Americans are divided about how to pay for medical care and insurance, an issue that will continue to be debated hotly as presidential candidates tout their plans for overhauling the nation’s health care industry.
Whether the “fix” is found in the Affordable Care Act, private insurance, "Medicare for all" or something totally different, some Americans are pointing to health care systems in other wealthy countries as models.
One such country is Germany.
Courtney Reich, 28, was diagnosed with Type 1 diabetes in 2009. Even though she was on her family’s health insurance at the time, she said she had to pay hundreds of dollars every month for her insulin, which was necessary for her survival.
But when the Chicago native moved to Germany, Reich said she was shocked to learn both her insulin and insulin pump were totally covered — no out-of-pocket expenses.
“As a student at a public university in Germany, I automatically qualified for the public health care system,” Reich said. “I was really surprised that everything necessary to take care of my diabetes was covered, 100 percent.”
Reich said she couldn’t help feeling like a drain on the country’s system, and expressed those feelings to her German friends.
They reassured her they simply viewed health care differently.
“It’s about having a safety net, because tomorrow you don’t know what could happen,” Reich told NBC News.
The ones who are able to pay more, pay more. And the ones who aren’t able to pay that much, don’t pay that much.
Six years later — still living in Germany — Reich has embraced the idea of a safety net.
“I don’t need to worry about crazy stuff coming up month to month. I’d rather be paying a steady fee and knowing I’m safe,” she said.
Principle of solidarity
Germany has what's called a universal multi-payer health care system. It encompasses both statutory health insurance for people who earn less than a certain salary, as well as private health insurance for those who earn more and choose to purchase their own.
Employers and their employees pay for most of the health care system in Germany through premiums. All workers contribute about 7.5 percent of their salary into a public health insurance pool. Employers match that 7.5 percent contribution.
This “all for one and one for all” approach to health care has roots in the Middle Ages, when German craftsmen paid into one fund that was used to help any of its members in case someone became ill or suffered financial hardship.
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The ideology lives on in the modern German system. Everyone covered by statutory insurance has an equal right to medical care.
“We are one big community,” said Dr. Henning Baberg, a cardiologist and the medical director of Helios Hospital Berlin-Buch. “The ones who are able to pay more, pay more. And the ones who aren’t able to pay that much, don’t pay that much.”
“But they all get the same treatment,” he added.
Baberg likens the difference between statutory and private health insurance in Germany to the difference between economy and business class on a commercial airline flight.
Same flight, same plane, same safety profile.
And the system imposes strict limits on out-of-pocket costs, greatly reducing the number of surprise medical bills. The maximum copay for prescription medications is about $10 or $11.
Flying business class
Helene and Michael Sula, both originally from Dallas, are also expatriates like Reich. Unlike Reich, however, they pay for private health insurance.
The Sulas chose to live in Germany for its central European location, and were taking advantage of the country’s proximity to the Austrian Alps when Helene tore her anterior cruciate ligament, or ACL, while skiing.
“When I fell, I didn’t think it was that bad,” Helene Sula, 32, recalled. “It wasn’t until a man came up to me and said, ‘We’re going to need to turn your leg back the other way’ that I realized something bad had occurred.”
The couple said Helene Sula was lucky to find a doctor who could do an MRI quickly once back in Germany; most places they called were booked for weeks — a common disadvantage for elective procedures. They credited their private health insurance not only with getting a swift diagnosis, but also insisting on having the best surgeon available to do the operation necessary to repair her injured knee.
“There’s a price difference, of course, but it’s your knee, so we thought we’d spend a little extra cash to get the best doctor available,” Michael Sula said.
The cost for everything related to Helene Sula’s knee surgery was about $2,000, compared with $14,000 for the same treatment in America.
Despite some language barriers, the Sulas said the German health care system was easy to navigate.
“It’s much easier to pay your bills and understand your coverage than in America, where you’re sort of left to figure it out on your own,” Michael Sula said.
Should the U.S. adopt Germany's setup?
Health care industry experts in the United States say the German system is a good example of an employer-based model of medical insurance.
“No one pays more than two percent of their family income for out-of-pocket health care costs” in Germany, said Robin Osborn, director of the International Health Policy and Practice Innovations program at The Commonwealth Fund.
“And if you’re sick, if you’re chronically ill, it’s one percent. No one goes bankrupt in Germany because of medical care costs,” she said.
But Osborn does not recommend the U.S. copy Germany’s or any other country’s health care system and adopt it here.
No one goes bankrupt in Germany because of medical care costs.
“It’s important to remember that we do have outstanding health care in the United States. We have pockets of excellence. We have integrated delivery systems that are the envy of the world,” she said.
“It’s just that not everyone gets that outstanding health care. It doesn’t exist uniformly across the country,” she added.
Baberg, who received medical training at the University of California, San Diego, said one advantage the U.S. health care system has is transparency. Although Germans can go to any hospital they want, it’s more difficult for them to find data on quality outcomes for individual facilities.
But, he added, the U.S. health care system is flawed in a different way: Americans with less money get less health care.
“That’s wrong,” Baberg said. “That’s not humanity. And humanity should be a big part of medicine.”