Observations leaving the US for Germany – Socialized health care

This is part 4 of multi part series, and I’m talking about my experiences with the health care system in this post. Here are the links to all the entries:

Part 1: The buildings & streets

Part 2: The food

Part 3: The quiet

Well, it’s official, I have left the US for Berlin, Germany. This is part four of a series of observations I’m making comparing my life in the US to the one here. This post is being written a few weeks after having moved, and I’ve now moved into my own apartment rather crashing with family. One of the things that is required to stay here is health insurance, and so I had to sign up for German health insurance. I’ve written about the US health insurance system before, and those articles were based on my experiences with it in the US. The German health insurance system is, to some degree, what the ACA was ostensibly aiming to be, with the addition of a public option. I think it serves as a good model for what is possible, and how it works.

First, let’s do a quick summary of the health care I was able to get in the US. In the US, for both my wife and I, we were paying roughly $900 a month total for the both of us. Many years ago, I was in a particularly bad car wreck, and had some extensive injuries. There weren’t any long-lasting effects, I haven’t had any issues since then other than some nasty scars, but my injuries were extensive enough that most of my body was a pre-existing condition. I’m caucasian, my wife is asian, and other than that, we are in good health. We see a doctor, other than for the usual checkups, less than once a year.  Nonetheless, pre-ACA, I was essentially non insurable without a group policy. Being an independent contractor, with my own corporation, this wasn’t generally a problem, but is just about what it cost to cover myself and my wife pre-ACA. After the ACA, my insurance costs rose by about $50 a month, but I no longer had to have a group policy, so it was much easier to deal with, and I became insurable, but I could see how there would be a bunch of people in similar circumstances to mine, without the resources or resourcefulness to get it done, and were for all intents and purposes uninsurable without getting it through work. Picking an insurance plan, both before and after the ACA, was always a joy. I’d spend hours trying to figure out the various caveats, deductibles, networks, and what is covered between various plans, and then hope I made the right choice when I had to use the insurance.

My deductibles ranged between $4000-$8000 per individual, depending on the year and what coverage is available. Many things aren’t covered, or are poorly covered. If I tried to make an appointment with my primary care doctor, I generally couldn’t get an appointment in under a month. If I had anything more urgent, I’d have to go to the urgent care or emergency room, even for things that weren’t quite an emergency. For example, I was sick and feverish for over a week. I had no need to go to the emergency room, but it was clear that I needed to be put on anti-biotics, but the appointment I tried to schedule was 3 weeks out, so urgent care it was. It generally felt incredibly wasteful, but at least the rise of urgent cares meant no more emergency rooms, which was what I would have had to do in the 1990s or 2000s.

Getting treated generally consisted of waiting for several hours, being seen by an RN, getting bandaged or my vitals taken, 5 minutes answering questions, maybe a prescription, paying a $50-$100 deductible on-site, and then waiting several weeks for the bills to arrive. I’d generally receive a single bill from the insurer, with a bunch of things on it, and a stamp saying “Do not Pay, this is not a bill”. Then I’d get a bill from the facility itself, a second bill from the doctor, and if I got an x-ray, then a 3rd and 4th bill for the radiology department and a separate one for the radiologist. The sums in these bills inevitably didn’t line up with what the insurer said, what I thought I would pay with my deductible, and often got sent multiple times, with different amounts each time. If the bill went up, I would be able to call whatever billing department was shown on the letter, spend an hour on hold, argue with them for a bit, and then have to pay only the lower amount of several received bills. When I had the car accident I spoke about earlier, my bill came out to around $250k. The insurance company refused to pay, I hired a lawyer, spoke to him once or twice, and then everything got paid (including the lawyer).

So far, here’s been my experience with the German system. I logged onto a website called Check24, which is a private company and helps you manage the health care offerings. They don’t charge you, the end consumer, but they get their money from either the health care providers or the government. I don’t know, and honestly, don’t really care, since I don’t have to pay. They also speak English, which helps, despite the fact that I speak German. I don’t read legalese and medical terms in German well, so trying to decipher it was difficult. Anyhow, I signed up for Check24, and they said they would handle everything between myself and the insurance companies on my behalf, and they spoke to me in English. They said I could choose between a public plan or a private one, and all the private plans were required to cover everything the public plan would cover, but the coverage for families works a bit different, and they can offer more than the public plan. Every resident is required to have insurance, it is mandatory, and instead of fining you, things like residency applications require the proof of insurance. If you want to live 100% off the grid, I suppose you can do so, but for all practical purposes, its mandatory and everyone will do it, since avoiding it is prohibitively difficult.

The public plan cost a percentage of your income, half of which is generally paid by your employer, and half by the person. It costs about 15% of your gross annual income, with half being paid by the employer, and caps out at €59400 annual income. That means that the highest you’ll ever pay is roughly €750 a month. The public plan covers your entire household, so any significant other, kids, etc. Emergency care and medically necessary care is free, and preventative care is generally not.  You can visit any public hospital, but not private ones, with this insurance.  You are not covered if you to a private doctor. If you are not self-employed or you make less than the annual cap, then you purchasing the public insurance is mandatory, however, you can purchase a supplemental insurance that provides you additional coverage with private doctors and facilities.

If you are self-employed, make more than the annual cap, or are purchasing a supplemental insurance, you can get private coverage. I myself opted for private coverage. The private coverage is per individual and not per household like the public plan. For individuals with disposable income, or smaller households, this means that the private insurance is often a better deal than the public insurance. For just my wife and I, private insurance costs just about what the public insurance costs, which is roughly equivalent to what I paid on the US. So far, at first glance, everything seems to more or less match what we get in the US, but here’s where the resemblance ends.

