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Health Policy in Germany after the election

Partner Institute: 
University of Technology, Berlin
Survey no: 
(14) 2009
Britta Zander, Julia Kimmerle, Leonie Sundmacher and Michael Bumler
Health Policy Issues: 
Political Context, Funding / Pooling
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no yes no no no no


Health policy was not among the openly debated issues during the campaigns for the 2009 general elections in Germany. However, only two days after the vote, the chancellor-elect Angela Merkel and her conservative party (CDU/CSU) were struggling with their new coalition partner the Free Democrats (FDP) for a direction in the reform of the German health care sector. The coalition treaty signed on 24th of October includes plans for a fundamental reform of the health care financing system.

Purpose of health policy or idea

Even though health policy did not play a central role during the election campaigns, it was one of the fields with clear positions in the respective party programs. During the negotiations on the coalition treaty, health policy was one of the heavily debated issues. The differences about a new direction in German health policy culminated in the controversy about the Health Fund: While the conservative CDU and CSU want to keep this central element of health funding, the liberal FDP wants it to be abolished. (c.f. HPM report "Health Fund now operational" survey no: (13) 2009).

The treaty now states that the health system has to be adjusted to curb rising costs associated with demographic change and price inflations resulting from technological innovations. Therefore, the new German government wants "to set a framework that enables the competition of ideas to develop while constantly striving for an improvement of the quality of care" (c.f. Koalitionsvertrag zwischen  CDU, CSU und FDP. Wachstum, Bildung, Zusammenhalt. October 2009, p. 77.)

After the treaty was signed, the governing parties agreed on reforming the health system extensively starting in 2011. Key issue will be the separation of increasing health costs from labor costs: employer's contribution to social health insurance will be capped at a level of 7% so that further increases in contribution rates will be borne by employees only.

In addition, tax-funded transfer payments could supplement low-income earners. Further, it is proposed to re-introduce competitive elements in the social health insurance system, namely pricing autonomy.

High-income earners will be given the opportunity to opt out of the social health insurance (SHI) and join a private health insurance (PHI) only one year after their earnings exceeded the income threshold for compulsory insurance instead of the previous three years.

Main points

Main objectives

Since the coalition treaty with respect to health reforms leaves much room for interpretation, heated debates can be expected among the members of the governing coalition.  In this discourse, it is worth taking a closer look at alternative party-programs in order to put each reform-proposal in a wider perspective. 

Main objectives: CDU/CSU

  • A priority for the CDU and its sister party CSU has been to further develop the SHI towards more generational justice as well as to improve fairness across sickness funds with different risk-structures
  • it has been intended to keep the risk adjustment scheme
  • A "citizen's insurance scheme" as favoured by the SPD has been strongly opposed

 Main objectives: FDP

  • Sickness funds should be provided with more autonomy in setting contributions and in the definition of benefits. These measures should enforce competition between the sickness-funds.
  • Instead of passing on rising costs in health care from sickness-funds to employers, the employers' contribution-rate of currently 7% should be fixed. In the long-run, this rate should be replaced by a per capita lump sum payment.
  • On the side of the employees, a lump sum payment should replace a rate related to income. Each insured contributes the same premium, irrespective of her/his income and risk profile. To support low incomes, the lump sum payments could be subsidized via the tax system.  

 Main objectives: SPD

  • The Social Democrats have intended to incorporate the private health insurances in the morbidity-oriented risk structure compensation scheme in order to increase redistribution between sick and healthy.
  •  They have been supporting the idea of introducing a "citizen's insurance scheme" with respect to health care and long-term care. The basic notion of the scheme is to cover all citizens by the same, publicly organized health insurance system. (c. f. HPM report "Proposals for SHI reform", survey (2) 2003)
  • In a next step all forms of income should be considered for the financing of the SHI. So far, only wages and salaries are liable for contributions. In addition, the tax share in the financing scheme should be increased
  • Contribution rates should be shared equally between employers and employees. The current employee-surcharge (October 2009) of 0.9% should be abolished. 
  • A further key objective of the SPD has been the strengthening of prevention activities. They have intended to introduce the so-called "Präventionsgesetz", an Act targeted at disease prevention and health promotion

