United States | News & Politics

In Germany - for all thay we may laud our comparatively progressive mandatory healthcare / public insurance system - there's an different perverse incentive.

Private insurance requires you to pay bills directly to the providers up front, then send them to the carrier for possible reimbursement. Mind, there is still some level of reimbursement, you don't just carry it all on your own, and there's regulations on how much providers can charge, but a larger bill may tear a hole into your savings, without knowing for sure when you'll get it back.Most doctors will prefer privately insured patients (guess why?), and in some cases only accept new patients if they're privately insured¹.

They can't really refuse prior patients, though some may tell you "Oh, you're in acute pain? I can see you in... three months." which is really funny if you have a joint issue now and need a prescription for something _now_¹.

The original purpose, as far as I can tell, is to get particular groups of people away from the public insurance system if they can afford to carry their own cost. That's not too bad on its own, but getting people to do so voluntarily obviously requires some incentive. That incentive is the privilege of better and faster care, because doctors obviously want to make more money too (within some ethical limits - some doctors really want to support the less privileged too, but with financial pressures of their own, they may have to compromise).

But within an environment where we have a shortage of medical personell and increasing prices for office space etc., that is leading to a situation where public patients struggle to find good care.

To enter private insurance, you have to either be a Civil Servant², self-employed or above the income threshold³ for mandatory public insurance⁴. It's voluntary, but if you can afford it, there's obviously good reasons to do so. Private carriers may still reject you based on age or preexisting conditions (does that sound familiar?), charge more for the risk etc.

The kicker? Once you're privately insured, returning to the public healthcare is a bit tricky, because you need to lose whatever criterion got you eligible in the first place. Self-employed? Guess you gotta find an employer to sell your soul to. Earn "too much"? Find a way to earn less. Civil Servant? Quit and lose all the other benefits too.

You don't have to check into this Hotel California style insurance, but if you don't, have fun finding some motel to take you in. And if you do want to leave, perhaps because the cost is getting too much on account of developing serious issues that allow the insurance to charge serious premiums, you have to basically make them kick you out by dropping down the ladder far enough.

Is it better than the US? Certainly. 90% of us are carried by public insurance, I don't have to worry about a sudden illness ruining me financially. My employer automatically deducts ~7% of my income to cover half and pays the other, so I don't worry about the bills. I have two meds I need, which I pay a combined total of ~10€ per month for (one is a monthly package about 70€, the other three months and change for 90€, but the insurance has to pay 90% of that).

But having moved and trying to find a new primary care provider, it sure sucks to hear "I'm sorry, but we currently only accept private patients. Try again in six months maybe."

¹Hospital ERs are required to accept you anyways, but for non-life-threatening conditions, you'll usually have to wait a long time and receive worse care by overworked staff annoyed at having to deal with non-emergency things because the actual non-emergency doctors won't.

²Special status with specific requirements, not all who work for a civil office qualify for Civil Servant benefits like job security (short of felony convictions, basically nothing can get you fired or your pay reduced), a special health plan where the state covers half your cost (even if privately insured), fixed pensions, exemption from social security contributions. There are restrictions too, but that'd be a whole post.

³Starting 2025, that would be 73,800 EUR gross income, about 78k USD right now.

⁴You still have to have some health insurance, it just no longer has to be public. If for whatever reason you don't, things get complicated, but I'm too fuzzy on that to make any claims.