Three German states have taken a case to Karlsruhe against the G-BA’s hospital minimum-volume rules, arguing that such national thresholds encroach on Länder authority over hospital planning. Their dispute centers on the care of the tiniest premature infants, those under about 1,250 grams, for whom reimbursement since 2024 is conditioned on clinics meeting annual patient-volume minimums. They warn that tying funding to numeric quotas risks creating Versorgungslücken, or gaps in care, particularly where population distribution and clinical expertise are uneven. Beyond this, they challenge other G-BA provisions—the limits for stem cell transplants, the staffing requirements for inpatient psychiatry and psychosomatics, and the tangled exemptions rules. Baden-Württemberg’s health minister insists the suit is a necessary last resort to safeguard the right of states to shape hospital provision; Schleswig-Holstein’s representative calls for the flexibility needed to guarantee regional coverage; Saxony-Anhalt’s minister asks whether the G-BA’s rules fit with the states’ obligation to ensure adequate hospital care. The G-BA, after all, is the apex body determining which services are reimbursed under Germany’s statutory health insurance.

What is really at stake goes beyond the arithmetic of hospital counts. It touches the quiet, almost invisible nerve of how a modern society learns which uses of scarce resources are prudent. The temptation of a central authority to translate the complexity of medical practice into fixed numbers is powerful, and it is exactly at these junctions that the knowledge problem—the dispersion of local information and expertise—makes itself felt with stubborn clarity. A national minimum-volume rule attempts to homogenize care across diverse regions; it assumes that a single standard can capture the contingent realities of geography, demography, and expertise. But knowledge in health care is not merely technical; it is situational, local, and tacit. What works in one province, with its particular pattern of illnesses, its hospitals, and its patient flows, may not work in another. To insist on uniform thresholds is to mistake the map for the terrain and to elevate bureaucratic neatness above the messy, living practice of medical care.

A policy that rewards clinics for meeting a number on a spreadsheet may, in practice, reward consolidation and the shutting of smaller facilities rather than the protection of universal access. The logic of minimum volumes can push resources toward larger centers and away from the frontier towns and rural districts where accessibility, time, and local knowledge matter most. In the relentless drive to reduce costs or standardize care, one risks losing the very elasticity that keeps a health system resilient in the face of shocks—an excess of central planning masquerading as prudence.

And there is another principle at stake: subsidiarity. The German federal arrangement is meant to blend national standards with local autonomy, enabling regions to tailor provisions to their populations while maintaining overall solidarity. When a national board sets thresholds for who gets reimbursed, and thereby who stays open or closes, it shifts power away from local decision-makers who best understand the immediate stakes, toward a distant mechanism that cannot behold the nuanced geography of need. If the courts affirm such centrality, they risk hollowing out the very willingness of communities to take responsibility for their own health provision, substituting universal rules for locally tested judgment.

The remedy, in a Hayekian sense, is not to abandon standards or to abandon the aim of ensuring adequate care. It is to preserve the discipline of competition, price signals, and local experimentation within a framework of solidarity that respects subsidiarity. Allow hospitals to compete for patients with transparent quality information, let risk-adjusted funding and flexible budgeting reflect actual needs, and keep regional authorities empowered to respond to shifts in population and disease patterns. Ensure that thresholds do not become traps that force otherwise viable local hospitals into closure or, conversely, turn once-vital clinics into perpetual dependents of a top-down ledger.

If Germany’s federal structure is to endure, it must shelter the distributed knowledge embedded in its regions—where doctors, nurses, patients, and communities understand the peculiarities of their care landscapes. The challenge before Karlsruhe is not merely a dispute over reimbursement codes and staffing checklists; it is a test of whether a society can balance the demand for consistent standards with the equally essential demand for local adaptation. The states’ appeal is a plea for the political and moral prudence that keeps hospitals near the people who rely on them, and for the humility to let local institutions learn how best to save lives in the particular conditions they face. In that tension lies the health of liberal order itself: a system not smothered by rules, but guided by the free interplay of information, responsibility, and voluntary cooperation punished neither by fear of error nor by the illusion that one size can fit all.