Does Facilitated and Early Access to the Healthcare System Improve Refugees’ Health Outcomes? Evidence from a Natural Experiment in Germany

Abstract

Because of their often-dramatic, life-threatening flight patterns and resulting pronounced health disparities, many refugees have a great need for medical treatment after arrival to their host countries. In Germany, refugees whose asylum application is not approved or whose duration of stay has not yet exceeded 15 months must request doctor visits, with a considerable amount of bureaucracy, from the local responsible authority. Since 2016, however, several federal states and municipalities in Germany have introduced electronic health cards ( eHCs) which give refugees immediate and unbureaucratic access to the healthcare system. We examine whether being eligible for eHCs because of this policy change had an effect on multidimensional health indicators for refugees in Germany. For empirical identification, we take advantage of variation in policy adoption across German regions and over time. Relying on the IAB-BAMF-SOEP Survey of Refugees, we find that being eligible for eHCs because of the policy change improved the mental well-being and subjective health assessment of recently arrived refugees, while having no impact on physical health status. These results can be traced back to the moderating effect of facilitated healthcare access on post-migration stress, which is known to affect primarily psychological well-being. Moreover, facilitated healthcare access appears to alleviate potential language and cultural barriers faced by refugees with low health literacy (measured by the ability to read or write in the origin-country language). Altogether, the article illustrates how structural and institutional constraints may shape individual health outcomes of adult refugees.

The Impact of Pre- and Postarrival Mechanisms on Self-rated Health and Life Satisfaction Among Refugees in Germany

“… Walther et al (2020) also found that postmigration factors such as greater stability, secure legal status, nontemporary housing, family reunification, language abilities and social contacts had a positive impact on refugees’ mental health outcomes and subjective life satisfaction ( see also Gambaro et al, 2018 ; Löbel and Jacobsen, 2021 ). Jaschke and Kosyakova (2021) found evidence of significant health improvements in terms of self-related health and well-being among refugees when they were provided early and comprehensive access to the health system.…”

“…A second postarrival stress factor relates to the housing situation . A lack of access to stable and secure housing has been shown to heighten refugees’ stress levels ( Porter and Haslam, 2005 ; Georgiadou et al, 2018 ; Walther et al, 2020 ; Jaschke and Kosyakova, 2021 ) since life in temporary collective accommodations hinders privacy and autonomy and increases isolation from the local community ( Adam et al, 2019 ). Moreover, poor housing situations might be linked to the financial and social deprivation that refugees are likely to experience in the early arrival stages ( Krahn et al, 2000 ).…”

“…Indeed, refugees who are not fluent in the host country language experience a lack of integration both in society and in the labor market. For instance, Green (2017) and Aljadeeah et al (2021) documented the importance of language knowledge and the existence of language barriers among refugees in Germany, which prevented them from having full access to health care ( see also Jaschke and Kosyakova, 2021 ).…”

“…For instance, approximately one-quarter of the recent refugees who arrived in Germany reported shipwrecks, two-fifth reported physical assaults, and 15 percent of female refugees reported sexual assaults ( Brücker et al, 2016 ). After arriving at the destination country, refugees often live under precarious conditions ( Robjant et al, 2009 ; Nickerson et al, 2010 ); are worried about family members remaining in countries of origin or other transition countries ( Nickerson et al, 2010 ; Löbel and Jacobsen, 2021 ); have to go through lengthy and, in many cases, stressful asylum procedures; ( Silove et al, 1998 ; Laban et al, 2004 ; Kosyakova and Brenzel, 2020 ; Kosyakova and Brücker, 2020 ), and face restrictions to healthcare services ( Silove et al, 1999 ; Norredam et al, 2006 ; Chase et al, 2017 ; Jaschke and Kosyakova, 2021 ). It has also been argued that – compared to economic immigrants – refugees are less oriented towards the labor market in their migration decision and, hence, are less likely to be positively selected based on health ( Chiswick et al, 2008 ).…”

“…The handful of studies examining the health status of recent refugees in Germany ( Dietrich et al, 2019 ; Walther et al, 2020 ; Jaschke and Kosyakova, 2021 ; Löbel and Jacobsen, 2021 ) have focused primarily on access to healthcare services and the role of family ties abroad, as well as the role of pre- and postarrival stress for psychological and physical health and psychological distress ( see meta-analysis by Hajak et al, 2021 ). These studies, however, mainly focused on the level differences while neglecting the role of the postarrival experiences for the development of health outcomes over the duration of the stay.…”