Table 3 Health care reforms since 1988. (Sources: Carrera et al. (2008); ASISP (2012))
Year enacted | Reform | Parties in government | Government majority in Bundesrat? | Consent Bundesrat required? | Both SPD & CDU/CSU support reform? | Reform content |
|---|---|---|---|---|---|---|
1988 | Health Care Reform Law (Gesundheitsreformgesetz) | CDU/CSU & FDP | Yes | Yes | No | Introduction/increase of co-payments for medical supplies, drugs, dental care, and inpatient care |
Fewer insured drugs | ||||||
1992 | Health Care Structure Reform Act (Gesundheitsstrukturgesetz) | CDU/CSU & FDP | No | Yes | Yes | Higher co-payments and user fees |
Mixed-payment system | ||||||
Budget cap for doctors | ||||||
Supply of doctors limited | ||||||
Reference pricing | ||||||
1996 | Health Insurance Contribution Exoneration Act (Beitragsentlastungsgesetz) | CDU/CSU & FDP | No | Yes | SPD states in Bundesrat agree to law | Co-payments for prescriptions |
Modest fee for initial ambulatory treatment | ||||||
Higher co-payment for inpatient care | ||||||
Lower benefits for spa treatment | ||||||
Over-the-counter medications no longer insured | ||||||
1997 | Second SHI Restructuring Act (2. GKV-Neuordnungsgesetz) | CDU/CSU & FDP | No | No | No | Budget caps for doctors & dentists |
Morbidity-based compensation for ambulatory doctors | ||||||
1998 | Act to Strengthen Solidarity in SHI (GKV-Solidaritätsstärkungsgesetz) | SDP & Greens | Yes | Yes | No | Softening of impact of higher co-payments |
Additional reference pricing for medicines | ||||||
Mandatory price cuts for medicines | ||||||
Rebate sysmtem for drug manufacturers and wholesalers | ||||||
1999 | SHI Reform Act (GKV-Reform 2000) | SPD & Greens | No | No | No | Diagnosis related group (DRG) payment |
Risk structure compensation | ||||||
2001 | Reference Price Adjustment Act (Festbetragsanpassungsgesetz) | SPD & Greens | No | Yes | Some CDU states in Bundesrat support legislation | Shift to reference pricing |
Ministerial control of medical pricing | ||||||
2001 | Pharmaceutical Budget Abolition Act (Arzneimittelbudget-Ablösungsgesetz) | SPD & Greens | No | Yes | Some CDU states in Bundesrat support legislation | Additional budget caps for doctors |
2002 | Pharmaceutical Expenditure Limitation Act (Arzneimittelausgaben-Begrenzungsgesetz) | SPD & Greens | No | Yes | Some CDU states in Bundesrat support legislation | Physicians’ budget cap |
Mandatory use of generic drugs | ||||||
2002 | Case Fees Act (Festbetrags-Anpassungsgesetz) | SPD & Greens | No | Yes | Some CDU states in Bundesrat support legislation | DRG payments |
2002 | Contribution Rate Stabilization Act (Beitragssatzsicherungsgesetz) | SPD & Greens | No | No | No | Reference pricing |
2002 | DRG Law for Hospitals (Gesetz zur Einführung des diagnose-orientierten Fallpauschalensystems für Krankenhäuser) (Fallpauschalengesetz-FPG) | SPD & Greens | No | Yes | Some CDU states in Bundesrat support legislation | DRG Payment |
2003 | SHI Modernization Act (GKV-Modernisierungsgesetz) | SDP & Greens | No | Yes | CDU/CSU support at early stage | Co-payments and user fees |
Modest reduction in benefits | ||||||
Reference pricing | ||||||
Reimbursement of out-patient care in EU | ||||||
Risk-structure compensation | ||||||
Increase in use of health technology assessments | ||||||
2007 | Law to strengthen competition between SHIs (GKV-Wettbewerbsstärkungsgesetz GKV-WSG) | SDP & CDU/CSU | Yes | Yes | Yes | Pooling of SHI contributions in a central “Health Fund” (Gesundheitsfonds) |
Uniform contribution rates across SHI funds; supplementary premiums for funds with insufficient revenue from the central fund | ||||||
Insurance mandatory for all | ||||||
2010 | Law on the Change of the SHI (GKV-Änderungsgesetz GKV-ÄndG) | CDU/CSU & FDP | Yes | No | No | Obligatory discounts on drugs,and price freeze until 2013 |
Employer SHI contribution share frozen at 7.3 % | ||||||
2011 | Law on Financing the SHI (GKV-Finanzierungsgesetz GKV-FinG) | CDU/CSU & FDP | No | No | No | Contributions to SFs increased (from 14.9 to 15.4 % in 2011) |
Employers’ share of contributions frozen at 7.3 % of qualifying income | ||||||
Compensation for low-income households | ||||||
Modest reduction in cost indexation for hospitals | ||||||
2011 | Law on the Re-organisation of the Market for Pharmaceuticals (Gesetz zur Neuordnung des Arzneimittelmarktes AMNOG) | CDU/CSU & FDP | No | No | No | Modified reference pricing for new drugs |
2012 | Law on Health Care Structure (GKV-Versorgungsstrukturgesetz GKV-VStG) | CDU/CSU & FDP | No | No | No | Adjustment in policies affecting supply of doctors |
Increase in ways that SFs can differentiate their services |