Keywords

Introduction

Germany’s post-war experience with populist radical right (PRR) parties has, until recently, been marked by the rise and fall of right-wing movements and parties. Some of these parties, for example, the National Democratic Party of Germany (Nationaldemokratische Partei Deutschlands, NPD), pursued clear right-wing extreme tendencies from the beginning, while others such as the Alternative for Germany (Alternative für Deutschland, AfD) moved towards the right-wing political spectrum over a course of time. Most of these movements never managed to establish themselves as a significant parliamentary and electoral force, apart from gaining a few seats in the parliaments of federal states, especially in the east of Germany. This changed with the federal election of 2017 in which the fairly new AfD managed to attract 12.6% of the votes and now forms the biggest opposition party in the 19th German parliament, the Bundestag. For the first time in Germany’s post-war history, a party that is now commonly characterized as populist and radical right (Berning 2017; Arzheimer and Berning 2019) has the opportunity to shape the parliamentary debate, policy agenda, and national mood in a way that was previously difficult to imagine, given Germany’s significant efforts, and arguably success, at containing and addressing radical right political tendencies against the background of its Nazi history.

Its status as the strongest opposition party in the 19th German Bundestag is also what distinguishes it from the other PRR practitioners covered in this volume. Most of the other parties have governed or have been part of governing coalitions, in national or state governments. The fact that populist radical right movements or parties had not had significant electoral successes until 2017 has been attributed to Germany’s mainstream public and political policy of containment, which is a public discourse against radical right tendencies that is embraced by politicians, the media, and civil society alike (Art, 2018). Given this long period of containment of radical right forces, the question arises if Germany’s AfD can be viewed as the party whose success ushers in a period of normalization of radical right views (Art, 2018), that is, a period in which AfD views gradually become normalized as one of several political platforms in a pluralist party system.

One way to begin addressing this question is by analysing policy initiatives brought forward by the AfD in select parliament committees such as the Committee on Health (Gesundheitsausschuss), as a proxy for examining the direction and the likely impact of the AfD’s role as the largest opposition party. The fact that such initiatives arise from the AfD’s position as an opposition group does not minimize its potential impact. On the contrary, scholars such as Minkenberg (2001) have shown that opposition parties can shape policy-making by influencing policy agendas and shaping debates. In the following sections, we begin with a brief history of the rise of the AfD and provide an assessment of the ways in which it can or cannot be characterized as a populist radical right party following Mudde’s (2010) definitions of the term. In the second part of the chapter, we use four cases of AfD policy initiatives in the Committee on Health of the Bundestag to exemplify not only the likely impact of AfD on health policy but also the challenge of characterizing some of these initiatives as reflecting populist radical right tendencies.

The History of the AfD

The AfD was established in 2013 by a professor of economics, Bernd Lucke, in response to the Eurozone debt crisis and the German government’s ensuing decision to provide bailouts for Greece and other Eurozone countries, despite having previously ruled out such bailouts (Art, 2018). As such, the AfD’s early days can be characterized as providing an economic liberal platform that centred on criticisms of the common currency zone within the European Union (EU) rather than on criticism of, or even opposition to, the EU per se, as now seems to be a unifying feature of PRR parties in Europe (bpb 2018). Initially, the AfD under Bernd Lucke was seen as a competitor to liberal parties such as the Free Democrats (Freie Demokratische Partei, FDP) rather than as threat of establishing PRR tendencies, although there are ambiguous accounts of the extent to which nativism, for example, was part of the party’s platform from the start (Art, 2018).

Fighting within the party over the ideological and programmatic direction of the AfD eventually led to the election of Frauke Petry as head of the AfD at the party’s conference in 2015 (bpb 2018). This paved the way for the AfD rebranding itself not only as a Eurozone-sceptical party but also as a party sceptical of, and opposed to, further EU integration, migration, and the acknowledgement of Islam as being a part of a multicultural Germany. Under the leadership of Frauke Petry, the AfD started to embrace a more nativist rhetoric that is also reflected in its election manifesto of 2017 and the policy programme that can be found on its website. In other words, it slowly transformed into a party with PRR characteristics. Following this, the AfD experienced significant electoral gains in 2017 (12.6% in 2017 compared to 4.7% in 2013). In addition, it gained mandates in all 16 state parliaments over time. Its success can at least in part be attributed to the refugee crisis of 2015–2016 during which the German government decided to grant entry to Germany for over a million refugees (Art, 2018). The AfD was able to harness public opinion and fears over the ramifications of Germany’s decision, now openly employing tools from the PRR playbook.

