health insurance and germany

There is no one in Germany without health insurance.

This isn’t because, as many people falsely assume, Germany has some sort of magical “universal” health insurance system that automatically covers everyone. It is because the system has been designed assuming that everyone will get in line. Which means that if you’re not in line, you’re not on the map. Which in turn means that there are almost no resources for people with low (or no) incomes without insurance. So it’s not that everyone in Germany is insured, it is that it is simply inconceivable, within the system, that you could not be.

The myth that everyone in Germany is insured probably stems from two facts. The first is that if you become unemployed, you can (read: are expected to) sign up at the Arbeitsamt (I suppose the equivalent of the Welfare Office in America). After you’ve jumped through a series of flaming hoops (and the reason some people choose not to deal with them is because they make you do the paperwork equivalent of getting stripped down and hosed off as well as requiring mind-numbing resume-writing seminars and one-euro job participation), they’ll pay you money each month and sign you up for their insurance. Even if you fuck up, and they cut your money down to nothing, they are supposed to continue to insure you. Because, haha, it’s illegal not to be insured in Germany. Which is the second fact that contributes to the myth that everyone has health insurance in this country.

So, imagine you are in Germany and you aren’t insured, for whatever reason. If you are ever caught (which might happen if you simply defaulted on a German insurance policy—be warned, they will eventually come looking for you) or attempt to sign up for a new insurance policy, you will be required to pay the premiums for every month that you were not insured. The logic is highly social—the system can only work if everybody is paying into it all the time—but the application is incredibly fucked up, particularly for the extremely poor. You don’t have enough money to pay for insurance? Take some time to get back on your feet financially, and then find out that you have gotten yourself into crippling debt with the insurance company because of it. Have qualms with the entire insurance system and want to opt out of it completely? Sorry, but no. The strange bit of logic here is that you are also supposed to pay back these premiums because you were insured the entire time. Even though you weren’t, had no insurance card, and had to pay for all of your doctor’s bills yourself. It’s sort of an enforced insurance illusion. Just thinking about it makes my head smoke.

Of course, there are a lot of positive sides to the insurance system here. Because it is illegal to be uninsured, it it also illegal for an insurance company to turn down your request for them to insure you (though I have the impression that this only applies to state insurance—the system is currently a mixture of private and state insurances which is a whole other can of worms that I’ll get into some other time) or to kick you out because it turns out you are really sick or have what they call a “pre-existing condition.” They even pay for a lot of neat things that I never would have dreamed of having covered on my American insurance policies.

But I would still rather live in a world without health insurance. I would still rather cut out all those middle men and middle women and pay my doctors directly. My current daydream is that instead of an insurance premium, everyone could pay a monthly chunk directly into the salary pool of a hospital or clinic and then be allowed to go there for free whenever the need arose.

Huge corporations have risen out of a universal fear of sickness, pain, and death and the only reason they sometimes seem to care about our health is because the healthier we are, the less money we cost them (though they like to thwart this logic as well—for example a midwife’s 250 euro fee for doing a home birth is not covered despite the fact that a home birth costs thousands of euros less than a hospital birth), and we all know what happens when you end up needing an expensive non-traditional operation to stay healthy—then you get denied coverage and are left to rot, at least in the United States. And it’s because of just such issues and cases, as well as the fact that I used to work for a publishing company whose clients were all insurance companies, that I’ve never felt like health insurance offered me all that much, well, insurance. And it is because of just such issues that I can tell you first hand that, yes, there are people in Germany without health insurance.

When people here hear that you are uninsured, their reactions tend to range from shocked to angry. People get rude. They say things like “you’d have to be stupid to not be insured these days.” The receptionists at doctor’s offices—who ask you which insurance company you are with when scheduling an appointment as part of their standard script—generally need to pause and take a deep breath before they are capable of continuing the conversation without comment. The only people, I’ve discovered, who don’t react adversely to the uninsured are doctors because the doctors know that people who don’t have insurance are people who pay their bills themselves, which at the end of the day often means more money in their pockets (there being different levels they are allowed to charge depending on state insurance or private or selbstbezahler, ie “self-payer”). Smart bunch.

