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. 2015 Jul 22;10(7):e0131483. doi: 10.1371/journal.pone.0131483. eCollection 2015.


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.

MeSH terms

  • Databases, Factual*
  • Emigrants and Immigrants*
  • Female
  • Germany
  • Health Services Accessibility*
  • Humans
  • Male
  • Retrospective Studies

Grant support

No direct funding was received for this study. KB was funded through a public contract with the Federal State of Baden-Württemberg (Germany) whilst conducting this research, and received grants in the scope of the young scientists programme of the German network ‘Health Services Research Baden-Württemberg’ of the ‘Ministry of Science, Research and Arts’ in collaboration with the ‘Ministry of Employment and Social Order, Family, Women and Senior Citizens’, Baden-Württemberg. The funding sources had no involvement in design, collection, analysis or interpretation of data, in the writing of the article, and in the decision to submit it for publication.