BERLIN, GERMANY — Minnesota is exporting more than corn and medical devices these days. It’s also exporting ideas, particularly innovative health care systems to Germany.
A 32-member delegation of German officials and health-care industry leaders recently returned from this year’s Minnesota session, which focused on health care access for all. Every year since 2005, German health ministers have returned with new ways to change the German health-care system.
“It’s a sort of job sharing,” says Ulrich Dietz, the head of pharmaceutical reimbursement for Germany’s Health Ministry. It’s a job sharing promoted by the German Academic Exchange Service to foster trans-Atlantic relations.
With the American military presence in Germany shrinking after the nation’s 1990 unification, the nation is intent on continuing its special relationship with the United States, a large market generally regarded here as an engine of innovation.
U of M connection a key
The University of Minnesota is one of five schools to found a Center for German and European Studies in 1998 (the others are Harvard, Brandeis, Georgetown and UC Berkeley). Why Minnesota should have won such a competitive grant in such heady company is clear to the center’s director, Dr. Sabine Engel.
“In the field of health care, we all think of Medtronic, managed care, the nonprofit mandate of health insurers, and the fact that nationally Minnesota leads — it has the lowest percentage of uninsured,” she says.
“You take all that, and it spells a very clear message: Minnesotans are curious, and we like to learn from others … to benefit ourselves as a community.”
The German government thinks it has been benefitting as well. Even before the conferences started in 2005, the administration had turned its attention to health-care management systems being developed in the United States.
So, in 2002, when Dietz was impressed by a health-care transparency system known as DRG (Diagnosis Related Groups), he went back to his bosses here. Every hospital in Germany now uses the system to group procedures by cost. The goal is to make the cost of every procedure the same, and Dietz says it’s working.
Americans slow to adopt cost-saving ideas
Some Americans may never benefit from these cost-saving ideas — although the DRG programs are used in Medicare — because the American health-care system is regulated by individual states, rather than a federal system.
Stephen Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, has met with German health-care experts and ministers since their first trip to the state. The United States, he says, can learn a lot from Germany, and from the 2006 reforms that will provide insurance to every documented person living in Germany by 2009.
“One thing that Germany has working is spreading the risk across the entire population,” he says. “We don’t have universal coverage, and Germany does essentially. In the long run, it holds down the costs at the societal level.” (Today, officials estimate there are 200,000 uninsured individuals in Germany out of a population of 80 million. In Minnesota, the estimate is 350,000 out of a population of more than 5 million.)
Minnesota policymakers are also wrestling with how to make health care more affordable and accessible. Between 1 to 2 percent of small businesses in Minnesota are dropping health insurance coverage per year, according to the state Department of Human Services. Employers in the private and nonprofit sectors increasingly are adjusting their budgets to pay for skyrocketing employee health-care premiums.
But the solution is not a single-payer system, according to Minnesota Human Services Commissioner Cal Ludeman, who chairs Gov. Tim Pawlenty’s Health Cabinet.
“There is more energy for a single-payer system,” he says, but “what does that mean for a system? Does that mean we will guarantee enrollment for everyone in Minnesota Care (the state’s low-income health-care safety net). That would be unaffordable for one state to manage.”
Germans still hold to social-welfare tradition
And Germany’s health ministers wouldn’t advocate for such a system, either. It’s never had socialized medicine like the National Health Service in Great Britain. But as Germany’s Health Minister Ulla Schmidt noted on a previous visit to Minnesota, Germans, while impressed by some American ideas, still hold their social-welfare tradition sacred.
“The principle,” she told a University of Minnesota audience in 2006, “is that the rich should pay for the poor. The young for the old. The healthy for the sick.”
It doesn’t quite work that way in practice. Because Germany’s public insurers are funded in part on a sliding scale based on income, “it’s really the middle class who pay for the poor,” says Andreas Brandthorst, a health-care policy researcher at the German Parliament. “The rich pay for themselves.”
