The Federal Joint Committee in the German health system. Political accountability deficit caused by a decoupled government institution?
Term Paper (Advanced seminar) 2014 13 Pages
Table of contents
2. Public Accountability as analytical framework in health system
2.1. Framework for analysing political accountability
2.2. Indicators for accountability deficits
3. The Federal Joint Committee in the German health care system
3.1. Legal status & effects on accountability relations
3.2. Insufficient Interest Representation & Intransparency
3.3. Conclusion-an example for weak political accountability and an accountability deficit?
This paper is grounded on the content and theoretical focus of the seminar Accountability, democracy and management in the welfare state, which I attended at the University Potsdam in summer semester 2014. It deals with the issue of using a couple of premises from the academic field of accountability to analyze one specific output of a reform in the German health care system in relation to the founding and the work of the Federal Joint Committee (Gemeinsamer Bundesauschuss/ G-BA)  since 2004.
The leading question in this paper is if one specific structural reform output in the German health system, concrete the institutionalization of the Federal Joint Committee according to the SHI Modernization Act (GKV- Modernisierungsgesetz/GMG) in the beginning of 2004, is an example for building a quasi- governmental institution with limited external political accountability relations which causes an political accountability deficit.
In this context we need at first take a closer look on the often used term accountability to get a better picture of its various meanings and circumstances of use in the literature, society and the media, so we have to briefly describe the meanings of the terms accountability, democratic and political accountability and accountability deficit. Accountability is nowadays often used to describe a social relationship between organizations or individuals who feel an obligation to explain and to justifiy his or her conduct towards other actors. Though it can be defined as “a social relationship in which an actor feels an obligation to explain and to justify his or her conduct to some significant other “. It could be also said that it is all about “[..] holding agents to account for meeting standards and expectations of various principals- including executives , legislatures[…] and various publics.“ Our relevant actor and accountor here is therefore the Federal Joint Committee to be precise its board with 13 members and the accountee will be the general public and relevant stakeholder in the national health system like the members of the statutory health insurance, patients mandatory or organizations who represent the interest of people with chronic diseases and handicapped persons.
In the literature there has been a large discussion about traditional and new types of accountability according to their analytical background and administrative context in which they appear. Examples for traditional types of accountability are: political accountability, bureaucratic accountability, personal accountability and professional accountability. In the following it will be all about using an image of political accountability and its features and mechanisms to test if we can reveal an accountability deficit of the Federal Joint Committee. Therefore it is important to refer about political accountability and its issues in a nutshell.
The idea of political accountability is close related to issues and questions of democracy and legitimation. That means that elected and even non-elected bodies of government “[…] have to answer for their actions to a wider public either directly, when politically elected or indirectly as subordinates of political elected bodies.”  The requirements of political accountability according to the legitimation and the structural setting of the institution are mentioned below more precise.
An accountability deficit refers to a condition where those who govern us are not sufficiently hemmed in by requirements to explain their conduct publicly- to legal, professional, administrative, social or political forums that have some sort of power to sanction them. According to Mulgan an accountability deficit on the national level occurs when, “[…] the control of elected leaders via hierarchical chains of command has been breached or weakened[…]”.
The object of desire which is to be analyzed with a framework of political accountability is the Federal Joint Committee (G-BA). It is the highest decision-making body of the self-government of doctors, dentists, psychotherapists, hospitals and health insurance funds in Germany. The members decide about the medical care guidelines to guarantee an adequate, appropriate and efficient treatment for all the members in the statutory health insurance system. About approximately 69 million people in Germany are member in the statutory health insurance and therefore somehow directly affected by the decisions of the Federal Joint Committee. It is therefore a powerful decision-making institution. In addition to that fact the Federal Joint Committee is not subject to external subject specific supervision. It is only subject to the legal supervision by the Federal Ministry of Health even though it is not a direct part of the public administration and the members are not public officials and there has been indeed a massive delegation of official tasks towards it. This institutional and legal background of the Federal Joint Committee should be analyzed in the third part closely to answer that question if the organizational modus affects the accountability logic.
That indicates that the decisions of the G-BA on the definition of the components of the medical care guidelines are almost untouchable afterwards in qualitative matters but therefore indeed in legal and procedural in an ex-post perspective by the Ministry of Health. This ability to determine main issues of the medical care system independent from the parliament has drawn criticism from some quarters. Many actors from society and key stakeholders in the health care system like representatives of patients and even some members of the German federal parliament had a few points of criticism on behalf of a missing control of decision making and the lack of transparency.
This strong cross-protagonist criticism towards this institution combined with its capability for crucial decision- making sets a frame for questions of accountability and related issues like ways to increase democratic control, information rights and transparent decision-making. It might be relevant though to follow that question and therefore apply an accountability framework to analyze the G-BA as institution in the national health system. To increase the relevance of this proposal it could be mentioned that it is often assumed that improved accountability is a necessary factor for improving health systems and also an indicator for good governance because accountability “has come to stand as a general term for any mechanism that makes powerful institutions responsive to their particular publics”.  Analyzing recent reform effects in the context of a national health system might also help to identify unintended reform effects although the accountability perspective was not included in the reform efforts connected with the SHI Modernization Act.
