Germany funds its excellent healthcare system through compulsory health insurance, the system that the Labour Party and Fine Gael are proposing for the Republic. Compulsory health insurance is common on the Continent but differs in detail from one state to another.
The German system is governed by the principle of social solidarity, a belief that everyone should have equal access to health care. Germany is a federal republic of 16 LΣnder. As its constitution stipulates that living conditions should be equal in all of them, the federal ministry of health regulates equal access to the same health-benefits package.
Germany was the first country to introduce a national social-security system when Bismarck, chancellor of the Prussian-dominated German Empire, made health insurance compulsory, in 1883. The social-security system now covers healthcare, medication and sickness, maternity and unemployment benefits.
Social insurance is funded by the contributions of workers and employers, like Pay Related Social Insurance (PRSI) in the Republic. PRSI covers sickness benefit but not medical care, principally due to the opposition of the Catholic church and the medical profession when it was proposed, in 1911.
Germans are insured by "sickness funds" - some regional, others based around companies, guilds, farmers' funds or the like. Fund membership is mandatory up to a certain level of income: 74 per cent of the population are mandatory members, 14 per cent are voluntary members, 9 per cent buy private health insurance and the remainder are state employees, such as soldiers, who receive free government care. In 1999, there were 453 sickness funds, all non-profit, and 52 private health insurers, 25 of which were traded on the stock market.
The sickness funds buy care for their members and dependants from hospitals or physicians' associations, which pay doctors. Legally, physicians' associations must provide care that is evenly distributed, socially and geographically.
In 1996, doctors' average incomes ranged from DM150,000 (£60,401) for general practitioners to DM250,000 (£100,669) for ear, nose and throat physicians, which was between three and five times as much as those of blue-collar workers and between two and three times as much as those of white-collar workers.
Unlike in the Republic, GPs are not "gatekeepers" to healthcare who then refer patients to specialists. The high cost of German healthcare is attributed to this fact, as well as to the practice of "doctor-hopping".
In 1997, Germany had 10 general practitioners per 10,000 people, compared with four per 10,000 in the Republic. Germany had 66 acute-care hospital beds per 10,000 people, compared with the Republic's three per 10,000.
German hospitals have an average bed-occupancy rate of 80 per cent, compared with an average of 95 per cent for acute Dublin hospitals. They can be publicly owned (55 per cent of all beds), private non-profit (38 per cent) and commercial-private (7 per cent).
While per-capita public spending on health care in the Republic is only now at or exceeding the EU average, Germany has been consistently spending above the EU average (see main graph). Recent increases have brought Irish spending closer to the German per-capita level, but years of higher spending would be required to rival the German system established during our years of neglect.
The Republic's income, measured as GDP per capita, now exceeds that of Germany and, while GDP is overstated because it includes the profits of multinationals, Ireland's lower GNP per capita exceeds the EU average and is not greatly below the income of Germans.
Since reunification, Germany has provided equal health care to its poorer eastern half, which, coupled with lower contributions due to higher unemployment, has put pressure on the system. There is growing recognition that what was regarded as a cost explosion in German healthcare is in fact a financing crisis. Costs have remained relatively stable.
Cost-cutting measures, such as patient payments introduced in the mid-1990s, were later reversed by the Social Democratic and Green government headed by Gerhard Schr÷der, in the 1998 Act to Strengthen Solidarity. In 1999, physicians threatened to put patients on waiting lists, hitherto unknown except for transplants, in response to a proposal to introduce global limits on sickness funds' spending. The limits were dropped.