The healthcare systems in the DACH region (Germany, Austria, and Switzerland) are all universal healthcare systems, meaning that all residents are entitled to healthcare coverage regardless of their income or employment status. While they look similar, there are some key differences between the three systems.

A multi-payer system in Germany

The origins of the German healthcare system can be traced back to the 1880s and it is solidly rooted in the principles of solidarity. This means that all people are covered by public health insurance regardless of their financial status, and will receive the same level of medical care. 

Health insurance in Germany is provided by either public health insurance (Gesetzliche Krankenversicherung) or private health insurance. 

Public Health Insurance

Public health insurance is compulsory. All residents, whether nationals or temporary residents, must contribute towards their health insurance every month. Everyone belonging to public health insurance (see below the possibility to opt-out) contributes to a fund which is based on their income and everyone has access to the same health coverage irrespective of age or income level. Older people are not expected to pay more than younger citizens/residents.

How much they pay is directly dependent on their income and employment status. This can vary between 14.6% to 15.6% of the monthly salary. The employer contributes half of the monthly contributions and the other half is deducted directly from the salary of the employee each month.

Dependents, such as spouses or children, can be added to the main member’s health insurance policy at no extra cost. The government subsidises health insurance premiums for low-income individuals and families.

Members are issued with a card which must be presented when they require medical treatment. Usually, they are required to pay a small co-payment and the rest of the cost is covered by the insurance. This ensures there are no surprise medical bills.

There is a list of medical services not covered by public health insurance, as with many other universal healthcare systems around the world. In general, inpatient care is provided by public hospitals and outpatient care is provided by a mix of public and private clinics and hospitals.

Private Health Insurance

Those citizens or residents that have an income over a threshold value of €66,000 per annum can join up with a private German health insurance company and opt out of public health insurance.

A private health insurance policy can be an advantage for those people who are young, healthy and high earners. It may be a more cost-effective option because you can choose a policy to fit your needs.

Policies get more expensive as you get older and health risks increase. Certain companies may either refuse to cover any pre-existing health conditions whilst others may increase their premiums accordingly to cover those pre-existing conditions.

The only way to get back onto the public health insurance system once you’ve opted out is if your income drops below the threshold value of €66,000.

All Austrians are covered by public health insurance

Austria has a very similar public health insurance system in place as Germany. It is very comprehensive and covers most residents and citizens. Healthcare services are very accessible and vulnerable groups are protected by various exemptions.

All residents are automatically enrolled in the public health insurance system. Contributions towards the fund are income-related and people with no or low income have free access to healthcare. Employees’ contributions are deducted directly from salaries and employers match the contribution. Healthcare is also free for those who are retired, studying, disabled or who earn below a threshold amount.

The Austrian healthcare system is a single-payer system, in which the government is the sole payer for healthcare services. In 2019, the Austrian government spent 10.43% of its GDP on healthcare.

The federal government regulates the Social Health Insurance (SHI) which is responsible for outpatient medical care and medicines whilst the individual states are responsible for financing and organisation of hospital care.

Healthcare funding is derived from general taxes and mandatory income-based contributions, approximately 40% and 60% respectively.

Patients have relatively unrestricted access to GPs and hospitals, including specialists. They can choose where to have treatment– including both SHI-contracted doctors and non-contracted doctors.

Private healthcare is available to those who can afford it and this has the perks of zero waiting times, greater choice of healthcare provider, etc. However, the quality of the care does not differ between the two and most people who have private healthcare use it to supplement their public insurance.

Private health insurance providers are regulated by the Financial Market Authority. 

Compulsory private health insurance in Switzerland

The current Swiss universal healthcare system is relatively in its infancy comparatively, as it was only established in 1994 when the federal government promulgated the Health Insurance Law. The law went into effect in 1996. 

The Swiss healthcare system is a mixed system, in which the government provides universal healthcare coverage, but individuals are free to purchase private health insurance if they wish. The government subsidises health insurance premiums for low-income individuals and families.

It is decentralised. Each state or canton responsible is responsible for the regulation and organisation of its healthcare system. Every one of the 26 cantons has its own constitution and contracts with healthcare providers. Every canton has an elected minister of public health and they collectively form the Swiss Conference of Cantonal Health Ministers, which is influential in policy-making.

The federal government is responsible for the safety and quality of medicines, promoting research and training and regulating public health initiatives. The cantons are responsible for aspects like licensing providers, hospital services, disease prevention by promoting health, and subsidising healthcare institutions. Municipalities are part of each canton and they are responsible for social support services, like long-term care.

Funding for the Swiss universal healthcare system is primarily from three sources:

1. compulsory contributions;
2. general taxes from cantonal, municipal and federal sources and
3. other social insurance schemes. 

Compulsory health insurance is provided by competing non-profit insurers who are regulated by the Federal Office of Public Health.

Healthcare insurance in Switzerland is not sponsored by employers. Citizens are required to purchase insurance which is enforced within each canton. The insurance policy usually covers only the individual and additional cover must be bought for dependents. Premiums differ accordingly and can range from CHF 4,248 (USD 3,511) to CHF 7,102 per annum. The premiums paid by individuals are pooled into a central fund and then adjusted and redistributed to the various cantons accordingly. 

All new arrivals to Switzerland must purchase health insurance within 3 months and the policy will be effective retroactively from the date of arrival.

There are complex healthcare coverage options available. Policies are divided into three age groups: those below 18 years, young adults between 19 and 25 years, and those over 26 years of age. Each has varying deductible levels.

Additionally, coverage models differ based on which healthcare providers are available to them, call-centre models where patients have access to a consultation hotline before seeing a doctor, accident coverage, etc.

Patients usually pay a 10% co-payment for most services, with exceptions for maternity and some other preventative services, like mammograms and certain cancer screenings.
This co-payment is capped at CHF 700 (USD 579) per annum for adults and CHF 350 (USD 289) for children below the age of 18. There is a higher co-payment for brand-name pharmaceuticals if there are cheaper generic alternatives available.

Additional private insurance is usually purchased to cover excluded services, provide a wider choice of healthcare providers or have access to better hospital accommodations.

Summary

Main similarities

• All three countries have universal healthcare coverage.
• All three countries have a mix of public and private healthcare providers.
• Patients in all three countries have a choice of healthcare providers.
• Outpatient care is provided by a mix of public and private clinics and hospitals.
• Inpatient care is provided by public hospitals.

Main differences

• The German and Austrian healthcare systems are both a social insurance system where residents must have statutory health insurance coverage through contributions. Switzerland, on the other hand, has a mandatory private health insurance system, where individuals are required to purchase basic health insurance from private insurers.
• The German government subsidises health insurance premiums for low-income individuals and families, while the Austrian and Swiss governments do not.
• Healthcare providers in Germany are paid on a fee-for-service basis, while healthcare providers in Austria and Switzerland are paid on a negotiated fee schedule.
• In Germany and Austria, patients typically pay a percentage of healthcare costs out-of-pocket, known as co-payments or co-insurance. In Switzerland, individuals have annual deductibles and coinsurance, which vary depending on the chosen insurance plan.

Overall, the healthcare systems in the DACH region are all high-quality and accessible. However, there are some key differences between the three systems, such as the way in which healthcare is financed and the way in which healthcare providers are paid.

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