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

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.

Fig 1. Simplified overview of entitlements to health care among asylum-seekers and refugees in Germany and transition between entitlements conditional on time and residence status.

Fig 2. Causal diagram of the hypothetical relationship between restricted access to health care and health care expenditures including mediators and confounders of the association.

Bold lines: mediating relations. Dashed lines: confounding relations. Causal relations: one-sided arrows. Non-causal relations: two-sided (hollow) arrows.

Fig 3. Population of asylum-seekers and refugees in Germany by entitlement of access to health care (1994–2013).

Y-axis: shows the total number of asylum-seekers/refugees registered in Germany on 31 December of each year. Restricted access: refers to access to health care according to sections 4 and 6 of the Asylum-Seekers’ Benefits Act (AsylbLG §§4,6). Regular access: refers to access to health care analogously to the general population according to the Federal Social Security Act (Bundessozialhilfegesetz, BSG) before 2005 and to Volume 12 of the Social Insurance Code (Leistungen nach dem 5.-9. Kapitel SGB XII) thereafter. 12/36/48 months: indicate the “waiting time” to regular access (according to section 2 of the Asylum-Seekers’ Benefits Act, AsylbLG §2) in respective time periods.

Fig 4. Per capita health expenditure on AS&R by type of access and absolute difference in per capita expenditure on health between the groups with restricted and regular access (1994–2013).

Long-dashed vertical line: indicates onset of REFORM1 in June 1997, which prolonged the, “waiting time” to regular access from 12 months (1994–1996) to 36 months thereafter (until 2006). Short-dashed vertical line: indicates onset of REFORM2 in August 2007, which prolonged the, waiting time”to regular access from 36 months (1997–2006) to 48 months (2007–2013). The observations in 1997–1999 were excluded from the analysis because the group with regular access (on 31 Dec) was zero, thus leading to artificially high differences in expenditures, and in 1997 to artificially high per capita expenditures for the total population. Expenditures for regular access before 2005 refer to expenditures categorised under the Federal Social Security Act (Bundessozialhilfegesetz).

Fig 5. Absolute difference in need variables (exposed minus unexposed group).

Y-axis: shows percentage-point differences between groups with restricted access (exposed) and regular access (unexposed) to health care for all need variables, except for, “mean age” where the difference is in years. The observations in 1997–1999 were excluded from the analysis because the group with regular access (on 31 Dec) was zero. The category, “Other/Unknown” comprises asylum-seekers with nationalities from Australia and Oceania, stateless asylum-seekers, and asylum-seekers for with unknown nationality.

Fig 6. Scatter plot and fitted values of per capita health expenditures on asylum-seekers and refugees by entitlement on access to health care.

Restricted access: refers to access to health care according to sections 4 and 6 of the Asylum-Seekers’ Benefits Act (AsylbLG §§4,6). Regular access: refers to access to health care analogously to the general population according to the Federal Social Security Act (Bundessozialhilfegesetz, BSG) before 2005 and to Volume 12 of the Social Insurance Code (Leistungen nach dem 5.-9. Kapitel SGB XII) thereafter. Dotted lines below/above fitted values: constitute 95% confidence intervals, obtained from robust standard errors clustered by year. The observations in 1997–1999 were excluded from the analysis in predicting fitted values for the group with regular access because the denominator (on 31 Dec) was zero.