In the discussion about the financial difficulties of the statutory health insurance (GKV), there are first calls for a significant reduction in the number of health insurance companies.

"Germany has almost 100 health insurance companies, no one needs that many," says health insurance manager Ralf Hermes, board member of the IKK Innovationskasse in Lübeck.

"It's hard to say how many registers are viable, but I'd guess half will do."

Christian Geinitz

Business correspondent in Berlin

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According to Hermes, if the “huge amounts of staff and structures” were reduced, a lot of money could be saved.

In his opinion, politicians should allow real competition, but otherwise stay out of insurance companies.

"The funds that don't make it have to merge or, if necessary, go bankrupt."

The IKK Innovationskasse with around 250,000 insured persons itself emerged from a consolidation when the IKK Mecklenburg-Vorpommern merged with the IKK Schleswig-Holstein in 2006.

Hermes says that companies with fewer than 100,000 insured have a very difficult time in the market because they have to buy many services - especially digital services - externally.

"Often there is a lack of money, staff and know-how." Around 50 German health insurance companies have fewer than 100,000 insured persons.

The largest German provider, Techniker Krankenkasse, on the other hand, has more than eleven million.

The number of cash registers has been falling for years

According to the National Association of Statutory Health Insurance Funds, 74 million people have statutory health insurance, which is 90 percent of the population.

They are taken care of by 97 health insurers, six fewer than in 2021. The number has been falling for decades: in 2000 there were still 420 providers on the market, in 1990 around 1150 and in 1970 more than 1800.

Hermes is against the system of a single dominant fund - comparable to the German pension insurance - because the health care system is very complex and authority-like monopolies are at the expense of all players.

But the current number of health insurers is still too high in view of the largely identical services in standard care.

There are also only minor differences on the price side.

All providers require the regular contribution of 14.6 percent of gross wages (up to the assessment limit).

Actually, a certain amount of competition should come about through the individual additional contributions, and in fact the range here varies between 0.7 and 3 percent.

But these two values ​​are outliers, the average additional contribution is 1.3 percent.

"In any case, it is clear that the fight for members is not about cheap contributions," says Hermes.

In his opinion, the cash registers can compete with each other much more in customer service and with additional offers.

His IKK wants to be the first house to pay for long-Covid treatments.

Even in the standard service, there could be more competition if the insurance companies had more freedom to negotiate with the service providers, he thinks.

So far, all health insurance associations have jointly regulated the total remuneration for standard care at state level in discussions with the health insurance physician associations.

"If there were more competition in all these areas, the wheat would quickly be separated from the chaff," says Hermes.

Expenditure increases faster than income

In the coming year, the risk is likely to increase that individual cash registers will run out of air.

Expenses are rising much faster than income due to expensive performance laws.

At the same time, the GKV assets are dwindling because the reserves are used to compensate for the deficit.

In order to cover the record deficit of 17 billion euros, the GKV Financial Stabilization Act of Health Minister Karl Lauterbach (SPD) provides for an increase in the average additional contribution by 0.3 points to 1.6 percent.

But even this increase could not be enough, as new calculations by Bitmarck Holding, the information service provider for health insurance companies, have shown.

The Bitmarck paper "Budget Planning 2023" states that for 71 percent of the funds, the increase in the additional contribution planned by Lauterbach will not be sufficient to cover the costs.

After reaching into the financial reserves, they simply no longer had enough assets to offset the expected flood of spending.

Some funds even ran the risk of slipping below the statutory minimum reserve.

The budget funds to support the statutory health insurance in the coming year will be EUR 16.5 billion, which is EUR 2 billion higher than in normal times;

plus another billion as a loan.

And yet Bitmarck states: "The competitive situation in the statutory health insurance system in 2023 seems to worsen significantly despite the federal subsidies." It is therefore quite likely that other providers will disappear from the market in the new year.