Bending the Cost Growth Curve and Expanding Coverage: Lessons from Germany’s All‐Payer System
A Tribute to Uwe Reinhardt

The 2020 presidential election campaign is well underway, and health care remains a top issue for Americans. President Trump has promised to release a plan to replace the Affordable Care Act after the 2020 election. Democratic presidential candidates, conversely, have proposed either a single‐payer, government‐run, Medicare for All plan or some form of a public option as an alternative for major health reform. Both Republican and Democratic reform proposals are likely to meet stiff opposition and skepticism from American voters, as polls have shown, as well as from members of Congress. What, if any, other options are available to voters and policymakers for meaningful reform going forward? According to the Milliman Medical Index (MMI), the cost of health care for an American family of four covered by an average employer‐sponsored preferred provider organization (PPO) in 2019 was $28,386 (approximately 45% of median household income¹), and $6,348 for an individual.² For the first time in a decade, the number of uninsured Americans has risen—by 2 million people in 2018.³ Increasingly, Americans are being priced out of needed health care, the theme of the new and final book by the late Princeton economist Uwe Reinhardt, Priced Out: The Economic and Ethical Costs of America Health Care, published in May 2019.⁴

Reinhardt was convinced that a “third way” for reforming the US health care system could be found in an all‐payer health care system, such as the German, Dutch, and Swiss systems. A successful transition to an all‐payer system in the United States would both bend the cost growth curve and expand coverage. As early as 2009, in a weekly New York Times Economix column, he wrote: “None of these countries uses a government‐run, Medicare‐like health insurance plan. They all rely on purely private, nonprofit or for‐profit insurers that are goaded by tight regulation to work toward socially desired ends. And they do so at average per‐capita health‐care costs far below those of the United States.”⁵ In another article published in 2011, he recommended that our “price‐discriminatory system be replaced over time by an all‐payer system as a means to better control costs and ensure equitable payment.”⁶

This perspective focuses on Germany’s all‐payer system. It begins with a discussion on what is an all‐payer system and its advantages, followed by a comparison of health spending in countries with different types of financing schemes: the mixed public‐private health insurance system of the United States; the all‐payer systems of Germany, the Netherlands, Switzerland, and Japan; and some single‐payer systems. This is then followed by a more detailed description of Germany’s all‐payer system and concludes with a discussion of lessons from Germany for the United States.

All‐Payer Systems

Reinhardt described an all‐payer system in his 2011 paper:⁶

Under an all‐payer system, all insurers in a state would pay all providers in a state the same price for a given health service, with adjustments only for differences in the price of the inputs used by health care providers, as under the current Medicare payment systems.

But unlike the current Medicare system, which sets fees unilaterally, the uniform fees under the all‐payer system envisaged here would be formally negotiated on a regional basis between representatives of providers and representatives of payers. As noted in the introduction, Germany and Switzerland operate such systems on a regional basis. The uniform, regional price schedules could also be negotiated in some way by an independent rate commission with representatives of providers and payers, as is the case in Maryland for hospitals.

He also pointed out that: “Although the idea of an all‐payer system for the United States might be highly controversial and revolutionary in the eyes of many health care providers and health insurers, it has circulated among policy analysts for some time. The idea was discussed in the early 1990s, after health care spending started to rise rapidly toward the latter part of the 1980s.”⁶

Advantages

Reinhardt saw three main advantages of an all‐payer system⁶:

• First, “an all‐payer system would reduce the cost of the current administratively complex system, which would allow private insurers to concentrate more resources on helping their customers coordinate their care in a cost‐effective manner.”
• Second, “such a system also would make it possible to constrain the overall annual growth of health spending so that it does not outpace overall economic growth. The idea would be to bend the traditional US health care cost growth curve, from its traditional trajectory—under which health spending has grown at a long‐run average annual growth rate of more than two percentage points faster than gross domestic product (“GDP+2”) over the past four decades—to something between one‐half to one percentage point faster than gross domestic product.” National health expenditure growth in the United States for the period 2018‐2027 is expected to average 5.5% annually, reaching $6 trillion and representing 19.4% of the US GDP in 2027,⁷ far higher than the GDP growth rate of 2.3% in 2019 and projected GDP growth of 1.8% for the period 2020‐2029.⁸
• Finally, “in an all‐payer system the perceived value of a health care provider’s work, signaled through prices paid as it is now in the United States, would no longer be a function of the socioeconomic status of the patient. Instead, it would be the same for all patients. Consequently, providers no longer would be given the incentive to refuse patients whose treatment is judged by society to have a relatively low value solely because these patients are poor—a problem now encountered by many Medicaid patients.”⁶

Regarding the “cost of the administratively complex current system,” a 2014 study found that the US multipayer health care system resulted in excess administrative costs of $350 billion in 2012, nearly 15% of health care spending.⁹ As will be described later, the administrative costs of an all‐payer system is much lower.

