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]) and a tendency towards lower GP (OR=0.61 [0.33-1.16]) and emergency department utilization (OR=0.74 [0.48-1.14]). ASR under the EHC model showed a tendency toward higher specialist unmet needs (OR= 1.89 [0.98-3.64]) and avoidable hospitalizations (OR=1.69 [0.87-3.30]) compared to ASR with regular access. A comparison between EHC and HV showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). 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 (and partly also GP) 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. Minor differences in unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Context and health: a systematic review of natural experiments among migrant populations

“…Nine studies combine two or more of these mechanisms in order to further strengthen the natural experiment design. For example, some studies 38,44,45 use a regional variation in exposure in combination with residential allocation mechanisms (e.g. in the context of a dispersed refugee population) in order to avoid bias through self-selection.…”

“…We found four types of contextual effects which were examined across studies: contextual factors of the place of residence in receiving countries (n=15) 27,29–32,34,36,40–43,46,49,60,61 , migration-context interactions (n=10) 59,62,63,65–71 , policy contexts (n=20) 26,28,33,37–39,44,45,47,48,50–58,64 , as well as cultural factors as context (n=1) 35 , the latter being an outlier in this set. Studies related to “contextual factors of the place of residence” examined specific regional characteristics such as regional deprivation, income inequality, neighbourhood disadvantage or migrant density among migrants in the resettlement phase.…”

“…Just under half of studies (n=22) 28,30–36,38,40–44,46,49,53,55,63–66 use regression adjustment as their statistical analysis approach (Appendix Table S6). Other popular approaches include difference-in-difference analyses (n=10) 39,47,48,51,52,54,56–59 , instrumental variables (n=8) 27,60,62,67–71 and regression discontinuity (n=3) 26,37,50 .…”

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 .…”