Health insurance reform: Germans will soon pay 225 euros – but for families in Turkey and the Balkans, everything remains free?

Additional contributions explode: Why international law could block a fair statutory health insurance reform

Free for Türkiye and the former Yugoslavia, expensive for us: The legal dilemma of the new health insurance reform

Germany's statutory health insurance system (GKV) is grappling with a historic multi-billion euro budget shortfall and exploding costs. To avert impending financial collapse, a controversial proposal is on the table: millions of Germans would soon lose free co-insurance for their spouses and instead have to pay around €225 per month. But this is precisely where national austerity measures clash with international law. A social security agreement with Turkey, over 60 years old, continues to guarantee free coverage for dependents of immigrants who remain in Turkey. While the actual costs of this agreement are negligible for the GKV budget, the looming inequality is politically explosive. A critical test is brewing, where heated emotions collide with stark facts – and the pressing question hangs in the air: how can the German healthcare system be reformed fairly and sustainably?

Health care reform and the Turkey dilemma: When domestic austerity policies clash with 60-year-old international agreements – and the little guy pays the bill

Germany's statutory health insurance system is in deep crisis. In 2024, health insurance funds recorded a deficit of €6.6 billion – the sharpest increase in expenditures in three decades. Expenditures grew significantly faster than revenues, at over 8 percent, and the Federal Court of Auditors has explicitly warned of a persistent structural imbalance. For 2027, the IGES Institute, commissioned by DAK-Gesundheit, forecasts a shortfall of around €11.8 billion unless fundamental structural reforms are implemented. Even the short-term surplus of €3.6 billion achieved by the 94 health insurance funds in the first nine months of 2025 masks the structural imbalance: at 0.19 months' expenditures, reserves remained below the legally required minimum reserve of 0.2 months' expenditures.

The average supplementary contribution has almost tripled since 2015, rising from 0.9 to 2.5 percent. Health Minister Nina Warken (CDU) emphasized that the surpluses achieved should not signal any relief, and referred to a short-term package of measures already in place for 2026. Without structural adjustments, the Federal Court of Auditors' unequivocal message was that supplementary contribution rates could rise to over 4 percent by 2029.

66 cost-saving proposals and a particularly hot topic: The abolition of free co-insurance

To close the looming funding gap, the Health Finance Commission appointed by Health Minister Warken has presented a total of 66 reform proposals, which are expected to generate savings of up to €42 billion by 2027. One proposal stands out in particular because it directly affects millions of households: the abolition of free co-insurance for spouses without young children. According to the commission's recommendations, affected spouses will in future have to pay a minimum contribution of around €225 per month – divided into €200 for health insurance and €25 for long-term care insurance.

Of the 74.2 million people with statutory health insurance, a total of 15.6 million are covered free of charge, the vast majority of whom are children. Around three million adults would be directly affected by the planned reform. Exceptions are to apply only to married couples with children under six and to households with dependent relatives requiring care. Employers' associations estimate the potential savings from abolishing free co-insurance at around 2.8 to 3.5 billion euros annually. The measure is politically controversial: CSU leader Markus Söder has already categorically rejected abolishing free co-insurance for spouses, calling it "completely the wrong signal.".

A treaty from the economic miracle: Historical roots of the German-Turkish social agreement

To understand the current debate in all its complexity, one must look back to the early 1960s. On October 30, 1961, the Federal Republic of Germany and Turkey signed the recruitment agreement in Bad Godesberg, laying the foundation for one of the most defining migration stories of postwar Germany. The economic miracle of the GDR urgently needed workers, especially after the construction of the Berlin Wall in 1961 abruptly ended immigration from East Germany. Until the recruitment freeze in 1973, around 867,000 Turkish workers came to West Germany, of whom approximately 500,000 returned to Turkey.