An all‐payer system also would eliminate the rampant price discrimination resulting from hospital mergers and acquisitions. There were 115 mergers in 2017.¹⁰ In 2018, hospital mergers declined 22% to 90 mergers, “but grew in size as part of a broader trend toward megamergers.”¹¹ Mergers have been growing in new geographic areas, suggesting a “systematic strategic move of health systems to expand market shares.”¹¹

Hospital mergers have led to higher prices as the acquiring health system gains greater market share following mergers. A 2019 paper by Cooper and colleagues¹² found that hospital prices grew substantially faster than physician prices in 2007‐2014. For inpatient care, hospital prices grew 42%, while physician prices grew 18%. Similarly, for hospital‐based outpatient care, hospital prices grew 25%, while physician prices grew 6%. Much of the growth in payments for inpatient and hospital‐based outpatient care was driven by growth in hospital prices, not physician prices. Other studies have reported similar results.⁴

US and German Health Spending in International Perspective

According to 2018 data from the Organization for Economic Cooperation and Development (OECD), national health expenditure (NHE) in Germany was 11.2% of GDP compared to 16.9% in the United States, or approximately 66% of US spending.¹³ Figure 1 shows NHE as a percent of GDP for the United States and Germany for the period 1992‐2018. On a per capita basis, the difference between Germany and the United States is pronounced: $5,986 for Germany versus $10,586 for the United States, or 57% of that of the United States.¹³

Figure 1. National Health Expenditure as a Percentage of GDP, United States and Germany, 1992‐2018

Data from OECD Health Statistics 2019.¹³

Figure 2 shows NHE in the United States and the all‐payer systems of Switzerland, Germany, Japan, and the Netherlands in 2018. The average spending of the four all‐payer systems was 65% of that of the United States.¹³

Figure 2. NHE as a Percentage of GDP in the United States and the All‐Payer Systems of Switzerland, Germany, Japan, the Netherlands, 2018

Data from OECD Health Statistics 2019.¹³

Figure 3 shows growth in health spending in the multipayer system of the United States; the all‐payer systems of Germany, the Netherlands, Switzerland, and Japan; and the single‐payer systems of Canada, Denmark, and Taiwan in the period 2008‐2018. The all‐payer systems of Germany, the Netherlands, and Japan all had moderate spending growth (Switzerland being the exception), as did the single‐payer systems of Taiwan, Denmark, and Canada. The Netherlands’ all‐payer system has shown a downward sloping NHE since 2014.

Figure 3. Growth in National Health Spending in Select OECD Countries and Taiwan, 2008‐2018

Data from OECD Health Statistics 2019. Data for Taiwan based on Health Statistical Trends 2018. Ministry of Health and Welfare, Taiwan. Adapted from Health Affairs.¹⁴

Germany’s All‐Payer System

Germany’s all‐payer system offers its citizens and legal residents universal health insurance, generous benefits, high delivery system capacity, free choice (insurers, doctors and hospitals), short waiting times, increasing public satisfaction, improved population health (as seen in the significant reduction in amenable mortality), and good cost control.

Solidarity as Explicitly Stated Distributive Social Ethic for German Health Care
Established in 1883 by Chancellor Otto von Bismarck, the German health insurance system is the world’s oldest. Solidarity is the explicit ethical principle guiding the German system, which manifests itself in universal health coverage, fairness in financial contributions to the statutory health insurance (SHI) funds (“sickness funds”), and equity in the benefits provided to all insured. Americans, wrote Uwe Reinhardt in Priced Out, “By contrast, … have never reached a politically dominant consensus on the issue. We debate these ethical issues in camouflaged form. The debate in recent years on repealing and replacing Obamacare is merely a continuation of this camouflaged and confusing debate. However, one can infer from actual reform plans the ethical platform on which they rest.”⁴