The AfD as a PRR Party

Lewandowsky (2015) outlines that scholars are still debating whether the AfD can be classified as a right-wing party. However, the policies the AfD promotes according to its election manifesto and its policy programme share important hallmarks with other PRR parties discussed in this book. The election manifesto and policy programme reflect nativist views. That is the xenophobic view of nationalism in which only a monocultural nation-state should be aspired to. In that, large sections cover issues such as culture, language, and identity in which the German cultural heritage is foregrounded, and other cultures and religions such as Islam are being rejected as foreign and as not being a part of German culture and identity (AfD 2016, 2017).

The party’s policies can be described as featuring authoritarianism in that they focus on domestic security and the strengthening of police forces, often coupled with statements of an alleged increase in crimes following the refugee crisis. Last, but not least, the extant literature seems to agree on the populist characteristic of the AfD (e.g. Lewandowsky 2015; Art, 2018). A reading of its election manifesto, its policy programme, and its press statements gives further support for the AfD’s characterization as deeply populist. The will of the people is at the centre of its policy direction as the AfD advocates for more direct democracy and referendums, explicitly naming the Swiss system as the model to be emulated within the German context (AfD 2016, 2017). Its party rhetoric and policies are targeted against the corrupt political elites, exemplified in its promotion of populist policies such as making the waste of taxpayers’ money, for example, as a result of delayed infrastructure projects financed through the public purse, a prosecutable offense (AfD 2017).

A more complex picture emerges in relation to health policy, both regarding the AfD’s classification as a PRR party and its impact in this policy field. The AfD positions on health policy issues are marked by one striking feature: its absence. That is to say that health policy received little attention in the AfD’s election manifesto in 2017 and virtually no attention in its general policy programme. Only little more insight about AfD positions on health policy can be drawn by the Berlin declaration, which was put forward by the party’s parliamentary group. The ten positions are vaguely stated on one page. In its election manifesto, the AfD focused on the healthcare access in rural regions of Germany (AfD 2017), which has been marked by a decrease of the availability of physicians and number of doctors’ surgeries in recent years. The AfD also focused on improving investments in hospital infrastructure and on improving the status of professional careers through better pay and better working conditions (AfD 2017). As in other countries, these issues are widely acknowledged challenges in the German healthcare landscape, and there is nothing uniquely nativist or populist about focusing on them. However, one of the paragraphs in the health section of the AfD’s election manifesto frames healthcare financing challenges as addressing increased spending on health care for refugees and asylum seekers that are covered by the sickness funds (AfD 2017: 60). The fact that increased healthcare expenditure was already a concern before the refugee crisis in 2015/2016 is omitted, thus demonstrating the AfD’s more subtle ways of framing policy problems with a nativist undertone. Explaining the apparent lack of attention on health policy is challenging and requires more research in the future.

The AfD and Its Response to the Early COVID-19 Crisis

The previous lack of attention to health policy seems to be reflected in the AfD’s uncertain and ambiguous positions during the early stages of the COVID-19 pandemic . They ranged from criticizing the absence of early lockdown measures in the beginning, to silence, to criticisms surrounding the economic consequences of lockdowns, and to ambiguous messaging around the appropriateness of face masks as a pandemic containment measure (Fiedler 2020). Thus, the AfD shifted constantly in order to accuse the German government of mishandling the crisis. While at first the AfD criticized the lack of strict early lockdown measures and closure of borders, it later criticized too strict and uniform lockdowns as Germany fared comparatively well through the first wave in the beginning of 2020 (Weiß 2020).

Infighting seems to continue between the moderates and pragmatists on a variety of topics, which apparently stifled the party’s response to the pandemic at the beginning. As a result, the AfD employed similar kinds of responses to the pandemic as other PRR parties discussed in this book. For example, strategies such as questioning the effectiveness or the need for mandatory measures such as the wearing of face masks, social distancing rules, and lockdowns, as well as labelling them undue and authoritarian restrictions of civil liberties, have been popular political frames employed by AfD politicians.