Do you have a love/hate relationship with health insurance? Have a better idea? Couldn’t imagine life without it?

Tomorrow check back for more ramblings about the German health insurance system and my experiences within it.

0 Comments on “health insurance and germany

  1. Well I don’t dream about a world without health insurance at all. Looks like hell to me. It’s easy to say such things if you’re young and healthy, and if I may add, a little naive and american. I’m glad I live in the Netherlands where there is an excellent healthcare system, and yes, it’s also illegal NOT to have it. If you have low income you pay less, so it’s affordable for EVERYONE. I think the lowest incomes only pay 30 euro a month.

    Even if I pay more for the insurance than I would by directly paying the doctor I’m glad we have this system. A disease or accident can happen to anyone and you don’t want to pay the doctor bills then. This system does what is’s supposed to do: pay for the healthcare for everyone. It’s short-sighted not to have a health insurance system like they do in Germany/Netherlands and lots of other countries. I think it’s anti social as well. We should as a society, care for each-other, especially at such a basic level like one’s health.

  2. Ellen: I would love it if there was a system of health care that was based on caring for each other. My qualm is with the way the current system is adminstrated and run. Germany’s certainly tries to be that social system, but I think it still fails on many levels. For example, imagine you have no income. You are still required to pay for insurance and guess what the payment per month is for someone set at the level of “no income”? 180 euros a month! If you have no income, I don’t understand how you can be expected to pay that much money each month, but I think the assumption is also that it is impossible to survive on no income, which is also not necessarily the case. And I am not picking numbers out of the air that I’ve heard somewhere, they’re coming from first-hand experience.

    See what I mean about telling people you’re not insured or have previously been uninsured? Your first response was to call me naive and place blame for my way of thinking on being American, young, and relatively healthy. I don’t expect everyone to agree on this, but please consider that I have thought about this topic a hell of a lot. Health insurance is one of those topics that makes me ragingly seeing-red angry. Almost as angry as the topic of prisons makes me, and that’s really fucking angry. These days I even have health insurance, and it still makes me insanely angry. I just think we could do a hell of a lot better.

  3. We could do a lot better, but it could be also a lot worse than in Germany. For me it’s personal right now, as my insurance covered a 10k+ bill last week … First of all it should be a lot more easy than it is in Germany, just make it: Every inhabitent has health insurance (and it’s the same for everyone) and every income has to pay a percentage for it (no income = no costs, big income = big costs).

    Actually there are to many people who are free of the “normal” insurances in Germany: If you earn big money, you don’t need to be in the regular system, you’re allowed to have private insurances. That’s all the money that’s missing in the system for the poor / “uninsured” people. (Besides: Any income that’s not regular wage, isn’t taken into account at all.)

    With a simple system you could save millions on insurance agents and the waterhead of administrations at the insurance companies. Just close them down. And than let’s start kickin arses at the pharma industries …

  4. Well here in the UK we call it the National Health Service. Everyone pays their taxes, and if you need healthcare you get it. Pretty simple, all told. Sure, it’s not perfect, but if you want fancy add-ons like a private room or more choice over appointments, you can pay for that directly yourself, or purchase a private health insurance policy. But the actual healthcare element is free at the point of delivery.

    If, like me, you have an accident-prone child who likes chucking themselves off high surfaces with reckless abandon you get to see a lot of the NHS in action, all the way from the ambulance, A&E, minor injuries, operations, in-patient, fracture clinic, physiotherapy, the whole nine yards. And what I see is that my child gets really good care and that I don’t at any stage have to worry about what it’s going to cost, or that I won’t be able to afford the best possible treatment. What’s not to like?