Self‐Governance and the Role of Government

A second important principle guiding Germany’s SHI health system is self‐governance. The German federal government’s role is limited to setting policy objectives at the federal level, with the implementation and enforcement left to the self‐governing stakeholders. Regulation of the German SHI is largely in the hands of self‐governing associations of sickness funds and associations of provider organizations through the Federal Joint Committee (FJC), the major payer‐provider entity established in 2004 by the Statutory Health Insurance Modernization Act (SHIMA).¹⁵ Within the legal framework provided by Germany’s Federal Ministry of Health, the FJC defines uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency; and ensures good access to high‐quality health care without undue shortages or waiting times through oversight of payer and provider associations.¹⁶

Inspired by the British National Institute for Health and Care Excellence (NICE), the 2004 SHIMA also created the Institute for Quality and Efficiency in Health Care (IQWiG), charged with performing health technology assessment of health care services and making coverage recommendations to the FJC based on evidence‐informed comparative‐effectiveness analyses.

Financing, Risk Pooling, and Risk Adjustment

Financing for the German SHI system is through payroll‐based premiums. The government plays virtually no role in the direct financing and delivery of health care. The legally set contribution rate in 2019 is 14.6% of gross annual wages up to a ceiling of €50,850 ($64,994), shared between employer (49.1%) and employee (50.9%).¹⁶

Collected premiums go into a central risk pool, “Central Reallocation Pool,” which in turn distributes funds to each sickness fund on a morbidity‐based risk‐adjusted capitation basis, taking into account age, gender, and 80 chronic and/or serious illnesses.¹⁶ The risk‐adjustment scheme minimizes adverse selection and creates a level playing field for all sickness funds, so that members with low income and high disease risk are as attractive to the sickness funds as people with high income and low disease risk.¹⁶

Mandate, Coverage, Choice, and Benefits

Health insurance is mandatory in Germany, and coverage is guaranteed.¹⁷ As of 2016, all citizens and legal residents whose annual income is less than $71,564 must enroll in a statutory health insurance (SHI) sickness fund, which also covers their dependents free of charge. Those earning above the income threshold could choose to enroll in either a private health insurance (PHI) plan or SHI.

SHI covers 87% of Germany’s population of 82.7 million; private health insurance (PHI) covers 11% or 8.8 million people; and government insurance schemes, for example, for military, police, and refugees, cover 2% of the population.¹⁶ Children in Germany are automatically covered by a tax‐financed federal program, a sharp contrast to the United States where 5.2% of children remained uninsured in 2018,¹⁸ and is growing.¹⁹

Germans can freely choose to join any of the 109 competing nonprofit SHI sickness funds (Reinhard Busse, written communication, June 26, 2019). This freedom of choice fosters healthy competition among sickness funds. Since SHI is individual‐based instead of employer‐based like US private health insurance, there is not the problem of “job lock”—staying in a job for fear of losing health insurance if the worker leaves a job.

Germans can also freely choose doctors and hospitals (when referred to inpatient care). There is no gatekeeping system.

SHI benefits are comprehensive, and include doctor visits, hospital outpatient and inpatient care, mental health care, dental care, optometry, physical therapy, prescription drugs, medical aids, rehabilitation, preventive services (dental‐, child‐, and chronic disease checkups, basic immunizations), hospice and palliative care, and sick leave compensation.¹⁵

Private Health Insurance

PHI is mandatory for civil servants, including teachers and the self‐employed.¹⁷ As of 2016, there were 42 PHI companies in Germany, of which 24 were for‐profit.¹⁵ PHI pays providers on a fee‐for‐service (FFS) basis. The government sets PHI fees, which are far higher than SHI fees.¹⁵ PHI covered benefits are similar to SHI.²⁰ Minor benefits not covered by SHI, such as certain dental services, can be obtained through PHI.¹⁷

Delivery System, Utilization, and Outcomes

Both delivery system capacity and health care utilization in Germany exceed that of the average for the European Union and the United States, with the exception of the numbers of MRI and CT scanners and cesarean sections, as Table 1 shows. As in the United States, health care is an important sector for German employment, accounting for 11.2% of the German labor force in 2011.¹⁷

Table 1. Delivery System Capacity and Utilization of Health Care Services in Germany and the United States, 2017 (or nearest year)

Data from OECD Health Statistics 2019.¹³

Amenable mortality in Germany declined by 37% in the period 2000–2014.¹⁶ Figure 4 shows the decline between 2005 and 2015. This is in sharp contrast to the stubbornly high rate in the United States during the same period.²¹ Figure 4 also shows that while the United States has the highest per capita health spending, it also has the highest rates of amenable mortality among wealthy OECD countries.