Along with the questioning of government measures comes a scepticism about the evidence base of such measures that culminated in outright denials of the existance of such, like the denial of scientific evidence in relation to climate change. As the pandemic evolved, the AfD reverted to familiar PRR territory , suggesting that scientists as well as the members of government make up the country’s elite, wanting to restrict the freedom of the people. As befits a party whose political stance on the COVID-19 pandemic can be described as chaotic at best and opportunistically populist at worst, the AfD frequently employs the rhetoric of far-right conspiracy movements that are at the heart of the so-called anti-corona (measures) demonstrations, for example, by accusing the German government of a “corona dictatorship”. As the second wave of the pandemic continues to hold Germany in a tight grip in November 2020, the AfD’s uncertain position seems to have given way to a PRR comfort zone that is characterized by denial (e.g. of the scientific evidence), non-compliance (e.g. of mandatory mask-wearing in Parliament and lawsuits against mandates for party conventions), protest (e.g. attending anti-corona measures demonstrations), and rhetorical scaremongering (Weiß 2020). Exemplary for the aforementioned populist methodologies employed by the AfD is an affair receiving broad national coverage and causing widespread outrage amongst the established parties in November 2020. AfD members of parliament allowed four right-wing activists to enter the Bundestag through a side entrance. These individuals publicly harassed lawmakers within the Bundestag on the day that amendments to infection control legislature aimed at boosting governmental authority during the pandemic were voted on. The AfD’s party whip later apologized (Deutsche Welle 2020); however, the occurrence clearly demonstrates the AfD’s utilization of the PRR playbook, leveraging its populist messaging to disturb regular political proceedings while ignoring previously set rules of good conduct and distracting from the lack of solid health policies they are able to present.

The Health Policies of the AfD

In comparison to other countries with active PRR practitioners, the AfD has not held a government position to this date and has only focused on opposition work. Given this situation, we focus on policy initiatives brought forward in the Bundestag Committee on Health by the AfD as the largest opposition party. Our analysis will thus focus on the political “supply side”.

Federal health policy in Germany is developed through joint efforts of committees and the full parliament. The seats in the committee are allocated according to electoral strength of the parties in the Bundestag. As per the rules of procedure, committees prepare the decisions of the Bundestag. Committees debate and discuss draft bills and revise them until it can be passed in the committee. Results from the committee are usually a recommendation to the plenary for decision. In a general proceeding, bills may be introduced by the government or any parliamentary part, which are first read in the plenary and are then forwarded to the committees for deliberation. Nonetheless, committees may act at their own initiative (Deutscher Bundestag n.d.).

In order to establish PRR patterns in the AfD’s health policy , we focused on more subtle observations through a qualitative examination of bills introduced into the Bundestag by the AfD. We extracted health policy-related bills (Anträge) introduced by the AfD in the 19th electoral term (2017–2021) with a cut-off date of March 7, 2020, from the Bundestag data base with search criteria of 19th electoral term, subject area health, and AfD as initiator (see Fig. 1).

Fig. 1
figure 1

Analysis of AfD bills introduced in the German Bundestag

Full size image

Until then, the AfD had brought forward 30 bills with the subject area of health. Of these, 17 were rejected, three were recommended to be rejected by the committee to the plenary, one was declared resolved (not relevant anymore), and nine were sent to the respective committee for further discussion. This shows that so far, the AfD has received no support from other parties in the Bundestag. However, the introduced bills show that while broad in topics, the AfD is willing to move away from a solely populist approach and frequently makes technical suggestions. Bills are characterized by liberal and conservative themes, such as the removal of budgets for ambulatory care or more competition between statutory sickness funds and private health insurances. Such policy directions are in line with some of the proposals other conservative or liberal parties have made (e.g. FDP). However, the party distinguishes itself from other conservative and liberal parties by nationalist themes and frames, commonly referred to as nativism in this volume. We illustrate this nativist element in our analysis in order to establish its right-wing characteristic.

We focus on two themes the AfD has tried to address in the course of its parliamentary work: (1) dependency on foreign pharmaceuticals and (2) immigrant influx of foreign health professionals. AfD bills carry the common theme that quality is increased if international dependency is reduced, and therefore the generosity of the benefit scheme in Germany increases by a definition of quality. In the first theme, three bills address the German dependency on foreign pharmaceuticals and import regulations.

The first bill demands the introduction of a notification obligation for pharmaceutical companies in case of a 14-day unavailability of prescription medication , an export ban on scarce pharmaceuticals and the revision of rebate contracts in the statutory health insurance (SHI) scheme to award two manufacturers rebate contracts of which one must produce agents as well as the medication within the EU (Deutscher Bundestag 2019b). The AfD criticizes that due to the price competition induced through the rebate contracts, domestically produced pharmaceuticals are sold to other countries with higher prices, creating gaps in pharmaceutical supply. The AfD also links competition over prices with drug safety, suggesting that foreign-produced active pharmaceutical agents are of bad quality (Deutscher Bundestag 2019d).

