Universal health care systems vary according to the extent of government involvement in providing care and/or health insurance. In some countries, such as the UK, Spain, Italy and the Nordic countries, the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights not on the purchase of insurance. Others have a much more pluralistic delivery system based on obligatory health with contributory insurance rates related to salaries or income, and usually funded by employers and beneficiaries jointly. Sometimes the health funds are derived from a mixture of insurance premiums, salary related mandatory contributions by employees and/or employers to regulated sickness funds, and by government taxes. These insurance based systems tend to reimburse private or public medical providers, often at heavily regulated rates, through mutual or publicly owned medical insurers. A few countries such as the Netherlands and Switzerland operate via privately owned but heavily regulated private insurers that are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance.
linkGermany has Europe's oldest universal health care system, with origins dating back to Otto von Bismarck's Social legislation, which included the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889.
As mandatory health insurance, these bills originally applied only to low-income workers and certain government employees; their coverage, and that of subsequent legislation gradually expanded to cover virtually the entire population.<2>
Currently 85% of the population is covered by a basic health insurance plan provided by statute, which provides a standard level of coverage. The remainder opt for private health insurance, which frequently offers additional benefits. According to the World Health Organization, Germany's health care system was 77% government-funded and 23% privately funded as of 2004.<3>
The 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. They may also opt for private insurance, which is generally more expensive
, but whose price may vary based on the individual's health status.<4>
Reimbursement is on a fee-for-service basis, but the number of physicians allowed to accept Statutory Health Insurance in a given locale is regulated by the government and professional societies.
Co payments were introduced in the 1980s in an attempt to prevent over utilization. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the United States (5 to 6 days).<5><6> Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).<7>
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Germany has a universal multi-payer system with two main types of health insurance. Germans are offered three mandatory health benefits, which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance.
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All salaried employees must have a public health insurance. Only public officers, self-employed people and employees with a large income above ca. 50000 EU (adjusted yearly) may join the private system.
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A person that opts out of the public health insurance system and gets private health insurance can not go back later to the public system, even if income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance one will be required to pay the higher premiums with less income.
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