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ARI SHAPIRO, host:

This is MORNING EDITION from NPR News. I'm Ari Shapiro in for Steve Inskeep.

RENEE MONTAGNE, host:

And I'm Renee Montagne. Today in Your Health, we begin a series on how five European countries manage to provide health care to nearly all of their citizens. Americans often think European health care means high taxes, long waiting lines, and rationed care. But in Germany very little of the tax money goes into the health system and it's one of the best systems in the world. NPR's Richard Knox visited Germany to find out if people there think they're getting good value for their money.

And just start us off with what you found.

RICHARD KNOX: Well, Renee, when I first arrived there I visited an old friend. Juergen in der Schmitten was a medical student when I first met him 17 years ago. And now he's a general practitioner. And we were sitting around after dinner doing an interview - it was about 11:00 o'clock - and Juergen got a call on his cell phone.

Dr. JUERGEN IN DER SCHMITTEN: (Speaking German)

KNOX: Juergen was on call and this was a woman who had a fever, and she wanted Juergen to make a house call. They talked for maybe five minutes, and in the end she agreed to come into the office the next morning. And I was sitting there thinking this was just a conversation that would never happen in America.

MONTAGNE: Yeah. It's hard to imagine - not that you would just get through to the doctor but at his house and at that late hour.

KNOX: Exactly. And if you did you certainly wouldn't have a long talk with him about whether he should come out to your house to treat the flu in the middle of the night.

So I decided to visit some German patients to see what they think about the German system. The first family I went to see was the Casagrandes - Sabina and Jan and their two little girls. They live in Cologne in western Germany, four flights up in a big old apartment with high ceilings.

Ms. SABINA CASAGRANDES: Hi, Sabina Casagrandes.

KNOX: Nice to meet you.

Ms. CASAGRANDES: Come in.

KNOX: Sabina is American, Jan is German. They say they've had really good care in the German health system. And they've used it a lot.

Ms. CASAGRANDES: I've probably been very expensive for the health insurance system here. When I was 33 years old I had a giant lump on my neck all of a sudden, where your thyroid is. And it was a big tumor.

KNOX: It took two operations to remove her cancer. Luckily it was curable with surgery, and Sabina says she had the best treatment she could imagine.

Ms. CASAGRANDES: Then I came home to my little daughter, who I couldn't really lift up even. And so I asked my doctor, What can I do? And she said, Well, your health insurance will pay for someone to come help you in the house.

KNOX: Her health insurance paid a friend to shop and cook and even help care for the baby until Sabina was back on her feet. The health care system that took such good care of Sabina isn't funded by government taxes. It's paid for by workers and employers. Germans pay about 8 percent of their salaries to a nonprofit insurance company of their choice, and their employers pay about the same amount.

It's roughly the same percentage for everybody. The less people make, the less they have to pay. The more they make, the more they pay. Germans call it solidarity. The idea is that everybody's in it together and nobody should be without health insurance.

Ms. CASAGRANDES: If I don't make a lot of money, I don't have to pay a lot of money for health insurance, but I have the same access to health care that someone who makes more money has.

KNOX: She does say that nearly 8 percent of her salary is a lot.

Ms. CASAGRANDES: Yes, it's expensive. You know, it's a good chunk of your monthly income. But considering what you can get for it, it's worth it.

KNOX: For instance, it covers an expensive medicine that Jan needs for a chronic intestinal problem. He says if they moved to America, they might not be able to buy insurance at all because of their pre-existing conditions.

Mr. JAN CASAGRANDES: (Speaking German)

Ms. CASAGRANDES: He says for him - or for us - the health care system in the United States is the major reason why we have never moved there and never will move there. Because both of us have chronic illnesses that have to have a lot of medical attention, and we would go broke.

Mr. CASAGRANDES: (Speaking German)

Ms. CASAGRANDES: It's also the number one reason in the United States that people personally go bankrupt, because of health care costs, which would never happen here, never.