The preliminary hypothesis is that the Federal Joint Committee is an example for insufficient political accountability relations through a reform in the health sector. Neither there has not been an increased amount of transparency nor an increased amount of political control possibilities towards the Federal Joint Committee as a result of the SHI Modernization Act. Therefore the G-BA is an example for a decoupled quasi-governmental organization with the nature of self- administration under weak hierarchical chains and a lack of basic democratic elements of control like the possibility to participate and legitimacy through elections.
In the following I will first present the accountability framework which tries to cover up all relevant premises and indicators of political accountability and second a model of accountability relations in the health sector. In the third part of this paper I will try to analyze the institutional context of the Federal Joint Committee to reveal under which logic the institution has been created and which effects occurred on the accountability relations to answer the question if there has been an accountability deficit.
2. Public Accountability as analytical framework in health system
As mentioned before the term accountability has different meanings and is often used in unclear distinction towards related terms like responsiveness and answerability and the analytical frameworks attached to the term to analyze certain developments is multidimensional. All health systems contain accountability relations of different types but there is always the same accountability logic as mentioned above- the relationship between accountee and a forum that holds the accountee to account for its actions and decisions. To show and adapt this fact towards our setting with the Federal Joint Committee we could use the following chart to visualize the main external political accountability relationships that would belong towards a functional political accountability.
Figure 1: Horizontal and vertical political relevant accountability relations:
illustration not visible in this excerpt
It is obvious that the political accountability environment of the G-BA as a quasi-governmental institution with legislative competence depends on a relationship model based on two sides. The first type, also called hierarchical accountability relation, affects the relation towards the superordinated government which is the Federal Ministry of Health and the second type, so called the vertical accountability relation, is the relation towards the public stakeholders like all members of the statutory health insurance, interest organizations etc.
In the next part it is shown that political accountability in health care is connected with certain indicators and mechanisms which could be used to analyze the Federal Joint Committee and its relations to answer the question if there is a weak or strong political accountability relationship or even an accountability deficit.
2.1. Framework for analysing political accountability
In this context political accountability has to do with the institutions, procedures and mechanisms that ensure that the government delivers on electoral promises, fulfils the public trust and aggregates and represents citizens interests and respond to societal needs and concerns. These goals are mostly achieved by the political process and democratic elections.
 The Homepage of the G-BA offers a complete version in english available at: http://www.english.g-ba.de/
 The SHI Modernization Act (GKV-Modernisierungsgesetz/GMG) came into force at January the 1th in 2004 to secure a high level of medical care at reasonable contribution rates in the future. This is ensured by a set of different measures including also structural reforms. See for further information about the reform background in the Recommendation of the Committee on Health and Social Security of the German Bundestag from 24 September 2003 on the draft Law on the modernization of the statutory health insurance (SHI Modernization Act – GMG. BT Drucksache 15/1584 available at: http://dipbt.bundestag.de/doc/btd/15/015/1501584.pdf
 See Gregory, Robert: 2012. Page 681: In this context he exposes that the term accountability is one of the most used words in the Anglo-American parlance of modern government.
 See Bovens, Mark: 2005. Page184.
 See Posner, Paul:2006.Page 73.
 See Erkkilä, Tero: 2004. Page 7ff.
 See Erkkilä, Tero: 2004. Page 10.
 See Bovens, Mark; Schillemanns, Thomas and T Hart, Paul: 2008.Page 229.
 See Mulgan, Richard: 2014. Page 548.
 See for further information about the tasks and legal base of the G-BA according to § 92 SGB V available at: http://www.sozialgesetzbuch-sgb.de/sgbv/92.html
 See the statistic of the Federal Ministry of Health (BMG) about the approximate number of members in the statutory health insurance for July 2014 on page 37 f. Available at the Homepage of the BMG under: http://www.bmg.bund.de/fileadmin/dateien/Downloads/Statistiken/GKV/Mitglieder_Versicherte/KM1_Januar_bis_Juli_2014.pdf
 See Kölner Stadt Anzeiger 22. 07. 2014. Lauterbach fühlt sich verhöhnt. Available at: http://www.ksta.de/politik/lauterbach-fuehlt-sich-verhoehnt,15187246,13398324.html
 See Ärztezeitung 1. 09. 2014.Union plant Neustrukturierung des GBA. Available at: http://www.aerztezeitung.de/politik_gesellschaft/default.aspx?sid=650478
 See Brinkerhoff, Derrick: January 2003.Page 5 f.
 See Bovens, Mark:2007. Page 449.
 See Gregory, Robert: 2012. Pages 681-682.
 According to the accountability model used by Bovens, Mark: 2005.Page 186.
 See Brinkerhoff, Derrick: 2003. Page 7ff.