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Effect of Restricting Access to Health Care on Health Expenditures among Asylum-Seekers and Refugees: A Quasi-Experimental Study in Germany, 1994–2013

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  • Kayvan Bozorgmehr
  • Oliver Razum

Abstract

Background: Access to health care for asylum-seekers and refugees (AS&R) in Germany is initially restricted before regular access is granted, allegedly leading to delayed care and increasing costs of care. We analyse the effects of (a) restricted access; and (b) two major policy reforms (1997, 2007) on incident health expenditures for AS&R in 1994-2013. Methods and Findings: We used annual, nation-wide, aggregate data of the German Federal Statistics Office (1994-2013) to compare incident health expenditures among AS&R with restricted access (exposed) to AS&R with regular access (unexposed). We calculated incidence rate differences (∆IRt) and rate ratios (IRRt), as well as attributable fractions among the exposed (AFe) and the total population (AFp). The effects of between-group differences in need, and of policy reforms, on differences in per capita expenditures were assessed in (segmented) linear regression models. The exposed and unexposed groups comprised 4.16 and 1.53 million person-years. Per capita expenditures (1994–2013) were higher in the group with restricted access in absolute (∆IRt = 375.80 Euros [375.77; 375.89]) and relative terms (IRR = 1.39). The AFe was 28.07% and the AFp 22.21%. Between-group differences in mean age and in the type of accommodation were the main independent predictors of between-group expenditure differences. Need variables explained 50-75% of the variation in between-group differences over time. The 1997 policy reform significantly increased ∆IRt adjusted for secular trends and between-group differences in age (by 600.0 Euros [212.6; 986.2]) and sex (by 867.0 Euros [390.9; 1342.5]). The 2007 policy reform had no such effect. Conclusion: The cost of excluding AS&R from health care appears ultimately higher than granting regular access to care. Excess expenditures attributable to the restriction were substantial and could not be completely explained by differences in need. An evidence-informed discourse on access to health care for AS&R in Germany is needed; it urgently requires high-quality, individual-level data.