  5. I agree with the first respondent as to the antisocial subtext of believing that one can “pay for healthcare as needed”. I guess one can of one never needs it. As someone who had spinal surgery in the US, and saw the bill (over 100,000) that my health insurance paid, thinking that I could give the drs, surgeons and anesthetists chocolate chip cookies as payment is incredibly naive. It’s also completely incorrect to believe that Germany doesn’t care for its actual poor: if you are on Harz IV, your health insurance is covered.Health insurance for children on public insurance (as the children of parents who are on it) is also free.
    And, having looked at it, living on Harz IV in Germany is like living in heaven compared to being poor in the US. One has a roof (x/qm per person), food, schooling, clothing. One’s children can achieve, through good grades, the ability to go to the same university (and schooling) as the children of the wealthy. Subways are free, museum entries are free, cultural enrichment courses in art and music are free: are you (OP) complaining about filling out paperwork to receive these things?
    Thank heavens my children have the legal right to remain here, in this country (or return here as desired) where they can always receive medical treatment, always have food and shelter, always have the right (with the proper grades) to receive a higher level education.

  6. gegengluck: Well said, well said.

    Freya: That way of doing things certainly does sound rather sensible. Is that similar to what goes on in Canada? I’m always hearing good things about their health care system too. But my only experiences are in America and Germany.

    G: Who said anything about paying doctors with chocolate chip cookies? Sheesh, don’t insult my intelligence. I pay doctors with what they ask for from me, that is, with money.

    It is awesome when health insurance functions as it should and covers the kind of scary medical bills that inspire people to sign up for it in the first place. I’m glad that your insurance paid that bill. But one of the reasons why I dislike the health insurance system, particuarly in America, is that that is often not the case, and big claims like that often end up being denied despite a lifelong membership in the insurance club.

    And yes, as I mentioned in the post above, if you go on welfare (which Hartz IV is one version of, for those of you who don’t live in Germany) your insurance is covered (so why does it sound like you are accusing me of having failed to mention this point?). But as I also mentioned in the post above, there are reasons why people choose not to go on it. And you do not get a free subway ticket when you are on Hartz IV, by the way. I know a number of people on it, here and in Berlin, who receive no such treatment. Where are you getting your information? There have been a number of attempts to create deals with the DB and offer a cheaper ticket for those on Hartz IV and other welfare that I’ve read about in various places, but those still cost something. You can often get an ID that proves you are low income and get a number of admissions reduced or for free though by no means all, I had one of those myself when I was an au pair.

    As for children of those on Hartz IV having the same chances as the children of the rich, there have also been a number of studies on just that topic that have shown that that’s actually not the case. I applaud Germany for all it does to try to be a highly social country, but one of the reasons I wrote this post is that often those goals are touted as the reality of the situation as opposed to something that is being aimed for. I think that people without insurance could be helped a lot more by being offered sensible options than by being criminalized and penalized for not having been able to afford insurance payments, by being able to talk about being uninsured instead of having to hide it because they are scared of being found out.

    What I find most critical within the system is the way it is organized. This post is not about complaining about having to fill out paperwork to get insured, it is about discrimmination and nonsense within the system that I feel very strongly about needing to be changed. Actually, haha, I have a sort of neurotic fondness for filling out forms. Anyway.

    I’m loving how much conversation this post has inspired so far. I don’t usually bother posting about topics that could be as contraversial as the insurance topic tends to be, but I thought if doing so might provoke some interesting conversation, then, neat.

  7. I understand your frustration, you have to pay 180 euro a month while you have no income. But if you just change your perspective you’d see the beauty of the system. Yes, you have to pay money. If you had income you’d also have to pay (high) taxes. But look what you get in return! You get excellent health care, a good public transport system, roads and pavements, free or cheap education and subsidized sport utilities like your beloved swimming pool. It’s a system of solidarity. And while you are not free to choose it, you do have a lot more freedom in life because you don’t have to worry. If you lose your job you still have health insurance. If you or your child needs medical attention there will not be a 100,000 bill and possible bankruptcy.

  8. Ellen: I don’t have to pay 180 euros a month, that is a situation the Beard has found himself in and he has several thousand of debt to pay the insurers because of their lack of ability to accurately assess people’s incomes and his own refusal to accept charity from a system he has no interest in being a part of. I have an income and, yup, I even have health insurance, and my issue with it all isn’t that it costs money, I am fine with health care costing something. What bothers me about health insurance, to attempt to put an enormous topic in a nutshell, is that it is not well run (thus making it much more expensive) on so many levels, and that it turns one of the most holy things there is (people’s health) into a business, to name my two biggest sticking points.

