Population Insurance Coverage For A Core Set Of Healthcare Services* (%) (2019):
Public Coverage: 89.5%; Primary Private Health Coverage: 10.5%; Total: 100%

*”Population coverage for health care is defined here as the share of the population eligible for a core set of health care services – whether through public programmes or primary private health insurance. The set of services is country-specific but usually includes consultations with doctors, tests and examinations, and hospital care. Public coverage includes both national health systems and social health insurance. On national health systems, most of the financing comes from general taxation, whereas in social health insurance systems, financing typically comes from a combination of payroll contributions and taxation. Financing is linked to ability-to-pay. Primary private health insurance refers to insurance coverage for a core set of services, and can be voluntary or mandatory by law (for some or all of the population.”

Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.

Annual household out-of-pocket payment, current USD per capita (2019): $691

Source: Global Health Expenditure Database. Health expenditure series. Geneva: World Health Organization. Last accessed March 23, 2022.

Out-of-Pocket Spending as Share of Final Household Consumption (%) (2019): 2.9%

Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.

“Germany has the oldest social health insurance (SHI) system in the world. Health insurance is compulsory, but people with an income above a fixed threshold or belonging to a particular professional group (e.g. self-employed people or civil servants) can opt out of SHI coverage and enrol in (substitutive) private health insurance (PHI). About 11 % of the population are covered by PHI; 89 % by SHI. Although coverage is universal for all legal residents and only 0.1 % of the population do not have health insurance, there are still gaps due to financial or administrative barriers (see Section 5.2). The multi-payer SHI system currently consists of 103 sickness funds and 41 PHI companies, and the three biggest sickness funds cover more than one third of the German population.”

Source: OECD/European Observatory on Health Systems and Policies (2021), Germany: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

“The German health system has a complex governance structure. The federal government defines only the legal framework, while regulatory details are specified in directives issued by the Federal Joint Committee – the highest self-governing decision-making body in the country. The Committee consists of representatives of associations of sickness funds, physicians, dentists and hospitals, as well as three independent members (plus patient representatives without voting rights). It takes decisions on SHI benefits, reimbursement systems and quality assurance.

“The states (Bundesländer) supervise the self-governing bodies at the regional level and are responsible for hospital planning and investments, as well as medical education. They are also responsible for public health services and the running of public health offices, which gained in importance during the COVID-19 crisis. At the same time, the crisis revealed the challenges faced by federal systems in coordinating and managing the pandemic. Governance mechanisms have been put in place to enable rapid, cross-state measures to respond to the crisis through ordinance authorisations, particularly by the Federal Ministry of Health (Box 1).”

Source: OECD/European Observatory on Health Systems and Policies (2021), Germany: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

“The German system provides universal population coverage either through social health insurance (SHI) (almost 90% of the population) or substitutive VHI [Voluntary Health Insurance]. As OOP [Out-Of-Pocket] policies of substitutive VHI vary widely (and data is largely unavailable), we focus on SHI. OOP spending in Germany is related to both direct payments for services not covered by SHI (e.g., over-the-counter drugs) and cost-sharing for SHI covered services, but the relative importance of cost-sharing versus direct payments is not known because of the health system’s accounting methods. OOP spending above reference prices for dental care and medical aids can be substantial; for example, reference prices for dental care cover only about 50% of the costs of standard care. Cost-sharing requirements increased in 2004 for such things as prescription drugs, inpatient care, and physician and dental care, while at the same time adult eyeglasses were excluded from coverage. Since these increased requirements became effective in 2004 they do not affect the average growth rate in the 2004–2014 period and therefore do not contradict the observed drop in average growth in 2004–2014 compared to the 1994–2004 period. The most plausible explanation for the low growth in this period is the fact that in 2013, co-payments for physician visits were discontinued. The most important protection mechanism against OOPs is the exemption of children under 18 years of age and a maximum cost-sharing limit of 2% of annual income (or 1% for patients with severe chronic conditions). This has remained largely unchanged over the study period.”

Rice, Thomas et al. “Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries.” BMC health services research vol. 18,1 371. 18 May. 2018, doi:10.1186/s12913-018-3185-8.

“The German health system and its governance is highly complex. It is the only country in Europe with coexisting SHI [Statutory Health Insurance] and substitutive PHI [Private Health Insurance]. Both schemes are separated along different organizational, regulative and financial lines (Figure 2.1). Care sectors are also separated in terms of organization, governance and financing. Due to separate legislation for individual sectors within public health, ambulatory and inpatient care, as well as in long-term care, there is strong fragmentation of service provision (Figures 2.1 and 2.2).

