Healthcare is Affordable, It's Not Free

My experience with the German health system

Photo by camilo jimenez on Unsplash

This is probably the most common misconception many people (particularly Americans) have about moving to Europe.

That everyone gets “free healthcare.”

It is true that all countries in Europe have what is known as “universal healthcare,” meaning that all people in a given country or region are able to get the medical care that they need, when and where they need it, without financial hardship.

And, it is true that the governments in all of these countries assumes some degree of responsibility for ensuring this — whether it is by a single-payer, government-funded system (like the UK or Sweden) or a system that combines the use of public and private health insurance (like Germany, France and Italy), these systems are all supported by taxes paid by the people benefiting.

Remember what I wrote here about our taxes almost doubling when we moved to Germany?

It’s not free.

And, in Germany, we still pay insurance premiums and have some very limited out-of-pocket costs for care. For example, if we want an extra screening test or elective procedure beyond the standard ones, we have the option to pay for it directly. This is always disclosed in advance, and you are told how much it will cost.

Public and private options

The German system uses a multi-payer model. The basic public insurance is administered by a group of nonprofit health funds. Private, for-profit health plans also offer health insurance at the same time.

We have chosen the public insurance option, known in German as gesetzliche Krankenversicherung (GSV) (statutory health insurance), because the premiums are lower. People who can afford higher premiums can also choose to have privaten Krankenversicherung (PSV), private health insurance, instead. But 90 percent of the German population is covered by GSV, with the insurance premiums are calculated on a sliding scale based on a person’s income.

Private insurance does have benefits in that some physician’s practices may see you sooner (some maintain separate banks of appointment slots for the privately insured) and things like a private room during hospital stays are covered.

Some providers also only see patients who are covered by private plans. When my son needed new glasses, we chose to go to a pediatric opthalmologist who only accepted private insurance or self-paying patients. We chose to pay out-of-pocket rather than waiting a long time (I think it was three or four weeks) to get an appointment at an opthalmologist that accepted public insurance.

Unless you have a more complicated vision problem, you can usually just go to a local optician, who will have an optometrist on staff who will do an eye exam. Because my kid is a kid and does need a more complicated prescription, we needed the specialist.

No opting out

Maintaining health insurance is mandatory. If you fail to enroll or to pay your premiums, you will be assessed a tax penalty. Requring everyone to have health insurance helps balance the pool of people covered, letting the premium payments contributed by healthy people offset the costs to cover people when they are ill or injured.

A severe illness can set in at any age and when this happens, treatment costs can very quickly be incurred that exceed the income level and assets of those affected. In a modern welfare state, however, no citizen should be without protection in the event of sickness. This is why all citizens who reside in Germany are required to take out health insurance.

—Statutory Health Insurance. German Federal Ministry of Health.

In Germany, your employer also pays half of your health insurance premiums. But, you decide what insurance plan to have. And, if you lose your job, you do not lose your health insurance. If you were already on a GSV insurance, the premium either goes to a set minimum, or - if you qualify for unemployment benefits - the government may cover it until you find another job. If you were covered by a private plan while employed, but lose your job, you will move to the public option.

German law provides a legal framework covering the treatments and services that must be provided, and then the insurance companies work out how this is done.

What it’s been like for us

Our experience with the German healthcare system has been an overall positive one. We have never not been able to get an appointment or the treatment we needed.

You may have to get a referral from your primary doctor ( your Hausarzt, literally ‘home doctor’) to see a specialist. But we have also been able to get specialist referrals in other ways. And, I haven’t always needed a referral. For example, I was able to directly make an appointment with an endocrinologist to monitor an ongoing health condition just after we arrived. I didn’t even have a Hausarzt, yet.

It took awhile to get used to not paying every time I went to the doctor. I felt like I was stealing something without stopping by the receptionist on my way out. A lot of times I would just hover around to make sure, and the people behind the desk would look at me like I was crazy, before I would ask if they needed me to check out, and they would tell me no , no - that it’s expected that I just leave.

Note: Sometimes, you do have to stop back by to make a follow-up appointment or get discharge instructions. But the doctor or nurse will tell you this. If not, you really are just free to go. If you do have something done that you will need to pay for, they also usually just invoice you later.

We also automatically have an electronic medical record that is maintained by the Krankenkasse (the health insurer). They have a record of all of our different visits, diagnostic test results, and record of what medications we are taking. Pharmacies and physicians’ offices access this info by scanning our health insurance card.

I can go to any pharmacy to get a prescription filled. It doesn’t have to be one that I’ve been to before, and it doesn’t have to be any particular network.

Also, I don’t think I’ve ever been charged separately for any prescription medicine, so I guess prescriptions are covered. I have only ever paid for things like acetaminophen or ibuprofen over-the -counter.