    Why do you lump the public transportation system and other tax-related bonuses into this argument? My insurance premium doesn’t have anything to do with them (it’s not collected through taxes, is yours?), and I don’t think I imply anywhere here that I have a problem with those things or contributing to their existence financially.

    And just to reiterate: I appreciate the positive aspects of the health insurance system here—that’s why I spent a paragraph talking about the positive points of insurance in Germany. Just because I think the system is largely broken doesn’t mean that I can’t at least look at the positive side of being forced to partake. I see the good sides, and I still wish we could do it another way.

    As for the bit about freedom, I have to disagree about having more freedom because of this: for me freedom from worry because I have been forced to participate in a system I not only had no say in creating but have no way to change does not feel like more freedom. I would prefer the freedom to pursue totally different options as far as health insurance and health care payments and health care and all go. And who knows, maybe if I had that freedom I would choose to participate in this system. I do not want to be freed from worry that I will some day die of some illness or another: that is a fact that I accept as a part of being alive, and I do not seek freedom from it or from worry. Both are just a part of life. I don’t wish to become sick, but in all honestly, having health insurance does not make me feel any less worried about becoming so. One of my major issues with many kinds of insurance is that you buy it for the feeling of security, but that it quite often doesn’t play out as you had hoped. Insurance companies have a long history of letting people down when they need them the most. But I’m starting to digress.

    I do not think it is right to only offer one option and then to force people to participate in it (but also, as I meant to imply but do not directly say above, I like that the system is trying to be social and that it is based on solidarity–good goals, but too often bad implementation). I see what your saying on the freedom point, but it simply does not make me feel that way. I resent not being allowed to opt out completely forever and ever and really legitimately pursue other options, and I do not think that security (freedom from worry) can ever replace freedom of choice. And as I’m sure you’ve noticed from reading here, freedom of choice, being able to choose, and respecting the choices of others are all things that are very very important to me.

    Ok, end ramble. 🙂

  9. Sounds like you can opt out of the requirement to participate in Germany’s national health insurance scheme if you are wealthy enough (or perhaps it’s like the UK system where you first have to see the national health doctor before you can be referred to your private doctor if you have private insurance)? I’m an American with relatives in the UK so I’m not clear on the details.

    Perhaps it’s an American viewpoint that we both prefer the freedom to not choose insurance although, like you, I do have health insurance. Personally, I choose to take care of my health through preventive measures like diet and exercise and even successfully reversed rheumatoid arthritis on my own without drugs although a rheumatologist told me it couldn’t be done. Medicine is big business and therefore has no real incentive to cure anyone imo. I go to doctors for a diagnosis, their opinion, and an outline of treatments available to me, but I take full responsibility for my health after that by doing my own research and making my own decisions which may include no treatment at all.

  10. Why is insurance – and the whole medical industry – so effed up everywhere in the world? It seems like there’s no system that’s perfect and poor people get screwed no matter what. Growing up we didn’t have health insurance and my parents wracked up a huge credit card bill on dentist and doctors appointments for my sister and I that they’ve only paid off in recent years. It’s so frustrating. Yet I’m afraid I don’t have any answers.

  11. So well argued! This is the sort of post I would be passing around for people to read, if it was about the clusterfuck that is u.s. insurance.

    But I so agree with the universal point that something as important as our health should not be managed by for-profit corporations.

    Side note – I request a post on the subject of why prisons anger you.

