Health ministry · Institutions
The German health system: who decides what
The Federal Minister of Health does not run hospitals, set doctors’ fees or decide which treatments insurers cover. Those powers are shared between parliament, the ministry, the Länder, federal agencies and a self-governing system of insurers and providers. To understand any reform, you need this map first.
Four organising principles
Most institutional features of the system follow from four long-standing principles.
Social insurance, not a national health service
Care is financed mainly by compulsory insurance contributions linked to earnings, not by general taxation. The system goes back to Bismarck’s 1883 health insurance law. It is still organised through legally independent insurance funds (Krankenkassen), not a state agency.
Solidarity
In statutory insurance, contributions depend on income, not on health risk, and everyone is entitled to the same benefits. Children and non-earning spouses can be insured free of charge through family co-insurance. This is explained on the statutory health insurance page.
Self-administration
The state sets the legal framework but delegates the detail to self-governing bodies. Insurers, doctors, dentists and hospitals negotiate fees and decide the benefits catalogue in the Federal Joint Committee. The ministry supervises the legality of those decisions.
Federalism
The Basic Law shares health powers between the federal level and the sixteen Länder. Berlin legislates on social insurance. The Länder plan hospitals, are responsible for funding hospital investment, run the public health service and supervise regional insurers.
Institutional map of the German health system
SourceEditorial schematic based on Social Code Book V; number of insurers: BMG, 1 Jan 2026; insured persons: GKV-Spitzenverband, mid-2026. Long-term care is financed separately through long-term care insurance, run by the care funds attached to the health insurers.
02 / The map
Seven layers, one system
Read the diagram from top to bottom. Parliament passes the laws, mostly in Book V of the Social Code (SGB V) for health insurance and Book XI (SGB XI) for long-term care insurance. Many health laws also need the consent of the Bundesrat, where the Länder governments sit.
The Federal Ministry of Health drafts bills, issues ordinances and supervises the legality of the federal self-governing bodies. Its agencies handle tasks that need scientific independence. BfArM authorises medicines and medical devices and monitors supply shortages. The Paul-Ehrlich-Institut is responsible for vaccines and biomedicines. The Robert Koch Institute is the national public-health institute for disease surveillance and prevention.
The Länder appear as a separate layer because their role is constitutional, not delegated. They decide which hospital is in the state hospital plan and which service groups it may provide, and they are meant to pay for buildings and major equipment.
The Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) is the most powerful body most citizens have never heard of. It decides which treatments the statutory funds pay for and sets binding quality requirements.
Money flows through the health fund (Gesundheitsfonds), managed by the Federal Office for Social Security (BAS). It passes risk-adjusted amounts to the insurers, which then pay providers under contracts and fee schedules. This is set out on the health financing page.
The dual system: GKV and PKV
Germany is one of very few countries where substitutive private insurance exists alongside the statutory system.
Statutory health insurance (GKV)
Membership is compulsory for employees below the compulsory-insurance income threshold, for pensioners who qualify, for students, and for recipients of unemployment benefits and basic income support. Contributions are a percentage of earnings: a general rate of 14.6% plus each fund’s additional contribution. Benefits are the same for everyone, whatever they pay. Insured people can choose their fund freely, so the funds compete on additional contribution, service and optional extras rather than on core benefits.
Private health insurance (PKV)
Self-employed people, civil servants and employees earning above the threshold can opt for private cover. Premiums depend on age at entry and health status rather than income. Contracts are individual, and each family member is insured separately. Civil servants get part of their costs paid by their employer through Beihilfe and insure the rest privately. Doctors bill private patients under a separate fee schedule, which is one reason waiting times differ between the two groups.
Political positionPolitical position In the Bundestag on 23 September 2026 Linnemann rejected abolishing the PKV, citing constitutional concerns and the dual system’s openness to innovation. He suggested applying GKV decisions to civil servants’ Beihilfe instead. The alternative, a single “citizens’ insurance”, is favoured by the SPD, the Greens and the Left.
Who delivers care
Germany separates outpatient and inpatient care more sharply than most comparable countries. Each sector has its own planning, payment and representation.
Hospitals
In 2024 there were 1,841 hospitals with 472,900 beds and 17.5 million inpatient cases (Destatis). Owners are public, non-profit (often church-based) or private. Operating costs are paid by insurers, mainly through diagnosis-related groups (DRGs). Investment is a Länder responsibility. See hospitals.
Office-based physicians
GP and specialist practices that treat GKV patients must be accredited and belong to one of 17 regional associations of statutory health insurance physicians (Kassenärztliche Vereinigungen, KVs). The KVs negotiate a total budget with the insurers, distribute it among practices, organise the out-of-hours service (116 117) and must make sure there are enough doctors. Their federal umbrella is the KBV.
Pharmacies
Community pharmacies must be owned by pharmacists, and an owner may run a main pharmacy and up to three branches. Prescription drugs are dispensed at uniform prices. Since 1 January 2024 the e-prescription has been mandatory. A pharmacy reform (ApoVWG) passed the Bundestag and Bundesrat in May and June 2026 Inherited.
Long-term care
Home care services and care homes are paid by long-term care insurance, a separate branch set up in 1995 with its own contribution of 3.6%. It covers part of the costs; the rest is paid by the person in care or by social assistance. At the end of 2025, 6.01 million people received benefits from social long-term care insurance (BMG). See nursing.