 Main objectives: The Green Party

  • They have been supporting a "citizen's insurance scheme", however, without a health fund system 
  •  The Greens  have also favored the idea of the health policy focusing increasingly on disease prevention and health promotion activities

 Main objectives: The Left Party

  • The Left Party has intended to introduce "a solidarity citizen's scheme", covering the whole population including previously privately insured
  • They have favoured the idea to abolish the contribution ceiling and have also supported the equal sharing of surcharges by employers and employees

Groups affected

Sickness funds, the insured, taxpayers, employers

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual highly controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent neutral system-neutral

Depending on the realized size and scope of modifications, this reform could represent a major change in the German health insurance system. The freezing of the employer's contribution at the cost of the employees would be unprecedented in the history of the German health system, though it has often been proposed.

The restructuring of the health system will be highly controversial. The current plans imply that employees will carry a higher burden in financing rising SHI costs - either via increasing contributions rates or private insurance in addition to the basic social insurance coverage.

Political and economic background

The health fund was the central element in the 2007 health care reform, which was passed by the Grand Coalition of CDU and SPD. ( c.f. HPM report "Health care reform in Germany: Not the big bang" survey no: (8) 2006)

It became effective in January 2009 and fundamentally changed the structure of health care funding in Germany: It is a centralized institution designed to collect and allocate contributions to social health insurance. Since its implementation, a nationwide uniform contribution rate for all sickness funds has been introduced.

Currently, a rate of 14.9 percent (October 2009) of the contributory income (employee: 7. 9%, employer 7%) has been fixed by the government and holds for all German sickness funds. In addition to these contributions, a subsidy is paid by the government. Both payments are pooled within the health fund. The payments are then allocated through a risk structure compensation scheme such that sickness funds receive a risk-adjusted (age, sex and surcharge for well-defined morbidities) lump sum from the health fund for each insured member (cf. HPM report "Morbidity-oriented risk structure compensation", survey (13) 2009).

The main purpose of the health fund was to implement a financing mechanism for the German health care system that provides a fairer allocation of financial resources with respect to the risk-structure of the sickness funds (c.f. HPM report "Health Fund now operational").

Due to diverging party objectives in health policy, major modifications of the health fund were expected in case of electing a new government. However, at this stage, according to the CDU, the health fund will not to be abolished, but adjusted (c.f. Regierungserklärung: "Deutschland zu neuer Stärke führen", 10th November 2009, p.7).

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no yes no no no no

Origins of health policy idea

The health fund was a compromise  between the former grand coalition parties. While the SPD was in favour of a citizen's insurance scheme, the CDU favoured a flat rate premiums scheme. Even though the CDU now seems to refrain from their once favoured flat-rate health lump sum payments, the FDP eagerly works on ideas to introduce such a scheme for the social health insurance in Germany.

The idea of a flat rate premiums scheme goes back to the establishment of the so-called "Rürup Commission"under the former coalition of SPD and the Green Party. This commission submitted two policy reform-alternatives for the German social security system (c.f. HPM report "Proposals for SHI reform"survey no: (2)2003). A flat rate premium scheme would require each German citizen to contribute the same premium, independent of income and health status. In that manner, contributions are decoupled from labour costs. Social inequalities including income differences could be addressed through the tax system.

In case the newly-elected FDP-CDU government decides to maintain the health fund and only modifies minor elements, this decision would also go back to the grand coalition. In the original compromise model, the sickness funds were allowed to set individual premiums as well as surcharges or refunds, while offering standard and compulsory health services. These elements, however, were altered under the grand coalition to comply with the political views of the governing parties as well as interests of other stakeholders. Therefore, it did not find entry in the current health fund model (c.f. HPM report "Health Fund now operational"survey no: (13) 2009).

With authorizing sickness funds to individually set contribution rates or premiums, the new coalition would follow this original compromise model of the former grand coalition.

Initiators of idea/main actors

  • Government
  • Providers
  • Payers

Stakeholder positions

Government: The new coalition agreed on fundamental health reform steps, presumably after the year 2011. For this purpose a committee will be established. Only a few days after the coalition treaty was signed, the CDU/CSU stressed their intention not to abolish the health fund as well as not to introduce a lump sum health payment in order to protect the principles of solidarity in Germany. The FDP, however, seems to insist on a system change by introducing a lump sum health payment. The opposition, however, strongly criticises the new coalition treaty due to its un-equitable implications and its attempt to introduce the lump sum health payment "through the back-door" by capping employer's contributions and introducing lump sum contributions for employees. They argue that these decisions on health policy do not imply any improvements for the insured.