Figure 4. Amenable Mortality per 100,000 People and Changes in Total Health Expenditure in Germany and Selected Countries, 2000‐2014

Reprinted with permission from the Lancet.¹⁶

Provider Payment: “Price‐Setting in Quasi‐Markets”

Uwe Reinhardt called Germany’s SHI system “quasi‐markets,” under which “price‐setting” takes place through negotiations between associations of providers and associations of payers.²² SHI sickness funds are responsible for paying SHI physicians and hospitals. SHI physicians in ambulatory care (GPs and specialists), who are private and for‐profit providers, bill their regional (state) associations of sickness funds directly according to a uniform fee schedule, and receive payments on a FFS‐basis by their regional (state) sickness funds.

German physicians contracted with SHI are not allowed to balance‐bill patients. Surprise medical bills, a source of great apprehension to American patients, are unheard of in Germany.

German hospitals are financed through “dual financing,” with financing of capital investments from the state, and operating costs paid predominantly by sickness funds (in the form of DRG payments), private health insurers, and patient out‐of‐pocket payments.¹⁵

Reference Pricing for Pharmaceuticals

The high costs of prescription drugs in the United States has commanded much attention from the Trump administration, Congress, and the American public. Figure ⁵ shows that pharmaceutical prices in the United States saw a significant jump around 2013, but intense political pressure since then may have moderated the rate of growth, from a 4.5% increase from 2017 to 2018, to a 2.1% increase from 2018 to 2019.²

Figure 5. Per Capita Pharmaceutical Expenditure in the United States, Germany, the Netherlands, and Switzerland, 2008‐2017

Data from OECD Health Statistics 2019.¹³

Figure 5 also shows that the all‐payer systems of Germany and Switzerland had moderate growth, whereas the Netherlands saw a slight decline in growth in per capita pharmaceutical expenditure from 2008 to 2017. OECD data on pharmaceutical consumption in the United States are not available. It is, therefore, difficult to know whether the high pharmaceutical spending in the United States is attributable to higher consumption of drugs or to some other factor. A 1996 study by the McKinsey Global institute, based on 1990 data, showed that “in 1990 Americans actually used $390 less in real health services per capita (both priced out at and expressed in US prices) than did Germans. However, Americans paid $737 more per capita than did Germans in higher prices for identical health care products and services.”⁴ Recent international data show that the United States has much higher prices than all other countries, which may explain the high drug spending in the United States.^4,14

Germany controls drug spending by relying on the SHI system’s “reference pricing” scheme. Sickness funds cover all drugs entering the market, unless they belong to a category excluded by law, for example, over‐the‐counter drugs or those not recommended by IQWiG based on cost‐benefit assessment at the request of FJC.²⁰ There is, in theory, no price control in Germany for pharmaceuticals; manufacturers can set prices freely at product launching. All prescription drugs, both patented and generic, are placed into groups with a reference price serving as a maximum level for reimbursement, unless they can demonstrate added therapeutic benefits.²⁰ Patients who desire a higher‐price substitute than those in a cluster pay the full difference between the retail price of that drug and the reference price SHI pays.¹⁶

A 2017 study showed that, between 2011 and 2016, prices of new drugs with additional therapeutic benefits over comparators received an average 230% price premium; and drugs that affected mortality, morbidity, and adverse events, received price premiums of 620%, 170%, and 90%, respectively.²⁰

When clustering is not possible, prices are negotiated between the national association of sickness funds and the drug manufacturer in the same manner as for drugs with additional therapeutic benefits, subject to the consideration that the annual treatment cost of the new drug does not exceed that of established therapy, or “comparator” drug prices paid in other European countries.²⁰

A price freeze on existing drugs, referred to as a “price moratorium,” has been in effect since 2009, according the Reinhard Busse (oral communication, October 16, 2019). The price freeze has since been extended through 2022, which allowed “an adjustment for inflation as of 2018.”²⁰

In 2016, drugs in the reference pricing clusters accounted for 81% of all prescriptions and 37% of total SHI drug expenditure.²⁰ SHI and PHI together cover 84% of all outpatient pharmaceutical expenditure in Germany, with the rest paid through patient out‐of‐pocket payments and SHI copayments. Patients generally pay a copayment of €5‐10 for drugs.^17,20 SHI fully covers inpatient drug expenditures.²⁰

Administrative Costs in Germany’s SHI

Average spending on administration in OECD countries in 2014 was around 3% of total health spending.²³ The type of financing scheme generally affects the health system’s administrative costs. OECD data show that multipayer systems, including all‐payer systems, have higher administrative costs than single‐payer systems. Moreover, the number of health insurance funds (insurers) within a multipayer system has a significant impact on administrative costs.

