How do they do it? Lessons the United States should heed.
Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years.
A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Self-governance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their healthcare providers. In 1993, the freedom to choose one's sickness fund was formally introduced, and reforms that encouraged competition and strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance.
Introduction
The German statutory health insurance system is recognized as one of the prototypes of modern health system configurations. Since its introduction in 1883 by the German Chancellor Otto von Bismarck, the guiding principle of the German health system has been solidarity among the insured. Solidarity manifests itself both on the income side and the provision side of statutory health insurance: all insured persons, irrespective of health risk, contribute a percentage of their income, and these contributions entitle the individuals to benefits according to health needs—irrespective of their socioeconomic situation, ability to pay, or geographical location. In this pooled-risk system, people with high income support people with low income, young people support elderly people, healthy people support people who are sick, and people without children support people with children.1,2 The Bismarck model is often compared with the Beveridge health system, which underlies a tax-financed national health service, and with health systems that are based on market principles.3,4 This highly stylized differentiation persists even though health systems worldwide have evolved by incorporating elements of each of the three models to meet new challenges, such as an aging population, new diagnostic and therapeutic technologies, and doubts about quality and cost-effectiveness, and to accommodate the advent of new instruments, such as health-technology assessment and diagnosis-related groups.
It is time for the United States to admit to the arrogance of "an exceptional system" and admit that our health system has a failing grade.
The Medicare 5-star rating system of quality is an empty box allowing hospitals to check the boxes to attain false quality values.
Furthermore, hospitals are notified when the audit will occur and adjust their 'best practices' for the visit of the inspectors.
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