“Health insurance is compulsory for all citizens and permanent residents, with SHI constituting the main source of financing health care. The multi-payer SHI insurance scheme covered 72.8 million people or 87.7% of the population in 2018. Employees above an opt-out threshold of income, € 62 550 in 2020, and certain professional groups, e.g. self-employed or civil servants, can opt to enroll in substitutive PHI. Thus, 8.7 million people (or 10.5% of the population) were covered by substitutive PHI (Bundesministerium für Gesundheit (BMG), 2019d; Statistisches Bundesamt, 2019b; Verband der privaten Krankenversicherung, 2019a) (see Section 3.3.1 Coverage for more detail). Another unique feature of the German health care system is that the vast majority of providers serve both insured populations. The few exemptions that are accessible only to those insured under substitutive PHI represent less than 1% of total hospitals in 2018 (Statistisches Bundesamt, 2020g).”

Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.

“Health insurance coverage is mandatory for the entire population. Coverage is virtually universal and less than 1% of the population is not insured. Some groups of people can choose between publicly financed coverage provided through the statutory health insurance scheme and privately financed substitutive coverage provided by private insurers. Access to substitutive private coverage is restricted to civil servants, self-employed individuals and high-income employees (the annual earnings threshold was €50,850 in 2012). These groups may opt out of the statutory scheme, but once they do so the return options are limited. For example, employees may only return to the statutory scheme when their earnings fall below the threshold. Individuals with substitutive private coverage who are older than 55 years are prohibited from returning to the statutory scheme.”

Source: Stefan Greß. “Germany.” In Voluntary health insurance in Europe: Country experience [Internet]. Sagan A, Thomson S, editors. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2016. Observatory Studies Series, No. 42.

“The archetypal Bismarck model is the traditional system of Germany, financed by multiple insurers, with employer-based schemes supplemented by the state, in which providers are privately owned and patients have direct access to specialists.”

Source: Bevan G, Helderman JK, Wilsford D: Changing choices in health care: implications for equity, efficiency and cost. Health Econ Policy Law. 2010, 5 (3): 251-67. 10.1017/S1744133110000022.

“The German health care system is notable for two essential characteristics: 1) the sharing of decision-making powers between states, federal government, and self-regulated organizations of payers and providers; and 2) the separation of SHI (including the social LTCI) and PHI (including the private LTCI). SHI and PHI (as well as the two long-term care insurance systems) use the same providers—that is, hospitals and physicians treat both statutorily and privately insured patients, unlike those in many other countries.

“Within the legal framework set by the Federal Ministry of Health, the Federal Joint Committee has wide-ranging regulatory power to determine the services to be covered by sickness funds and to set quality measures for providers (see below). To the extent possible, coverage decisions are based on evidence from health technology assessments and comparative-effectiveness reviews. The Federal Joint Committee is supported by the Institute for Quality and Efficiency (IQWiG), a foundation legally charged with evaluating the cost-effectiveness of drugs with added therapeutic benefits, and the Institute for Quality and Transparency (IQTiG), which is responsible for intersectoral quality assurance. It has 13 voting members: five from the Federal Association of Sickness Funds, two each from the Federal Association of SHI Physicians and the German Hospital Federation, one from the Federal Association of SHI Dentists, and three who are unaffiliated. Five patient representatives have an advisory role but no vote. Representatives of patient organizations have the right to participate in different decision-making bodies—for example, the subcommittees of the Federal Joint Committee.

“The Federal Association of Sickness Funds works with the Federal Association of SHI Physicians and the German Hospital Federation to develop the SHI ambulatory care fee schedule and the DRG catalogue, which are then adopted by bilateral joint committees.”

Source: Commonwealth Fund. International Health System Profiles: Germany. Last accessed Sept. 30, 2019.

“The Federal Ministry of Health (“Bundesministerium für Gesundheit” – BMG) is responsible for policy-making at the federal level. Its tasks include developing laws and drawing up administrative guidelines for the self-governing activities within the health care system. The Ministry of Health directs a number of institutions and agencies responsible for dealing with higher-level issues of public health, such as the Federal Institute for Drugs and Medical Devices (“Bundesinstitut für Arzneimittel und Medizinprodukte” – BfArM) and the Paul Ehrlich Institute (PEI). The Federal Institute for Drugs and Medical Devices makes decisions concerning the approval of pharmaceuticals. The Paul Ehrlich Institute is responsible for approving vaccines.