The system is also very proactive about preventive care. A few months after our arrival, I got a letter in the mail from our insurer informing me that—as I had reached a certain age — I should get a screening mammography. The letter indicated I should choose from one of three pre-selected dates and times listed and send the letter back. Or, I could call them and arrange a different time if none of the options worked for me. (I chose a time and went in, and everything went smoothly and results were all clear.)

I guess I can see why people think the healthcare is free, since we just pay the premiums and, obviously, we pay taxes, but don’t usually pay anything else.

So far, we have not had to go to the hospital, though, so I am not sure how inpatient or emergency stuff works.

Some hiccups:

• We had a hard time finding a pediatrician’s practice. Most Kinderärzte in our borough were either not accepting new patients at all, or only babies or newborns. Oour kids were 12 and 15 when we moved here. This may just be a factor in Berlin, which has seen very rapid population growth in recent years, or the specific part of Berlin we live in.
  We managed to get by with going to a pediatric practice on the other side of the city for my son. For my daughter, we kind of did one-off visits during different physicians ‘open hours’ whenever she was sick, (more on that, below). Once she turned 16, my normal internist was willing to take her as a patient.

• They don’t really have urgent care clinics here. In the States, at least, there are freestanding walk-in clinics that see people for minor ailments and injuries that are not serious enough for the emergency department, but still need to be treated promptly (i.e., you can’t wait the two weeks or whatever for the next open slot in your doctor’s office.) In Berlin, these types of last-minute visits are still handled in doctor’s offices.¹ Practices are required to have regular Sprechstunde (this literally translates to “speaking hours” but is most often translated as “open hours” in the documents I’ve seen. These are for unscheduled sick visits. If you have a regular Hausarzt, already, you may go to these or they may have a preferred method for getting you in at the last minute. But they are also required to see outside patients during these hours. So, if you don’t have a primary doctor, already, you can go there.

• The front desk staff can be scary. You may go to the doctor thinking that the person sitting behind the front desk is happy to welcome and assist you. But you would be wrong. The person or persons there are there to keep the flow of patients moving smoothly and as quickly as possible. Otherwise the wait times in a busy practice during flu season would be 12 hours long.
  They are the ‘bad cop’ to (hopefully) the doctor’s ‘good cop.’ Particularly if you not a regular patient and don’t have an appointment, and especially if the office is busy, the receptionist may seem to be doing their level best to turn you around and get you to go somewhere else, some other time. They may be very abrupt to the point of rudeness.
  My advice to anyone doing it for the first time: Be as firm and polite as possible, and no matter what happens, just keep going.
  Also, speak German, even if you just started learning. The practice website may say that English is spoken there, but that means the doctor speaks it. The front desk staff often does not, and you asking them to is asking to get shut down.

• They take combating antibiotic-resistance seriously. You can probably score heroin easier than getting a prescription for azithromycin here. Most doctors will only prescribe a course of antibiotics as a last resort, or if the lab results showing the bacterial infection are literally staring them in the face. At a macro level, I understand. But when your kid has been awake with a severe cough all night for a week straight, you don’t want to hear that they just need to rest and drink some herbal tea. But you are probably going to hear that.

The price/worth comparison

Compared to its peers in the EU and other OECD nations, Germany spends a lot of money on healthcare - around €6,000 per person, almost 13 percent of its gross domestic product (GDP).

(The EU average for healthcare expenditures as a percentage of GDP is 10 percent, and the OECD average is 9.2 percent. By comparison, the United States, also an OECD member, spends approximately $14,885 per person per year in healthcare expenditures, which amounts to 17.2 percent of its GDP.)

Does it get its money’s worth?

Well, the country scores well when it comes to access to care.

According to the EU-SILC survey, rates of reported unmet needs due to costs, waiting times or travel distance in Germany were among the lowest in the EU in 2022. There was virtually no difference between the lowest and the highest income quintiles, and cost does not appear to be a barrier to receiving care.
-Organization for Economic Cooperation and Development (OECD). State of Health in the EU - Germany Country Health Profile 2023.

And, Germans have an average life expectancy of 81.2 years, slightly higher than the EU average. And significantly higher than the U.S. average of 76.3. Annual deaths from preventable or treatable conditions are 129 per 100,000 which is lower than the average for similarly economically developed nations.

There are concerns that not enough is currently spent on preventive care and access to mental health services needs to be improved.

But, overall, Germans have virtually universal access to high quality healthcare.

For me, the best way to sum up the health system is that while it isn’t completely free, and there will always be room for improvement, you don’t have to worry here about health costs wiping out your savings or simply not being able to get the care you need because you can’t afford it.

1. The exception, I think, is that for young children and an urgent problem, parents usually do go to the emergency department at the hospital. Though I think that happens in the States a lot, too. A fever in a baby can quickly be a medical emergency, for example.