Comment by foepys | Hacker News Reader

Comment by foepys | Hacker News Reader

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I'm from Germany and here it's exactly the other way around.

Public health insurences (there are over 100, but they are all organized in an umbrella organization) give out licences to doctors to be allowed to practice on publicly insured patients. The doctors get some amount of money they can spent on patient-specific prescriptions, but in general the doctors only prescribe the active ingredient. When the patient goes to the pharmacy to get their prescription, the pharmacy looks up the insurence and hands the patient the medicine that the insurence dictates. A doctor can prescribe a specific medicine but has to pay for it themselves (mostly from the money the insurences previously provided, see above).

Insurences check about 10% of all hospital bills and just don't pay what they deem unnecessary. Hospitals are therefore careful not to do things the insurences didn't approve of. There is an open catalog of therapies that the public insurences will definitely pay and how much it may cost, so it's not a secret.

They will also push for modern treatments if they reduce recovery time and have less risks.

There is a lot more to the system but that's the gist.

I came here to extol the virtues of the German system. There's a lot more to it:

- It's priced according to income, not health condition

- You will never, ever be refused necessary healthcare, and you'll know it's covered before work begins

- You are not punished for using your insurance, and the premiums won't change

- There is no deductible, except a 5-10€/month co-pay for prescriptions

- Your employer/employment has no impact on your coverage, or the insurer you choose

This is for the public system. The private system is a bit more complicated, but generally, the same rules apply. The only difference is the pricing structure, and the possibility of having a deductible (usually ~1000€/year).

American expats tend to have trauma that affects their insurance choices. My job is to reassure them that our system is completely unlike the American system.

If you want a plain English overview of the system, you can have a look here: https://allaboutberlin.com/guides/german-health-insurance

One important caveat to the German system is that if you make over a certain amount and are healthy, the private system will actually be cheaper since it's not tied to income.

I'd say the average programmer makes $120k/yr USD after about 5 years in, which is roughly €100k EUR. What would a German citizen making 80k-100k EUR pay in healthcare monthly? I think my employer subsidizes about $200/mo into a medical program for just myself. Curious how it stacks up to Europe (which seems to do health care better than the US by leaps and bounds?)

The article linked in the comment chain you responded to gives numbers. For public insurance (which covers all essential care with no deductibles)

> The ninimum is 200€, [...] If you make more than 58050€ per year, you pay around 400€ per month. This is the maximum contribution (Höchstbeitrag). If your salary is higher than 58050€, you will not pay more.

For private insurance (possible if you earn above 64k or are a freelancer) its not linked to your income so rates vary.

> Private is cheap when you are young If you are young and healthy, you could pay as little as 175€ per month (350€ for freelancers) for private insurance. If you make a lot of money, this is much cheaper than public insurance.

But there are deductibles and fees can go up if you have frequent health issues. Freelancers cannot be covered by the public system so it only works when you're an employee, otherwise you're on private insurance.

An employee would pay a little under 350 euros and their employer an equal share. It is calculated as 7.3% of your salary until your salary passes about 56k euros. Then it’s calculated as 7.3% of 56k regardless of much you earn. Not working spouses are automatically co-insured without any extra cost

It's not really 7.3%, since you need to account for the Zusatzbeitrag, and the Pflegeversicherung. In total, it's half of (14.6 + ~1.2 + 3.3)%, so around 9.5% assuming you don't hit the price limit.

The article linked above gives better, more recent figures on those limits.

Yes, the Pflegeversicherung is a separate thing, but it's charged by the health insurer, it's mandatory, and private insurers include it into the price. It's much simpler to bundle those things together.

I have no idea what those words mean, but long German words are cool.

The caveat of this caveat is that if you're employed and you choose to go private and you stay private for 5 years, you won't be able to switch back to public.

Exceptions being if you're under 55 and earn less than the limit amount (something like 65k EUR roughly) or if you earn under 450 euro per month (the so-called mini job).

If you're older than 55, you're f'ed, good luck with your private insurance in old age, 'case you're not allowed to go public. They've taken this measure because people were using private insurance for long stretches and then switched to public as they were reaching retirement, straining a system they haven't contributed to

Yes. Just to illustrate that, a high-earning self-employed developer would pay the maximum ~895€ amount, while they'd pay roughly half on the private system.

The point about no deductibles isn't entirely true: if you are publicly insured, you have to pay 10€ for every day you spend in the hospital. There is a hard cap at 280€ per year, after that the insurance pays the 10€ per day. Also you don't have to pay it if you are underage, are on state-aid, or for a few other, rare reasons.

I should correct that to "deductibles are a non-issue"

This is awesome. Can you think of any major downsides to an approach like the German system takes?

The private system is a bit of a problem. People with a high income (and the self-employed) end up switching to it save money, depriving the public system from their high contributions. It also means wealthy people get better access to healthcare, particularly mental health.

It also means that in a bid to save money, self-employed people pick an option that's cheaper now (private), but will cost them a lot more over time, with no option to switch back.

Normally, if you switch to private, you must stay on private. This prevents people from getting cheap private insurance when they're young, and cheap public insurance when they're old. In practice, you can just get a low income job for a year at age 50, and get forced back onto the cheaper public system. It's a solid financial decision.

This is similar to the Situation with affordable care act in the US. I think max vs min age premiums are capped. Which means old people get a deal, and young people overpay. If people paid their true cost to the system, insurance would cost $50 if you are 20, and $2,000 if you are 70.

The same thing ultimately happens here where the young and healthy leave the public pool, leaving the older and sick. As rates go up, the cycle continues.

I don’t see how anything except a $0 for everyone really works. Otherwise you just have people gaming the system (like the 50 year old in your example working a year of low paying job to qualify)

Ironically despite the lower cost, the German medical system also provides a wider range of services than are provided in the US.

For example my mother in law had an unusual cancer and after her treatments she had a rest spa paid for; once the treatments could no longer help she had in home care. In the US, good luck.

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