In getting the private coverage, the first step was choosing a plan. I had several offers, and here’s what my German private insurance covers. It covers everything that is an emergency or medically necessary. I can see whatever doctor I want, and they’ll pay for it, if its an emergency. If I want to see a specialist, I first have to get a general care physician to recommend it, otherwise only 80% is covered. I don’t have a primary care physician the way I do in the US, I can see *any* general physician first, and as long as I’m referred, specialists are 100% covered. My deductible is €500 a year, total. I will never pay more than that. If I travel, I’m covered, unless I play to be outside Germany for longer than 30 days, in which case I have to pay a supplemental travel insurance cost. I get vision care, dental care, and regular health care. If I’m hospitalized, I get a per-diem. If I have to stay in a hospital, for any length of time, I’m guaranteed a 1 patient private room. Preventative care is mostly covered (I think roughly 80%, up to the deductible, otherwise I’m covered).

To get the health care, I had to get an exam from a general care physician.  I went onto Google Maps, found a general care physician who was nearby who’s office was open. I walked there, and told the nice lady at the front desk that I needed to get a physical for my insurance. She asked if I had an appointment, and I said no, so she said I might have to wait a while, and to take a seat. After an agonizing wait of… 20 minutes, the doctor was ready to see myself and my wife. He took our heart rate, our blood pressure, etc., listened to our lungs, and then asked us a series of questions about any conditions we have (about 20 or so). When he listened to my lungs, he saw my scars from the car accident, and asked me about them. I explained the accident, he asked if I had any issues since, and then explained that the insurance company would probably have some more questions for us. He signed the form, stamped it, and we paid €50 for the both of us. That was it.

A couple days later, as the doctor had warned us, the insurance company stated that they needed a supplemental examination because of my scar. They sent a form, I walked back over the doctor, explained what happened, and they told me to take a seat. I waited about 10 minutes, and the same doctor called me in. He asked me if I had any blood in my urine or stool, I said no, he stamped the form, and I was on my way. I didn’t pay anything the second time. I sent the form in, and I got an email saying I was insured. That was it.

Since then, I haven’t had to use the doctor for anything yet, but I’ve spoken to several Germans about their experiences using the system. One person I spoke to talked about a business trip to Florida, where he got very sick. He ended up going to the emergency room in the US, waited for several hours, and then they saw him. They took his pulse, heart rate, etc., told him he was just sick, gave him a Tylenol and some anti-biotics. He received a bill directly from the US hospital for $4500 (which is low for an emergency room visit), and he gave it to his insurance company in Germany, and they paid it. Some time after, he got knee surgery here in Germany. He got the surgery, and didn’t pay anything out of pocket, but by mistake, the bill got sent to him instead of the insurance company. The insurance company paid around $2000 for his knee surgery here in Germany. The stories I’ve heard from others are similar. It sucks if you’re in the public health care system, as you have to go relatively noisy hospitals that have lots of people, but they take good care of you, and you don’t have to pay anything. If you have the money, you can upgrade to private doctors, still get the public coverage, and just have a better experience.

As for the mandatory things, with the government telling me what I have to do? Yes, I have to go buy the insurance here, and they’re pretty strict about it. Everyone has to do it, and you can whine and complain all you want, and you don’t have a choice. On the upside, health care is something you largely don’t have to think or worry about, and it will bankrupt you. If you need to see a doctor, you just go see one, and that’s it. You show your information, and you walk out. You don’t pay anything, you don’t really worry about. I haven’t had to see a specialist, but my impression from the doctor so far is that if I did need to see a specialist, as long as you have a credible story, you’ll more or less get a referral within a couple hours from walking into any general care physician. I’ve spent less time and money here, so far, researching plans, getting insurance, paying for it, getting a physical, and getting signed up for both my wife and I than I did even trying to figure out the coverage on my US plan. The total time spent on it so far, around 8 hours, including waiting to be seen the doctor’s office.  If my coverage in the US was only twice as difficult as the German system, it would still be an unrealistic dream.

So when people on the news and in the media talk about the horrors of the European socialist system, they don’t know what they’re talking about. For every cherry picked horror story of someone here not getting covered, I can find 100 examples in the US of even worse. The exceptions here are the norm in the US. Health care in the US was something that consumed hours, days, and weeks, plus many thousands of dollars for coverage that I dreaded using. Actual having health issues would cost thousands more. It consumed the voting public and the media, and was a huge issue with seemingly enormous consequences, and it felt monumental every time I had to make a decision. It’s gone from that, to something with about the weight of trying to choose a phone provider. If I make the worst decision possible, it nonetheless won’t have a huge impact on my life. I can spend a few hours on it to try and optimize my decision for the best outcome, and other than that, I honestly don’t have to think about it anymore. From my first visit to the doctor, within minutes, I trusted the system enough to realize that if I had any sort of emergency, I wouldn’t have to think about it much, and it would be taken care of. Sure, there’s probably some thing that I could get in the US if I pushed hard enough that won’t be covered here, and I could find aggravating. But I don’t care, because that seems like a small price to pay for the peace of mind in knowing that, for most of my day to day health care needs, and any dire emergency, it’s just not something I need to think or worry about anymore.

That’s the health care system that I would hope that the US, supposedly the most capable, strongest, and richest nation in the world be able to build, but is a far cry from it actually got. I still hope that there’s a way that the US can still build that system, but not until it realizes what is possible and what the reality is actually like.


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