Solidarity principle

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The solidarity principle describes solidarity as a fundamental principle of social security . This means that a citizen is not solely responsible for himself, but that the members of a defined solidarity community give each other help and support. The solidarity principle, also the solidarity principle, is the structural basis of the statutory health insurance (GKV). It represents the most important and central principle of social security in the event of illness, in which the illness risks to be insured are shared by all insured persons.

The solidarity principle in the statutory health insurance

The assessment of contributions for health insurance protection is based in principle on the individual financial performance (performance principle) of the insured. The amount of the contribution depends solely on personal income and is not based on the personal risk of illness, such as age, gender or health status. The benefit entitlement, in turn, is based solely on the degree of individual need, according to basically the same criteria (need principle); all insured persons are covered to the same extent, regardless of the contribution paid. The duration of membership and the lack of use of services over a longer period of time also do not lead to entitlement to benefits in the sense of saving benefits.

Solidarity compensation forms

By orienting the contribution assessment to the individual performance capacity on the one hand and through the granting of benefits on the other hand, a solidarity compensation takes place. This means considerable redistribution between the groups of insured persons. The solidarity principle within statutory health insurance is not implemented through direct and immediate assistance between individuals, but rather as an interpersonal redistribution of expenses for health care and supportive cash benefits. In the GKV there are different forms of redistribution and solidarity compensation:

Compensation
Compensation for damages is understood as solidarity compensation between healthy and sick people, both fundamentally and purely from an insurance perspective. It requires a sufficiently large number of contributors in order to finance the treatment of relatively fewer sick people by paying in relatively many healthy people with relatively few services used.
Social balance
Social equalization refers to the redistribution between higher and lower income. With the largely wage-proportional contribution financing, the GKV occupies a special position among social insurances.
Risk balancing
In the case of risk equalization, the members with a low risk of illness stand in solidarity with those insured with a higher risk of illness. This results from the assessment of contributions based solely on earned income, ignoring the statistical risks of the insured.

In addition to these three central forms of solidarity compensation, there is also talk of family burden compensation - through non-contributory family insurance - and generational compensation. However, these two forms of compensation are basically a characteristic or manifestation of the other solidarity compensations mentioned and do not appear alongside them as independent solidarity compensations. On the one hand, the fact that the obligation to pay contributions is linked to gainful employment means that no contribution is levied for spouses without their own work income and children. On the other hand, there is no performance-triggering characteristic “age” in the statutory health insurance system, the different health risks are compensated by the risk compensation, and there are also old net payers who pay for young sick people, which is why a generation compensation cannot be viewed as independent.

Scope of the solidarity principle

The needs-based care of all insured persons is legally anchored in § 1 SGB V, which states that it is the task of the statutory health insurance to maintain, restore or improve the health of the insured persons. The scope of the legal entitlement to medical services is specified in SGB V.

The solidarity principle is limited, on the one hand, by the economic efficiency principle and the requirement coverage principle in §12 SGB V and §70 SGB V, which are directly related to one another. It states that the services must be sufficient, appropriate and economical, but not exceed what is necessary. The service providers and health insurances have to guarantee a needs-based and uniform supply of the insured in accordance with the generally recognized state of medical knowledge. On the other hand, social solidarity and support should not completely replace personal responsibility and self-help, for which reason the principle of solidarity is accompanied by the principle of subsidiarity. This means that illness costs can be borne individually up to a certain level and the larger solidarity community only occurs when the individual or the smaller community is overwhelmed. The principle of subsidiarity can be found, among other things, in co-payments, for example for medicines, remedies and aids, dental treatment, dentures or hospital treatment. In contrast to private insurance, there is an obligation to insure and make contributions by law (i.e. public law); this is not to be confused with the obligation to contract under private law, because there is no contractual relationship in statutory social insurance. Hence the different legal process: It is not civil jurisdiction that is responsible, but social jurisdiction. Basically, according to §5 SGB V, workers, salaried employees and those employed in vocational training are obliged to participate in the solidarity community. Employees with an income above the compulsory insurance limit, the self-employed and civil servants and thus just under 10% of the population can exempt themselves from the effects of the solidarity principle. The publicly organized private insurance is open to them.

