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This is the first in a Series of two papers about Germany and health
Introduction
The German statutory health insurance system is recognised 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 stylised 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 ageing 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.
The G20 summit hosted by Germany in July, 2017, and the approaching 135th anniversary of the German statutory health insurance in 2018 provide impetus for taking stock of Germany's health insurance system and its development, trends, performance, and opportunities for change.
In this Series paper, we describe how the German health insurance system expanded both the population coverage and the benefits package while keeping cost-sharing low, and we explain how the characteristics of the German statutory health insurance were modified to achieve this. We review developments since 1993, with empirical analysis of data to assess the performance. We look at the statutory health insurance system through the prism of its 135 year history, recognising its remarkable resilience: it survived, with key principles intact, different forms of government (an empire, republics, and dictatorships), two world wars, hyperinflation, and the division and subsequent reunification of Germany. We describe...