Serfdom in Health Care

Probably because socialism ruled in one part of Germany for almost 40 years, but this cannot be an excuse for reinstatement of a rule that had been overcome for centuries—German ambulatory health care system has been transformed into serfdom over the past 20 years or so. To better regulate this sector was the primary intention, to cut the ever growing health care expenses was the argument, and a hate-crime-like propaganda campaign of intimidation against physicians and health care professionals provided the backdrop. The following article not only discovers similarities between medieval and temporary rules but also historical roots that helped them to redevelop. This analysis is not about how the problems can be better tackled in the future, so it not provides any quick solutions. It is a mere analysis.

It is difficult to spot these laws that re-established serfdom in a particular economic sector as German constitution like in many other modern developed countries rather prohibits serfdom. Despite of this many rules de facto removed civil rights granted by the constitution. These are.

  1. The free choice of medical practitioner. Now it says the patient certainly can choose an other physician, but this will not be covered by health insurance, and as the physician is not allowed to accept payment out of the patient’s own pocket.
  2. The free trade of goods and services. Even if there is a demand a physician can not offer his service. The service is not paid for by health insurances and again cannot be paid for by patients themselves.
  3. The free choice of the place residence. A physician receives payment if and only if he stays at a definite place. He cannot move without permission.

How German politicians succeeded in re-establishing serfdom in one economic sector?

Decades ago, physicians created a local organization to ease payment handling. In principle, this was a good idea. Neither the patients had to pay for health care service directly, nor the health insurances had to process invoices for each patient separately. Instead, the invoices are collected by the local organization and health insurances pay them. From the local organization, physicians receive their monthly payment adjusted to the service actually provided. This way to handle payments significantly reduced the burden of administration for each physician and assured equal pay for equal work. However, these organizations have been transformed into rulers comparable to medieval landowners, or manors. As politicians granted them more and more control functions the physicians became serfs.

What are the points that make German ambulatory heath care system similar to serfdom?

The following table compares the features.

Medieval Serfdom German outpatient Health Care
1 A contract that cannot be denounced assures the mutual dependence identical
2 The peasant is not allowed to leave the land. A physician serf leaving his assigned area spells he loses all his income.
3 A peasant had a fixed workload and all what he accomplished above that was his own property. A physician serf doesn’t has such a freedom.
4 Peasants were allowed to sell surplus on the town’s free markets. The only way to sell medical services is through the manor.
5 A peasant was allowed to employ helping hands as much as necessary and economically reasonable. More than one employe for a limited time is strictly forbidden.
6 There had to be paid a fee annually and when business is handed over. Identical.
7 A peasant can pay a ransom to leave serfdom. There is no such thing in German ambulatory health care system.
8 With moving borders a serf got an other landowner. Same thing.
9 Legal regulation left the peasants almost without rights to sue their landowner. The possibilities to control the manor are limited, cumbersome, expensive, and enormously time consuming. They practically don’t exist.
10 In order to consolidate its power the landlord regularly demonstrated peasant’s powerlessness. A complex system of intimidation is established.

ad1) The core of medieval serfdom was formed by a contract between landlord and peasant. In this contract the landowner warrants legal protection from outlaws, in internal disputes among peasants, and even international affairs that is wars. On the other hand, the peasant guarantees that he will till the landlord’s soil. A similar contract forms the core of German ambulatory health care system. A local organization called Kassenärztliche Vereinigung (KV) serves the role as landlord and the physicians are like peasants. The land in agriculture is the patient pool in health care. As the medieval contracts defined the soil that a peasant had to till; the contracts in German ambulatory health care determine size and composition of the patient pool to be treated by each physician. Typical of contracts that consolidate serfdom is (1) neither side can repudiate it, (2) there is no way for a professional neither peasant nor physician to earn a living without such a contract, so the contract captivates labourers.

ad2) As in medieval times fugitive peasants have been recaptured and punished by brutal force, the German physician serfs are disciplined by economic pressure. If a physician leaves his place he loses all possibilities of creating income except he finds an other manor, an other local organization, that will offer a contract. It is not likely that the new position will be an improvement. Good positions are subject to bribery, of course, as such a system promotes bribery and corruption.

ad3) Here is a difference that makes contemporary health German health care system even more restrictive than medieval serfdom. While a medieval serf had to accomplish a certain amount of work on a landlord’s land and was free for the rest of the time, this is not the case for a physician serf, which leads to the next important difference.

ad4) A peasant had the opportunity to sell own products on town’s free markets. A serf physician is not allowed to do so except for outlandish products and services with no serious medical use and which rather damage a physician’s reputation as a serious scientist.