Solidarity principle vs. Equivalence principle

The solidarity principle of the GKV is opposed to the equivalence principle on the part of private health insurance (PKV). It is called equivalent because the amount of the contribution depends on the individual risk and the desired range of benefits. There are different optional benefits, for example, for hospital stays, dentures, the reimbursement of costs for alternative practitioners, daily sickness benefits and daily hospital benefits. In addition, a risk assessment determines the amount of the contributions, including factors such as the age at entry, the state of health at entry (previous illnesses) and the amount of the agreed deductible. There is a purely insurance-related balance between the sick and the healthy. The risk equalization is largely intercepted via the risk assessment; there is no social equalization between different income groups. While everyone pays a contribution in solidarity with the solidarity system, everyone insures themselves against their own risk within the PKV.

Solidarity principle in other areas of social security

The principle of solidarity can also be found in the other social insurance schemes in Germany, in which the insured form a community of solidarity. In general, the healthy help the sick with their contributions to health insurance, those in need of care in long-term care insurance , the young support the old in pension insurance (see intergenerational contract), and in unemployment insurance , employees pay for the unemployed. However, the principle of solidarity is not as comprehensive as in the GKV with income-independent solidarity. B. both pension and unemployment insurance are linked to the amounts previously paid in.

In the pension insurance - with the exception of the old-age insurance for farmers - the amount of benefits depends on the amount and number of contributions. A standard contribution is paid to the farmers' pension scheme, which can be reduced by subsidies if necessary.

In accident insurance , in contrast to GKV, risk compensation is included in the calculation of the premium. The statutory accident insurance is also an exception in that, by law, the liability of the company (employer) towards their employees in the event of an accident at work is replaced by the accident insurance. For this, the entrepreneurs (not the employees) have to pay appropriate contributions to their community of solidarity - namely those of the entrepreneurs in the various industries. Hence the frequent designation of the accident insurance institutions as "professional associations".

A general exception to the solidarity principle that every insured person is entitled to the same benefits are benefits that have a wage replacement function, such as sick pay , maintenance allowance , transition allowance , unemployment benefit, etc. a. These remuneration compensation benefits are based on the amount of the contributory remuneration.

Problems and limits of the principle of solidarity

Premium refunds for unused services tend to result in different premiums according to the individual risk and thus lead to a risk-equivalent differentiation similar to private health insurance. Due to the exclusion of services and co-payments, the sick, especially the chronically sick, are burdened disproportionately with costs, and the redistribution mechanisms inherent in the principle of solidarity are weakened. An increase in “individual health services”, which the patient pays directly to the doctor when they use them, a division of the service catalog into basic and optional services or the introduction of special tariffs would threaten to undermine the solidarity principle further.

The contribution assessment limit represents a further violation of the solidarity principle. It causes contributions to be frozen above a certain contribution amount, so that higher earners above the contribution assessment ceiling pay a lower percentage of their income to health insurance than less well-paid people. Thus, although they pay nominally above-average contributions, in relation to their performance they pay a rather lower contribution, which means a break with the performance principle of the statutory health insurance.

For low-wage earners, there is also a lower limit for the assessment of contributions: Voluntarily insured persons must pay contributions based on a fictitious income of at least one third of the monthly reference amount (2015: 945 euros); they are full-time self-employed, even with a fictitious minimum income of three quarters of the monthly reference figure (2015: 2,126.25 euros) ( Section 240 (4) SGB V). For low-wage earners, this leads to a far disproportionate contribution burden. This affects not only small businesses but also students who drop out of student health insurance after they have reached the age of 30 or the 14th semester, as well as unemployed people who (e.g. due to existing savings or other income (e.g. rental income)) are not entitled to unemployment benefits II , as well as housewives who live in an illegitimate partnership and are therefore not co-insured with their partner, but on the other hand are not entitled to unemployment benefit II despite a lack of income because their partner (with whom they form a community of needs ) earns too much .

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