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.
Table 1.
Type of officially reported expenditures used to calculate health expenditures among asylum-seekers with restricted and regular access to health care.
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.
Table 2.
Descriptive details of the study population by year and type of access.
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.
Table 3.
Change in the dependent variable “absolute difference in per capita health expenditure (∆IRt)” in Euros per one unit increase in the independent variable ∆NEEDt (adjusted for secular trends and between-group differences in age and sex).
Table 4.
Crude and adjusted estimates for effects of restrictive reforms on level and trends in the dependent variable “absolute difference in per capita health expenditure (∆IRt)” in Euros.