A Tale of Two Health Care Systems

The view from a balcony at the hospital in Stuttgart, Germany where I gave birth to my daughter. My stay came without a bill.

I’m not interested in using my blog to fan political fires, so I’ll keep this post personal. Here’s the premise: I’m a healthy, fit, relatively young woman who’s experienced two very different health care systems, one in the U.S., one in Germany. I’ve been pregnant, given birth, stayed in the hospital, and taken my children to doctors in both countries. I’ve earned salaries in both countries and seen portions of those salaries leave my hands to pay for health care.  In this context, I can confidently say I prefer Germany’s system.

Let’s rewind. Two years ago, my husband and I were employed at a small charter school in Michigan. The school, like any small business, worked tirelessly to find the best health insurance rates for its employees, a task that became more and more difficult each year. When we were first hired there in 2007, one of the perks was a 15% bonus, designed to pay for health care, added onto our gross salaries.  Though it had once covered the cost of health care with plenty left over to contribute to retirement, rising insurance costs meant that eventually we spent the entire 15% then dipped further into our monthly paycheck to pay for care. The year we left, our business manager sent an e-mail informing the staff that, to his displeasure, rates had once again increased, this time by 17%; “Let me know if you have any great ideas,” he wrote.

We had decent insurance there– not the cushy kind provided by the union-affiliated public schools, but certainly not terrible by U.S. standards. We had predictable, if somewhat convoluted, out-of-pocket maxes, co-insurance percentages, co-pays, and a prescribed network of doctors we could use. We never had dental or vision insurance though, and costs were relatively high– when my son was born in 2009, we carefully budgeted $3,000 to pay for his birth (and were glad we had nine months to save up for it). We ran across the occasional surprise too; my primary care physician once ordered an ultrasound and I ended up with an inexplicable $900 bill; the insurance company said my ultrasound was processed through a lab whose services they didn’t cover. My husband and I struggled to write that check– we had just purchased our first home and were on a tight budget.

I grew accustomed to the co-pays– $20-$30 every time anybody in the family, including my infant son, needed to see a doctor. But we thought twice before scheduling any appointments, and medical costs were penciled into our monthly budget with big question marks; we always sensed we were one freak accident or emergency away from financial misery. We knew people who were still paying for heart attacks, pregnancy complications, and hospital stays they’d experienced years before.

When my husband and I moved to Germany in 2010, we became part of a health care system we could not have imagined back home. Yes, we had to help pay for our health care here too (all German workers are required to pay a portion of their salary towards health care– in 2008 the figure was about 8%, and the employer contributes the same amount), but suddenly there were no more question marks in the budget. We had to pay a 10-Euro ($14) co-pay four times per year in order to see doctors as often as we wished, and our son’s health care– checkups, emergency room visits, and prescriptions alike– cost nothing. Pregnant women also receive free care. I was seen regularly by both an OB and a midwife throughout my pregnancy, at no additional cost. When a complication in my third trimester landed me in the hospital for five days, I called my health insurance company, anxious about the unpredictable bill I felt certain would arrive. “There won’t be a bill,” the woman on the other end of the line repeated several times before I finally believed her. The hospital doctors sent me home on modified bed rest, but not before they brought a social worker to my room; she was in charge of helping to organize my “Haushaltshilfe,” or domestic help, which involved the insurance company paying for someone to come to my home and do the kinds of chores I wasn’t allowed to do for as long as the doctors felt I should be taking it easy. My slack-jawed disbelief must have baffled the social worker, because she finally said, with bemused patience, “Don’t you realize that it’s much cheaper to pay for domestic help for a week or two than to care for a premature baby?” Perhaps without knowing it, she had just articulated the purpose of preventative care.

My husband and I have yet to experience the dreaded long waits and inadequate care so many Americans associate with socialized health systems. When my husband tore his ACL, he had an appointment for surgery within 3 weeks; his sister, who suffered the same injury in Colorado, waited four months for hers, while my father in Michigan waited six weeks for a prostate cancer operation.

Yes, Germany requires everybody to pay for health care. You aren’t allowed not to have health care. This concept doesn’t tend to sit well in the U.S., where compulsory anything is viewed with skepticism. But we must acknowledge that Americans don’t always know what to do with their own freedom when it comes to health; a 2009 WebMD article asserts that “despite health recommendations, most [Americans] still aren’t making smart lifestyle choices.” According to the World Health Organization, 16% of the U.S. GNP is spent on health care (in comparison to Germany’s 10.4%) and the cost per capita is twice as high, yet life expectancy is lower while rates of maternal mortality, infant mortality, and non-communicable diseases are higher. Something doesn’t add up. Why is American health care so expensive…and so ineffective? Perhaps the latter contributes to the former– the sicker people become, the more everyone’s costs skyrocket.