It’s the cost of health care that keeps German officials coming back to the United States for ideas. Germany is facing a demographic shift: a glut of aging pensioners with fewer, younger taxpayers to pay into the social welfare system. Today the average age of a patient in a German hospital is 60, and climbing. It’s a shift the government has seen coming, and why it continues to look across the Pond to make its own health-care system more cost-effective.
Another reason the United States has appeal to Germany is American companies’ ability to format health-care management systems for a large country. The German government contracted with 3M, the Maplewood-based company, to assemble the DRG system.
There was a bidding process, but it was clear that the project’s enormity meant that 3M was the only company that could make it happen for the right price. (3M just renewed a five-year maintenance contract with the Germans. 3M wouldn’t disclose the contract’s worth, but the company enjoys a 65 percent market share in providing health information systems in Germany and considers it a booming market.)
Germans wonder why Moore’s ‘Sicko’ skipped their system
“We are the European country that absorbs a lot of American ideas in health care,” says Dietz. “Maybe (that’s) why it wasn’t mentioned in Michael Moore’s film ‘Sicko.’ ” The film took audiences to Great Britain, Canada and France to debunk American prejudices about government-regulated health care.
Another reason why the controversial filmmaker may not have included Germany is that the nation’s voters, for the most part, have not politically punished politicians who have shepherded health-care reforms. Those changes have opened up the heavily regulated health-care system to market forces and crowned the consumer king of health-care decisions.
The Social Democrat Ulla Schmidt, for instance, is Europe’s longest-serving health minister, a record seven years. She is now working in a Grand Coalition government with the conservative Christian Democrats and appears to be politically secure heading into Germany’s 2009 elections.
But German politicians still face criticism that their health-care system is becoming too “American.” Germans fear the same trend occurring in the United States is coming to their country.
“The difference between rich and poor is increasing,” says Mario Rios-Miranda. A Chilean by birth, his parents, who supported Socialist President Salvador Allende, came to Germany in 1973 after the coup. Social equity is important to him — he runs a community center and lending library named for Allende in the low-income Neukölln neighborhood here.
Neukölln’s residents are experiencing inequity in the health care system — more doctors are leaving the neighborhood in pursuit of privately insured patients, who can be charged more. A common belief that the privately insured receive better treatment was reinforced recently by a study at the University of Cologne that found that those on public insurance had to wait three times as long to see a doctor. About 90 percent of Germans are on public insurance, like Rios-Miranda.
But even for those on private insurance, there is one constant criticism of the United States, regardless of political affiliation or income level.
“They don’t do enough for health care,” says Andreas Dämon, referring to the American government. A 31-year-old banker in Frankfurt, he’s on private insurance and welcomes the German government’s most recent health-care reforms. He benefits from them: He won’t be penalized if he switches back to public insurance. Previously, it was almost impossible to rotate out of private insurance to a public provider. And the reforms imposed new caps on how much private insurers can charge their clients, a new regulation that is an incentive for Dämon to stay privately insured.
Political debate in Germany nearing gridlock on health issues
A political debate this year that would require private insurance companies to pay more into the public insurance funds appears to be headed toward gridlock. Even in Germany, where almost everyone agrees that wealth, to some extent, should be redistributed, there are limits to social welfare.
Minnesota experts and officials would like to see U.S. movement on addressing such issues as the uninsured, double-digit increases in health care premiums that companies say hurt attempts to attract qualified workers, and crippling pharmaceutical costs for the elderly.
But so far, the exchange of ideas has been flowing one way.
Schondelmeyer has observed the political and social climate of changes, and lack of changes, in both the American and German health-care systems: “It’s a broader issue that we, the United States, as a society don’t seem to accept some minimal level of providing health care in the country.”
German officials prefer not to judge why American politicians have been unable to make use of pilot projects that Germany is implementing.
“When good ideas and political will meet,” says the German Health Ministry’s Ulrich Dietz, “then you can have success.”
Ann Alquist, a Twin Cities journalist, has been working in Germany since 2007 as part of the Fulbright Young American Journalist Program.