The Electronic Health Insurance Card for Asylum-Seekers in Berlin: Effects on the Local Health System

Document Type : Original Article


1 Department of Health Care Management, Technical University Berlin, Berlin, Germany

2 Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany

3 Berlin School of Public Health, Berlin, Germany


In debates on asylum-seekers’ access to healthcare it is frequently claimed that restrictions are necessary to prevent unduly high health service utilization and costs. Within Germany, healthcare provision for asylum-seekers varies across the different states. Berlin’s authorities removed some barriers to healthcare for asylum-seekers by introducing an electronic health insurance card (HIC) in 2016. We used the HIC introduction in Berlin as an opportunity to investigate the effects of improved healthcare access for asylum-seekers on the local health system.
The study applied a mixed-methods design. A cost analysis compared expenses for outpatient and inpatient health services for asylum-seekers before and after the HIC introduction, based on aggregate claims data and information on expenses for humanitarian healthcare provision that were retrieved from the Berlin authorities. Semi- structured interviews with 12 key informants explored organizational effects like administrative workloads and ethical dilemmas for staff. We performed a content analysis and used respondent validation to enhance the accuracy and trustworthiness of our results.
The HIC has reduced bureaucratic complexity and administrative workloads; it has enabled unprecedented financial transparency and control; and it has mitigated ethical tensions. All the while, average per person expenses for outpatient health services have declined since the HIC introduction. However, our cost analysis also indicates a rise in the utilization and costs of inpatient care.
The HIC introduction in Berlin suggests that the removal of barriers to healthcare for asylum-seekers can create win-win-situations by reducing administrative workloads, advancing financial transparency, and mitigating ethical tensions, whilst cutting the costs of outpatient healthcare provision. Removing barriers to healthcare thus appears to be a more prudent policy choice than maintaining mechanisms of restriction and control. However, high inpatient care utilization and costs warrant further research.


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Volume 11, Issue 8
August 2022
Pages 1325-1333
  • Receive Date: 25 August 2020
  • Revise Date: 24 March 2021
  • Accept Date: 28 March 2021
  • First Publish Date: 17 April 2021