Health care system distrust has emerged as a critical barrier to care, varying by social characteristics and affecting health outcomes through inadequate health care behaviour. However, research outside the US-American health care setting is sparse. Based on a conceptual model of health care related distrust, the study aimed to (1) assess the extent of health care system distrust in Germany, (2) examine social inequalities in distrust, and (3) explore associations between distrust, unmet need, and medication non-adherence in the German population. A cross-sectional online survey was conducted with a randomly selected sample drawn from a panel representing the adult population (N = 3246). Health care system distrust was measured using the 9-item Revised Health Care System Distrust scale, comprising competence and values subscales. Two items to assess unmet need and medication non-adherence as well as various social characteristics were additionally included. A substantial proportion of the respondents reported distrust in the German health care system. For instance, about one-fifth (strongly) disagreed that the health care system does its best to make patients' health better. Multiple logistic regression analyses revealed various social inequalities regarding age, gender, migration history, education and income depending on the subscales. Additionally, both types of distrust were significantly associated with increased odds of unmet need and medication non-adherence after controlling for social characteristics. Health care system distrust is prevalent in Germany and linked to social inequalities and adverse utilization. Addressing distrust requires targeted, patient-centered interventions emphasizing competence, empathy, communication, and equity.