Suggested Citation

  • Kayvan Bozorgmehr & Oliver Razum, 2015. "Effect of Restricting Access to Health Care on Health Expenditures among Asylum-Seekers and Refugees: A Quasi-Experimental Study in Germany, 1994–2013," PLOS ONE, Public Library of Science, vol. 10(7), pages 1-22, July.
    • Handle: RePEc:plo:pone00:0131483
    DOI: 10.1371/journal.pone.0131483
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    1. Petia Genkova & Pia Keysers, 2018. "Migration and Divesity Potentials for Organisations: the Case of Germany," European Journal of Business Science and Technology, Mendel University in Brno, Faculty of Business and Economics, vol. 4(1), pages 69-80.
    2. Gottlieb, Nora & Schülle, Mirjam, 2021. "An overview of health policies for asylum-seekers in Germany," Health Policy, Elsevier, vol. 125(1), pages 115-121.
    3. Yves Jackson & Adeline Paignon & Hans Wolff & Noelia Delicado, 2018. "Health of undocumented migrants in primary care in Switzerland," PLOS ONE, Public Library of Science, vol. 13(7), pages 1-13, July.
    4. Saleh Aljadeeah & Veronika J. Wirtz & Eckhard Nagel, 2021. "Barriers to Accessing Medicines among Syrian Asylum Seekers and Refugees in a German Federal State," IJERPH, MDPI, vol. 18(2), pages 1-16, January.
    5. Lukas Kratzsch & Kayvan Bozorgmehr & Joachim Szecsenyi & Stefan Nöst, 2022. "Health Status and Access to Healthcare for Uninsured Migrants in Germany: A Qualitative Study on the Involvement of Public Authorities in Nine Cities," IJERPH, MDPI, vol. 19(11), pages 1-18, May.
    6. Yonas Semere Kidane & Sandra Ziegler & Verena Keck & Janine Benson-Martin & Albrecht Jahn & Temesghen Gebresilassie & Claudia Beiersmann, 2021. "Eritrean Refugees’ and Asylum-Seekers’ Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study," IJERPH, MDPI, vol. 18(21), pages 1-20, November.
    7. Kohlenberger, Judith & Buber-Ennser, Isabella & Rengs, Bernhard & Leitner, Sebastian & Landesmann, Michael, 2019. "Barriers to health care access and service utilization of refugees in Austria: Evidence from a cross-sectional survey," Health Policy, Elsevier, vol. 123(9), pages 833-839.
    8. Leonardo Mammana & Chiara Milani & Paola Bordin & Lorenzo Paglione & Chiara Salvia, 2020. "Health System Response during the European Refugee Crisis: Policy and Practice Analysis in Four Italian Regions," IJERPH, MDPI, vol. 17(15), pages 1-22, July.
    9. Allen, William L. & Ruiz, Isabel & Vargas-Silva, Carlos, 2024. "Policy preferences in response to large forced migration inflows," World Development, Elsevier, vol. 174(C).
    10. Violeta Alarcão & Miodraga Stefanovska-Petkovska & Ana Virgolino & Osvaldo Santos & Andreia Costa, 2021. "Intersections of Immigration and Sexual/Reproductive Health: An Umbrella Literature Review with a Focus on Health Equity," Social Sciences, MDPI, vol. 10(2), pages 1-29, February.
    11. Ferdinand Garoff & Natalia Skogberg & Antti Klemettilä & Eero Lilja & Awa Ahmed Haji Omar & Olli Snellman & Anu E. Castaneda, 2021. "Mental Health and Traumatization of Newly Arrived Asylum Seeker Adults in Finland: A Population-Based Study," IJERPH, MDPI, vol. 18(13), pages 1-12, July.
    12. Porthé, Victoria & Vargas, Ingrid & Sanz-Barbero, Belén & Plaza-Espuña, Isabel & Bosch, Lola & Vázquez, Maria Luisa, 2016. "Changes in access to health care for immigrants in Catalonia during the economic crisis: Opinions of health professionals and immigrant users," Health Policy, Elsevier, vol. 120(11), pages 1293-1303.
    13. Kevin Claassen & Pia Jäger, 2018. "Impact of the Introduction of the Electronic Health Insurance Card on the Use of Medical Services by Asylum Seekers in Germany," IJERPH, MDPI, vol. 15(5), pages 1-11, April.
    14. Francis Bakewell & Sarah Addleman & Garth Dickinson & Venkatesh Thiruganasambandamoorthy, 2018. "Use of the emergency department by refugees under the Interim Federal Health Program: A health records review," PLOS ONE, Public Library of Science, vol. 13(5), pages 1-8, May.
    15. Rolke, Kristin & Wenner, Judith & Razum, Oliver, 2019. "Shaping access to health care for refugees on the local level in Germany – Mixed-methods analysis of official statistics and perspectives of gatekeepers," Health Policy, Elsevier, vol. 123(9), pages 845-850.
    16. Ulrich Trohl & Karoline Wagner & Vivian Kalfa & Sarah Negash & Andreas Wienke & Amand Führer, 2021. "Sick and Tired—Sociodemographic and Psychosocial Characteristics of Asylum Seekers Awaiting an Appointment for Psychotherapy," IJERPH, MDPI, vol. 18(22), pages 1-15, November.
    17. Dourgnon, Paul & Pourat, Nadereh & Rocco, Lorenzo, 2023. "European immigrant health policies, immigrants’ health, and immigrants’ access to healthcare," Health Policy, Elsevier, vol. 127(C), pages 37-43.
    18. Gallagher,Allen William Andrew & Ruiz,Isabel & Vargas Silva,Carlos Ivan, 2022. "Policy Preferences in Response to Large Migration Inflows," Policy Research Working Paper Series 10055, The World Bank.
    19. Woranan Witthayapipopsakul & Hathairat Kosiyaporn & Sonvanee Uansri & Rapeepong Suphanchaimat, 2022. "Effect of the Promulgation of the New Migrant’s Employment Law on Migrant Insurance Coverage in Thailand: An Interrupted Time Series Analysis, 2016–2018," IJERPH, MDPI, vol. 19(7), pages 1-12, April.
    20. Jaschke, Philipp & Kosyakova, Yuliya, 2020. "Does facilitated access to the health system improve asylum-seekers' health outcomes? : Evidence from a quasi-experiment," IAB-Discussion Paper 201907, Institut für Arbeitsmarkt- und Berufsforschung (IAB), Nürnberg [Institute for Employment Research, Nuremberg, Germany].
    21. Pia Jäger & Kevin Claassen & Notburga Ott & Angela Brand, 2019. "Does the Electronic Health Card for Asylum Seekers Lead to an Excessive Use of the Health System? Results of a Survey in Two Municipalities of the German Ruhr Area," IJERPH, MDPI, vol. 16(7), pages 1-9, April.
    22. Karl Puchner & Evika Karamagioli & Anastasia Pikouli & Costas Tsiamis & Athanasios Kalogeropoulos & Eleni Kakalou & Elena Pavlidou & Emmanouil Pikoulis, 2018. "Time to Rethink Refugee and Migrant Health in Europe: Moving from Emergency Response to Integrated and Individualized Health Care Provision for Migrants and Refugees," IJERPH, MDPI, vol. 15(6), pages 1-6, May.

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