KNOX: I met another couple who know both the American and German systems. They live on the other side of Germany, in Berlin. They own a children's shoe store in a well-off area of the city. Nicole and Chris Ertl sell high-quality European shoes - tiny Italian sandals, French and Danish boots in wonderful colors.

Chris is from San Diego. His wife Nicole is German. She also works part time as a physician therapist and so she gets her health care through her job. And like the Casagrandes, she's happy with her coverage.

Ms. NINA ERTL: It's a good deal. It's really good because it's a package.

KNOX: She pays a premium of $270 a month for insurance that covers her children too. Nicole pays a single $15 co-payment once every three months to see her primary care doctor and another $15 a quarter to see each specialist as often as she wants. The kids don't have any co-payments at all, and insurance even covers her daughter's orthodontia bill.

Ms. ERTL: They have good care, because the kids have everything free. The drugs or something, it's always free.

KNOX: Until they're how old?

Ms. ERTL: I think 18.

KNOX: But even though her insurance covers the kids, it doesn't cover her husband. Because Chris is self-employed, he has to buy insurance on his own, from a for-profit insurance company.

About one in 10 Germans buys this so-called private coverage. It's not just for people who are self-employed. Anybody who makes more than $72,000 a year can opt out of the main system. It's kind of a safety valve for people who want more and can pay for it. But most people don't opt out. Chris says that's because there's a fundamental difference in the way Germans view the government's role in health care.

Mr. CHRIS ERTL: The general opinion in Germany is always that the government will do it for us. And in the States, I think you grow up knowing that no one's going to help you do anything. If you want health care, go get it.

KNOX: The German government doesn't provide health care or finance it directly. It regulates the insurance companies closely - the nonprofits in the main system and the for-profits where Chris gets his coverage. So Chris's insurer can't raise his rates if he gets sick or jack up his premiums too much as he gets older. And the government also requires insurers to keep costs down so things don't get too expensive.

Mr. ERTL: Where am I better off medically? I would probably say Germany.

KNOX: In some ways, Chris Ertl's coverage is better than his wife's. He gets his choice of top doctors - the chief of medicine, if he wants. If he goes to the hospital, he gets a private room. When he goes to the doctor, he gets a free cup of coffee and goes to the head of the line. All this annoys Nicole.

Ms. ERTL: So when he goes to the doctor, he has a lot more service.

KNOX: Germans really hate any hint of unfairness in health care. The fundamental idea is that everybody must be covered and everybody should get equal treatment. And that's why it's unthinkable that 48 million people wouldn't have health insurance - the situation in America. As an American, Chris Ertl thinks that's shameful.

Mr. ERTL: It's terrible. It's unbelievable. It shouldn't happen.

KNOX: Germans, he says, would never tolerate that. And their system has been working for 125 years.

MONTAGNE: Now, I'm just hearing you, Dick, to say that this system has been around for - I think I heard you right - 125 years?

KNOX: Yeah, remarkably, it has. And in fact it even dates back further, to the craft guilds of the Middle Ages. And when Germany became a nation in the 1880s, one of the first big things that the government did was to unite all of these what they call sickness funds into one system. So the Germans have lived with it for a long time and that's one reason that this feeling of solidarity runs so deep.

MONTAGNE: And over that time, how have they made it better so that it seems to be working so well now?

KNOX: Well, I think one of their secrets is they're always tinkering with it, partly to respond to feelings like Nicole's. When things begin to go off track they have a fix and they do a reform every three years or so. And they also have done that to keep costs pretty much under control. And costs are, like everywhere else, a big issue in Germany.

And there's a lot of pressure, and the population is aging even faster than ours. So for instance, 13 years ago they enacted a long term care insurance system, which is something, you know, we've yet to do.

People agree, Germans are going to have to pay more for health care in the future, but the striking thing to a visiting American is that this system is really fundamentally sound.

MONTAGNE: NPR's Richard Knox. Thanks very much.

KNOX: You're welcome.

(Soundbite of music)

MONTAGNE: Compare average medical bills from American with those from Europe. You can do that at an interactive graph at npr.org/health.

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