  12. Well, my boyfriend blew one of his fingers off last year and I think that’s when I sort of decided not to be so pissed off with the tax system here in Sweden. (If you’re self-employed, like my boyfriend and hopefully soon me, you pay a 60% income tax plus a 25% VAT. Mm, yes, I know, that’s a lot!) Aaanyhow, while waiting for the ambulance, while watching the paramedics patch up what they could what with muscles falling out (yep) and bone poking out, while in the E.R. overhearing the doctors and surgeons considering a helicopter transfer to save his hand (!!!), while waiting for him to get back from surgery, during the transfer to Gothenburg, while waiting for him to get back from ANOTHER surgery and so on and so forth, it was fucking relieving to not have to think about or worry about insurance. The whole thing ended up costing us about 200 EUR and that’s including the initial ambulance lift to the E.R., admittance, the surgery, miscellaneous drugs, the transfer to Gothenburg, more surgery, physiotherapy and stuff I probably forgot about. So, yeah, I’m pretty happy with the system over here, though of fucking course it could be a lot better! What I love most about it, though, must be that everyone under the age of 25 is entitled to counseling, contraceptives, STD tests, pregnancy tests and abortions COMPLETELY anonymously (even when you’re a minor; it would be illegal for an employee to contact someone’s parents about it) and for free. So, yay, our government managed to do something right! ^^

  13. I am intrigued to discover that the system in Germany is just as effed up (although perhaps in different ways) as the American one.

    My experience in America is not much different from others living in the strange blurry margins between desperate poverty and basic affluence. When I was growing up, I had health insurance through my father’s job, but as soon as I was an adult and married that was not available.

    Since I have held a series of contractor-level jobs over the years while I was working on my BS degree and now my MA one, I have never been in a position to have work-related health insurance, and since my husband is in the same boat, we have had to be self-pay patients most of the time.

    It was only relatively recently when we qualified for state insurance, which means we have to do all the hoop-jumping and the degrading interview/paperwork process for application every 6 months. Until we both have “real” jobs (as in, those with salaries and health insurance attached), we will be in this boat, and so will our kids.

    It is not so bad…but not so good either. People in America are competing just for basic jobs now, ones that pay hourly wages for semi-skilled labor, and I think we are lucky we have work at all. The chances of us getting jobs with health benefits, even with college degrees, are slim. I hate that we can only access state health insurance, but if we didn’t have it, the cost of medical care would be too high for us to even afford it.

  14. I find insurance to be pretty ridiculous in America, but I still am able to find decent care at a cost I can afford. Instead of 20% of our income going to premiums and still needing to try to set aside thousands of dollars for the deductible, co-pays, percentage they don’t cover, and prescriptions, I take my kids and myself to a doctor that offers $20 (the same price as co-pays on the health plan offered at my husband’s job )office visit clinic days. They handle preventative care and labwork, if I need any. Because we are uninsured, the urgent care center charges a flat rate of $80, and we use them if we can’t wait for a clinic day, or need stitches. Some of the hospitals around here have excellent charity programs. When I injured my knee last year, I only paid a couple hundred dollars for the doctor’s bill. The hospital charge was completely covered, including X-rays, meds,crutches, everything. That works for anyone at or below 150% of the poverty line, I think. Above that line there is a sliding scale. Insurance would remove our ability to save, and slowly bankrupt us, so that a catastrophic health event would likely leave us unable to pay premiums. What the hell is the point of that? The whole reason to insure yourself is that it will pay when you need it to. If it goes away as soon as you need it…

    I’ve lived in several cities in different regions throughout the US. There are options almost everywhere. Finding the information you need to take care of yourself can be really tough though. It’s really important to know and research your area. Jadebabylon said she can get state insurance where she lives, but in our state, adults can only get on Medicaid if you are living on less than a third of the poverty level, unless you are pregnant or disabled. Those kinds of differences can form significant obstacles if you move or just lack the knowledge and resources to maneuver through the system effectively.

  15. Preferring freedom of choice over security when it concerns healthcare is a very American point of view. 😉

    My point was that just like you don’t have a choice whether you get health insurance you also don’t have a choice whether you pay taxes or not. And you don’t get to say how the money is spent, other than your vote once every few years. Of course it’s not perfect, nothing ever is. But it’s far better then the alternative, which is no health insurance (or taxes) at all.

    As for insurance companies letting people down when they need them the most, I have never heard of anyone in Europe not getting a proper treatment when they were sick. Never. I do know these things happen in the US, but this is Europe!

