German doctors and hospitals will cheerfully bill you directly, no insurance necessary. They would be hesitant to schedule you for a very expensive procedure without an insurance card, but I just had surgery to insert and later remove pins to heal a broken finger as a "Selbstzahler" (self-payer), because I'm privately insured. This means that they simply sent me the bills, totaling about 1000 EUR, I paid them out of my checking account, and it's my own problem to get re-imbursed from my insurer. I think they checked my ID to make sure the billing address was legit.
Edited to add: I am merely a permanent resident of Germany, not a dual citizen.
I was a weird edge case, so had to get private: at the time of my residence permit application, I was a resident of a country that did not have compulsory health insurance (pre-ACA USA), married to a German with private insurance, and not yet employed (and no immediate prospects). I had to have German health insurance to get the residence permit, so private it was.
That makes sense. One has to love all those edge cases, right? I always choose to stick with public health care, even if I am elibible for private insurance for years now. There are reasons for that so, not the least some nasty past medical issues public insurers don't care about but private ones would at least increade premiums over.
The fun thing with private insurance so is that you see the invoices and amounts. Always puzzles me when I see those from my Dad...
Private insurance is great if you get it young enough, and without pre existing stuff, and get good conditions concerning premium increases with age.
Private health insurance in Geany is tricky, and since I stick with public I only have limited insight from the few times I looked at private insurance.
So, rule of thumb is that private health insurance gets more expensive with age and previous health issues (everything from injuries, sports, diseases, cancers...). So it is benefitial to get into privatr insurance early, because insurers price premiums over the expected life time value. As a result, the earlier to start paying into it, the lower the premiums down the road are going to be. E.g. some government jobs have defacto private insurance, and no way into public one, and if people do not start contributing during their active service, once they loose state provided coverage (again different from public insurance), premiums sky rocket upon retirement.
Public insurers (private companies offering the legally defined coverage) have to take everyone (some edge case exceptions apply to e.g. artists and the like), cannot adopt premiums based on anything patient related (thry have some leeway based on internal cost to increase premium for everyone of their members by a limited percentage).
Private insurers can more or less do whatever they want, even excluding pre existing conditions in some cases. Sucks if you had, e.g., cancer early in your life.
Are taxes used to subsidize the "public insurers" as defined by your comment?
Otherwise, I do not understand how the risk pool could possibly work. It seems like much of the healthy and young people would buy "private insurers", and the sick and old would be denied, so they would have to go with "public insurers".
But then that would mean the prices would be sky high for public insurance compared to private insurance?
One wrinkle: you have to be on public insurance if you're employed and making less than about 60k EUR/year (adjusts with inflation, more or less) AND (starting a few years ago) have been working less than three or four years. You get an exemption to the earnings rule if you're part time during the early parental years.
So that's how they make sure that most of the healthy, young people are in the public insurance system for at least a few years.
Sounds like people who earn more money can opt into a less costly risk pool, and people who earn less are forced into a more costly risk pool?
And because this was becoming too lopsided, they sacrificed the newest generation of higher income workers by requiring they be in the costlier risk pool for a few years?
Not at all. The private insurers limit the risk pool by excluding stuff, or denying people. The public risk pool is the vast majority of the 80 million Germans. And the whole health care system is basically built around this system. Nothing is becoming lopsided, and nobody is sacrificed, because the public coverage is really good.
EDIT: Regarding public coverage, the only supplemental insurances that are actually really useful are extended pay beyond the legal limit of 6 weeks per diagnosis and additional dental coverage. Other than that, I cannot imagine a worse case than cancer, and I got chief surgeon treatment 2 weeks after the diagnosis while being in under public insurance. So the system works just fine, even in some of the worst imaginable cases.
After a certain age you can't any longer switch from private to public insurance (exceptions exist). This is meant to prevent exactly such cases where you'd use cheap private insurance when young and healthy, and cheap public insurance at old age.
Taxes are not used to subsidize the public insurers. The risk pool is, as pointed out in the sister comment, that basically the majority of Germans are in the public model.
> even excluding pre existing conditions in some cases.
I think it most cases. I’ve had multiple private insurance companies reject me for minor pre existing conditions (some pills for anxiety/depression, minor surgery on my wrist etc). The brokers said I must have perfect health for 5 years and then reapply.
In my case private insurance would be significantly less than the public insurance I have now
Edited to add: I am merely a permanent resident of Germany, not a dual citizen.