Dr Gertrud Demmler of SBK, one of Germany's largest statutory health insurance funds, describe the EUR 18 billion funding gap facing the country's health system, what the July 2026 GKV Contribution Rate Stabilisation Act does and doesn't fix, why consolidation among health insurance funds is set to continue, and the case for outcome-based rather than input-based reimbursement. She also addresses tensions with the pharmaceutical industry over the recent savings reform, and argues that financial stability is a precondition for, not an alternative to, deeper structural reform of German healthcare.
Statutory health insurance covers around 90 percent of the population in Germany and is widely regarded internationally as a model for comprehensive healthcare coverage. At the same time, the system is currently under considerable financial pressure. What are the main causes of this development, and what impact could it have on the quality of care in the coming years?
It’s not a lack of money. By international comparison, Germany deploys disproportionately large resources while simultaneously underperforming on key quality indicators. It’s equally true that Germany has so far offered a breadth of access to healthcare that is internationally unique — both access to care itself and fast, comprehensive access to innovative medicines. However, it has also become a reality that in Germany it can be difficult to get a doctor’s appointment or to receive the right care.
Healthcare spending has been rising unchecked for years, largely due to regulatory interventions in pricing and reimbursement. We also have a care system in which it is often pure chance whether a patient receives the appropriate therapy. People are not infrequently forced to see several doctors before finding the right care. This is an important reason why Germany is among the countries worldwide with the highest number of doctor visits per capita — because that costs money without benefiting the quality of care.
If we don’t take countermeasures now, two things threaten to happen at once: contributions will keep rising, and care still won’t improve, because we’re treating symptoms instead of causes. Financial stabilisation is not an end in itself — it’s the precondition for having the time at all for genuine structural reforms, such as a primary care system.
The GKV-Spitzenverband [National Association of Statutory Health Insurance Funds] puts the funding gap for 2027 at around 18 billion euros. According to federal government projections, this could grow to roughly 44 billion euros by 2030 without reforms. To what extent does the GKV Contribution Rate Stabilization Act, passed in July 2026, contribute to sustainably managing this challenge — and what further steps would be needed should the funding gap continue to grow?
The need for action was undeniable, so I welcome the fact that the law realigns spending growth more closely with revenue trends. That’s fundamentally the right approach. Broad access to healthcare and an economically sustainable contribution burden are the twin foundations of Germany’s social health insurance system. You can’t have one without the other.
On closer inspection, however, the so-called “Stabilisation Act” is above all a shifting of the funding burden onto insured members. This happens through a number of individual levers that place significant burdens on particular groups of contributors: a substantially rising contribution assessment ceiling, new surcharges, higher co-payments. At the same time, the federal government is cutting its own subsidy — which is meant to cover, among other things, non-insurance-related benefits such as contributions for citizens receiving Bürgergeld [basic income support] — by two billion euros annually. Statutory health insurance is a contribution-funded organisation that manages and is responsible for its own resources. The federal subsidy has remained unchanged since 2017, and its share of the system’s total expenditure has fallen from 6.4 to 3.9 percent since then. The federal government and the federal states must fully fund the tasks they hand over to the system, rather than quietly offloading them onto contributors.
Above all, we need the political will to put a definitive end to this structural cost-shifting between the federal government, the states, and social insurance, rather than repeatedly repackaging it through new instruments. Financial stabilisation is the precondition for reform, not an alternative to it. Only this way do we gain the time needed for the necessary structural reforms: a reorganised emergency care system, a genuine primary care system, and needs-based hospital planning.
Over the course of its history, SBK has grown through several mergers, most recently merging with BKK Voralb at the start of 2026. What strategic considerations lie behind this path, and how do you expect the German health insurance fund landscape to develop over the coming decade?
SBK and BKK Voralb — both company health insurance funds (Betriebskrankenkassen) with a close corporate connection — share the same self-understanding. The merger was based on the conviction that insured members and employers benefit from a stronger yet still close-by partner. Closeness to companies and customers is preserved.
A question that comes up frequently at the moment is: should health insurance funds simply be merged to save costs? But that maths doesn’t work out. By law, 95 percent of statutory health insurance spending flows directly into the care of insured members. Fewer funds won’t change that. And even of the roughly five percent that is administrative costs, 70 percent goes directly toward advising and supporting insured members. Austria’s move to a single unified fund clearly shows that the hoped-for savings failed to materialise — quite the opposite, it actually led to additional costs.
With less diversity among funds, we would lose closeness to insured members and employers, freedom of choice, competition for the best service and cost structure, the regional engagement of smaller funds, and the innovative drive that comes from that competition.
Regardless of the debate over the number of health insurance funds, we’ve been seeing consolidation and a marked decline in the number of funds for decades. For the coming ten years, I expect market consolidation to continue. This is driven by fundamental trends such as technological development and an ageing society. That’s already happening entirely on its own, without any political mandate.
You have publicly advocated for embedding transparency as a precondition for higher quality in the German healthcare system. What should such transparency look like in practice, and in which areas is the need to catch up currently greatest?
Even in the 21st century, the German healthcare system lacks transparency about the real state of care. Germany is excellently positioned when it comes to evidence orientation, but there is no systematic reconciliation with actual care delivery. That also explains the enormous deployment of resources alongside below-average quality.
Furthermore, steering and reimbursement in the German healthcare system are oriented around input, not outcome: more treatment means more money. That logic is wrong and increasingly unaffordable. What matters is not how much treatment is delivered, but how successful that treatment is.
We need same-day transparency for contracting partners and those responsible for care, along with a stronger orientation toward impact and outcomes in reimbursement. This includes consistently involving patients and patient experience. Only this way can we achieve a genuine quality orientation and build a learning system.
As a board member of one of Germany’s leading statutory health insurance funds: How do you assess the relationship between health insurance funds and the pharmaceutical industry — and where, beyond the classic cost and price negotiations, do you see room for stronger collaboration?
To stay with the current financial topic: I observe with concern the vehemence with which certain actors, including from the pharmaceutical industry, are currently pushing back against the recent savings reform — in some cases even with threats to exit the market — in order to protect their own vested interests. I consider that the wrong approach. Anyone who praises the value of broad access on the one hand must also acknowledge, on the other, that we need to keep economic sustainability in view, so as not to risk placing an unreasonable economic burden on the community of insured members. The globally driven focus on drug prices doesn’t do this issue justice. Reordering healthcare and working together in a spirit of trust requires genuine willingness to cooperate from all parties involved. We must not place our own economic interests above the shared responsibility for a solidarity-based healthcare system. Only then can long-term, sustainable healthcare financing also be secured in the interest of the pharmaceutical industry.
