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Examining the State of European Health

As Germany’s healthcare system undergoes its most radical shake-up to date, an appraisal of public healthcare elsewhere in Europe shows that the German model is one of the most expensive.


Ailing or on the road to recovery?

German Chancellor Gerhard Schröder reached a landmark agreement with the conservative opposition in July to revamp the country’s ailing healthcare system, which is plagued by skyrocketing treatment costs and premium rates.

The reforms will force patients to pay more for treatment and reduce public health insurance coverage for several services, such as dentures and health spa visits, in an attempt to make up for a cash shortfall of €3 billion ($3.4 billion) detected last year.

The government says the measures will result in savings of €23 billion by 2004. The deal marks the largest overhaul to Germany’s public healthcare system -- the most expensive after those of the United States and Switzerland -- since German unification in 1990.

Indeed, a look at the German model, shows it to be both complicated and costly.

Health insurance is mandatory in Germany. But the sort of coverage a person receives depends on how much money she earns. People who earn below a certain level must choose to be a member in one of numerous statutory health insurance companies, which are self-regulated and compete with each other.

Yet, medical services offered by statutory health companies don’t vary significantly because they are bound by a legal catalogue of "mandatory services" they must provide. Health insurance premiums are split equally between employers and employees and currently average at 14.3 percent of gross wages.

Citizens may freely choose doctors and clinics. Those who earn more than the set income level --currently €3,375 -- may opt for private health coverage, whose premiums and services differ. The same rules apply to freelancers and civil servants.

Germany ranks third in global comparisons of per head health costs.

The Netherlands

Except in emergencies, all patients in the Netherlands must first visit a general practitioner (GP) of their choice when they have health problems. Only GP’s can decide when a patient should treated by to a specialist or a hospital. But the patient can choose which specialist or hospital to go to.

Only around six percent of patients are actually referred elsewhere though, since Dutch GP’s receive excellent training and are required to regularly undergo further training. Statutory health insurance premiums amount to 10.25 percent of gross income, almost a third less than German citizens pay.


The French public health system was rated as the best in the world by the World Health Organization in 2000. The state plays a key role in this much-lauded model. It controls the network between the financial institutions, doctors and patients. Since 1996 parliament has passed a budget for the health insurance system each year. Two-thirds of French citizens are part of the statutory health insurance system. The rest of the population participates in special models with individual premium and service regulations.

The French too, may choose their own doctors. If they fall ill, they can decide themselves whether to go to a general practitioner or to a specialist. But the patient has to cough up as much as 70 percent of the costs of medicines, which are sometimes very high. To balance it out, statutory health insurance premiums are largely shouldered by employers, while employees pay only around 0.75 percent of their salaries.

United Kingdom

The National Health System (NHS) in the United Kingdom is state-backed and financed entirely by health insurance contributions. Medical services are poor in comparison to other western European countries: waiting for an appointment for an operation can take up to 18 months. Thus many patients are flown to Germany or France for treatments.

Older patients must sometimes do without vital services. For example, insurance coverage no longer includes artificial hip replacements for people over 60. Patients may take out additional private insurance policies to cover services the NHS does not provide, such as alternative treatments in an private clinics. Statutory health insurance premiums amount to at least 10 percent of gross pay.


Switzerland is one of the countries with the highest concentration of doctors in the world -- a total of 14,000 -- and medical treatment is considered to be among the best available. Since 1996, Swiss citizens have been required to take out health insurance policies with one of 100 insurance companies. The companies are bound to relatively liberal regulations regarding the services they offer, which are monitored by a federal authority.

In addition, citizens may choose from diverse insurance models. Premiums are tied to income levels, and patients must pay a contribution from their own pockets during each visit to the doctor.

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