  16. Ellen: Hmm, then I wonder what the Patrtiot Act and all the other acts that exchange security for freedoms in America in the last years were about, if that’s such an American point of view? In my experience of America, it’s not the norm to think that way. But maybe you’ve had more experience there then I, I don’t know a thing about you, except that you live in Holland. I would say that a distrust for the insurance system is probably a very American way of thinking, while trust in it is a very European way of thinking. Doesn’t make either of us right about our assumptions all the time though of course.

    “But it’s far better then the alternative, which is no health insurance (or taxes) at all.” I think we’re going to have to agree to disagree on that one. I do not find it better than an alternative (of which there are thousands, I’m sure).

    I have heard of people not getting the treatment they need here, in oh-so-social Europe. But because of the myth of insurance being universal and extremely social here, there aren’t any options for people in those situations, which is one of the things I find very aggravating about things here. Can’t fix something that no one is admitting is broken. More often I hear about insurance only covering the cheapest and not necessarily the most effective treatments, which doesn’t amount to complete abandonment, but which makes just as little sense as far as promoting health goes. Small-scale example: insurance here only pays for the cheapest fillings at the dentist. These fillings tend to fall out rather quickly, in the experience of several people I know, often within six months. So you can keep going back and having the dentist replace them every six months so that the insurance pays, or you can pay the dentist on top of your premium for something that will actually solve the problem. A very small example, but an example all the same of ways in which even the insurance system here isn’t as awesome as it could be.

    Everyone else: Thanks for commenting!

  17. Pingback: the twisted webs they weave: getting health insurance in germany | click clack gorilla

  18. Funny that in all that there was no comment on the fact that medical bills are often far more expensive than they need to be… again, not saying they should be free, but goodness have I been overcharged for things. I went through a horrible medical experience a few years back and while yes, it was great having insurance to cover some of the ridiculous tests the doctors came up with to try and figure out what was wrong, I ended up paying some fairly hefty bills just to go in and see a doctor for five minutes while he told me he couldn’t do anything to help me. Not to mention the cost of drugs! Doctors are often some of the wealthiest people here in Amieland, while my acupuncturist can barely make it from month to month… because, of course, she can’t get any money from the insurance system, which doesn’t typically cover things like acupuncture.

    Point was, everyone who is arguing about the importance of health insurance, would it be so important if we had relationships with doctors or healers who we knew would take care of us, and if we didn’t have such ridiculously expensive health care?

  19. I don’t have a better how-to-do idea, just know it’s bad not to have it or access to affordable medical care, one year I walked around for a whole summer on what turned out to be a broken ankle, kept swelling up again & again, got cast at county hospital, cut off cast off myself 6 weeks later with serrated kitchen knife

  20. I am an American and I know that a lot of people here do not want to be forced by the government to purchase insurance from a private/or government insurance company. It is the issue that the insurance company makes billions off of those that pay into it and we still have copays and denied or limited services. Those insurance companies CEO’s plus others make millions while we pay more and more every year for less and less.

    If our premiums actually went to paying for the actual costs of our health care, not administration and CEO’s and their profits and to mismanaged hospitals I think we would get more for our money. The government bureaucracies of the proposed government “health insurance” are and would be even worse for graft, greed and mismanagement.

    Even the so called “Not for Profit” are not any better as they just waste more, take more, hire more and add it to the cost so that there is no “profit” and thereby are “non profit” when they are.

    We have to pay $800 a month on a retirement salary of $2700 (off the top of this) plus co pays. My Dr. wants me to have a series of injections in my back for a ruptured disc that is a $300 copay each time. They are to be 2 weeks apart. Add it up, $800 plus $900. There is no way I can affort that. We live in a very modest home, don’t eat out, don’t go anywhere because we cannot affort it. Just the utility bills and the other manditory insurance (home – $3000 a year, car – $1200 a year), food takes everything. All the while these insurance companies profit off of peoples illnesses. Not right!

    I know people have to be paid to do a job, it just ins’t right that those insurance big wigs are sitting up there in their multimillion dollar houses while I can’t pay my own house note or have medical care because I cannot pay for the costs (that allow him to not have to worry about anything)!

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