Potsdam Declaration by the German Statutory Health Insurance Funds on the occasion of the joint conference of the Umbrella Organisations of the Statutory Health Insurance Funds and the German Federal Ministry of Health held on 15/16 January 2007 "The social dimension in the Internal Market Outlook for the future of healthcare in Europe" AOK-Bundesverband, Bonn The Federal Association of Local Health Insurance Funds BKK Bundesverband, Essen The Federal Association of Company Health Insurance Funds IKK-Bundesverband, Bergisch Gladbach The Federal Association of Guild Health Insurance Funds See-Krankenkasse, Hamburg The Maritime Health Insurance Fund Bundesverband der landwirtschaftlichen Krankenkassen, Kassel The Federal Association of Agricultural Health Insurance Funds Knappschaft, Bochum The Insurance Fund for Miners Verband der Angestellten-Krankenkassen e. V., Siegburg Federation of Salaried Employees Health Insurance Funds AEV - Arbeiter-Ersatzkassen-Verband e. V., Siegburg The Federation of Employees Alternative Health Insurance Funds
Statutory health insurance an indispensable building block of a national economy Health policy aims to keep citizens in good health, to improve and, should they fall ill, to restore their health. Access to possibilities for maintaining or restoring health must be available to each citizen regardless of their social status, their financial situation and where they live. This requires a comprehensive system of health security to which all citizens have effective and barrier-free access. Europe is host to differently-structured social security systems which exist in parallel. The traditional, historical structures of the individual national health systems are closely aligned to the respective social and fiscal systems, and to citizens specific preferences and needs. Germany has a tried and tested, efficient, internationally-recognised system of health security which has hitherto been marked by a self-administered organisation that is responsive to the needs of the insured. The umbrella organisations of the statutory health insurance funds in Germany (GKV), as the oldest branch of social insurance, have a relevant, decisive part to play in the development of this high-performance healthcare system in which almost one out of every ten employed persons in Germany is engaged. It guarantees more than 70 million insured persons affordable, comprehensive protection should they fall ill. From screening new-borns to organ transplantation, the insured have access to all medically-necessary care that is in keeping with the recognised medical and technological state-of-the-art. Here, the funding system, based as it is on solidarity, guarantees that each member is only burdened according to their financial capacity largely measured by their work earnings regardless of any past personal illnesses or health risks, which, in private health insurance, would lead to supplementary payments being imposed in addition to the basic contribution rate. With annual benefit expenditure of more than Euro 130 billion, statutory health insurance bears the lion s share of total expenditure in the healthcare system, and hence is a major economic and growth factor for the national economy. Statutory health insurance is also a stability factor in terms of the labour market and of employment, given that a major part of the expenditure flows into labour-intensive, promising service sectors within the healthcare system. Social protection creates the confidence and security which are needed to face the challenges inherent to modern societies of flexibility and a readiness to take risks. The more varied, mobile and individualised a society is, and the greater the division of labour, the greater the importance attaching to insurance against major hazards such as illness, the need for long-term care, unemployment and occupational diseases, as well as to ensuring an income in old age. In this sense, social security itself is a production factor which will continue to grow in significance. Productivity and modernisation of society therefore require stable social security systems, and hence stable statutory health insurance.
The challenge of the Internal Market The growing together of Europe within the framework of the European Union is a success story which has provided the citizens of all Member States with peace, increased prosperity and greater freedom. Embedded in the general globalisation process, European integration not only makes people more mobile, be it in their capacity as private individuals, as workers or as serviceproviders, but it also increases the mobility of goods and services. The social security systems have had to and must continue to adjust to the changes this brings to the framework conditions. The necessary European legal framework was created by Regulation (EEC) No. 1408/71 (and its successor, Regulation (EC) No. 883/04) to provide citizens with social insurance and health security when in another Member State. With regard to the mobility of healthcare providers, this was achieved via mutual recognition of professional qualifications by virtue of Directive 2005/36/EC and its predecessors. This has made health an asset which is accessible Europewide in a mobile Europe, the provision of which in accordance with the principle of subsidiarity as enshrined in the EC Treaty continues to be responsive to citizens needs and subject to the sovereignty of the individual Member States. Many European actions in particular those of the EU Commission as well as the case-law of the European Court of Justice (ECJ), however, have a direct or indirect impact on the health and long-term care sector of the individual Member States. Here, it is an explicit goal of the statutory health insurance funds to use the opportunities of the Internal European Market to benefit insured parties who wish to also receive the necessary services abroad. The functionality and financeability of the healthcare systems in question may, however, not be jeopardised by the initiatives of the Commission and by the ECJ s case-law either in the providers or patients countries of origin or in the country in which the benefits are claimed. In accordance with the EC Treaty, health policy is, by and large, the sole preserve and responsibility of the Member States. This makes economic, political and cultural sense, and should be inviolable. It guarantees responsiveness to citizens needs, functionality, quality of supply and affordability in keeping with the intentions of the community of insured parties who fund it. It is therefore desirable in the EU to reaffirm the consistently high status of social security in subsidiary administration. At the same time, importance continues to attach to voluntary cooperation and networking between the Member States. It might be helpful in the quest for solutions and against the background of shared, current problems and future challenges facing the healthcare systems in the Member States to take a look over the fence and glean from our neighbours respective strengths and weaknesses likely paths to improving our own systems. If the Member States practice a health policy in line with best practice, this can contribute, in the medium term, to greater coordination of health policy. The statutory health insurance funds concur with the European Commission that there is a need here to harmonise general access to, and the high quality and long-term financeability of, medical services. Among the tools of cooperation which are basically suitable in this case, European comparisons in the framework of the Open Method of Coordination, trans-national cooperation at Euregio level, and other voluntary cooperation agreements should be mentioned. These approaches facilitate a modernisation of the healthcare systems in Europe in a manner which is democratically legitimised, unbureaucratic and aligned to the problems which we face.