Every now and then students in my English class at the international school would ask me about the health care debate in the U.S. My European students genuinely struggled to grasp the fact that many Americans do not have health insurance at all. They were horrified when they found out how much I had to pay to have a baby in the U.S. (and how much I would have had to pay if I hadn’t been insured at all).  They understood that President Obama was trying to institute a form of nationalized health care and could not believe how many people were opposed to it. “But Mrs. Baughman,” one ninth-grade German boy said, “don’t Americans understand that if everyone has access to health care, the whole country will be healthier and better off?”

That ninth grader’s question has echoed on a global scale. According to a March 2010 TIME Magazine article on the European response to U.S. Health Care Reform, “the fundamental difference between Europe and the U.S., Europeans believe, is that Americans regard public services as a bonus rather than a basic right. For some, this is evidence that the American system is deeply flawed. ‘It was a scandal that the world’s richest country for so long offered its citizens such pitiful protection against illness or injury,’ wrote Gregor Peter Schmitz, Washington correspondent for Der Spiegel…”

A 2008 NPR report on the success of Germany’s health care system asserts that “Germans really hate any hint of unfairness in health care. The fundamental idea is that everybody must be covered and, preferably, everybody should get equal treatment…But it’s unthinkable that 48 million people wouldn’t have health insurance at all — the situation in America.”

It is perhaps normal to fear what’s unknown; in that case, I wish more Americans could personally experience the benefits of German health care. We Americans value our freedom. But would we rather be free to choose whether or not we actually have health care, or free to be healthier ourselves under a system that ensures some form of health care for all?

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10 thoughts on “A Tale of Two Health Care Systems

  1. One stat you forgot. Germany does not have a standing army. I believe the U S Army is there keeping Russia out of your back yard. If we brought all our armies, air forces and navy home we’d could afford the best medical system in the world. It might get a little dicey protecting yourselves though. Just a thought.

    1. Thanks for your comment, which makes the excellent point that no system is without compromise. However, I’m not convinced we can draw a clear line between U.S. military spending and lack of better health coverage. It’s true that the U.S. spends more than any other country on its military, but this spending is largely funded by the federal government and tax revenues. Germany’s health care system does not rely on either of these two sources, but rather on employer and employee contributions (see this article, “Health Reform Without A Public Plan: The German Model,” about successful non-government-run health care systems), suggesting that it would be possible to improve health care in the U.S. without sacrificing a strong military. As to the U.S. Army’s presence in Germany, former U.S. Army Officer Phillip Carter suggests in his 2004 Slate article “We have how many troops in Europe?” that the purpose of continued installments in Europe since the Cold War has more to do with geographic proximity to the Middle East. Carter notes that while “[d]uring the Cold War, of course, these troops were stationed overseas as part of a strategy known as “forward deployment.” If the Soviet Union or North Korea were to invade, these units would already be located near the battlefield…” but he then writes: “Today, the military units stationed in Germany spend most of their energy on Iraq.” Though his article is 7 years old and therefore rather out of date, Carter makes a good point about the changed, post-Cold-War purpose of U.S. military bases in Europe. For example, The United States Africa Command (AFRICOM) is currently based in Stuttgart; a friend who works for AFRICOM once explained to me that Germany’s central geographic location is convenient for this operation, echoing Carter’s point.

  2. Your description of your experience with two different health care systems is eye-opening. Your blog post reminded me a bit of a commentary written in the Star Tribune by John Bryson, a former professor of mine at the University of Minnesota who wrote about his experience with the British health care system. http://www.startribune.com/opinion/103002689.html?page=all&prepage=3&c=y#continue

    Reading what you wrote raised more questions for me. Does everyone pay 8% of their salary, regardless of how much they make? If you and your employer are contributing to health care, is your health care coverage tied to your job? (Do you have to switch plans/doctors if you switch jobs?) How are people covered who are unemployed?

    My family is covered through Chris’s insurance plan at work. As an engineer with a good salary, a smaller percentage of his paycheck goes towards the health care premiums than one of his lower-paid co-workers who works on the factory line. When he considered switching jobs, my main concern was having to switch health care plans (and possibly doctors) when I was 32 weeks pregnant. And then there’s always the worry hanging over our heads. If he were to lose his job, he – and his wife and children – would have no health insurance.

  3. Kirsten, thanks for sharing that article by Mr. Bryson! It was really interesting, and certainly rang true for me.

    Unfortunately I’m not totally sure how to answer your question about salary percentage. But according to Wikipedia, “The [German] government partially reimburses the costs for low-wage workers, whose premiums are capped at a predetermined value. Higher wage workers pay a premium based on their salary.” Most people are paying the 8%, but people who make more than a certain amount per month have the option of purchasing private insurance, which apparently has some advantages (though I’ve been very happy on my public plan). I do know that premiums for the unemployed are financed by unemployment insurance. So a German who loses his or her job (which actually is much harder to do here, it seems) would not automatically lose health insurance too.

    I loved this point by Uwe Reinhardt, who wrote about different national health care systems in the New York Times: “‘These countries all mandate the individual to be insured for a basic package of health care benefits…Many Americans oppose such a mandate as an infringement of their personal rights, all the while believing that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it. This immature, asocial mentality is rare in the rest of the world.”

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