they
can accept as clients so they're
really just carrying out orders.
They're basically charities.
They don't exist to make a
profit for investors like American health
insurance companies. They're there
to keep people healthy.
That's what they're there for.
They follow all sorts of
rules that American insurance companies
wouldn't dream of.
This system is funded through
compulsory contributions based on a
percentage of citizens' salaries with
employers sharing the costs.
There are also built
in safety nets.
The government will pay into S.H.I.
on behalf of the
long term unemployed.
Despite being non-profit organizations,
sickness funds compete for
customers by offering specific
coverage and perks.
This competition has changed over the
years as the system has allowed
citizens more choice.
As of 2019, there are about
100 statutory health insurance companies,
but there used to be many more.
When Germany's system was first
established in the late 1800s,
sickness funds were linked
to a person's profession.
It used to be that people were
assigned to a specific sickness fund
based on their
occupation or region.
Now Germans can choose where they enroll
and they can change funds on
a yearly basis.
As a result, sickness funds begin
marketing themselves in order to
retain customers and
attract new ones.
This also led to the funds
merging so they could become more
competitive. Some of the sickness funds
offer perks that might seem
similar to credit card rewards.
You still can get a bonus for going
to the gym and a bonus having a
checkup. This is in
the public system.
And if you get a certain number
of bonus points, then you get a
voucher. But kind of trivial stuff like
200 euros a year or something
like that. 200 euros a year.
Nothing which is particularly relevant
to the person who's paying
their 840 a month.
As of 2017, roughly 87 percent
of Germans receive their primary
coverage through S.H.I.
and 11 percent of
the population through P.H.I.
The remaining population, such as
soldiers, police officers and
refugees receive health insurance
through specific government
programs. All individuals
insured through P.H.I.
pay a risk related premium with
separate premiums for each dependent.
These risk based premiums mean that
costs will increase as the
insured gets older. As a
result, the government regulates P.H.I.
so people don't become overburdened
by premiums as they age.
The biggest issue with private health insurance
if you opt out of a
public system is affordability
in old age.
If you don't impose these financial
constraints on insurers, then the
government will be lumbered about a whole
lot of old people who reach
85, 90, 95.
It's gonna be totally able to
pay for their health insurance, so
it'll all fall back
on the government.
Once someone switches to P.H.I.,
they can not switch back to S.H.I.
in the future. But Tanner says
there are ways around that.
If you're a freelancer in the private
system, you just can't get a
job paying less than the threshold.
Any employee earning under about 5000
euro a month is required to
have public.
If they own more than
that, they can opt out.
So if you are a freelancer, you
want to go back into the public
system for some reason.
Then you'll get a part time job with
a friend, pays you 500 a month
for a few months, and then
you react in the public system.
So there are ways to do it. The
only reason you probably want to do
that, though, is if you have
lots of children, because children can
be covered free in the public system,
in the private system, have to
pay separately for each child.
Germans can also buy supplemental
private insurance while staying in
S.H.I.. For example, many Germans
buy supplemental dental insurance.
The public system pays like for
major dental work, about half the
cost and then you get supplementary to
take it up to 80, 90 percent
of the cost.
Germany's system is not perfect.
With so many different insurance
companies, there's a lot of
bureaucracy that contributes
to costs.
One of the financial things thinking
it's a big system administered
by more than 100 organizations is
called krankenkassen, each of those
has a head office and a president
and vice president and a financial
officer, a whole lot
of unnecessary bureaucracy.
This may be one of the reasons that
the German system is not as cost
effective as other
European countries.
More than 30 percent of both
Germans and Americans felt bureaucracy
was a major issue
in their country's system.
Wait times can also be an
issue for people in S.H.I.
Thirty seven percent of Germans cite wait
times as one of the biggest
problems within their system, while 22
percent of Americans feel the
same.
Generally I think people are quite
happy with the public system.
It works reasonably well.
The major issue in big cities
— I'm in Berlin, Munich, Düsseldorf,
Hamburg. It can take quite a while
to get an appointment with a
specialist. It is the case that
the doctors prefer private patients
because they own up to three times
more if they see a private
patient.
So what can the United States
learn from the German system?
Germany has managed to balance
cost controls and universal coverage
while also maintaining competition.
And Germans generally
like their system.
In one survey, not a single German
said they had to wait more than
four months for an elective surgery,
while four percent of Americans
said that they had to wait that
long for the same kinds of
procedures. And only 7 percent of
Germans said they experienced a
barrier to care because of cost in
the past year compared to 33
percent of Americans.
Those citizens really like it.
They like the fact
that everybody is covered.
They like the fact that
the costs are totally predictable.
You know what it's going to cost
you and how much your insurance
company is going to pay you before
you walk in, unlike the United
States. They think it's normal that
the insurance company pays every
claim. They can't believe that insurance
company might deny a claim.
And they think it's normal that
they get to choose the doctor.
They don't understand America, where
the insurance company says we
won't cover a doctor Jones.
You have to go
to Dr. Smith instead.
So the main thing I learned in going
around the world is you have to
make the commitment to provide
health care for everybody.
That's the destination.
It turns out there are many
different routes to that destination.
I found, you know, the Canadian
model, the French model, the British
model, the German model.
They all get to this goal
in different ways and different models.
So I don't care what the model is.
I think it's important that you
make the commitment to cover
everybody. And this is something
the world's richest country has
never done.