What the German statutory health insurance wants of Europe: 1. Promotion of cohesion in Europe by amplifying the social dimension: We must do our utmost to tie the supranational economic and investment area of the EU with a more patent social-economic perspective for citizens than has been the case heretofore. As a consequence, in the interest of improved cohesion within the EU, the Lisbon Strategy also urgently needs to be flanked by a strong social policy. In this process, the Member States in question must remain the decision-making level subject to voter scrutiny in the shaping of future social policy in the healthcare sector. By no means may the principle of subsidiarity be circumvented and undermined by Internal Market legislation. This is the only way in which those Member States with a strong leaning towards the social welfare state can ensure a high level of social protection in the context of intense Internal Market competition. 2. Support of sustainable reform strategies in the Member States by applying international experience: Healthcare reforms are carried out regularly in many EU Member States. In structuring these reforms, the political players can learn from the experience of the other Member States. European exchange of experience at the different political and institutional levels should hence be continued and intensified. However, since major structural elements of the healthcare systems are differently structured at national level, reform strategies can only be successful if national peculiarities are taken into account. National sovereignty in the organisation of healthcare systems and the validity of the principle of subsidiarity are already derived from the fact that funding comes from the national solidarity-based community and from taxpayers. Within this framework, the statutory health insurance funds are calling for consistent reform strategies which are capable of securing, sustainably and in the long term, the European healthcare systems ability to perform under the conditions of a fast-changing labour market, of massive demographic change and ongoing medical and technological progress. 3. Securing the mobility of Europe s citizens and creating transparency: Europe and its citizens need transparency also when it comes to cross-border healthcare provision. The necessary European framework has been created in the shape of Regulation (EEC) No. 1408/71 (and its successor, Regulation (EC) No. 883/04). In order to enable citizens to make optimum use of their rights to healthcare in Europe, they need simple, universally-accessible information as to the possibilities and conditions of the cross-border claiming of benefits. European initiatives have already been taken to this end, and the statutory health insurance funds are also making their contribution on behalf of the insured. With its case-law on patient mobility on the basis of the reimbursement procedure, the ECJ has increased cross-border accessibility to medical services for all citizens of the EU in formal terms. This was already transposed into national law in Germany as of 1 January 2004 in the course of the Statutory Health Insurance Modernisation Act (GKV-Modernisierungsgesetz). At the same time, Parliament created the possibility for the statutory health insurance funds to conclude contracts directly with service-providers in other EEA countries. The statutory health insurance funds support the call for the adoption of the rights created by the ECJ by all Member States where this has yet to take place. The statutory health insurance funds however consider that the cross-border cost reimbursement right
established by the ECJ can, in practice, only supplement the existing procedure under Regulation (EEC) No. 1408/71, but cannot provide an equivalent alternative. All in all, there is no need to create further sources of law in addition to national law and Regulation (EEC) No. 1408/71. Unanswered questions on patient mobility can be solved within this existing set of rules. 4. Strengthening of subsidiarity and cooperation: Healthcare structures which are highly responsive to citizens needs are indispensable for citizens acceptance of care. The goal may not be a European super state, but the networking of national cultural and social areas. There is no need for new European regulations in the healthcare sector for this to be achieved. Existing regulations also ensure cross-border uptake of benefits. Cooperation schemes are helpful, such as the Euregios, and diverse other supra-regional cooperation mechanisms which are very well taken care of by existing EU law. Only subsidiary policy-making competence, supplemented by networking and cooperation among the Member States, can maintain responsiveness to citizens needs and transparency while simultaneously making use of all the advantages proffered by the large economic and social area constituted by Europe.