Germany is expecting up to 1.5 million asylum-seekers in 2015 who need shelter, food, and access to basic services. The continued influx of migrants is a major challenge for Germany’s health care system, which is tasked with providing essential medical services for the new arrivals — and may have to deal with novel and unexpected challenges such as mushroom poisoning among foraging asylum-seekers and refugees.

How does a system geared toward providing comprehensive coverage to a population of 80 million deal with a large number of new migrants? And how can policies be crafted to respond to this challenge?

Access to health care for migrants in Germany evolves along three stages depending on their status and length of stay (Exhibit 1). Upon arriving in Germany, an asylum-seeker will first be given shelter in a centralized reception center run by one of the German states. The center will process the migrant’s application for asylum and conduct basic health screenings. Afterwards, the asylum-seeker will be relocated to the county, which is responsible for providing basic benefits such as food, clothing, housing, and limited access to health care. Regular access to health care is available once the application has been accepted or after 15 months, regardless of the application status. Individuals in the latter group are not only those still awaiting a decision, but also those with a negative decision who either cannot be expatriated on various grounds or are waiting for expulsion.

Screening For Communicable Diseases

To prevent and control the spread of disease, health assessments are conducted immediately on arrival. Currently, federal law mandates that all new arrivals should immediately be screened for tuberculosis. The scope of further health examinations is determined by the states. For example, in North Rhine-Westphalia, the most populous state, all newcomers should receive an offer for comprehensive vaccination and a first medical assessment. This screening is offered by dedicated or commissioned medical staff in the reception centers, and aims mainly to prevent the spread of communicable diseases, as recommended by the European Centre for Disease Prevention and Control. Severe cases will be referred to hospitals or outpatient specialists.

At the moment, the immediate worry is coping with the strain caused by the rising number of asylum-seekers, also on the health care system. Offering all screening services in a timely fashion in reception centers has become a major challenge due to limited capacities. In fact, authorities often have to rely on voluntary support by local doctors. Efforts are underway to allow refugees with a medical background to assist in providing services. Still, as recent outbreaks of measles and chickenpox in reception centers and county-level housing have shown, timely and complete screening must remain a priority.

Addressing The Immediate Health Needs

Germany restricts access of asylum-seekers initially to emergency care, treatment for acute diseases and pain, maternity care, and vaccinations. Translator services are also covered as needed. Additional care can be granted on request; however access is restricted by bureaucratic procedure: asylum-seekers typically must apply at the responsible municipal authority for a certificate of entitlement to receive the additional care. Often, this process has to be repeated for each episode and referral.

The rationale of restricting access to social services, including health care, goes back to the early 1990s, when rising numbers of asylum-seekers from former Yugoslavia led to a tightening of Germany’s asylum policy. Restricted access to social services was intended to reduce the country’s appeal (“pull factor”) to refugees.

But evidence clearly shows that such strategies of deterrence do not work and are not in the country’s enlightened self-interest. A recent study revealed that restricted health care access for asylum-seekers and refugees in Germany has led to delayed care and ultimately higher costs. A further impetus for easing restrictions on health care services is the European Union reception directive, which sets out higher standards of medical services for vulnerable persons.

Municipalities, which are at the forefront of providing care to asylum-seekers, have long seen these defects. For the past few years, the city-states of Bremen and Hamburg have been providing their asylum-seekers with health insurance cards like those used by the general population. They enable direct access to doctors and hospitals without having to apply for a certificate of entitlement. Claims are processed by the sickness funds and billed to the municipality. Officially, the restriction to acute and emergency services remains, but the decision is now moved to the doctor’s medical discretion and no longer made by a municipal administrator.

Contrary to concerns, easier access has not led to a run on services, and has actually reduced administrative costs by streamlining bureaucratic procedures and freeing administrative staff for other tasks.

It was difficult to transfer this model from the city-states to territorial states with many municipalities and rural communities. But now, Germany’s largest state by population, North Rhine-Westphalia has found a way to enable its municipalities to issue these cards, too. A recently adopted federal law will facilitate other states to follow suit.

In the immediate future, efforts to reduce bureaucratic hurdles need to continue; however, it is just as important is to address the linguistic, cultural, and societal barriers to access. This is a particular concern for ensuring proper mental health care. Studies show that more than half of the asylum-seekers and refugees arriving in Germany have mental health problems, especially minors. And institutional accommodation and restricted economic opportunities have been associated with worse mental health of refugees. While mental health services are available, and there are specialised services for traumatised refugees, uptake is low due to low awareness and cultural barriers. Other issues that need urgent attention are providing adequate shelter to avoid crowding and ensuring good hygienic condition.

Long-Term Integration

On being accepted as refugee, or after 15 months, unrestricted access to health care will be granted in the same way as for members of the general population. This can be effected either through welfare (social security benefits) or by gaining regular membership of the Statutory Health Insurance through employment or unemployment benefits.

How the absorption of refugees will affect the health care system in the medium and long-term is an open question. This influx of patients means that overall health care utilization is bound to increase, but it is less clear whether individual refugees will use relatively more or less care than the general population. Due to the healthy migrant effect, refugees often show a low level of utilization. On the other hand, immigrants are known to have a low level of health literacy, and the adverse effects of socioeconomic status may dominate.

Policy Considerations

Good access to health care is not only a human right, but has also been shown to save money through early and continued intervention. Good health care for refugees is also in the self-interest of host countries: healthier individuals are more likely to contribute to the host country’s economy and society. Early public health efforts may therefore facilitate the migrants’ immediate and later integration.

Also in the interest of host countries is that once integrated into the workforce, refugees may contribute more to financing the health care system than they receive in benefits. Considering Germany’s demographic prospects, the current wave of new arrivals has the potential to stabilise health care financing and strengthen the health workforce.

Ultimately, even if the current number of refugees amounts to only small fraction of the population, their integration will impact the German health care system. Diversity will increase, and the system will need to ensure that services are delivered in a culturally and linguistically appropriate way.

Furthermore, as research has shown, institutional accommodation and restricted economic opportunities are associated with worse mental health of refugees. Therefore, current proposals to lengthen stay in central receptions centers to up to six months may backfire. The challenge of housing and schooling refugees and integrating them into the job markets is also a question of high relevance to public health and the health care system.

Exhibit 1