Analogous to the French case, the analysis of programmatic action in German health policy follows the PAF research protocol to trace the extent to which programmatic action is present. This is confirmed by existing publications (Bandelow & Hornung, 2020; Hornung & Bandelow, 2020), which are similar in their findings regarding the following elucidations. Nevertheless, the following subchapters serve to identify the programmatic group and its policy program both to validate the findings and to identify the core of the programmatic group to be identified for expert interviews. Most central to the analysis of programmatic action in Germany is the discovery of the institutional factors that enabled programmatic action despite the different system compared to France.

6.1 Policy Program in German Health Policy

Similar to France, health care reforms adopted in Germany pursued a strategy of centralization in order to concentrate competences and provide control over expenditures. In contrast to France, however, German health care reforms resorted to the introduction of elements of competition to achieve these goals (see Table 6.1). A first step in this direction was taken with the Health Care Structure Act (Gesundheitsstrukturgesetz, GSG) in 1992, which granted insured persons the free choice of sickness fund and established a risk structure compensation (Risikostrukturausgleich, RSA) between the different funds (Perschke-Hartmann, 1994, p. 265). Mätzke (2010, p. 135) sees this as a starting point for an increasing role and distinct organizational identity of the health ministry, based on policy-making in cross-partisan consensus and overcoming resistance from organized interest groups and a related shift from self-governance to hierarchical decision-making, for example, with the goal of cost containment. For the hospital sector, the reform included a change in financing that shifted from the remuneration of full cost cover to standardized prospective case financing (Busse & Schwartz, 1997).

Table 6.1 Substantial health care reforms in Germany 1990–2010
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Besides the content of the reform, the research literature on the GSG focuses on its genesis against the backdrop of the previous history of reform and Germany as a grand coalition state. According to this literature, the major structural reform and the “paradigm change” (Gerlinger, 2014, p. 35) it initiated resulted primarily from a cooperation of various party-political, but also administrative actors. In the final compromise concluded in Lahnstein, interest groups and representatives of sectoral actors were excluded (Reiners, 1993, pp. 29-33). This compromise was largely driven by the then health minister Horst Seehofer, and the chief negotiator of the Social Democratic Party (Sozialdemokratische Partei Deutschland, SPD), Rudolf Dreßler, and developed into a philosophy that they later adopted when communicating reform proposals (Seehofer et al., 1996). This exclusion of actors had been learned from earlier reform attempts under former minister Norbert Blüm, which failed due to strong resistance from interest representatives (Reiners, 2017b, pp. 24-25).

In the years following the GSG, many reform steps were taken toward reforming or adjusting the RSA scheme, which is one of the core elements of the competition-oriented regulation introduced to the German health care system (Busse, 2001, p. 175; Wysong & Abel, 1996, pp. 214-215). Others served more to contain costs, for example, by increasing co-payments and adjusting the SHI benefits catalogue (Kamke, 1998). Germany also introduced a general practitioner-centered model of health care (gatekeeper model) to allow sickness funds to use this as an element in competition with the other sickness funds and to reduce costs and contributions. The 1990s can also be seen as the starting point for breaking up established structures of contracting between sickness funds and physicians’ associations, which were under the umbrella of collective contracts and opened up to the possibility of selective contracts (Mehl & Weiß, 2015, pp. 461-462).

The general trend toward more competition in the context of solidarity and equal access continued in the 2000s, for example, with the Health Care Reform Act (Gesundheitsreformgesetz, GRG) of 2000, which made it possible to conclude contracts for integrated care (Kifmann, 2017; Lisac et al., 2008, pp. 184-186). It also introduced a new system of financing inpatient care according to diagnosis-related groups (DRGs), through which inpatient care is no longer reimbursed as per the length of stay but with a fixed rate calculated for a specific diagnosis (Arnold, 2000). This system was inspired by the Australian system, as it was considered more transparent and equitable compared to other systems (Milstein & Schreyögg, 2020, p. 28). Increased efficiency, transparency, and quality were cited as key goals of this reform (Braun et al., 2008).

In 2003, the SHI Modernization Act (GKV-Modernisierungsgesetz, GMG) again expanded the possibility of selective contracts between (individual or associations of) service providers and (individual or associations of) sickness funds (Bode, 2010, p. 66). In particular, the local sickness fund in the subnational state of Baden-Württemberg took advantage of the opportunities offered by these modes of governance (Hermann & Graf, 2012; Rohrer, 2017). As noted by Ulla Schmidt, then health minister, “the 2004 reform introduced explicit financial incentives for sickness funds and providers of health care jointly to develop contracts for proper disease and chronic care management, concepts that we Germans actually had picked up in the United States” (Cheng & Reinhardt, 2008, p. 206). This suggests that some of the ideas adopted in Germany were borrowed from other countries and inspired by the US system. To contain costs and allow competition between pharmaceutical companies and the sickness funds, the reform introduced the possibility of discount contracts to reduce spending on pharmaceutical products. These had been already discussed in Lahnstein and propagated by Rudolf Dreßler (Dietz, 2008).

The GMG also took some steps toward a more hierarchical form of institutional design. This relates above all to the establishment of the G-BA, the highest decision-making body of self-governance in the German health care system. It resulted from a merger of the previous negotiating bodies of the peak associations of service providers and payers, that is, physicians and hospitals, and the sickness funds. Similarly, the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWIG) was founded to provide evidence-based support for the decisions of the G-BA. At that time, the centralization tendencies of health care financing were further reinforced by the introduction of a tax-financed federal subsidy paid for non-insurance services (Jacobs, 2009, p. 28)

Continuing the strategy of cost containment through competition and centralization of decision-making, the Act to Strengthen Competition in the SHI (GKV-Wettbewerbsstärkungsgesetz, GKV-WSG) of 2007 is often mentioned in the same breath as the GMG and the GSG (Reiners, 2009). Among other things, this included the creation of the health care fund for the central administration of contributions and their distribution among the sickness funds according to the RSA scheme, as well as the installation of the GKV-SV. From an organizational and legal perspective, there has been much discussion about the legal and organizational status of sickness funds and physicians’ associations as public corporations (Kruse & Kruse, 2006; Schillen & Kaiser, 2018). Furthermore, morbidity components have been added to the RSA scheme (Buchner et al., 2013) to remove incentives for sickness funds to select their insureds based on their health risks, thereby distorting the playing field for competition (Jahn et al., 2009, p. 45). Götze (2013) emphasizes that only then would the goals of the GSG and true price competition have been achieved. To strengthen the solidarity aspect, the GKV-WSG made health insurance mandatory and universal through, which was also partly inspired by policies in the Netherlands (Manouguian et al., 2006). Key points of the GKV-WSG had also been prepared by another commission, the 16-member cross-coalition federal-state working group that drafted the key points of a health care reform (Grimmeisen & Wendt, 2010, p. 164). It included high-ranking politicians from the federal and state levels, including Josef Hecken (then still minister in Saarland), as well as administrative staff (Sucker-Sket, 2006).

