The statutory health insurance system was established with the Health Insurance Act (Krankenversicherungsgesetz) of 1883. Chancellor Otto von Bismarck had created a welfare state based on solidarity as part of a political response to the emerging workers’ movement.
The implementation of comprehensive health coverage for workers removed the fertile ground for discontent for the social democrats and the labour unions and supported Bismarck’s idea of German unification, as already pronounced in the Royal Proclamation of Emperor Wilhelm I in 1881 (appendix p 1).
Although often portrayed as the originator of statutory health insurance, Bismarck built on traditions and preexisting structures, particularly with regard to the five types of solidarity-based relief funds (for journeymen, craftsmen, factory workers, workers or tradespeople, and community funds), which can partly be traced back to the Middle Ages.
1 Innumerable reforms took place until and after the German reunification in 1990; however, from a historical perspective, the statutory health insurance system is characterised by a high degree of structural continuity.7 The 1883 law defined the founding principles of today’s statutory health insurance.
First, according to the principle of solidarity, the size of the insurance contributions is based on the ability to pay; in turn, the insured individual is entitled to benefits according to need. Second, statutory health insurance is compulsory insurance in which employers take part in the financing. Finally, statutory health insurance is based on selfgoverning structures, which means that competencies are delegated to membership-based, self-regulated organisations of sickness funds and health-care providers.
Germany’s many historical events have shaped its statutory health insurance system. Despite setbacks and interruptions due to political circumstances, the structural continuity of statutory health insurance endured and is one of the key features of the development of Germany’s health system (appendix p 2).