The recruitment agreement originally stipulated the so-called rotation principle: guest workers were to return to their home countries after two years and be replaced by new workers. This principle quickly proved to be an illusion, as companies were unwilling to lose their skilled workers. Consequently, the rotation principle was abolished as early as 1964, and family reunification was permitted from the same year onward. In response to this changed reality, Germany and Turkey concluded a more comprehensive social security agreement in 1964, which explicitly extended insurance coverage to family members remaining in Turkey. This agreement remains in force today and forms the legal basis of the current controversy.

How the agreement works: Lump sums instead of individual invoices

The German-Turkish social security agreement allows employees of Turkish origin who are insured in Germany to insure their family members remaining in Turkey free of charge through their regular family insurance. Billing between the participating insurance providers is not done on a case-by-case basis, but rather via annually agreed monthly flat rates per family – regardless of the actual number of family members or the actual scope of services. This flat-rate calculation is based on the average cost of living in the family's country of residence, i.e., the Turkish price level.

The fiscal consequences of this system are revealing. In 2023, the monthly flat rate per family was just €21.06. By comparison, the average cost of the German statutory health insurance system per insured person in 2022 was around €310 per month. In other words, providing care for an entire family in Turkey costs the German health insurance system less than one-fifteenth of what it costs for an average insured person in Germany. This cost disparity is not a design flaw, but a deliberate element of the agreement, which takes into account the different price levels in both countries. Furthermore, no direct money transfers to private accounts take place: Payments flow exclusively between the participating insurance providers.

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Tiny sums, huge outrage: The fiscal classification of Türkiye's payments

Anyone following the public debate might easily get the impression that payments to Turkey are a significant factor in the statutory health insurance (GKV) financial crisis. A look at the sober figures from the GKV umbrella organization considerably puts this picture into perspective. In 2022, around €13.1 million flowed to Turkey, and in 2023, the figure was €13.4 million. During the same period, total GKV expenditures amounted to over €300 billion. The share of payments to Turkey in total GKV expenditures is therefore less than 0.005 percent.

It should be noted that between 2020 and 2023, a total of approximately €90 million was paid to immigrant families in several countries – in addition to Turkey, also to families in Bosnia and Herzegovina, Montenegro, Serbia, and North Macedonia. The share of costs for the entire EU and EEA area in the eligible benefit expenditures of the statutory health insurance system (GKV) amounted to only about 0.24 percent in 2024. These figures clearly demonstrate that anyone presenting the abolition of the social security agreement as a significant contribution to resolving the GKV financial crisis is not practicing sound fiscal policy, but rather appealing to emotions.

The legal knot: Why national reforms could fail due to international agreements

Herein lies the real political and legal dilemma. The planned reform concerns exclusively the free co-insurance under German national law. The German-Turkish social security agreement, on the other hand, is an international treaty that cannot be overridden by a unilateral change in domestic law. The National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) has clearly stated in its position paper that this is currently only a recommendation from the Finance Commission on Health and that the design of benefits for those insured abroad under the agreements cannot be influenced by the state.

The German Bundestag's Research Services have unequivocally determined in a report that family health insurance for relatives living in Turkey is just as free of charge as it is for family members residing in Germany. The same applies to the successor states of Yugoslavia, with which Germany also maintains a social security agreement dating from 1968, which continues to apply to Bosnia and Herzegovina, Montenegro, Serbia, North Macedonia, Croatia, and Slovenia after the dissolution of Yugoslavia. A reform of national law would thus create a two-tiered legal system: A skilled German worker with a non-working spouse would pay €225 per month from a certain cut-off date, while a colleague of Turkish origin would continue to have his family in Anatolia fully insured free of charge – as long as the agreements are not renegotiated.

The structural justice question: unequal treatment or historically grounded differentiation?

This potential inequality is at the heart of the political conflict. However, a more objective view reveals two distinct perspectives. On the one hand, the regulation arose from a specific historical context: The guest workers of the 1960s were recruited with social security provisions for their families back home because permanent residency, and thus family reunification, was initially explicitly discouraged. The agreement served as compensation for the restrictions on family reunification at that time. On the other hand, societal reality has fundamentally changed: The descendants of the guest workers have long since become part of German society, and new generations of immigrants encounter different circumstances.