A final step in the reviewed reforms can be seen in the AMNOG of 2011, which came close to adding a fourth hurdle for pharmaceutical products to enter the market. Newly produced drugs must now be assessed for an additional benefit compared to existing pharmaceutical products, and only if this is established may the company enter into price negotiations with the GKV-SV. Otherwise, the drugs are transferred to the reference price system. However, it is questionable what impact this regulation will have on the access to pharmaceuticals for the insured (Henschke et al., 2013).

The course of German health care reforms has been analyzed in detail by several authors and studies. A high level of agreement concerns the observation that the German health care system has become increasingly economized and marketized (Ewert, 2009). Reforms since 1990 are often described as following a “third way” vision, which essentially means the introduction of elements of competition into an otherwise publicly structured, hierarchical governance structure (Allen & Riemer Hommel, 2006; Kuhlmann et al., 2009, p. 515). In this context, health policy reforms required political trade-offs between the goals of solidarity on the one hand and financeability and competition on the other (Stock et al., 2007). Another key finding of health policy analyses is the increased role of the state and hierarchical modes of governance to weaken self-regulation (Rothgang et al., 2010), although this view is contested. Some see the reforms more as strengthening corporatist bodies (Altenstetter & Busse, 2005). In general, scholars agree that the aforementioned reforms are an ongoing reform program, whose reforms are interrelated in terms of problem identification, goals, and instruments (Gerlinger, 2010; Lisac et al., 2010). Hartmann (2003) classifies the policies of the 1990s after the GSG as a distinct phase compared to the phase of cost containment before it, and the health care policies of the governing coalition of the SPD and the Greens (Bündnis 90/Die Grünen) until its end in 2002 as a continuation of this phase (Hartmann, 2003, p. 270).

The ideas of these reforms can be traced back even further to the Enquete Commission Structural Reform of the SHI (Strukturreform der gesetzlichen Krankenversicherung) (Götze, 2016, p. 186), which in its final report already advocated the introduction of competitive elements in the health care system, such as a risk compensation scheme and the elimination of strict differences between sickness funds according to the occupational group they insure (Deutscher Bundestag, 1990). Manow (1994, p. 97) notes that this can be seen as a cross-party and cross-ideological consensus. Based on the Enquete Commission and, to some extent, the Structural Commission at the DGB Federal Executive Board on “The Future of Solidary Health Security”, which is still cited in some works by proponents of these ideas (Rosenbrock, 1992), it can be assumed that the reforms implemented in subsequent years made use of the ideas agreed upon by these groups of people in these commissions. Other authors who see a substantial connection between the reforms as part of a larger policy program were themselves part of the group that drove these reforms (Knieps, 2016). They also trace the ideas behind the reforms to the development of a scientific discipline, namely health economics under professor Philipp Herder-Dorneich (Rebscher, 2016, p. 47).

Some of the reforms, such as the introduction of the Health Care Fund, are seen by scholars as a compromise in the ideological conflict between the advocates of solidarity (with the party-political representative of the SPD) versus the advocates of self-responsibility and financeability (with the party-political representative of the Christian Democratic Union (Christlich Demokratische Union Deutschlands, CDU) and the Christian Social Union (Christlich-Soziale Union, CSU). It is interesting, however, that even reforms formally initiated by the red-green government explicitly refer to the principle of self-responsibility in their presentation of the reform (Deutscher Bundestag, 1999). Indeed, this could be an indication of the occurrence of a “Nixon-goes-to-China effect” (Wenzelburger et al., 2018). However, the clear reference by Ulla Schmidt to “solidarity and affordability of a high-quality health care system [as] the twin goals of our reform” (Cheng & Reinhardt, 2008, p. 205) and Horst Seehofer (“For me, solidarity and personal responsibility are brother and sister” (Seehofer, 1996)) shows that there was a broad cross-party consensus, a programmatic identity, guiding the statements of central actors in health policy. Nevertheless, such an effect is also visible in the health care reforms in Germany (Knieps, 2016, p. 29).

As in the French case, some structural policies cannot be linked to reform programs and seem to be empirical examples of theoretical perspectives that focus on scandals and external events or beliefs and interests. These include the abolition of the Federal Health Office, which was absorbed in several other agencies following the concealment of contaminated blood products (Laschet, 2019). Toward the end of the 1990s, the two Acts on the Reorganization of the SHI, which linked co-payments to contribution rates and reduced the benefits catalogue, were met with alienation by all those who had supported the reform path taken earlier. Several actors criticized the reforms (Cassel et al., 1997; Hermann, 1997) and they were reversed by the new governing coalition after the change of government in 1998 (Knieps, 2016, p. 27). After the change of government, the Solidarity Strengthening Act is only a counter-reaction to the Reorganization Acts. While the 2000 health reform contains rudiments of further programmatic action (see below), the development of health policy up to the GMG is characterized by being primarily the result of a proliferation of individual interests and also the result of partisan effects.