The welfare chauvinist theme in this bill is based on the ideology of increased benefit generosity for SHI beneficiaries expressed through the improved quality and availability of medication. At the same time, the AfD utilizes its populist capabilities to put a spotlight on the shortages of the current system within the country. The party creates fear of inadequate treatment due to the current setup of the welfare system that does not help the general population (welfare populism). The use of the word “dependency” on foreign imports in the bill illustrates how the AfD frames its initiatives in ways reminiscent of a welfare populist undertone. Dependency is a strong word that suggests a systemic misalignment between goals (e.g. generating savings through rebate contracts on the one hand and ensuring adequate domestic supply of pharmaceutical products on the other), leading to an alleged situation in which the German population receives pharmaceuticals of suboptimal quality from abroad. It is this choice of framing that distinguishes the AfD’s bill from the positions of other parties on the effects of pharmaceutical rebate contracts that are not uncontroversial in political and health policy circles. Framing the issue as a dependency issue that suggests an overreliance on products from abroad regardless of other issues such as expenditure control is an example of the AfD’s narrow understanding of the challenges in pharmaceutical policy.

The second bill targets import quotas imposed by the Federal Government through payer and pharmacist associations on local pharmacies. To reduce pharmaceutical expenditure in the SHI scheme, pharmacies must currently generate 5% of their end-product revenue from imported pharmaceuticals. The bill demands a removal of the mandate on pharmacies to dispense imported pharmaceuticals should no specific product be prescribed by a physician. The AfD argues that savings achieved through the current import quota are slim while introducing safety risks such as dubious procurement channels. The AfD also suggests that domestically produced and marketed pharmaceuticals are superior compared to imported medications. While the bill includes a thin health economics perspective, it becomes clear that the AfD sees fraud opportunities in the import regulations as a core issue, since import quotas allows for “qualitative inferior, stolen or counterfeit medication” to be dispensed to the public, thus posing a threat to the country (Deutscher Bundestag 2018a). In its plenary presentation, the AfD stated that import quotas result in the import of safety issues and risks (Deutscher Bundestag 2019c). Additionally, AfD states that these effects could potentially expose the German SHI system to illegal activity from abroad and suggests that existing control mechanisms are ineffective. In summary, the welfare chauvinist theme emerges again, as generosity increases are defined through improved quality and a safer pharmaceutical care supply to the general public. It can also be argued that there is a financial increase in generosity to the SHI beneficiaries, as the removal of the import mandate could theoretically result in increases in SHI pharmaceutical expenditure.

The third bill regarding the dependency on foreign pharmaceuticals aims at restricting the influence of EU online pharmacies on the German market. A decision by the Court of Justice of the European Union (CJEU) paved the way for the market entry of online pharmacies in 2016 (Deutsche Welle 2016). EU online pharmacies in other countries are not bound to the German pharmaceutical price regulation and may offer bonuses and discounts to customers. EU online pharmacies are also subject to VAT (value-added tax) regulations of their originating country, which may be lower compared to the German tax code. The AfD criticizes the “unfair competition” between foreign and domestic pharmacies, which threatens the existence of pharmacies across Germany. This conservative theme of reducing generosity across the board for SHI beneficiaries, who may receive rebates on their prescriptions, also demonstrates the theme of nativism, in which the monocultural state is ideal. The perceived threat in this case are foreign EU online pharmacies that allegedly endanger the adequate supply of pharmacies across the country (Deutscher Bundestag 2019a). In turn, the AfD argues that both patients and domestic pharmacies would benefit from a ban on foreign online pharmacies, with the provision of pharmaceuticals being ensured and domestic pharmacies losing unfair foreign competition. While this AfD bill was rejected by the parties in parliament, other parties on both sides of the spectrum have recognized the issue and are working to resolve this discrepancy in fairness. This emphasizes the reluctance of established parties in the Bundestag to vote in favour of AfD bills, with no AfD bills accepted in the committee on health and the Bundestag plenary.

These three bills targeting the foreign influence on the pharmaceutical supply demonstrate the AfD’s interest in increasing the assumed qualitative generosity for the beneficiaries of the SHI insurance programme while being prepared to accept increases in expenditure. The PRR party sees the dependency on international non-EU suppliers as a threat to the pharmaceutical care of the German population and aims at reducing this threat through a refocus on national capabilities and structures, thus decommodifying the people’s dependence on international manufacturers and distributors. It speaks to the party’s embrace of welfare chauvinist policies in which the reduction of so-called dependency on “foreign” pharmaceuticals is portrayed as a benefit for the German population and in which international imports are seen as threats to healthcare quality and local economic competition.

