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Tsung-Mei Cheng and Uwe E. Reinhardt Shepherding Major Health System Reforms: A Conversation With German Health Minister Ulla Schmidt Health Affairs, May/June 2008; 27(3): w204-w213. [Abstract] [Full Text] [PDF] [Reprints & Permissions]

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German Model For U.S. Reform? Think Again

Susan L. Erikson   ( 17 April 2008 )

Letter Misses the Point

Tsung-Mei Cheng, Uwe E. Reinhardt   ( 18 April 2008 )

German Model For U.S. Reform? Think Again 17 April 2008
Susan L. Erikson, Asst. Prof. of Global Health Faculty of Health Sciences, Simon Fraser University Send comment to journal: Re: German Model For U.S. Reform? Think Again slerikson{at}sfu.ca Susan L. Erikson	The recent interview with German Health Minister Schmidt was excellent, and her advice for the U.S. is sound: Create infrastructures that increase the likelihood of universal care and timely health interventions; avoid expensive emergency room care; and bargain collectively. The interview, though, completely missed several very important distinctions between the U.S. and German systems. As a model for U.S. reform, the German system may be too different from the U.S. system at its core, beginning with the enormous difference it makes that German insurance companies/sickness funds are not-for-profit. Over the ten years I conducted research on German health care governance, I discovered other core differences. Health care policy making is organized around physician self-governance (which is not problem-free but poses different and, I would argue, lesser problems than those resulting from insurance company profit seeking). In Germany, health care competition is considered special and incomparable to the kind of marketplace competition acceptable for buying, as Minister Schmidt says, autos or refrigerators. Normal market competition is widely understood in Germany to be bad for health. One additional point: With the creation of IQWiG in 2004, Germany has built in a mechanism for evidence-based medicine to directly and constructively influence policy. New protocols must pass efficacy and affordability tests. The mechanism is again not problem-free, but unlike in the U.S., where science and evidence-based practice is, in effect, optional to health care policy creation and reform, the German system has structured into policy processes an intentionality about forming close science-medicine links. Minister Schmidt's comments about solidarity touch on one of the most poignant differences between the two systems. Social solidarity is a core value in German health care creation and reform. Germans, individually and collectively, in private and in public, regularly reflect on how important health care equity is to keeping all social systems -- economic, political, environmental -- working well. There is a collective consciousness that universal health care is good for individuals and the societal fabric as a whole, and that when you have too many people uninsured and ill, communities fray and come apart. (The U.S. is often mentioned as proof positive of this cautionary tale.) This difference makes clear that U.S. health care reform would require culture change that goes well beyond the political and economic transformations discussed in the interview.
Letter Misses the Point 18 April 2008
Tsung-Mei Cheng , Uwe E. Reinhardt Send comment to journal: Re: Letter Misses the Point maycrein{at}princeton.edu Tsung-Mei Cheng, et al.	Professor Erikson's comments on the cultural differences between Germans and Americans are right on the mark; but she misses the point of our interview with Minister Ulla Schmidt when she writes, "The interview, though, completely missed several very important distinctions between the U.S. and German systems." The point of the interview was to allow Minister Schmidt to inform the readers of Health Affairs on recent developments in German health policy. It was not to present a side-by-side comparison of the German and American health systems or cultures or to assess the feasibility of transplanting Germany's system to the U.S. Germany is a genuine nation in which social solidarity in certain basic human experiences -- health care prominently among them -- form the cement that forges a nation out of mere groups of people sharing a geography. The United States lacks that social cement, which can explain why it lacks anything resembling national policies on health, education, and justice and why it will be difficult -- perhaps impossible -- ever to adopt in the U.S. a genuine, coherent national health policy such as Germany's.