6.2 Programmatic Actors in German Health Policy

In order to gain further insight into the group of actors who advocated increased economization of the health care system and the ideas of increased centralized regulation to ensure solidarity within these competitive structures, the analysis of newspaper articles represents the second step of the German study. Analogous to the French case, the daily newspaper with the highest circulation in Germany, the Süddeutsche Zeitung, is taken as the reference point. As this German newspaper is also considered center-left in its orientation, this selection rules out a potential bias when comparing discourse networks of France and Germany stemming from different orientations of the two newspapers under study. Like in France, it may be that some topics or actors gain more attention from leftist newspapers compared to right-wing-oriented newspapers. Given that the research interest pursued here lies in the reconstruction of the reform trajectories and their supporting actors, the way that newspapers frame political events and reforms has little to no effect on the results. Also, an overestimated or underestimated role of policy ideas and/or actors would become visible when cross-checking the results of the discourse analysis with interview data and document analyses.

To ensure comparability of results, the search bases on the same keywords, namely “social security/health insurance” (Krankenversicherung) and “health policy” (Gesundheitspolitik). In the period between 1 January 1990 and 31 December 2010, 409 articles containing these keywords were published. Focusing only on those that discuss reforms more concretely, 146 articles remain in the sample to be analyzed with the Discourse Network Analyzer.

As in the French case, the detailed history of newspaper articles on health policy reforms in Germany also allows for tracing the dominant debates at the time of discussion. It also allows a step-by-step review of the reform history. The health policy coverage of the 1990s begins in 1992 with a public discussion of the attempts and questionable success of the governing coalition to contain health spending and the measures used to achieve this goal. The SPD accused the governing coalition of being unable to reduce health care costs, while public debates centered on whether increasing co-payments, reducing the benefits catalogue, reforming remunerations, and budgeting were appropriate tools to address this problem. At that time, the then minister of health, Horst Seehofer of the CSU, invited Rudolf Dreßler, then the SPD’s main health policy expert, to work together on a health care reform.

Following the 1992 reform, the SVR-G’s “Gesundheitsweisen” (health experts) presented another starting point for further health care reforms in a scientific report in 1995 (SVR, 1995). It explicitly advocated more competition in the health care system. While the SVR-G held back with clear recommendations and opinions, a tendency toward required competition between sickness funds was already apparent here, allowing individual premium reductions through optional services (5 February 1994). Seehofer emphasized that the ideas of the sectoral actors should first be clarified before concrete reform steps were taken in the next direction.

The media reported at that time that various actors were calling for the implementation of the so-called third stage of health reform. This meant linking an increase in contribution rates with increases in co-payments, parity-based financing of contributions, and the targeted expansion of prevention and rehabilitation in the sense of solidarity-based health care. In an interview on 6 July 1996, however, Seehofer made it clear that he believed prevention was best left to the individual and not to the sickness funds. As a result, preventive services and precautionary measures in particular were removed from the benefits catalogue, which met with strong resentment and criticism from the SPD. However, he was unable to push through the division of health insurance benefits into compulsory and optional benefits. When Horst Seehofer presented the draft bill for the planned reform of health insurance in February 1996, the SPD under Rudolf Dreßler presented a counter-draft with the threat of using the newly won majority in the Bundesrat as veto power. The draft reforms for “further development” ultimately failed. This was also due to three state election results in March 1996, which strengthened the Liberal Democratic Party (Freie Demokratische Partei, FDP) and weakened the SPD, thus preventing a repetition of the grand-coalitionary compromise as in Lahnstein.

Horst Seehofer’s term in office was followed by Andrea Fischer as health minister of the Greens under Gerhard Schröder’s red-green coalition. With her planned health reform included the introduction of global budgets, a positive list, responsibility for hospital investments resting with the sickness funds, and the review and process evaluation of new medical devices. The latter also led to an intensive discussion about whether medical progress necessarily entails an increase in costs or whether it can also reduce costs (Steinkohl, 1999). The conflict also became apparent again within the governing coalition, partly due to Rudolf Dreßler’s still strong position. But the CDU also threatened to reject the reform in the Bundesrat. Interestingly, there were also talks between old friends Rudolf Dreßler and Horst Seehofer at this time. Finally, the reform ended up in the mediation committee. As expected, no compromise was reached, so Andrea Fischer subsequently passed a version of the reform reduced by the points requiring approval. This contained only the budgets for drugs, physician fees, and clinics, as well as a strengthening of the selective contracts. The example of Rudolf Dreßler and Horst Seehofer during the time of incumbent health minister Andrea Fischer shows that old friendships and biographical intersections have a lasting effect, because both “overthrew” a health minister who was not part of the group, although there was definitely consensus on some points such as contracts between sectoral actors, co-payments, competition, hospital restructuring, and individual responsibility for certain benefits.

Even if the compromise between Horst Seehofer and Rudolf Dreßler was a political one, the Enquete Commission at least had a personnel effect, that is, many of the members of the Enquete Commission were at least involved in the public discourse, if not in the solutions agreed upon in Lahnstein. If we look at the discourse network in Fig. 6.1, which shows that the media discourse in the selected newspaper between 1990 and 2000, some names emerge that were members of the Enquete Commission. In addition to Horst Seehofer, these are Paul Hoffacker and Dieter Thomae. With them, however, the network remains politicized. The politicization can easily be explained by the chosen media organ and the logic with which journalistic reports are written. As mentioned above, sectoral actors and potentially programmatic actors are hardly observable in public discourse, but operate in the background. The discourse network is thus more indicative of the policy program, whose ideational roots are still to be found in the biographies of actors. If the policy program is shared broadly publicly across party-political actors, there is high probability that a programmatic group is working behind the scenes that has reached a cross-party consensus on a far-reaching reform program.

Fig. 6.1
A network diagram for health policy in Germany from 1990 to 2000. It has nodes for consensual concepts, conflictual concepts, academic or advisory actors, political actors, actors from corporatist and self-administrating bodies, and bureaucrats. The diagram has dependencies of nodes.