We have already demonstrated the conservative, welfare chauvinist, and in parts welfare populist characteristics of AfD bills. Similar tendencies can be identified in other areas of health policy , such as the accreditation of foreign health professionals. As other developed countries, Germany is experiencing a shortage of healthcare professionals, especially in rural areas. In a bill proposing the increase of accreditation standards of foreign health professions, the party describes dangers that have occurred and may occur through an insufficient assessment of technical skills and language capabilities. In its reasoning, the bill mentions the alleged inferiority of foreign physicians and shows the common PRR theme of non-natives endangering the healthcare system. The relatively short bill (1.5 pages) lacks detail and reliable evidence undermining its proposal (Deutscher Bundestag, 2018b). The suggestions and themes outlined in the bill are underlined by the discussion in the General Assembly of the Bundestag. The AfD blames the established parties for failures in health policy, which supposedly led to a shortage of physicians, now needing to be filled with foreign health professionals. The AfD stresses that forged certificates, insufficient capabilities, and language barriers lead to significant risk of malpractice (Deutscher Bundestag 2018c). The AfD thus implies that the currently existent accreditation system threatens the safety of care provision to the benefit of migrant physicians seeking employment in Germany. The alleged acceptance of safety risks by the established parties to the detriment of the common citizen is criticized by the AfD, thus establishing a welfare populist pattern. These remarks add to the growing, qualitative evidence that AfD bills, while attempting to contribute to the resolution of policy problems, exhibit nativist and authoritarian characteristics with a thin ideology.

In summary, the AfD blames the established German parties with failures, which lead to problems in the provision of care for its citizens. Many of the targeted structures were introduced as a response to shortages in financial and human resources. Interestingly, the AfD relies on a definition of generosity through quality, as the reliance on international markets is seen as a negative impact factor on the quality of pharmaceutical provision. The provision of health services is in turn subject to growing foreign influence without the necessary control and enforcement strategies in place, again a clearly authoritarian theme utilized by many PRR parties across Western Europe.

Conclusion

The AfD provides an interesting case study when examining the impact of PRR parties on health policy, both because of its role as an opposition party and because of its ability to frame known policy problems in a nativist, populist, and authoritarian way. The apparent lack of attention on health policy in its election manifesto and policy programme notwithstanding the AfD has brought forward several bills in the Bundestag Committee on Health, none of which have been accepted by the other parties. The topics covered in the bills are not necessarily nativist or populist in character because they frequently refer to widely acknowledged health policy issues. However, what distinguishes the AfD from its parliamentary counterparts is its framing of the issues as nativist, populist, or authoritarian. This is hardly surprising, given that framing is at the heart of the policy process, with every party and policy-maker engaging in some form of framing. Still, it is surprising in the context of the German political system which has thus far been credited with success in containing PRR tendencies. It is too early to tell what the impact of the AfD’s framing of common policy problems will be on the parliamentary and national debate, but it is likely that the AfD is already having an impact in putting topics on the policy agenda that would have otherwise perhaps not reached it.

More generally, the AfD case raises interesting questions about how to conceptualize and measure a PRR party’s impact, or any party’s impact for that matter. One way to conceptualize and operationalize it is through hard outcomes such as votes and seats gained. On that measure, the AfD has had a large impact on the German policy landscape. Another measure would be to look at the way other parties meet the challenge of the rise of PRR parties, with the literature suggesting that often PRR topics and frames are co-opted by other parties to regain votes. To a certain extent, this has been visible in Germany with the CDU and the CSU being embroiled in discussions about their programmatic directions and with many members calling for a reorientation of the parties to more conservative and less liberal values.

Finally, our analysis of AfD bills in the Bundestag Committee on Health to examine the AfD’s impact on health policy has underlined that opposition parties play a role in agenda-setting and in moving the debate. Our analysis has also shown that the features that characterize PRR parties – nativism, authoritarianism, and populism – do not have to be visible in equal measure in every parliamentary or other activity but that PRR messages can be transported in more subtle ways such as framing widely acknowledged policy problems through nativist and populist lenses. If these subtle, but powerful, framing efforts do not continue to be met with opposition by the other parties in the German system, it is more likely that the AfD’s role and positions will become more normalized and less contained over the years.

Summary Box

  1. 1.

    The AfD in Germany is distinct from other PRR parties covered in this volume because it has not been a part of a governing coalition to date.

  2. 2.

    The AfD’s positions on health policy are marked by thinness with regard to coverage in the election manifesto and the policy programme.

  3. 3.

    In the Bundestag Committee on Health, the AfD introduces bills on widely acknowledged health policy problems that are not characteristic of PRR topics per se.

  4. 4.

    AfD’s parliamentary work can be characterized as incorporating conservative, welfare chauvinist, and populist themes in their bills while covering nativist, authoritarian, and populist issues of health care.

  5. 5.

    For a party or practitioner to be classified as PRR, the PRR features do not have to be present in every activity, bill, statement, or publication. PRR themes can be subtle, and attention needs to be paid to how issues are framed.