Prevention Is Covered by Insurance, the Feeling of Safety Is Paid by You

A form from a gynecology practice separates what the law provides from what costs extra. It acknowledges that statutory screening is sufficient and offers security on the same sheet for a bill. That is not illegal, but it has been criticized for years.

Originally, some of us had come to Germany for the ongoing reporting on the AfD. But the country offers a collection of things that make you stop and pay attention, from gynecologists to Sea Bridge and the Malteser wish program to pension reforms, and everywhere the country seems no longer to know its own citizens. Here is a small thoughtful story that came into our hands.

On a clipboard in a gynecologist’s office lies a sheet that at first glance feels like a threat, cancer screening for an additional fee. It is not. It is an explanation of individual health services, known as IGeL, the German term for what the patient pays for herself, and in many practices it is a familiar sight. The document itself states that the services covered by insurance ensure adequate early detection under the law. And then it offers more. Since early 2020, these rules have applied. Women between twenty and thirty four receive an annual smear test, the Pap test, to detect cervical cancer early. From age thirty five onward, it is combined every three years with an HPV test. The annual visit to the gynecologist remains an important part of prevention for everyone. That is the program, and the sheet does not hide it.

Over that program, the practice lays out a price list. Fifty euros for a vaginal ultrasound, sixty euros and thirty one cents for a breast ultrasound, which requires a separate appointment, ten euros for the annual smear after age thirty five and fourteen euros and fifty six cents for the laboratory, ten euros for the HPV test and forty one euros and fifty nine cents for the laboratory, sixteen euros and eight cents for sexually transmitted disease screening and ninety nine euros and nine cents for the laboratory. The bill comes according to the medical fee schedule and cannot be submitted to insurance. The justification the sheet gives is not medical but emotional. Many patients, it says, feel less secure with the longer intervals, and because cervical cancer can remain unnoticed for a long time, regular screening is crucial for personal peace of mind. None of this is illegal. But the language works on emotions, and that is exactly what has been debated for years.

The annual smear after age thirty five is the revealing line. Many women believe insurance has taken something away from them, even though screening was only changed, Pap and HPV every three years instead of Pap alone every year. Whether more frequent testing makes sense is a question of risk and personal history for a physician to weigh, not a question of wanting more control. Sold as reassurance, the wording lives off a loss that never actually happened. The law places a foundation under all of this. An individual health service must be voluntary and free of pressure, and both its benefits and its limits must be explained. You may refuse it, and the patient must then be treated exactly the same as before. The form includes a box for no, placed next to those for ultrasound and the smear, along with a seasonal flu shot. That box is proof that the rest is voluntary, and a reminder that voluntary is not the same thing as weightless.

There is also what the form does not mention. Contributions to Germany’s statutory health insurance are among the highest in Europe. Month after month, a substantial part of wages disappears into it, and at the end of that chain sits a woman in a chair who is asked to pay once again for the certainty of being healthy. There is something degrading in filling out such a form after paying into the system your entire life. Whoever gives that much should not have to bargain over a feeling at the threshold of prevention.

Fear is the oldest salesman, and it sells best where the product is real. Cancer is real, and the desire to be safe from it is the most human desire there is. That is exactly what makes the price list uncomfortable. When a practice writes that the free screening is sufficient and in the next line offers security for money, it has put a price on a feeling, and once a feeling has a price it can never again be truly free. The patient signs that the prevention offered by law is enough and still pays because the sheet has already taught her that sufficient does not feel like enough. In Germany, you do not have to buy cancer screening. But the feeling of being safe has quietly become a product.