The German Sickness Insurance Programme 1883-1911 : its relevance for contemporary American health policy
This study describes and analyzes the German Sickness Insurance Programme in the years between its enactment in 1883 and its recodification in 1911, as part of Germany's comprehensive social insurance system. It traces the evolution of health policy between 1883 and 1911 and discusses the impact that this landmark policy had on the well-being of the German population. Although the antecedents to modern German health policy may be traced to the sixteenth century, the period between 1800 and 1911 is a watershed period. The purpose of the study is twofold: 1) to provide a detailed description of the German model for countries1 without a national health service or national health insurance programme and 2) to study the changing roles of consumers and providers and the effect these changes have on access to care and cost containment, two issues which face policy makers throughout the world. As a social political analysis, this study explores proximate rather than definitive sources and causes for policy decisions. It attempts to delineate and explicate the issues surrounding the need for and enactment of the German Sickness Insurance Act of 1883: Where did the substantive ideas originate. Were they accepted or challenged. By whom. What is the relationship between policy objectives and policy output. How was quality of life affected. The infrastructure of medical services on which the programme relied at its inception is described as are legislative precedents for the Sickness Insurance Act of 1883. The operational aspects of the sickness insurance programme (for example, eligibility criteria, benefit design and programme financing) at the time of its implementation in 1884 are detailed. The study then focuses on the evolution of the programme (that is, changes in eligibility, benefit design and provider reimbursement) and the political and social forces which caused those changes. The interplay between consumer and provider concerns, as well as the changing level of organized input into the policy making process from these two groups is highlighted. The study concludes with an analysis of the programme's impact on the German citizenry, their access to health care and health insurance and the programme's ability to contain costs while expanding access. The analysis specifically assesses the impact that changing roles of consumers and providers have on achieving the goals of access and cost containment. The preconditions for effective implementation of a similarly structured programme elsewhere, specifically the United States, are noted. The limited intervention of the German government in both the financing or administration of the sickness insurance programme as well as its use of a multiple payer system, enhances its political appeal for American legislators and therefore the likelihood that the model could be replicated in the United States.