The healthcare voucher is one way federal states can regulate access to health care for refugees and asylum seekers.
Administrative staff of the social welfare office in charge issue a medical voucher that entitles asylum seekers to see a doctor. Billing as well as payment of costs is made by the social welfare office. Currently, there are two main approaches in the allocation of healthcare vouchers by the federal states and municipalities: (1) Asylum seekers need to apply in person at the social welfare authority in charge for a single healthcare voucher, which they need to present to the attending doctor. For each additional treatment a renewed personal audition to the welfare office is required, for review and reissue of the voucher. (2) Asylum seekers receive every three month a general healthcare voucher from their local welfare office (partly unsolicited, delivered by post), which allows them to go to any physician of their choice.
Referrals to specialists and hospitalization
For referrals to specialists or other doctors, a new healthcare voucher needs to be requested at the welfare office. If the voucher is deposited with the first doctor that sees the patient, she*he has to certify the need of further examination or treatment by another (specialized) physician. The letter of referral is annotated with “benefits under AsylbLG “. The same applies for a scheduled hospitalization: Only with prior consent of the insurance provider – the social welfare office – a referral for an in-patient hospital treatment can take place. Again, by means of the healthcare voucher, the social authority is responsible for the billing and payment of costs.
Unlike a scheduled inpatient or outpatient treatment, in case of an emergency, medical treatment can be given in a medical practice or in hospital without prior submission of a healthcare voucher. Established physicians and hospital administrations can claim the settlement of costs of the medical treatment directly with the social welfare office as the cost-bearer – within the legal scope of restricted services according to AsylbLG.
Scope of services
The legal basis of medical treatment and scope of services are §§ 4 and 6 of AsylbLG, which – compared to the health benefits for statutory insured persons – suggest restricted medical care.
Ambiguous and, thus, arbitrary interpretations of the scope of provision
What benefits are included or excluded according to AsylbLG has been repeatedly a subject of controversy and has often lead to refusal of benefits by the social welfare authority and public health officers during assessments. For example, in the restrictive interpretation of the legal text, the qualification of health services to include only “acute illnesses and pain” is often interpreted to mean the treatment of chronic diseases were excluded, because they are not acute. However, chronic diseases can be painful also. Moreover, it is not medically unambiguous when an illness is defined as acute and when as chronic. This is a general problem of the reduced and ambiguous scope of provision according to AsylbLG: The actual interpretations in practice vary largely from municipality to municipality and from clerk to clerk.
Specific arbitrariness in the issuing of healthcare vouchers
If professional medical personnel already struggle with this issue, the practice of issuing healthcare vouchers opens the floodgates to bureaucratic arbitrariness. Because case workers at the social welfare offices – who usually have no medical expertise – have to decide whether medical treatment is needed and whether, for instance, in their opinion, the illness is acute, painful or chronic. Thus, the decision if and what treatment is necessary is handed over to administrative staff. A specific need for treatment may, however, only be determined after an examination and a subsequent diagnosis – conducted by medical professionals. Those, who are caught in this practice, are subjected to fear and the feeling of being at the mercy of the employees of the social welfare office. The result is that healthcare vouchers are not requested, or only after a serious aggravation of the – then acute –medical condition out of fear or insecurity. This delay causes patients to suffer unnecessary pain, increased disease morbidity, and even deaths have been documented. 1 Attending physicians are often also unsure which treatments are approved and can be claimed from the cost bearer; they know neither the administrative procedures nor the legal basis. Therefore, they are often discouraged from treating patients adequately.
Stigma and discrimination through healthcare voucher practice
Another problem is the stigmatization and discrimination through an obvious “special” treatment and the label “asylum seeker”. This applies to the application for a healthcare voucher at the social welfare office as well as the visit at the doctor’s practice. Neither receptionists nor physicians are free of bias and prejudice against asylum seekers and refugees. The label “asylum seeker” or the note “restricted medical care according to AsylbLG” on healthcare vouchers and doctor’s referrals prevents an unprejudiced encounter, as well as an unbiased medical assessment of what treatment is needed.
Bureaucratic obstacles and increased costs
In recent years, the German Medical Assembly has – like NGOs, refugee councils and actors in health policy – repeatedly pointed out that the medical care of refugees and asylum seekers through the practice of distributing healthcare vouchers is causing unnecessary costs, because of an increased administrative burden, and hinders proper medical care. The introduction of the electronic Health Card (eHealth Card) in Bremen (2005) and in Hamburg (2012) has, however, shown that these cards relieve social welfare offices in terms of personnel and costs, because they reduce the administrative processes and their associated controlling and accounting efforts. From the perspective of beneficiaries, the eHealth Card removes the bureaucratic obstacles of application for healthcare vouchers; a much more straightforward access to services according to AsylbLG is granted.
The access to healthcare irrespective of gender, ethnicity, religion or residence status is a human right that Germany has committed to in several international legally binding agreements, 1
Nevertheless, asylum seekers, refugees, persons with short-term residence permits and migrants without residential status receive in theory and practice, under AsylbLG, only reduced medical benefits. This lack of medical care can lead to chronification, to worsening of the disease or even death. In addition to individual consequences for the patients, this results in higher costs for the healthcare system.
Particularly difficult is the access to healthcare for people without legal residence status. Most social welfare offices and many medical centers transmit their data to the immigration authorities; given the risk of rapid deportation, many persons concerned do not seek help in medical practices or hospital, or only once the disease has greatly worsened. Treatment on the basis of the Anonymous Healthcare Voucher (AHCV) allows
- access to medical treatment without needing to fear that data will be transmitted to the authorities, and at the same time
- healthcare conforming to the common standard of statutory health insurers, in accordance with the human right to health.
