Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states

Abstract

Background Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers’ access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Hospitalizations of Ukrainian Migrants and Refugees in Poland in the Time of the Russia-Ukraine Conflict

“…Recently, inequalities in access to healthcare according to the local policy model among newly arrived refugees were reported [ 37 ]. Results from our study may be the basis for incorporating the needs of refugees and migrants in national and local health policies, as well as supporting access to healthcare for war refugees and migrants.…”

Asylum seeking and refugee adolescents’ mental health service use and help-seeking patterns: a mixed-methods study

“…In terms of health insurance entitlements, the 15–18 months post-arrival waiting period would apply to all participants, according to the Asylum Seekers’ Benefits Act (in German: Asylbewerberleistungsgesetz (AsylbLG)). The extent to which access to (mental) healthcare would be eased by their inclusion in the statutory health insurance system or by their provision with EHC, depends on the year of arrival and location of resettlement within each German federal state 26 , 30 , 66 .…”

“…Depending on the federal state of resettlement, ASR minors and adults need to obtain healthcare vouchers for every medical visit or are provided with electronic health cards (EHC) 28 . However, both access models are distinct to the access provided to regular citizens and other migrant groups, perpetuating or worsening health inequalities 29 , 30 .…”

Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers and refugees. Results from a cross-sectional survey in Berlin, Germany

“…Background Despite substantial health needs, asylum-seekers and refugees (ASR) in Germany exhibit lower utilization of ambulatory health services than statutorily insured persons as regards ambulatory specialist healthcare and ambulatory mental healthcare (1)(2)(3)(4)(5)(6)(7)(8).…”

“…Despite substantial health needs, asylum-seekers and refugees (ASR) in Germany exhibit lower utilization of ambulatory health services than statutorily insured persons as regards ambulatory specialist healthcare and ambulatory mental healthcare (1–8). In light of comparatively high incidence rates of emergency room visits and avoidable hospitalizations among ASR in Germany (1,2,4,5,7), this raises concern: Formal and informal access barriers may make ASR forgo timely treatment in the ambulatory sector and instead use other, potentially inadequate and more costly emergency health services (4,9,10). Incomplete information about ASRs’ medical history and healthcare needs among health service providers may exacerbate such patters, leading to inadequate, insufficient or misguided provision of healthcare (11,12).…”