German health care: a bit of Bismarck plus more science.

losses from restructuring and amalgama‐ tions. There were negotiations for legislative amendments right to the final hours of par‐ liamentary debate. It is not the insurance system itself that is so heavily contested. Germans definitely want their social health protection to con‐ tinue, and with good reason. Comparative analysis has suggested that statutory health insurance systems such as those in Germany, France, and the Netherlands produce better responsiveness, equity, and life expectancy than taxation based systems, although at greater cost.3 4 In Germany, most decisions about health policy and many key reimburse‐ ment decisions are made by the federal joint committee, which represents the providers (particularly doctors and hospitals), statutory insurers, and recently patients.5 The ministry of health has only a legal oversight function. This keeps health policy in the hands of the health system rather than government, although the dispersal of power among competing stakeholders ensures constant dynamic negotiation. The Institute for Qual‐ ity and Efficiency in Health Care (IQWiG), established in 2004, provides evidence assess‐ ments to support decisions (box). Table 1 | Access to health care reported by sicker patients in three countries, 20057