The debate is complicated by the fact that a distorted picture is often painted in public discourse. The narrative of uncontrolled access to the German healthcare system or the claim that multiple wives can be co-insured repeatedly circulates. Both are factually incorrect: Turkey has recognized monogamy exclusively since 1926, and benefits are provided solely through in-kind assistance via the Turkish social security system, not as direct payments to individuals. Cost levels are aligned with the significantly lower Turkish price level, so the actual burden on the German statutory health insurance system remains marginal.

A look at everyday life: What 225 euros means for lower incomes

Anyone who assesses this conflict solely using macroeconomic indicators loses the crucial perspective: that of the individual. For a family with a lower-middle-income income—for example, a saleswoman, a warehouse worker, or a caregiver—225 euros per month is not an abstract figure, but a tangible cut in the household budget. This corresponds to a significant portion of food expenses, a full month's electricity and heating bill, or several weeks' pocket money for children. This household will not understand why their co-insurance should become subject to contributions, while their neighbor—with the same contribution rate and potentially the same income—can continue to insure their family in another country free of charge. The fact that this unequal treatment is legally explainable and fiscally insignificant does not change its emotional and social impact. A sense of justice is not created in the statistics office, but at the kitchen table. If the government does not actively resolve this contradiction or at least explain it openly, it undermines the trust of precisely those people who support the statutory health insurance system with their contributions every day. Social peace in a society is not solely based on macroeconomic rationality – it requires the feeling that the same rules apply to everyone. If this feeling is permanently damaged, rifts emerge that extend far beyond health policy.

Structural problem meets symbolic politics: What the debate about the system reveals

The intensity of public attention focused on payments to Turkey, which represent less than one hundred-thousandth of total statutory health insurance (SHI) expenditures, is symptomatic. It demonstrates how easily fiscally insignificant but emotionally charged issues can overshadow the actual reform debate. The structural problem of the SHI system is fundamentally different: expenditures are consistently rising faster than revenues, a consequence of demographic change, advances in medical technology, increasing nursing care costs, and increasingly complex hospital care. The funding gap of up to €47 billion by 2030 cannot be closed by terminating social security agreements.

Nevertheless, it would be politically unwise to simply ignore the question of fairness. If the free co-insurance for domestic spouses is abolished, an asymmetry will inevitably arise between national law and continuing international law. This asymmetry is legally explainable, but politically it requires explanation. The federal government and its coalition partners will have no choice but to either amend the agreements through diplomatic renegotiations or to communicate transparently why historically established international obligations remain valid even when national law changes. Both require political courage and sound judgment – ​​two qualities that are rare in a debate dominated by social media and cycles of outrage.

Reform perspective: How can the contradiction be resolved?

From an economic perspective, several solutions are conceivable, although they have different timeframes and political complexities. In the short term, clearer communication is needed: The German government should proactively demonstrate that the payments to Turkey are fiscally insignificant and that the agreements simultaneously offer considerable advantages to German citizens abroad – tourists, expatriates, and seconded workers. In the medium term, renegotiating the agreement would be advisable to adapt it to changed economic and social realities. It should be taken into account that the Turkish price level has risen since the 1960s and that the monthly flat-rate payment system could be modernized.

In the long term, however, the real problem is structural: the financing of statutory health insurance must be fundamentally reformed to permanently balance rising expenditures with stagnant revenues. The Finance Commission has provided an important impetus with its 66 proposals. Crucial issues—such as the financing of basic income recipients, the reimbursement structure for hospitals, and the efficiency of service delivery—offer potential savings of several billion euros annually. In comparison, the Turkey debate is nothing more than a diversionary tactic that, while appealing to understandable feelings of justice, offers no substantial solution to the real challenges facing the German healthcare system.

The real test for the coalition will be whether it is able to separate the substantive from the symbolic level: on the one hand, to implement a structurally viable financial reform, and on the other hand, to reassess old international legal obligations in a modern context without stirring up old resentments or creating new social upheavals.