The concept has been developed by the Medibüro Berlin (Medicare office Berlin – network for the right of healthcare for all migrants) and the Medizinischen Flüchtlingshilfe Göttingen (Office for the medical assistance for refugees Göttingen) and has been further refined for Lower Saxony in collaboration with the Medinetz Hannover (Medi-network Hannover). The healthcare voucher and the Health Card are supposed to ensure a free choice of physicians and therapists, they should refrain from any restrictive qualifications of the scope of medical provision and the costs for interpreters required for medical treatment should be included in the scope of provision. Anonymous Healthcare Vouchers are distributed by independent refugee organizations with good local networks that have long been working in medical healthcare for refugees and, thus, are well known to people concerned; medical management ensures the adherence to confidentiality for people concerned. The appropriately qualified personnel at distributing offices assess the medical problem and the social situation of their clients. Then, if needed, a healthcare voucher or a Health Card is issued and clients are transferred to medical practices or hospitals. Additionally, upon request, people are redirected to an advisory office that deals with residence-related problems. Funding is provided either by the health insurance (for Health Cards), local government, the federal state (for healthcare vouchers), or managed by the independent organization or distributing office. Services have to be – as for all statutory insured persons – “sufficient, appropriate and cost-effective” (§ 12 para. 1 SGB V); in accordance with § 27 para. 1 SGB V, persons are entitled to medical treatment according to the medical indication.
Background and development of the Anonymous Healthcare Voucher in Lower Saxony
For the AHCV, due to practical difficulties in the administration of the health insurers, the model of choice was a Landesfonds (regional funds), managed by a board of trustees with distributing offices in Göttingen and Hannover. The AHCV runs as a three-year pilot project with an annual Landesfonds budget of €500,000 (of which approx. €420,000 for medical treatment). Furthermore, according to a decision of the Landtag (state parliament), from the 18 December 2014, the feasibility of the “Bremen Model” – statutory health insurance for all people with legal residence status – has to be “examined” (which still has not been finalized, but is now supposed to occur by April 2016). After completion, the AHCV-project will be evaluated on the basis of continuously collected data in order to establish if a national expansion is advisable. Optional legal advice for refugees, funded by the federal state, is provided in conjunction with healthcare in both cities.
Healthcare is significantly restricted because the Ministry of Social Affairs insisted on the following points in the implementation of the Anonymous Healthcare Voucher.
Means of settlement: A physical healthcare voucher, no electronic card is being provided. For referrals to specialists and hospitals, as well as for every new illness, a voucher, valid for maximum 3 months, is issued; the reasons given for this practice is cost control due to the annual cap of €500,000 (of which approx. €420,000 for treatment costs). Additionally, the Ministry of the Interior demands that other AsylbLG-groups receive equal treatment – their treatment in Lower Saxony still depends on the social welfare offices as an administration through the statutory health insurers has not been realized yet by the competent ministries.
The Ministry of Social Affairs achieved the cooperation of the associations of statutory health insurance physicians and dentists and the regional associations of pharmacists. Settlement is according to the current regular rates covered by insurers; hospital costs are being reviewed by the AOK (health insurance provider). The institutionalization under terms of anonymity is historically unprecedented so far.
Patient data are kept safe at the distributing offices of Medizinischen Flüchtlingshilfe Göttingen and the Medinetz Hannover and within clearing houses, respectively.
Psychotherapy is supposed to be limited to crisis intervention; it remains to be seen, if this notion can withstand the reality of widely spread traumatization of people without legal residence status.
Scope of provision
According to the Asylpaket I (asylum package I), which has altered § 1a of the AsylbLG, medical treatment may or ought to be (depending on the perspective of the respective physician) limited according to § 4 AsylbLG, which can mean a restriction of health benefits. A predominantly medical advisory board is supposed to give recommendations on borderline cases and on expensive treatment, as can occur especially in hospitals – alternative, an emergency hospitalization or legalization could be an option, if the persons concerned agree.
The latest changes of the asylum law has also added restrictions, especially the changed § 1a AsylbLG; according to which treatment only may or ought to be limited to § 4 AsylbLG , § 6 („Additional services“) of AsylbLG, thus, ceases to exist.
In January 2016, the distributing offices in Hannover and Göttingen commenced the project. The difficulties of project implementation are going to be the medical impossibility of a mere acute care, which is supposed to exclude prevention and treatment of chronic illnesses even in isolated cases – the foreseeable result is aggravation of conditions and permanent damage, and therefore increased costs. The first year of the project will show if sick people without legal residence status in Lower Saxony actually will receive the health services that are medically indicated under these circumstances.
References and further reading:
References and further reading:
- Classen, Flüchtlingsrat Berlin: Sozialleistungen zur Krankenbehandlung nichtversicherter Ausländer
Flüchtlingsrat Berlin, Oktober 2014: Stellungnahme zur Anhörung des AS-Ausschusses des Deutschen Bundestages zum „Entwurf eines Gesetzes zur Änderung des AsylbLG und des SGG“, BT-Drs.18/2592 vom 22.9.2014, S. 39 ff.
- The concept of the Anonymous Healthcare Voucher (for people with no legal residence status)
- e.g. International Covenant on Economic, Social and Cultural Rights (“UN Social Covenant”, Article 2 para. 1 in conjunction with Article 12), The UN Convention on the Rights of the Child (Article 24), Charter of Fundamental Rights of the European Union (Article 35). ↩