Discourse network of health policy in Germany, 1990–2000. Source: Own illustration, created with the software visone (Brandes & Wagner, 2019). The red outlines emphasize the programmatic content of the discourse

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In 2001, Andrea Fischer was finally replaced by Ulla Schmidt as health minister. However, the problem of rising costs had still not been solved, and the question of contribution rate stability and which services should be paid for by the sickness funds and on what basis remained under discussion. In this situation, Ulla Schmidt proposed a reform of RSA with an extension to include a morbidity orientation and introduced flat rates per case, which had already been discussed in the 1990s as a means of increasing efficiency, as a remuneration system in hospitals. At the same time, she abolished measures pushed through by Andrea Fischer, such as the drug budget. Although these measures met with criticism from the sectoral partners, there was no political resistance even in the absence of conspicuous health policy personalities. This was also due to internal disagreement within the CDU/CSU; the separation of elective and compulsory benefits was welcomed by the CDU but rejected by the CSU. In 2002, a group of scientists close to the SPD presented a draft for the health policy of the future (4 April 2002—key elements of a new health policy). This group included well-known names who had also played a role in the Enquete Commission or in other health science contexts, including Gerd Glaeske, Jürgen Wasem, Christopher Hermann, and Karl Lauterbach. They called for greater consideration of evidence-based and independent institutions in quality assurance, a strengthening of integrated care, improved use of the general practitioner-centered model, and a greater role for disease management programs (DMPs). Fittingly, since the 2000s there has also been increasing talk of quality competition instead of price competition, that is, the possibility of choosing between different health insurance plans according to the quality of care (such as general practitioner-centered models, selective contracts, and DMPs). Related to this, the GMG in the early 2000s introduced bonus programs for sickness funds, which were also intended to further develop competition among them. To contain costs on the revenue and expenditure side, the reform also decoupled dentures from the SHI benefits catalogue and increased co-payments for medicines. A practice fee required every patient to pay €10 quarterly when visiting a doctor.

In 2003, the Herzog Commission drew up important proposals for reforming social security. These later served as the basis for the CDU program, which envisaged a fundamental change in the financing basis of SHI from financing via income-dependent contributions to income-independent capitation payments. However, the CSU rejected the proposals presented, except for the point about freezing the employer contributions. At the same time, the Rürup Commission set up by the federal government was also working on social policy proposals, whose members tended to be close to the SPD. Interestingly, the Rürup Commission also came up with the proposal of a capitation payment. This was also the strategy proposed by the SVR-G, of which Bert Rürup was a member at the time. The commissions’ findings had a decisive influence on the election campaign and the subsequent coalition negotiations in 2005.

Following the commissions’ findings, internal conflicts arose between supporters and opponents of the proposals developed. CSU party leader Edmund Stoiber spoke out in favor of the capitation fee, while CSU Health Minister Horst Seehofer rejected it. Within the CDU/CSU parliamentary group, a compromise solution crystallized for a health premium as a reaction to the conflicts, which would place a greater burden on higher earners and thus also include an income-related component. This was supported by the CSU and parts of the CDU. Edmund Stoiber’s compromise proposal set the flat rate to be paid at 109 euros, but no more than 7% of income.

In the coalition negotiations for the grand coalition in 2005, however, the parties agreed on a compromise, namely the establishment of the health care fund through the GKV-WSG. Here, health insurance contributions were combined uniformly and then redistributed among the sickness funds according to their expenditures and the morbidity-oriented risk structure compensation (Morbiditätsorientierter Risikostrukturausgleich, Morbi-RSA). The federal subsidy already introduced in the GMG to finance non-insurance benefits was actually to be abolished, but was reintroduced in response to the “solidarity-based” tax financing of the capitation fee demanded by the CDU and CSU. The GKV-WSG 2007 also set the contribution rate to the sickness funds at a uniform percentage. In order to maintain competitive structures, though, the sickness funds were allowed to levy an additional contribution on an individual basis. These structures largely still apply today, even though the additional contribution was made income-dependent in 2015 (Simon, 2016).

Toward the end of the 2000s, the reform discourse changed slightly as other problems came onto the agenda. Medical deserts and the insufficient provision of health care in more sparsely populated areas posed substantial challenges to health policy actors, as did a financing reform of long-term care insurance. The goal of cost containment also remained on the agenda, but it was achieved through two developments: First, the unpopular health minister Philipp Rösler failed to push through the capitation fee against the resistance of the coalition partner CDU/CSU, even though it had been stipulated in the coalition agreement. Instead, the CDU/CSU advocated a reform of the health care fund. This was demanded in particular by the CSU, in persona Markus Söder and Horst Seehofer. The latter in particular vehemently opposed the introduction of capitation fees, also to the displeasure of the coalition partners CDU and FDP. A final compromise led to a hierarchical definition of an average additional contribution, which was offset by a reduction in the overall contribution if a certain fixed amount was exceeded. In the same breath, the additional contributions were decoupled from employers’ expenditures. On the other hand, the reaction to the financial crisis prompted health policy-makers to increase the contribution rate by 0.6 percentage points to 15.7%. Only later did it become apparent that this adjustment of the contribution rate was in fact an overreaction of German health policy to the financial crisis (Blum & Kuhlmann, 2016).

In contrast to the discourse network shown in Fig. 6.1, the discourse network of health policy in Germany between 2000 and 2010 (Fig. 6.2) shows a different picture in terms of density and number of connected nodes. It is populated by more actors, and among these actors are not only politicians but increasingly also actors from the self-governing institutions of the sickness funds. These include, for example, Christopher Hermann from the local sickness fund of Baden-Württemberg, and academics who advocate competition in the health care system, including Jürgen Wasem and Gerd Glaeske. Besides, some core topics of the discourse are highlighted. The dispute between CDU, CSU, and SPD over the future financing of the SHI system with the main instruments of citizens’ insurance, capitation fees, and health premiums, which is being driven throughout the debate, is also visible in the discourse network. In addition, evidence-based medicine, general practitioner-centered care, and the call for the creation of an agency to monitor quality in health care, partly with reference to the National Institute for Health and Care Excellence (NICE) in the UK, were among the policy instruments promoted by non-political actors. There is also agreement on these themes, suggesting that they fit the public narrative and perceived health care reform needs and solutions. As a consequence, the discourse network shows that less polarization of a discourse is associated with it being shared by a larger number of people. The respective instruments that constitute a policy program are discussed unanimously in the media and hardly criticized.

Fig. 6.2
A network diagram for health policy in Germany from 2000 to 2010. It has nodes for consensual concepts, conflictual concepts, academic or advisory actors, political actors, actors from corporatist and self-administrating bodies, and bureaucrats. The diagram has dependencies of nodes.

