Aim. To examine why the demand for substitutive voluntary health insurance in Germany is low. Method.Acomparison of the benefits andcosts of statutory andvoluntary health insurance in Germany, basedon a review of literature publishedin academic journals andbooks as well as gray literature. Results. Employees in Germany with gross earnings over 40,500 a year can choose to opt out of the statutory health insurance scheme (Gesetzliche Krankenversicherung, GKV) andpurchase substitutive voluntary health insurance instead. Only a quarter of these employees and their dependants actually choose to opt out; the majority remain in the GKV. Substitutive voluntary health insurance does not generally afford greater benefits than the GKV in terms of services provided or choice of insurer and only affords marginal benefits in terms of choice of provider. It is also more expensive than the GKV for people with dependants, elderly people and people in poor health. Consequently, the choice to opt out andpurchase substitutive voluntary health insurance is more likely to be taken by young, healthy or single people or couples with double incomes. Conclusion. Our analysis suggests that the demand for substitutive voluntary health insurance in Germany is low because the costs of opting out of the GKV are, in general, higher than the benefits afforded by purchasing substitutive voluntary health insurance. In the long term substitutive voluntary health insurance does not appear to provide good value for money when compared to the GKV, particularly for people with dependants, elderly people, and people in poor health
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