Historically the town’s free markets gave rise to developments that finally discontinued serfdom in developed countries. Obviously, German politicians have learned from history, by disallowing free trade they cut all progress by the roots.

ad5) While a medieval peasant had the chance to buy labour, physician serfs are not allowed to do so. The local organization try to preserve their monopoly.

ad6) Fees and dues are common everywhere, and as the organization provides legal protection, demanding a fee is understandable. The question is however, does the provided service justifies the fee. Clearly unjustified this fee appears to those who only suffer restrictions no legal protection.

ad7) If it were allowed to pay a ransom to free oneself from serfdom, this would have ended serfdom in German ambulatory health care system immediately.

ad8) In medieval times a landlord was able to sell his land along with his serfs. Practically this would be possible in Germany too. If borders changed within the country, certainly the physician serfs had to contract with an other manor. This rarely happened in the past, but I am not sure whether this lack of dynamism is positive or negative.

ad9) Of course, a physician serf has the right to sue his manor after several appeals have been denied by the manor, but even then the serf physician ends up at a court where at the first instance two of three judges are recruited by the organization to be sued. At the second instance still one of three judges is from the organization, the last instance only is made entirely of independent judges. Not necessary to mention, it takes years, even decades, through all these instances, especially if you are right. Conclusively this control mechanism nearly does not exist, which is quite similar to feudalism.

ad10) Permanent repression and intimidation is a hallmark of each dictatorship, and so it is the case with German health care system too. German mass media and mostly left wing politicians permanently offend physicians by phrases that would earn them massive public disapproval if directed against minorities or women, for instance, but obviously physicians in Germany are regarded as people to whom human rights do not apply.

The most sophisticated method of intimidation is the so called regress. Health insurances have the right to claim damage if costs of a physician’s prescribed pharmaceutics exceed the average value. Not only that this rule does not yet exist when perpetrated, as the average can be calculated only after a certain period of time, this rule also secures that always a certain number of physicians is condemned, however the average might be, as this number is defined by the variance only. If all patients were the same and treated the same, the variance would not exist and no physician could have been convicted. But patients are not the same, as we all know, and therefore there will always be a variance corresponding patients variability, and conclusively this rule always yields a number of physicians that can be publicly punished for wasting money. The statistical method is only to disguise the arbitrary character of this punishment, to give it a more contemporary touch. In principle it is the same as making a random choice, or as Roman emperors put it, decimating. The purpose of such measures is to let the physicians feel their powerlessness to escape the system, which is meant to raise discipline.

What are the consequences of feudalistic rules?

Feudalistic rules are common in Germany. After all leading European countries have removed feudalism, such as Netherlands, England, and France, Germany still stuck deep in feudalism. Serfdom actually has been removed in the area where I live only a couple of more years than a century ago. After feudalism has been finally removed 1918, some of its rules have been reinstated by German fascists, and in East Germany under Russian protection such rules survives till 1989. It is not surprising though that only a few years later, mostly left wing politicians, again reinstated such rules in an isolated economic sector trampling human right. I wished that German society became more sensitive to violations of human rights.

But it is not only that deficiencies in perception of human right violations promote the development of rules that actually violate them. It also works vice versa. Rules that impose severe restrictions distort the understanding of human rights and freedom. Here is why in Germany and especially in East Germany extremism is on the rise. Also feudalism hinders progress. So it was the long lasting feudalism in Germany that prevented Germans from becoming a significant colonial power. Not until after the final removal of feudalism German economy started to flourish. On the other hand, the reinstatement of feudalistic rules in German health care marks the decline of this sector. Not only gifted scientists leave the country also whole research institutes and companies. Actually the newly elected government raises some hope for changes to the better. Also I hope that American health care reform can provide some directives if only they do not try to copy the German mistakes.


1 Comment

  1. E. Baganz said,

    2011/03/27 at 1:51 pm

    I wanted an interpretation of serfdom and I should run into scary you!
    I see parralels in the US. Makes me despise organized Politics, or organized religion for that matter, more than before. Dishonesty and deception rule today. The Melting Pot Mind seems to be disapearing at an alarming rate.

    German native who has lived in the US since 1954.

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