Otto von Bismarck, called “the Iron Chancellor” had a project, to unify Germany under the leadership of his homeland, Prussia, and its king, Wilhelm I.
He succeeded when in 1871 Wilhelm I was proclaimed Kaiser, (emperor). Bismarck through three carefully plotted and planned wars, by diplomacy, with cunning, threats, and political will and skill had forged a new German Empire, a second Reich, in the heart of Europe.
It united Prussia with 25 other German kingdoms, principalities, grand duchies and duchies under the forceful national leadership of Prussia and the Kaiser as the head of state with Bismarck as chancellor, the head of government.
On the domestic front Bismarck contended with many political opponents and forces gathering strength in the latter part of the 19th Century in Germany, including notably the Catholic Church on the one hand and the Socialist Party on the other.
To bind Germany’s working class more closely to the idea of Empire, to the new powerful nation state by giving its members a sense of economic security — but also to ward of the appeal of socialism and the Socialist Party to the workingman, between 1883 and 1889, Bismarck created the first national social welfare program.
He capped it off in 1889 with the creation of an old age pension plan financed jointly by workers and employers. It anticipated passage of the American Social Security Law in 1935 under President Roosevelt by 46 years.
That was the last piece of the Iron Chancellor’s social welfare program, designed by that arch conservative to hold at bay the forces of socialism and the specter of unrest among the working class that he considered potential threats to his empire project.
The first piece, passed in 1883 by the Reichstag, the German parliament, he named the Sickness Insurance Law. Funded by employer and worker contributions, it established national health care benefits and up to 13 weeks of paid sick leave. It became the first system of national health insurance.
The third piece of his three-part system of social insurance came about in 1884 with adoption of the Accident Insurance Law to provide disability income and medical care for injuries on the job.
In 1890 the first Kaiser Wilhelm’s young, and very stupid grandson, Wilhelm II, fired Bismarck, who went off into the sunset to do what you do when you are a used-to-be. He wrote his memoirs.
The Iron Chancellor died in 1898, 20 years ahead of the abdication of Wilhelm II, who led Germany into World War I, watched 3 million German soldiers die and his empire dismantled; although he did live to see, from exile in Holland, the rise and fall of a Third Reich. But that’s another story.
Today, Germany is the leading economic power in Europe ranking as fourth largest economy in the world with annual GDP of $3.8 billion after the U.S., China and Japan. As or even more importantly, it is the anchor of the European Union, the bulwark of democracy in Europe because, right now, we have ceded that responsibility to the Germans – of all people, to the Germans — who surrendered to us unconditionally 72 years ago come May 8.
Within its own borders, Germany still maintains a system of national health insurance without doubt descended from that created by Bismarck.
It is not a centralized system. Private physicians provide care, hospitals are mostly not for profit and more than 90 percent of the population is covered by a nationwide health insurance plan paid for by employer contributions and public subsidies.
The amount of subsidy for each person depends on income. High-income earners can opt out of the system to buy private insurance from insurers who determine premium payments based on the health status of those who decide to take private coverage. But 90 percent of all Germans are in the public system (and no silly small, intellectually limited man like Paul Ryan, a creature who has sucked his living form the public teat virtually every day of his adult life, would have the temerity to tell them this shows a lack of initiative or inability to fend for themselves).
Like every modern health coverage apparatus and health system, Germany’s deals with rising costs, care management and expanding pharmaceutical choices and expenses.
That goes with the territory as it does in every other first world first world nation and democracy, and all but one of them has a system of national health insurance.
Among the world’s top ten economies, China, Japan, Germany, Britain, France, Italy, Brazil and Canada, have some form of a universal or near universal national health plan. The exceptions are India, where a chaotic mix of private and public health care systems is but part of that nation’s seething troubles, and the second of course is the United States of America.
Nations as diverse and widespread across the globe as Algeria, Ghana, Egypt, Israel, Singapore, Thailand, all the Scandinavian countries, even the tiny Isle of Man, have national health systems.
Each is different, each has a multitude of distinctions, differences, rules and different distributions of responsibility between public payers, employers, recipients and mixes of public and private care providers and centers of care. But all have one thing in common – they are designed to provide a base national system with a unity of purpose, universal health care.
All but India, And the United States of America.
So how did that happen to us? Why do we have a mélange of public programs of health coverage that carve out some segments of the population – the poor, children, poor children and seniors over age 65 (don’t call us aged any more) while leaving everyone else to depend on their employers or just fend for themselves if their employers do not provide health care or if people are self-employed.
In 1900 in the United States, by one estimate I read, the average person spent about $5 a year on health care. That would be $146 today. Not a lot of health care.
It was a fee for service system. You went to see the doctor if you were sick or injured or, believe it or not, the doctor came to see you. He, most doctors were men then though there were women doctors — provided his services. You paid in cash. If times were hard and you raised chickens maybe you paid him in eggs. But you paid him then and there with whatever you had to pay or as soon as you could.
That was pretty much the way it stayed although people here had taken notice of what Bismarck accomplished in Germany.
One of them former President Theodore Roosevelt ran in 1912 as a third party candidate on the Bull Moose ticket and proposed a system of national health insurance.
When Franklin Roosevelt proposed Social Security there were some around him, including his secretary of labor, Frances Perkins, who urged him to incorporate health coverage. FDR thought that a reach. He focused on and kept it to an old age income support program like the one Germany adopted 46 years before.
He intended to get back to the subject but one thing or another, especially WWII, kept him from bringing it up again, much less getting something passed into law.
But the world had not stood still and had become more complicated. Filling beds became important for hospitals that depended on patients to keep the lights on and the doors open.
In 1920 the Baylor University Hospital in Dallas came up with a scheme to assure a steadier flow of patients.
It made an offer to Dallas schoolteachers to provide assured hospital care if they paid 50 cents a month into a fund to finance their care. This small plan evolved and gave rise to the entire Blue Cross/Blue Shield system throughout the United States.
So the idea of coverage cost pools, of health insurance, came into being and slowly began to pop up here and there, even during the depression. But for the most part health care remained a mom and pop, pay as you go, fee for service business.
Then something happened to change that. World War II happened.
Peeling the Onion 