Discourse network of health policy in Germany, 2000–2010. Source: Own illustration, created with the software visone (Brandes & Wagner, 2019). The red outlines emphasize the programmatic content of the discourse

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The discourse network analysis of German health policy between 1990 and 2010 has shown that there has been a lively debate about adequate reform strategies in response to the challenge of rising health care costs. In the first ten years, the discourse was largely dominated by political actors. Although the ideas discussed in the Enquete Commission—including selective contracts, the RSA scheme, and other competitive elements—were slow to enter the debate, the main instruments discussed were simple ones that were known to have a reducing effect on health care spending. As a result, policy-makers struggled mainly to reduce the benefits catalogue, introduce budgets for health care, or increase co-payments. It was not until the 2000s that the instruments of the policy program “competition in a solidaristic framework” (Knieps, 2017, p. 12) came into the spotlight and manifested themselves in the public debate. This is the time when one can speak even more of programmatic action, as the public discourse networks become denser and populated by diverse actors from academia and self-governance.

6.3 Biographies and Identities of German Programmatic Actors

Continuing with the actors in the discourse network, it is noticeable that, in contrast to France, not so many administrative actors were visible in the network. Instead, the discourse was largely shaped by party-political experts and experts who, in one way or the other, found their way into self-governance. In addition, those who occupied the positions relevant to the adoption of reforms, most notably the leaders in the relevant departments in the health ministry, stayed in the background.

Based on the relevant formal positions in the German health care system shown in Fig. 4.2, it is possible to identify in retrospect the central actors who held these positions during the period under review from 1990 to 2010. In particular, it can also be shown whether new institutions were created that were occupied by biographically related actors and after their joint promotion of a policy program. The positions formally considered relevant are found at the highest levels of self-government. In addition to the department of health insurance in the health ministry, these are primarily positions in the represented organizations of today’s Joint Federal Committee, that is, the KBV, the DKG, and the GKV-SV. In addition, the SVR-G, which is based in the health ministry, potentially plays a decisive role.

Looking at these positions, the key position in the health ministry—and comparable to France—has been occupied by a programmatic actor even after the first reform steps had been implemented. The German counterpart to Dominique Libault is Franz Knieps, who occupied the post between 2003 and 2009 and was thus responsible for two to three of the four most important health care reforms. A more detailed look at the formal key positions in the German health care system and the individuals who occupied these positions during the period under study is presented in Table 6.2 as the starting point of the analysis. It highlights the role of Franz Knieps in the health ministry during an important period of reform. At the same time, it shows that the centralization of health care institutions in turn the actors who now occupy central positions to be traced back to the institutions that were relevant before the institutional change initiated by the programmatic group.

Table 6.2 Occupied positions in key institutions of German health policy
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The board of directors of the GKV-SV, founded in 2007, was chaired by Doris Pfeiffer, Johann-Magnus von Stackelberg, and Volker Hansen, whose biographies had in common that they had held top positions in the federal association of local sickness funds (AOK-Bundesverband, AOK-BV) before the 1990s. Interestingly, the first impartial chairmen at the top of the G-BA, Rainer Hess, also came from this network. He stayed until 2012, marking the end of programmatic action with the AMNOG as the final reform step.

Another interesting body that had evolved over the years was the SVR-G. Originally convened for the concerted action in the health sector, it became an important stop in the careers of programmatic actors and a place of intellectual debate that was inspirational for the further development of the policy program. Many of the former members of the SVR-G were present in the media, such as Karl Lauterbach, who continues to play an important role in health policy in the recent era of the COVID-19 pandemic and is frequently quoted in public discourses (Dyer, 2020). Others, such as Rolf Rosenbrock and Günter Neubauer, were previously part of the Enquete Commission and were able to transfer these ideas and institutionalize them in the SVR-G. Similarly, it was the SVR-G that carried some reform ideas, such as the reorganization of sickness funds, to the Enquete Commission. As can be seen from the commission’s final report, Martin Pfaff and Gerd Glaeske, then members of the SVR-G, had advised the members of the Enquete Commission on this topic (Deutscher Bundestag, 1990, p. 17f). Looking at these examples, it can be stated that there was an intensive cross-commission exchange with biographically connected individuals who pursued a common policy program.

Despite the fact that there were biographical intersections between health policy actors in Germany that laid the foundation for programmatic action, the clear link to institutions and the discourse network is less visible compared to France. This is mainly because the programmatic group was less formally visible and acted more informally. This is not to say that the Enquete Commission was an informal occasion alone. Nevertheless, it is striking that much of the collaboration appears to have taken place behind the scenes. This is evident not least from the lower visibility of programmatic actors in the discourse network. Instead of being present in the daily newspapers, the programmatic group used the channels of the sectoral publication organs to disseminate their ideas. The programmatic actors participated in a number of joint publication projects. One of the most recent major ones is a written account of the program “solidarity-based competitive order” (Cassel et al., 2014). Published in 2014, when the introduction of competitive elements in the health care system had already been largely realized, the authors identify challenges to further implementation of this program, one of which appears to be the lack of consideration of these ideas in the coalition agreements (Jacobs & Rebscher, 2014, p. 67). The programmatic group was also active in some sector-specific forums that provided ongoing intellectual reflection behind the scenes of the public debate. One example is the Federal Managed Care Association (Bundesverband Managed Care, BMC), whose board still consists of former programmatic actors who continue to publish their programmatic ideas (Amelung et al., 2017), and whose chairman himself pushed for market-based reforms in health care, inspired by the US experience (Brown & Amelung, 1999).

Looking at the actors who occupied the relevant positions in the central institutions of the German health care system dentified in Fig. 4.2 between 1990 and 2010, the analysis shows the intersecting biographies of key actors whose start of cooperation dates back to the Enquete Commission and the compromise agreed in Lahnstein. One key person who develops here is Franz Knieps, head of the department of health care, statutory health insurance, long-term care insurance in the health ministry from 2003 to 2007, after having made his career in one of the largest sickness fund associations. Christopher Hermann also was part of the secretariat, at that time seconded from the scientific service of the German Bundestag. Christopher Hermann then became a research associate at the Ministry of Social Affairs and Health of North Rhine-Westphalia, succeeding Hartmut Reiners, who held a central position in the health ministry of the state of Brandenburg. Hartmut Reiners confirmed in an email that he was in charge of coordinating the health policies of the SPD-led states and therefore worked very closely with Christopher Hermann. These three individuals can be considered part of the core programmatic group around health policy reforms in Germany from the 1990s onward.