Providers: The German Hospital Federation approves that coalition partners did not again decide in favour of cost containment measures borne by the hospital-provider side. Also the Marburger Bund endorsed a new financing system, as long as it is less bureaucratic and the principles of fairness and solidarity are kept.

Payers: Representatives of the sickness funds have generally opposed the abolishment of the health fund as well as the freezing of employer's contributions: The insured will be unilaterally burdened and their consumer behaviour is going to be constrained through either contribution increases in the SHI or capital covered contributions in long-term care or both. Furthermore, they fear an increasing role of private sector in insuring health risks. However, the Association of German sickness funds favours a higher pricing autonomy for sickness funds and higher tax subsidies. The PHI strongly supports the new coalition treaty.

Civil Society: The Unions fear increasing costs to burden the insured alone means an end to the principle of mutual solidarity.

Actors and positions

Description of actors and their positions
The new coalitionvery supportivevery supportive strongly opposed
German Hospital Federationvery supportiveneutral strongly opposed
Sickness fundsvery supportiveopposed strongly opposed
Private health insurance companiesvery supportivesupportive strongly opposed

Influences in policy making and legislation

The concept of the health fund was derived from the original proposal of health experts but realized in line with the political views of the grand coalition. Since the health fund was implemented as a steppingstone for later reforms, the new direction of the Conservative government largely reflects proposals presented by the "Rürup Commission".

Actors and influence

Description of actors and their influence

The new coalitionvery strongstrong none
German Hospital Federationvery strongstrong none
Sickness fundsvery strongstrong none
Private health insurance companiesvery strongstrong none
The new coalitionPrivate health insurance companiesGerman Hospital FederationSickness funds

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Expected outcome

Assessors of the Federal Insurance Authority (Schätzerkreis) estimate that the health fund in its current form and the sickness funds will face a 7.5 billion Euro deficit by the end of 2010. Since the coalition treaty does not include any measurements to cut costs it is likely that the deficit could grow further. An economic downturn and rising unemployment rates would further diminish health funding. If additional expenditures would be financed through tax-funded transfer payments, it would be possible to achieve a socially balanced funding. However, since the tax reform planned by the Free Democrats will further reduce possibilities for federal spending on health, the sustainability of these transfer payments will be challenged.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable two system more equitable
Cost Efficiency very low low very high

Medium term considerations to establish flat-rate health premiums combined with a social compensation scheme could cost additional 22 billions, according to an estimation by the IGES institute. As far as it can be judged at the point of writing, the proposed measures are not likely to improve cost efficiency. The reform might shift the financial burden to the consumer-side and therefore foster an even more regressive health care financing scheme.


Sources of Information

Andrea Fischer, Martin Albrecht and Bertram Häussler: Analyse der gesundheitspolitischen Wahlprogramme der fünf im Deutschen Bundestag repräsentierten Parteien. Studie des IGES Instituts. September 2009.

Hibbeler, B.; Schmitt-Sausen, N.; Stüwe, H.: Koalitionsvertrag: Streit um Details vertagt. Dtsch Arztebl 2009; 106(44): A-2172.

Koalitionsvertrag zwischen  CDU, CSU und FDP. Wachstum, Bildung, Zusammenhalt.

Lisac, M.: Health care reform in Germany: Not the big bang. HealthPolicyMonitor, November 2006.

Ognyanova, Diana and Reinhard Busse. "Health Fund now operational". Health Policy Monitor, May 2009.

Weinbrenner, Susanne and  Reinhard Busse: Proposals for SHI reform. Health Policy Monitor, November 2003.

Author/s and/or contributors to this survey

Britta Zander, Julia Kimmerle, Leonie Sundmacher and Michael Bumler

Suggested citation for this online article

Britta Zander, Julia Kimmerle, Leonie Sundmacher and Michael Bumler. "Health Policy in Germany after the election". Health Policy Monitor, November 2009. Available at