Former office · hospitals
The reform of the reform
Germany's hospital reform was passed in 2024, before Nina Warken took office. Her task as health minister was to make it workable — and, in parallel, to slow the growth of hospital spending. Both drew strong reactions from hospitals and the Länder.
- Inherited
- Hospital Care Improvement Act (KHVVG), 2024
- Adjusted
- Hospital Reform Adjustment Act (KHAG), Bundestag 6 March 2026
- Capped
- Hospital cost growth 2027–2029, GKV act of 10 July 2026
Background
What the 2024 reform set in motion
Hospital planning is a Länder competence; the federal government regulates hospital remuneration through social insurance law. Every hospital reform therefore needs both levels.
The Hospital Care Improvement Act (Krankenhausversorgungsverbesserungsgesetz, KHVVG), prepared under health minister Karl Lauterbach, passed the Bundesrat on 22 November 2024 without referral to the mediation committee. It rested on three pillars.
First, service groups (Leistungsgruppen): hospital treatment is divided into 65 groups, each with minimum requirements for staff, equipment and experience. A hospital may provide and bill a service only if the responsible Land assigns it the corresponding group. Second, a reserve remuneration (Vorhaltevergütung) is to cover a large part of hospitals' fixed costs independently of case numbers, reducing the incentive to treat as many cases as possible. Third, a transformation fund of €50 billion over ten years is to finance mergers, conversions and closures, originally half paid by statutory health insurance and half by the Länder.
The timetable was ambitious: the Länder were to assign service groups by the end of 2026, followed by a gradual conversion of the financing system in 2027 and 2028, to be completed in 2029. Whether that schedule and some of the quality criteria were realistic — particularly for rural regions with few alternative providers — became the central question of the implementation phase, and the starting point for the adjustment act of 2026.
6 March 2026
The Hospital Reform Adjustment Act
The Krankenhausreformanpassungsgesetz kept the structure of the 2024 reform but changed its pace, flexibility and financing. The coalition groups of CDU/CSU and SPD voted for it; the AfD, the Greens and the Left voted against.
More time for the Länder and hospitals to implement service groups and adapt structures.
Wider scope to grant exceptions to quality requirements where needed to secure provision.
A reduced number of federally uniform groups.
The statutory insurers' half of the €50 bn transformation fund moves to the federal budget, relieving contribution payers.
- 6 March 2026
Bundestag adopts the KHAG
Second and third reading.
- 27 March 2026
Bundesrat
The Länder chamber lets the law pass.
- April 2026
In force
Implementation continues under the adjusted rules.
Spending
Hospitals in the 2026 savings law
As the largest single block of statutory insurance spending, hospitals were central to the GKV contribution-rate stabilisation act passed on 10 July 2026. According to the Federal Ministry of Health, the law provides:
- A cost cap for 2027 to 2029: increases in hospital prices are limited to the growth of the basic wage rate minus one percentage point. From 2030 the regular rules apply again.
- Mandatory second opinions: from 2028, two procedures per year with high case volumes require a second medical opinion before planned surgery.
- Staffing and billing rules: nursing staff minimum requirements are developed further towards quality-based staffing standards, and audit rates and thresholds for billing checks are raised.
The ministry framed the cap as limiting future increases to general economic development rather than cutting existing budgets. Combined with the KHAG's shift of the transformation fund to the federal budget, the government's argument was that hospitals would be restructured with public investment while their running costs grew more slowly.
Debate
Rationale and criticism
The criticism below is attributed to the organisations that voiced it. The government's rationale is taken from ministry statements.
KHAG — adjustment of the hospital reform
March 2026Government rationale
Keep the reform's core logic — service groups, quality criteria, specialisation — but make implementation practicable, give the Länder responsibility for regional exceptions, and stop contribution payers from financing a structural fund that is properly a public task.
Criticism
The German Hospital Federation (DKG) criticised that important questions had been postponed rather than answered, above all hospital financing, and called the reserve-remuneration model "völlig untauglich" (wholly unsuitable) because funding still depends on case numbers. After the Bundesrat vote it also objected to nursing staff minimums becoming a binding criterion for assigning service groups. Opposition parties voted against the law.
GKV act — hospital cost cap
July 2026Government rationale
Hospital spending rose by around €8 bn in a year; without limiting its growth, contribution rates could not be kept stable in 2027. The cap applies for three years while the structural reform takes effect.
Criticism
DKG chief executive Gerald Gaß warned that a law that could worsen care for 80 million people, push hospitals into insolvency and endanger up to 140,000 jobs must not be rushed through parliament; the DKG later put the total withdrawn from hospital care at around €30 bn by 2030. In June 2026 the Länder objected to limits on price adjustments, the end of full refinancing of nursing pay rises, higher audit quotas and insufficient federal funding for basic-income recipients — objections the DKG endorsed. The Marburger Bund doctors' union warned of risks to patient care.
Status
Both laws were passed during her tenure. How hospitals fare under the combination of service groups, a capped price path and the transformation fund will become visible from 2027 — under her successor.
Unresolved
Questions the reform still has to answer
None of these are settled by the 2026 legislation; they define the next phase of hospital policy.
Does reserve remuneration secure rural hospitals?
The original promise was to finance necessary hospitals with low case numbers. Hospitals dispute that the current model achieves this.
Where do exceptions end?
More flexibility for the Länder can protect local provision, but too many exceptions would weaken the quality logic that justified the reform.
Can hospitals restructure while their prices are capped?
The transformation fund pays for change; the cost cap restrains running budgets. Whether the two fit together depends on implementation speed.
How will patients notice?
Concentration may mean longer journeys for some treatments and better outcomes for others. Evaluating this needs reliable outcome data — one argument for the Medical Registers Act.
Sources & further reading
- vdek — KHVVG passes the Bundesrat (22 Nov 2024)
- Barmer — KHVVG overview
- Forvis Mazars — KHAG passed by the Bundestag
- German Hospital Federation — on the KHAG Bundestag decision (6 Mar 2026)
- German Hospital Federation — on the Bundesrat decision (27 Mar 2026)
- Federal Ministry of Health — GKV stabilisation act passed (10 Jul 2026)
- German Hospital Federation — timetable of the GKV savings law (2 Jul 2026)
- apotheke adhoc — hospitals back Länder criticism of the savings law (11 Jun 2026)
- Deutsches Ärzteblatt — Bundestag approves GKV savings package
- Federal Ministry of Health — speech in the final Bundestag debate on the 2026 health budget (27 Nov 2025)