The analysis of actors’ biographies also points to other intersections that are of interest for the study of the adopted reforms. In contrast to the ENA in France, the importance of higher education in Germany depends less on the institution or location (as may be the case in the UK and the US) than on the subject. In the 1990s, health economics became an important source of influence for ideas on the organization of health care. Thus, the focus on competition in health care is not accidental. As indicated in the document analysis, Philipp Herder-Dorneich’s students, as one of the first two German health economists, substantially shaped the ideas and paths of the policy program. Jürgen Wasem, one of his students, can be considered a scientific part of the programmatic group, as his work on the Morbi-RSA scheme was transferred to policy (Jahn et al., 2009; Wasem, 1993; Wasem et al., 2016). Together with Eberhard Wille, Jürgen Wasem was a member of the Scientific Advisory Board on the Further Development of the Risk Structure Compensation Scheme (Wissenschaftlicher Beirat zur Weiterentwicklung des Risikostrukturausgleichs) (BAS, 2020). Participation in this scientific advisory board and in the SVR-G also enabled cross-institutional collaboration and further elaboration of the policy program with proposals for its redesign.

A special biographical connection seems to be the AOK-BV. Franz Knieps began his career there, as did many others. Hartmut Reiners writes in a private email: “What we had in common was that we, as economists, social scientists or lawyers, were involuntary pioneers, because health care and especially SHI was a ‘terra incognita’ in the academic field until the 1980s. At the same time, the academisation of the health insurance associations was pursued, especially in the AOK, driven by its board and WIdO founder Alfred Schmidt (DGB). At that time there were only two professors of economics, [Philipp] Herder-Dorneich in Cologne and Theo Thiemeyer in Bochum, and a lawyer ([Bernd] von Maydell), who had their main focus of work here. Their staff and doctoral students then made a career in the ministerial and health insurance bureaucracy and formed an informal network that had and still has a forum in the journal ‘Gesundheits- und Sozialpolitik’ (Health and Social Policy), which was co-edited by Franz Knieps”. Hartmut Reiners’ quote refers to a common source of ideas and contacts in the network decisively built up by the local sickness funds (AOK) and their federal association at the federal level. The publications by the WiDO (Scientific Institute of the Local Sickness Funds; Wissenschaftliches Institut der Allgemeinen Ortskrankenkassen) obviously influenced or at least accompanied the health care reforms (Cassel et al., 2008).

Based on the findings generated in the previous sections, especially the discourse network, document analysis and formal position analysis, the analysis of biographical intersections draws on actors who were visible at several points in this empirical study. Specifically, the actors selected as anchoring examples to substantiate the existence of a programmatic group held different positions in the ministry (Franz Knieps), in the self-governance (Christopher Hermann), at the Länder level (Hartmut Reiners), and in academia (Jürgen Wasem). They got to know each other through the Enquete Commission and the subsequent Lahnstein compromise. In addition, their cooperation was intensified through working groups, for example, the respective key point discussions on the health care reforms of 2003 and 2007 (Schwartz & Mosebach, 2003; Wasem, 2009). The call for more competition in health care was even shared even by normally opposing actors, such as employee and employer representatives (DGB, 2003). Sources for the biographical information on the following anchoring examples are the BKK DV (2020), Wolfangel (2020), the Universität Duisburg-Essen (2020), and personal interviews.

Anchoring Example: Christopher Hermann

  • Until 1987 Law, policy, and history student

  • 1987–1990 Scientific service of the German Bundestag

  • 1990–1997 Research assistant at the Ministry of Social Affairs and Health of North Rhine-Westphalia

  • 1997–2000 Group leader at the Ministry of Social Affairs and Health of North Rhine-Westphalia

  • 2000–2011 Member of the board of the AOK Baden-Württemberg

  • 2011–2019 Chairman of the AOK Baden-Württemberg

Anchoring Example: Franz Knieps

  • 1975–1981 Law student at the universities of Bonn and Freiburg

  • 1982–1986 Research assistant to Bernd von Maydell at the Institute for Labour Law and Social Security Law at the University of Bonn

  • 1986–1987 Consultant for basic legal policy issues at the AOK Federal Association

  • 1987–1988 Secondment to the Federal Ministry of Labor and Social Affairs to support Minister Norbert Blüm’s work on health reform

  • 1989–1998 Head of the Policy Department of the AOK Federal Association

  • 1998–2003 Managing Director Politics at the AOK Federal Association

  • 2003–2009 Head of the Department of Health Care, Statutory Health Insurance, Long-Term Care Insurance in the Federal Ministry of Health

  • 2009–2013 Management consultancy Wiese-Consult

  • 2013 WMP HealthCare GmbH

  • Since July 2013 Chairman of the BKK federal association

Anchoring Example: Hartmut Reiners

  • Until 1988 Scientific institute of the local health insurance funds

  • 1987–1990 Enquete Commission “Structural Reform of the Statutory Health Insurance”

  • 1988–1992 Health ministry, North-Rhine Westphalia

  • 1992–pension Head of the policy unit of the health ministry in Brandenburg

Anchoring Example: Jürgen Wasem

  • 1978–1983 Study of Economics Political Science, and Social Policy

  • 1983–1985 Research Assistant and Doctorate at the University of Cologne, chair of Philipp Herder-Dorneich

  • 1985–1989 Consultant in the Department of Health Care and Health Insurance in the Federal Ministry of Labor and Social Affairs

  • 2003 Member of the Herzog Commission and advisor to Ulla Schmidt

It is striking that the local sickness fund associations and their scientific institute represent the roots of several programmatic actors that were brought together in the Enquete Commission. Moreover, the Enquete Commission, the Lahnstein Compromise, and the SVR-G represent biographical intersections shared by many programmatic actors. Thus, it can be concluded that these biographical commonalities are the source of programmatic action.

