Immigrant Care in Germany

About one in five Germans is an immigrant, according to census data from the German Federal Statistics Department.  In fact, Germany is the second most popular migration destination in the world, after the United States. I would argue that this is one of the reasons that Germany is the most dominant economy in Europe. 

Here in St. Louis, the Mosaic Project collected data which show a compelling link between the percentage of foreign-born people in a given region and that region’s economic vitality. There is every reason to believe that the same phenomenon applies in Germany.  In fact, when it comes to healthcare, immigrants may be net financial contributors of health services if they pay proportionately more in taxes, as well as provide the otherwise scarce labor to staff health services. Data show that around 12% of all health service workers in Germany are immigrants.  Also, there is evidence that new immigrants to a country are typically healthier than the native-born population, thereby creating a “health dividend” for the receiving country (increase in labor supply that uses healthcare resources less and stays on the job more).

Of course, any such benefits can wane over time if, as often happens, immigrant populations start taking on the unhealthy habits of the native-born population and if the immigrants are denied access to care.  Germany has moved to avoid falling into this cycle by allowing undocumented immigrants to gain access to affordable care in case of acute illness and pain, as well as pregnancy and childbirth. The country also provides health insurance to any legally registered immigrant. 

Still, the risk of accidents at work among adults is twice as high for migrants than the native-born, and working conditions that threaten health are experienced disproportionately by semi-skilled and unskilled workers. These types of workers are over-represented among all migrant sub-groups.  Also, industrial accidents have tended to be higher among migrants working with poor safety measures.

Questions of interest for me while in Germany will include how the country finances care for, as Germans term them, “irregular” members of the society and what factors led to the political will to be able to provide the care. Also, how well have immigrants been integrated into the overall system?  Are there cultural competency issues?   Are there issues endemic primarily to immigrant populations that remain vexing? 

All of these are compelling questions for us in the U.S. The ability to care for people with market-based solutions and, perhaps more-so, the overcoming of ideological objections, are the largest obstacles to long-term healthcare reform (of which the ACA, I believe, is only a first step). Is there something from the German experience that might be instructive?  The Germans are also having to deal with cultural differences, for example treating a Turkish - mostly Muslim - population. How are they dealing with the issue of providing culturally competent care, something that is challenging for us in America? 

What questions would you, the reader, want answered?

Germany's Federal Joint Committee

Over the next few weeks leading up to my departure for Germany, I’ll be discussing the topics I plan on exploring, along with some brief background on each one.  My purpose is to solidify my own thoughts on these issues and, perhaps, draw some insights from people who visit this blog.

In Germany, the various levels of government have virtually no role in the direct delivery of health care. A large degree of regulation is delegated to self-governing associations and provider associations. The most important body is the Federal Joint Committee, created in 2004 as a public health organization authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine decisions regarding healthcare.  The Committee has wide-ranging regulatory power to determine the services to be covered by sickness (insurance) funds and to set quality measures for providers. To the extent possible, their coverage decisions are based on evidence from health technology assessments and comparative-effectiveness reviews.  The Committee is composed of physicians, psychotherapists, dentists, pharmacists, hospitals, sickness funds and patients (although patients do not have a right to vote).

I will hopefully be meeting with members of the Committee and/or their staff when I visit Berlin, which will give me an opportunity to learn much more.  What I like at first blush is the German emphasis on making decisions about healthcare based on evidence and results rather than political expedience and ideology.  That’s not to say that there aren’t politics involved; certainly there are, and I plan to speak with politicians across the political spectrum to better ascertain how government interacts with the healthcare system.  But the evidence I see from my research is that the German system, much more than ours in the United States, is focused on making public health and access to care a national priority. The first question in the U.S. over any healthcare initiative is often whether or not conservatives will see it as government overreach or whether liberals will see it as ignoring vulnerable classes. In Germany , the first questions seems to be whether the initiative will achieve a desired public health outcome that is measurable.  The Committee appears to be a valuable structure for this framing by putting daylight between the politicians and the healthcare professionals. Of course, it is possible that these professionals will have their judgments clouded by some of the same factors that influence legislators, which would make the system much less innovative than it could otherwise be.  This is something I look forward to examining.

Preparing for the Eisenhower Experience

Starting April 26, I will formally begin my Eisenhower Fellowship by traveling to Germany (click here for an overview of the philosophy of Eisenhower Fellowships and information about the program).   I hope to learn a great deal about the German universal health system and what aspects of their experience might be applicable here, particularly within the St. Louis region. And I look forward to learning about the delivery of rural healthcare in Mexico, as well as exploring the issue of immigration from the Mexican point of view, when I visit that country in July.

I have established five goals for my Fellowship:

* Improve my capacity to run Casa de Salud to the best of my ability

* Refocus the conversation around immigration with the purpose of helping achieve the goals of the St. Louis Mosaic Project and city/county efforts to be foreign-born friendly

* Stimulate ideas around public health that could be promulgated to the City of St. Louis Board of Health (on which I serve) and incorporated by the city's health department to improve the agency’s ability to serve

* Generate concepts around Medicaid expansion/transformation that could be conveyed to key legislators and stakeholders for their consideration in the effort to find an acceptable expansion model

* Provoke thought regarding improvements to the delivery and cost of care at the local and state levels that could provide models for the further development of the Affordable Care Act

My hope is that some of you will interact with me through this blog and through Twitter (@riopedre) so that I may take your input into account as I prepare for the Fellowship and when I speak with healthcare professionals and other stakeholders in both countries.

I thank my Program Officer, Jason Riley, for his on-going help and Sabine Ganter-Richter for serving as my Program Coordinator in Germany.