Administrative costs accounted for approximately 5% of total SHI spending in 2014,²³ which, although high relative to the average of 3% for OECD countries, pales in comparison to the 7% for US traditional Medicare and Medicare Advantage, and 13% for US private insurers (including profits).²⁴ According to the Planning Department of the National Health Insurance Administration of Taiwan’s Ministry of Health and Welfare, Taiwan’s single‐payer National Health Insurance, administrative costs were 0.77% of total NHI expenditure in 2019.

Lessons From Germany For the United States

Germany’s solidarity‐based health care system offers a number of important lessons for the United States. First, Germany’s all‐payer system demonstrates that making explicit the distributive social ethic of a health care system is most helpful for guiding that system toward socially desired goals (for example, universal health coverage, affordable health care), a theme stressed by Reinhardt in Priced Out.

Solidarity, the consensus social ethic that has guided the German health care system since its inception, has served the country well. The history of moderate health spending growth in Germany (see Figure 3) over the past decade is attributable to the fact, according to Reinhard Busse, that German associations of providers and associations of insurers, which jointly decide on the prices of health care services and goods and the growth of health spending from year to year, “share the solidarity value so they don’t increase fees unreasonably” (oral communication, October 16, 2019).

Americans, noted Reinhardt, have never reached a social consensus on the solidarity value, nor ever clearly answered the question: “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in health care?”⁴ In sharp contrast to Germany, market power in the United States wielded by individual providers and individual payers determines the prices of health care services and goods. This has not only resulted in rampant price discrimination and increasing costs as noted earlier, but also is the reason for the many “bizarre and curious facts about our health care system” that Reinhardt documents in his book.⁴

Second, the principle of self‐governance and limited role of government in Germany’s SHI system should appeal to Americans, given the intrinsic distrust by many of their government. One is reminded, yet again, of Reinhardt’s 2009 commentary about the all‐payer systems of Germany, the Netherlands, and Switzerland: “All three countries offer their citizens reliable, portable health insurance based on the principle of social solidarity, but without a government‐run health insurance plan like Medicare.”⁵

A third lesson is the importance of three coexisting conditions that are necessary for achieving universal health coverage (UHC). Reinhardt considered these conditions to be the “three‐legged stool for universal health coverage:” mandate, guaranteed issue, and adequate government subsidies. If any of the legs is missing, UHC would be impossible to achieve.²⁵ In Germany, the three‐legged stool is alive and well, but in the United States, the health of the three‐legged stool is in critical condition: the individual mandate is missing; the fate of guaranteed issue regardless of preexisting conditions is uncertain; and the Republican threat to reduce government subsidies for purchasing health insurance continues to loom large. The United States presently is a long way from achieving UHC.

Fourth, in addition to the ability to control costs through various schemes in its all‐payer system, there is no price discrimination and no surprise medical bills, and administrative costs are far lower than in the United States.

Finally, Germany’s reference pricing system for pharmaceuticals is clearly a useful model for the United States, especially at a time when American policymakers and the American public are eagerly searching for ways to reduce pharmaceutical prices and better control pharmaceutical spending.

Conclusion

For many years, Uwe Reinhardt was concerned about the “collision” over time of two powerful, long‐term trends in our economy: 1) the rapid secular growth in the cost of American health care, and 2) the growing inequality in the distribution of income and wealth in the country.⁴ He felt that “these two trends have combined to price a growing number of American families out of the high‐quality or at least luxurious American health care that families in the upper strata of the nation’s income distribution would like to have for themselves.”⁴

He also believed that an all‐payer system, such as Germany’s, with its many strengths and appealing attributes, including industry self‐governance and limited government role, could serve as a model for the United States to help bend the cost growth curve and expand coverage, as well as create a kinder health care system for all Americans. In the upcoming 2020 national elections, much is at stake regarding the future of US health care and it will be up to American voters to decide which candidates are best suited to lead the nation in pursuing meaningful reform.

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Published February 2020
DOI: 10.1111/1468-0009.12453