6.4 The Decline of the Programmatic Group in German Health Policy

The previous chapters have provided evidence and empirical trajectories of instances of programmatic action in French and German health policy from 2011 to 2020. To assess the influence of institutional settings on the presence and absence of programmatic action, this subchapter presents a case in which programmatic action did not occur and investigates the reasons why this is the case. It also outlines how the PAF can be falsified. With respect to the French case, PAF scholars concluded that the old programmatic group is still active and relevant even in the recent COVID-19 pandemic (Hassenteufel, 2020). It is therefore useful to look more closely at the period after programmatic action in German health policy to evaluate which of the explanatory factors for programmatic action have changed to explain the absence of programmatic action since then. Against the backdrop of the formulated hypotheses on the influence of political institutions on programmatic action, the results later show under which institutions programmatic action occurs.

As in the previous empirical studies, the analysis of the German health care reform period from 2010 to 2020 starts with an overview of adopted policies with the aim of identifying a possible reform program. As Table 6.3 shows, however, the directions of the individual policies are not visibly linked. Under health minister Hermann Gröhe, health policy focused only on prevention and innovation. By overreacting to the financial crisis in 2010, the German health care system had overcome its financial problems. Money was abundant and was used to address the problems that arose. For example, financial incentives were used to attract more physicians to sparsely populated areas and to offer new services for those in need of care and the seriously ill. Only the rapid pace of reform under Jens Spahn as a health minister and his restructuring of the health ministry, including the designation of a unit for digitalization and the placement of one of his party trustees at the top, might give a hint of a hidden reform program of digitalization.

Table 6.3 Substantial health care reforms in Germany 2010–2020
Full size table

The major structural reforms under Jens Spahn can be illustrated very well by a few, also known as “omnibus laws” because of their comprehensive nature. Only these are listed in Table 6.3. In terms of content, the reforms essentially encompassed four central aspects, which can be summarized under the headings of patient-centeredness, care policy, digitalization, and increased state oversight. With regard to patient-centeredness, a return to parity financing of health insurance contributions was already agreed in the coalition agreement and implemented with the Act to Relieve the Burden on Insured Persons in SHI (GKV-Versichertenentlastungsgesetz; GKV-VEG). To counter the constant criticism of a “two-class system of medicine”, which has recently been increasingly reflected in the question of how long patients have to wait for specialist appointments, the Appointment Service and Care Act (Terminstellenservice- und versorgungsgesetz; TSVG), established a uniform appointment service center for specialist appointments. In addition, office hours for physicians are being expanded.

In addition, there was a particular pressure from emerging challenges of the shortage of skilled workers (especially nursing staff), drug safety, and slow progress in digitalization. Jens Spahn responded to the challenges in care policy with an immediate care program that creates 13,000 additional positions in inpatient care for the elderly and ensures full refinancing of these positions in hospitals. In addition, it was decided to decouple the nursing staff costs from the DRGs. Both measures were adopted in the context of the Act to Strengthen the Nursing Staff (Pflegepersonalstärkungsgesetz; PpSG. With a view to a planned comprehensive reform of nursing care, the conclusion of collective agreements was envisaged. In the area of digitalization, the most prominent innovation is probably the possibility of making digital health applications reimbursable by including them in the health insurers’ benefits catalogue. In addition, health care providers will be required to connect to the telematics infrastructure by a specified date. The Corona pandemic has also spurred some developments, such as the electronic certificate of incapacity for work and the e-prescription (Digital Care Act (Digitale-Versorgung-Gesetz; DVG)), which is also linked to the electronic patient record that must be offered to every patient by their health insurer from January 2021. In addition, the BMG taken over a majority stake in the gematik, the company responsible for the telematics infrastructure, which was previously led by actors of the self-governance.

Compared with previous health care reforms in Germany, there are few similarities. The RSA scheme and the free choice of sickness funds were generally considered a success. Nevertheless, as early as 2000 there were calls for continuous adjustment of this scheme, for example with the introduction of a regional and morbidity component (Busse, 2001, p. 176). Jens Spahn complied with these demands in the Fair Sickness Fund Competition Act (Fairer-Kassenwettbewerb-Gesetz; GKV-FKG) and even made rhetorical reference to Lahnstein (Rottschäfer, 2019), but earned criticism from sectoral actors (Litsch, 2019). Although the reforms are based on two special reports by the Scientific Advisory Council on the Further Development of the Risk Structure Compensation Scheme at the (now renamed) Federal Office for Social Security (Bundesamt für Soziale Sicherung, BAS) (Drösler et al., 2017, 2018), in which some members of the programmatic group were involved, members of the programmatic group in particular see the reform efforts around Jens Spahn as a “rhetorical relic” (Hermann & Graf, 2020) at best. Hermann (2020) concludes that the program of a solidarity-based competitive order is becoming increasingly unrecognizable under the grand coalition. With the appointment of new members of the SVR-G and the Scientific Advisory Council at the BAS and the dismissal of Jürgen Wasem and Eberhard Wille, Jens Spahn has even directly discharged members of the former programmatic group, which can also be seen as evidence of the decline of the programmatic group.

Looking at the reforms in detail, one could most readily assume that the substantive relationship between the individual measures was shaped by the ministers. Gröhe focused more on strengthening prevention and improvements in care policy. Spahn, on the other hand, announced digitalization as a central topic right at the beginning of his term in office. However, the setting of priorities by ministers alone contradicts the idea of the PAF and the premise of programmatic groups. The ministers acted as individuals and chose these topics as central to themselves. They did not act in groups and certainly not in programmatic groups. Certainly, ministerial policy was informed by the support of advisory groups, but even these did not function as programmatic groups because they had no biographical connections. The new leadership department under Spahn in the ministry could have been considered a new programmatic group under certain conditions. However, with the exception of State Secretary Thomas Steffen, there were no biographical connections to Spahn, and these were not based on biographical connections that would have had a content background (e.g., in committees or commissions). It was rather the partisan connection that paid off here.

