Stefan Huster DIREKT 01/ 2018 SHAPING HEALTH CARE FAIRLY THE SITUATION IN GERMANY FROM A POLITICO-ETHICAL PERSPECTIVE AT A GLANCE Providing a viable health care system and avoiding social disparities in medical treatment are among the welfare state’s most important tasks. In principle, the German health care system does indeed provide that, but it also presents a series of structural prob­lems. Prevention policy remains a cause for concern, in particular its inadequate efforts to eliminate the considerable social inequalities besetting health care. INTRODUCTION Health care is a special good. Being healthy is not only a key component of personal well-being, but also a precondition for participating in many other areas of everyday life, such as the world of work. One of the welfare state’s key tasks is thus to ensure viable, generally accessible health care that meets people’s needs and helps them deal with health problems. Making sure that no one has to face illness alone is also a symbolic expression of the mutual concern that citizens of a free and democratic community owe one another. Health care provision must therefore be inimical to social differentiation. The kind of medical care someone receives – or indeed whether they receive any at all – should not depend on their ability to pay. A two-tier health care system would be unfair. At the same time, citizens have an interest in health care provision that is not only good, but also affordable. This calls for more economical and focused management of the avail­able resources. The health care system must be designed to be as efficient as possible(»rationalisation«). In light of medi­cal advances and demographic developments, however, thought must also be given to which services should come first(»prioritisation«) and which are not strictly necessary (»rationing«), so that health care costs do not rise to unaccept­able levels(Huster 2011). Yet it is also important to bear in mind that excluding and restricting services risks opening up a social divide with regard to health care provision, because these services can then(only) be accessed by better-off citi­zens who have the means to pay for them. This is particularly worrying given that there is already a close link between social and health status in Germany. For example, the life expectancy of men in the lowest income quintile is almost 11 years shorter than that of men in the uppermost quintile, while among women the difference is around eight years. If only the years spent in good health are taken into account, the differences are even greater(Lambert/ Knoll 2014). In a country where 90 per cent of the population is covered by statutory health insurance, this inequality of health care opportunity cannot – or can only marginally – be attributed to different levels of access to health care; more important are social determinants of health, such as working and living conditions, lifestyle and experiences of social ex­clusion(Siegrist/Marmot 2008). Hence, any attempt to address this inequality needs to involve other policy areas, such as education, environmental protection and social policy. On one hand, this suggests that when it comes to health care – and also the distribution of health-related resources – one needs to look beyond provision; on the other hand, health care provision should not exacerbate these social inequalities – the needs of vulnerable groups should receive particular con­sideration. Looking at the German health care system in these terms, one finds strengths and weaknesses(cf. Busse et al. 2017). By international comparison, it provides good, generally access­ible medical care – albeit with room for improvement. Yet the costs are high and certain structural problems adversely affect quality, efficiency and fairness of provision. This con­>