Rehabilitation
Medical rehabilitation is paid by different bodies depending on its purpose. Pension insurance pays when the aim is to keep someone in work, health insurance for older people and those not in work, and accident insurance after workplace accidents. This fragmented responsibility is a long-standing issue in coordinating care.
Health workforce
About 6.2 million people worked in the health sector at the end of 2024, 4.6 million of them women (Destatis). There were about 446,000 practising physicians at the end of 2025 (German Medical Association). See medical workforce.
The self-governing bodies
The bodies that shape day-to-day care in the GKV.
| Body | Who it represents | Main tasks | Supervised by |
|---|---|---|---|
| G-BA (Federal Joint Committee) | Insurers, physicians, dentists, hospitals; patient representatives (right to speak, no vote); three impartial members | Binding directives on the benefits catalogue, quality assurance, needs planning, benefit assessment of new drugs (AMNOG) | BMG (legality; may object to directives) |
| GKV-Spitzenverband | All statutory health and long-term care insurers | Federal framework contracts, fee negotiations, AMNOG price negotiations, voting members in the G-BA | BMG |
| KBV / 17 KVs | Office-based physicians and psychotherapists in the GKV system | Fee schedule (EBM) with insurers, distribution of fees, guarantee of outpatient care, appointment services | BMG (KBV); Länder (regional KVs) |
| KZBV / KZVs | Dentists in the GKV system | Dental fee schedules and outpatient dental care | BMG; Länder |
| DKG (German Hospital Federation) | Hospital operators’ associations (a registered association, not a public body) | Negotiates the DRG framework with insurers, appoints members of the G-BA | No state supervision as an association |
Source: Social Code Book V (§§ 91, 217a, 77 ff.); editorial summary. Patient representation in the G-BA is regulated in § 140f SGB V.
The model has clear strengths. Decisions are made by people with expertise, are largely independent of election cycles, and are paid for by the system rather than the federal budget. Critics point to slow procedures, decisions shaped by the interests of the bodies at the table, and the difficulty of reforms that cut across sectors, such as moving treatment from hospitals to practices. Every health minister in recent decades has used legislation to impose deadlines or outcomes on these bodies. Linnemann’s announced primary-care system would also require major changes to how the KVs, insurers and hospitals divide responsibilities Proposed.
Federal, Länder, self-administration: who is responsible?
A quick reference for working out who is responsible when something goes wrong.
Contribution rates and benefits
Federal: the general rate (14.6%) and the long-term care rate (3.6%) are set by law. The BMG announces the official average additional contribution each autumn after the estimators’ group has met. Insurers: each fund sets its own additional contribution. G-BA: defines the detailed benefits. The 2027 average additional contribution is not yet set Open question.
Hospital structures
Federal: payment system, service groups and quality criteria (KHVVG, KHAG). Länder: hospital plans, assignment of service groups, investment funding. Self-administration: InEK calculates the DRG weights; insurers and hospitals negotiate budgets.
Doctors’ practices and waiting times
KVs: must ensure there are enough practices, run the appointment services and the 116 117 on-call service. G-BA: needs-planning directive. Federal: legal framework; the primary-care reform is announced for November 2026.
Medicines and shortages
Federal / BfArM / PEI: authorisation (alongside the EU’s EMA), pharmacovigilance and shortage monitoring. G-BA and GKV-Spitzenverband: benefit assessment and price negotiation under AMNOG. Länder: pharmacy supervision.
Public health and crises
Länder and municipalities: public health offices (Gesundheitsämter) implement infection protection. RKI: surveillance and recommendations. Federal: the Infection Protection Act; a Proposed Gesundheitssicherstellungsgesetz on keeping care running in crises was announced on 23 September 2026. See health security.
Long-term care
Federal: SGB XI, contribution rates, benefit amounts (PNOG bill adopted by the cabinet on 30 September 2026). Care funds: pay benefits; the medical service assesses need. Länder: care infrastructure and training. Municipalities: social assistance where own resources are not enough.
07 / The minister’s levers
What a federal health minister can actually change
Since 29 July 2026 Carsten Linnemann has had the levers available to any federal health minister. He can introduce bills, with cabinet and coalition agreement. He can issue ordinances where the law allows it. He can object to G-BA directives on legal grounds. He supervises the federal agencies and the federal self-governing bodies. And he controls the BMG’s budget: €14.33 billion in the 2027 draft, against €21.77 billion in 2026. Most of that budget is transfers, the largest being the federal subsidy to the health fund.
What he cannot do is decide hospital plans, fix individual fees or order a fund to lower its contribution. This is why so many of his early announcements are framework laws, from primary care and emergency reform to bureaucracy reduction and data registries, and why his principle of steering patients better depends on the cooperation of the KVs, insurers and Länder. The minister’s page follows each file.
Sources & further reading
- Federal Ministry of Health — GKV financial results 2025 (93 funds) (10 Mar 2026)
- GKV-Spitzenverband — Key figures Q1/2026 (Jun 2026)
- GKV-Spitzenverband — Administrative costs and number of funds
- Gemeinsamer Bundesausschuss — Tasks and organisation
- Destatis — Hospitals 2024 (6 Nov 2025)
- Destatis — Health workforce 2024 (27 Jan 2026)
- German Medical Association — Physician statistics 2025
- Federal Ministry of Health — Long-term care insurance, facts and figures (Jul 2026)
- Federal Ministry of Health — Government question time (23 Sep 2026)
- German Bundestag, hib 733/2026 — Minister in the Health Committee (23 Sep 2026)