“When it comes to matters concerning statutory health insurance, the Federal Joint Committee (G-BA) is the highest decision-making body within the self-governing health care system. It includes members representing doctors, dentists, psychotherapists, the statutory insurers, hospitals and patients. As the central entity of federal-level self-governance, the Federal Joint Committee makes decisions concerning which medical services will be covered by the statutory insurers and what form that coverage will take.”

Source: InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Health care in Germany: The German health care system. 2015 May 6 [Updated 2018 Feb 8]. Last accessed August 19, 2019.

“The Federal Joint Committee (G-BA) is a public legal entity comprising the four leading umbrella organizations of the self-governing German healthcare system: the National Associations of Statutory Health Insurance Physicians and Dentists, the German Hospital Federation, and the Central Federal Association of Health Insurance Funds. In addition to these four pillar organizations, patient representatives also participate in all sessions; they are entitled to put topics on the agenda, but not to vote.”

Source: The Federal Joint Committee: Who we are and what we do. Gemeinsame Bundesausschuss (Federal Joint Committee). Last accessed September 30, 2019.

“The framework for health care in Germany is based on central decision making:

“1) Legislation established by the parliament,
“2) Decrees issued by the Ministry of Health,
“3) Directives issued by the G-BA under supervision of the ministry, and
“4) Contracts between self-governing organizations under supervision of the ministry.

“There is no competition on products on services between the funds. All provide the same services as defined by the G-BA (Gemeinsamer Bundesausschuss) or the different umbrella organizations of the SHFs (referred to in the following the Statutory Health Insurer’s organizations (SHIs). Private insurance covers nearly the same services but allows additional benefits (e.g. first class service) – there is competition between private insurers. Since 2004, decision-making in statutory health insurance has been integrated into a trans-sector federal joint committee that is supported by an independent institute for quality and efficiency in health care, the German IQWiG. Since 2008, according to the new Competition Enhancement Act, the IQWiG has to evaluate the cost-benefit ratio of pharmaceuticals in Germany based on international accepted guidelines in evidence based medicine and in health economics.”

Source: ISPOR—The Professional Society for Health Economics and Outcomes Research. Global Health Technology Assessment Road Map: Germany – Pharmaceutical. Updated June 2009. Last accessed Oct. 2, 2019.

“The German health care system is divided into three main areas: outpatient care, inpatient care (the hospital sector), and rehabilitation facilities.

“The institutions responsible for running the health care system include the associations and representatives of various providers and professions, health insurers, regulatory bodies, the Federal Ministry of Health, patient organizations and self-help groups.

“The basic principles of the health care system

“The health care system in Germany is based on four basic principles:

“Compulsory insurance: Everyone must have statutory health insurance (“gesetzliche Krankenversicherung” – GKV) provided that their gross earnings are under a fixed limit (“Versicherungspflichtgrenze”). Anyone who earns more than that can choose to have private insurance (“private Krankenversicherung” – PKV).

“Funding through insurance premiums: Health care is financed mostly from the premiums paid by insured employees and their employers. Tax revenue surpluses also contribute. To give you an idea of what this means: State-funded health care systems like those in Great Britain or Sweden draw on tax revenue. In market-oriented systems such as that in the United States, many people have to carry the costs of treatment and loss of earnings due to illness themselves, or have to get private health insurance.

“Principle of solidarity: In the German health care system, statutory health insurance members jointly carry the individual risks of the costs of medical care in the event of illness. Everyone covered by statutory insurance has an equal right to medical care and continued payment of wages when ill – regardless of their income and premium level. The premiums are based on income. This means that the rich can help the poor, and the healthy can help the ill. However, these premiums are only calculated based on a percentage scale up to a certain income level (“Beitragsbemessungsgrenze”). Anyone earning more than this amount pays the same maximum premium.

“Principle of self-governance: While the German state sets the conditions for medical care, the further organization and financing of individual medical services is the responsibility of the self-governing bodies within the health care system. These are made up of members representing doctors and dentists, psychotherapists, hospitals, insurers and the insured people. The Federal Joint Committee (“Gemeinsamer Bundesausschuss” or G-BA – please also see below: “Structure and institutions of the health care system”) is the highest entity of self-governance within the statutory health insurance system.”

Source: InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Health care in Germany: The German health care system. 2015 May 6 [Updated 2018 Feb 8]. Last accessed August 19, 2019.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.

Page last updated Sept. 1, 2022 by Doug McVay, Editor.