Which three value decisions shape the institutional design of a solidarity-based health system such as Germany's, and what follows from them?

Solidarity financing (access must not depend on ability to pay), the equality principle (comparable situations get comparable care) and stable contribution rates (insurance income should only grow with wages). Together they push the cost pressure onto the providers of health services.

1. Solidarity financing. Access to health goods does not depend on ability to pay, which would be unjust; health is too important to leave to individual purchasing power. Personal responsibility for health-conscious behaviour is not asked about, and there is no deductible (although supplementary and private insurance exist).
2. Equality principle (Egalitätsprinzip): everyone in a comparable situation should receive the same care.
3. Stable contribution rates (Beitragssatzstabilität): the income of statutory health insurance (GKV) should grow in line with total wages, not faster; otherwise the competitiveness of the economy and many jobs could suffer.

The consequence: if spending grows faster than income but income is capped and access is guaranteed to all equally, the gap does not disappear. It is passed on to the providers (hospitals, doctors, nurses) as pressure, which does not resolve the mismatch between income and expenditure.

Go deeper:

• Noll & Wolf (2017) — section on the institutional design and its three value decisions (German).