Who pays,where.
Thirteen health systems. Four ways to pay. Free, and kept current.
13 systems. 4 models.
Bismarck
Contributions from wages pay sickness funds or insurers.
Beveridge
Taxes pay. The State runs most of the care.
National insurance
Taxes pay one public insurer. Care is often private.
Many payers
Employers, insurers and the State each pay for different people.
Every real system blends models. Each country sits where most of its money comes from.
Within each model, ordered by total health spending in 2024, largest first. Source: OECD, Health at a Glance 2025.
Germany
More on Germany
Europe at a glance.
| Question | Netherlands | Belgium | France | Germany |
|---|---|---|---|---|
| Model | Bismarck | Bismarck | Bismarck | Bismarck |
| Who pays | Private insurers | INAMI / RIZIV via sickness funds | Assurance Maladie, mutuelles | Statutory sickness funds |
| Who assesses | Zorginstituut | Committees, with KCE | HAS | IQWiG assesses, G-BA decides |
| Who sets price | Insurers; the Minister for costly medicines | Maximum price, then contracts | CEPS | GKV-Spitzenverband |
| Health apps | No dedicated route | Through care pathways | PECAN, one year | DiGA, on prescription |
| The gate | The sluis (a lock on costly medicines) | Article 111 contracts | ASMR: added-benefit rating | Added benefit |
Twelve words that open every door.
The vocabulary of health money, one line each.
- Payer
- Whoever’s budget pays the bill.An insurer, a sickness fund, the State, a hospital, or the patient.
- Reimbursement
- The payer pays back all or part of the cost.Approval lets you sell. Reimbursement means someone else pays.
- Approval
- Permission to sell, after checks on safety, quality and whether it works.For medicines, a marketing authorisation. For devices in Europe, a CE mark. In the US, FDA approval or clearance.
- Basic package
- The list of care that insurance must cover.In the Netherlands, the basispakket.
- Bismarck and Beveridge
- Two ways to fund health.Bismarck: insurance paid from wages, as in Germany. Beveridge: taxes, as in the UK.
- HTA
- Health technology assessment: is it worth paying for?Done by bodies such as NICE, HAS, IQWiG or Zorginstituut.
- Comparator
- What your product is compared with.The question behind every assessment: better than what?
- Added benefit
- How much better than the comparator.More benefit usually means a higher price.
- QALY
- One year lived in full health.A common unit to compare very different treatments.
- Cost per QALY
- The extra cost for each extra healthy year.England and the Netherlands use it to judge value. Germany does not.
- Reference pricing
- Copying prices from other countries.Why your first price follows you everywhere.
- Confidential deal
- A secret discount or condition in return for coverage.Also called a managed entry agreement.
Sources
Status October 2026. Sources: Zorginstituut Nederland, NZa, Rijksoverheid (NL); INAMI/RIZIV, KCE (BE); HAS, CEPS, Arrêté of 10 September 2024 on PECAN (FR); BfArM, G-BA, IQWiG, GKV-Spitzenverband (DE); Dutch Ministry of Health report on digital health financing in Europe (December 2025). Other countries: CMS, NICE, AIFA, Ministerio de Sanidad, SGK, MHLW, Canada’s Drug Agency, PBAC, FOPH.
Health spending order: OECD, Health at a Glance 2025, 2024 data (spending per person at purchasing power parity × population). Four models: after T.R. Reid, The Healing of America (2009), and the Commonwealth Fund country profiles.