From a content perspective, digitalization alone does not constitute a program. Thus, at least the reform communication coined by Jens Spahn contains neither a clear naming of problems that are to be solved by digitalization. Nor does it indicate, with reference to a clear uniform name of a program, which concrete measures can be derived to solve these problems. Nor does it state the goals of such a program. Thus, the call for more digitalization itself does not yet meet the criteria required of a policy program of a programmatic group. While a reform of integrated care is currently being discussed, former programmatic actors claim that the idea of cooperation and integration had failed (Brandhorst et al., 2017). The pandemic has provided new impetus and, among other things, raises the question of cooperation between the inpatient and outpatient sectors, even in sparsely populated regions. From this perspective, the distribution of vaccines is also driving regionalization efforts, which are also aimed at optimizing integrated care while taking regional characteristics into account. Here, then, the Corona crisis offers a window for far-reaching reforms that are probably better explained from an MSF perspective than by looking at programmatic groups.

The discourse-analytical analysis of potential programmatic actors reveals a strong reorientation both in the programmatic debate and among the prominent personalities. As in France, media coverage of health policy declined to a similar extent, so no further discourse network is shown here either. The content was also about topics other than finance, solidarity, and competition. After the 2011 reforms, care policy and prevention came to the fore as major topics. Finally, under minister Hermann Gröhe, a redefinition of the concept of the need for care was undertaken, which Daniel Bahr had not yet succeeded in doing. During the election campaign for the 2013 general elections, the concepts of capitation fees and citizens’ insurance were discussed again, but neither was seriously pushed through. Health policy at this time is characterized by an astonishing cross-party consensus in which there are no deep conflicts because of the absence of financial pressure. This is due in no small part to the consensual policy of health minister Hermann Gröhe, which largely differs from that of Jens Spahn, who is more prone to conflict and interested in his own career (Bandelow et al., 2020). The transition of the income-independent additional contribution to an income-based model was also largely uncontroversial.

Only after the historic election in 2017 and the failed coalition negotiations between CDU/CSU, FDP and the Greens is this lack of conflict resolved. The SPD is entering the renewed negotiations for a grand coalition with the demand for citizens’ insurance. However, this does not become part of the coalition agreement; instead, the negotiating partners agree on an honorarium commission (BMG, 2018). The strong dominance of party-political figures and high-ranking politicians is also striking in the health policy debates between 2010 and 2020. All publicly prominent actors in the debate are health politicians (Karl Lauterbach, Ursula von der Leyen) or were or are health ministers (Daniel Bahr and Jens Spahn). The discourse is almost entirely unpopulated by actors from various key positions in the system, for example, from the ministerial bureaucracy, academia, or actors from self-governance. Health policy is thus apparently not the subject of a policy program of programmatic actors, but shaped by party-political debates that only play a real role in election campaigns. The centering of health policy around the person of Jens Spahn is one of the main differences from earlier reform periods. This is not to say that the respective ministers were not strong personalities or that there were no political conflicts over areas of health policy regulation, especially financing. However, reforms in the past were worked out much more in the shadows of the ministers. The media analysis also reveals some interesting statements against the backdrop of the theoretical perspective of policy feedback effects. Franz Knieps. as one of the former programmatic actors, states that it is necessary to design reforms in such a way that they provoke new reforms afterward (Bohsem, 2013). The reasoning behind this is that every reform has loopholes for actors to use the regulations in favor of their interests.

With regard to the biographical trajectories, and in contrast to the investigation period between 1990 and 2010, the individuals who have occupied the formal positions in the health care sector in the last ten years to date are neither biographically conspicuous nor linked by commissions or common experiences and career paths. Within the last few years, the relevant department in the health ministry has been filled by changing actors following the legacy of Franz Knieps, from Joachim Becker to Sonja Optendrenk, who recently took over as head of this department. When Jens Spahn took over the health ministry, he institutionally restructured the ministry’s organization by establishing a management department in which he primarily placed people whom he trusted personally and with whom he had a biographical connection. While the strong role of shared biography generally fits the logic of programmatic action, the fact that this leadership division, far from being open to external actors of the health care system, resembled a “closed shop” of actors working predominantly to push the health minister in his own political ambitions, did not resemble the construction of an overarching vision for the health care sector. While the minister’s agenda can be described as programmatic in that it followed a clear strategy of digitalization and patient-centered reforms, it was not linked to a programmatic group.

This becomes even clearer when looking at those in key positions who also do not share a biographical history. The new board members of the GKV-SV, Gernot Kiefer and Stefanie Stoff-Ahnis, come from different sickness funds and were not part of commissions or expert groups, in which they could have been involved in developing ideas for translation into policy programs. The current impartial chairman of the G-BA, Josef Hecken, does have a ministerial career behind him and was part of the preparatory group for the 2007 reform, apparently benefiting from the ideas he came up with himself. In his new position, however, he is no longer involved in any working groups, but is implementing measures instead of preparing them. This is another sign that the programmatic group is being dismantled.

Based on the observation that there is no evidence of programmatic actors in public discourse or at the level of formal positions in the health care system, no anchoring examples can be found in the analysis of professional actor biographies. Instead, the analyses show that there may very well be actors who have reached their positions through programmatic groups, such as in the case of the GKV-SV or Franz Knieps’ many years as department head. Even Franz Knieps’ successor in this position, Ulrich Orlowski, is seen in some eyes as his heir. In fact, however, given the diminished role of ministerial influence on major health care reforms (in part because such reforms did not exist in this form), a decline in programmatic action is becoming apparent. Although Ulrich Orlowski can still be seen as a programmatic actor to some extent, as he is also linked to other actors in the programmatic group through publications (Orlowski & Wasem, 2007) and close relationships (Interview G5), his activity in the reform process was clearly less visible and influential. Although some programmatic actors continued to hold important positions in the health care system, their influence diminished after the formation of the grand coalition in 2013. Hermann Gröhe was a rather weak, consensus-oriented health minister under whom no major policy change occurred (Bandelow et al., 2018). Jens Spahn uses the policy field for his own purposes and ambitions to reach higher positions. He has even dismissed some of the former programmatic actors in key positions in the health care sector (Klein, 2018).