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

Yuliya Kosyakova,Philipp Jaschke

doi:10.1177/0197918320980413

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.

Highlights

Refugee1 migration and integration have become prominent topics in research (Brell, Dustmann, and Preston 2020; Hatton 2020) and politics in recent years (OECD 2018), as migration figures have increased in response to war, persecution, and other forms of violent conflicts associated with events like the Arab Spring in late 2010 (Hatton 2020; Valdez 2020)
Germany has evolved as the main refugee destination among high-income OECD countries in absolute and relative terms (Brucker, Kosyakova, and Vallizadeh 2020): from 2015 to 2018, 41 percent (1.6 million) of the 3.9 million first-time asylum applications in the EU-28 were submitted in Germany (Eurostat 2019)
Representative longitudinal data from the IAB-BAMF-Socio-Economic Panel (SOEP) Survey of Refugees,3 we find that being eligible for electronic health cards (eHCs) because of the policy change improved the mental well-being and subjective health assessment of refugees who arrived in Germany between 2013 and 2016, while having no effect on physical health

Summary

Introduction

Refugee migration and integration have become prominent topics in research (Brell, Dustmann, and Preston 2020; Hatton 2020) and politics in recent years (OECD 2018), as migration figures have increased in response to war, persecution, and other forms of violent conflicts associated with events like the Arab Spring in late 2010 (Hatton 2020; Valdez 2020). Representative longitudinal data from 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 refugees who arrived in Germany between 2013 and 2016, while having no effect on physical health 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 (Silove et al 1999; Robjant, Hassan, and Katona 2009). We define individuals as belonging to the treatment group — those eligible for the eHC via policy change — if the following conditions apply: (1) refugees reported Their assigned place of residence in a region subject to the above-described policy intervention; (2) their asylum application was not yet decided by the date of the policy intervention (independent of the eventual decision type by the interview date); and (3) they arrived less than 15 months before the date of the policy intervention. Note that we refrain from imputing the missing dates of arrival or asylum decision because such missing information is likely to not be random and to correlate with education and literacy (see Table A3 in the Online Appendix)

Results

Discussion

Declaration of Conflicting Interests