The Health and Medical Care of People Without Regular Health Insurance

An Exploratory Cross-Sectional Study

Estimates put the number of people in Germany with only limited or no health insurance at over 1 million (1). Those affected include, among others, people without regular residence status, homeless individuals, non-German EU citizens, and insured persons with contribution arrears owed to their statutory or private health insurance (2).

Germany-wide, needs-based health care provision requires more precise knowledge about the state of health of people without regular (that is to say, with no or only limited) health insurance (PWHI) as well as their utilization of medical care. The aim of this study was to generate target group-specific knowledge based on a cross-sectional study and a comparison with representative data on the general population.

Methods

Data collection was carried out using a multilingual, anonymous, written cross-sectional survey (MoveCitizenS study, DRKS00029186). Respondents consisted of adults who had visited a drop-in center for PWHI at seven locations in Germany (Berlin, Bielefeld, Bonn, Düsseldorf, Frankfurt, Mainz, Wiesbaden) between February and August 2023.

Based on established measurement instruments (European Health Interview Survey [EHIS]/Gesundheit in Deutschland aktuell [GEDA—German Health Update] [3] and RESPOND [4]), a German-language questionnaire was developed by the multiprofessional study team and translated into five languages (Albanian, Arabic, English, French, Spanish) using the TRAPD method (5). This took into account feedback from pretests using cognitive interviews with experts in the healthcare sector and individuals in the target group.

Health status was investigated with regard to general health status, prevalence of chronic diseases, physical pain, and psychomorbidity. The frequency of medical care utilization was investigated for the previous 12 months. This applied to the outpatient sector (general, specialist, dental, and psychotherapeutic/psychiatric care) and the inpatient sector (inpatient stay/emergency hospital admission). The results are reported descriptively as relative frequency estimates (including 95% confidence intervals, CI).

To investigate possible associations between self-reported health insurance status (independent variable) and health status/utilization (dependent variables), the data from the sample were compared with survey data from the general population in Germany (GEDA 2019/2020-EHIS) (3) using conditional logistic regression analyses. To improve the comparability of the samples, a 1: 1 propensity score matching analysis was performed. In this way, n = 113 pairs were formed from the PWHI and GEDA samples. Potential confounders were determined by means of directed acyclic graphs (www.dagitty.net) and used as matching variables (age group, sex, educational status).

All analyses were defined in advance and published as an analysis protocol (www.osf.io/wrsb5).

Results

A total of 126 individuals took part in the PWHI survey study (response rate, 54.1%): average age 43 years (standard deviation ± 12.8; range: 23–75), 56.1% (n = 69) female. In all, 15.1% (n = 19) reported having German citizenship, 11.1% (n = 14) that of another EU country, and 65.1% (n = 82) that of a third country. Educational status (according to the International Standard Classification of Education) was high in 15.9% (n = 20), medium in 38.1% (n = 48), and low in 38.9% (n = 49). A total of 19.0% (n = 24) reported being in employment.

Since a non-response analysis was unremarkable, only available data were evaluated (complete case analysis). The descriptive results are shown in Table 1.

Table 1

Health status and utilization of medical care among the surveyed people without regular health insurance (PWHI, n = 126)

The regression analyses show that PWHI are more likely to report moderate to very poor health status compared to people in the GEDA sample (odds ratio [OR] 5.33; 95% CI [2.62; 10.87]; missing values, n = 2 [1.8 %]).

The likelihood of non-utilization of primary (OR 6.13 [2.90; 12.93]), specialist (OR 2.40 [1.31; 4.38]), or dental care (OR 22.67 [7.13; 72.04]) within a 12-month period is higher in PWHI than in the GEDA sample. With regard to psychotherapeutic/psychiatric and in-hospital care (as an inpatient or emergency department patient), no statistically significant differences were found (all OR around 1 with a 95% CI between [0.45; 2.73]).

Discussion

The study shows that PWHI often do not seek medical care, or do so only rarely, whereas their somatic and mental health appears to be poor. A comparison of these survey results (PWHI) with health data on the general population (GEDA) shows clear differences in subjective health status based on health insurance status, irrespective of age group, sex, or educational status. PWHI use primary, specialist, and dental care less frequently compared to the general population and presumably not in line with their needs. On the other hand, utilization in the inpatient sector and the field of psychiatry is comparably rare. Presumably, a worsening in the health status of PWHI leads to inpatient care, which, however, could have been avoided through outpatient/preventive care.

Individuals with limited health insurance coverage (for example, those with contribution arrears owed to their health insurance carrier) are less likely to seek advice from counseling centers for PWHI than are individuals without any health insurance coverage (often third-country nationals). Thus, the latter are over-represented in our sample. Due to this, as well as the fact that the questionnaire was limited to six languages, there is a risk of selection bias, and the study results can be generalized to only a limited extent. Data were collected in the form of self-reported information (with possible bias due to memory lapses). Information on confirmed diagnoses is lacking. The results represent only a section of a heterogeneous group of PWHI and should be seen as an initial approach to the topic.

Conclusion

Civic drop-in centers provide medical assistance to PWHI, mostly outside of the regular health care system. Some additionally help affected individuals to obtain regular health insurance cover. However, care is provided to a very limited extent. Therefore, the results point to a concrete need for action aimed at:

• Continuing and sufficiently financing the existing low-threshold care services on offer
• Ensuring a broad range of outpatient and inpatient care (acute care, chronic disease care).

The success of this should be monitored by means of comprehensive health monitoring, taking into account the heterogeneity of the population. This supports a needs-based improvement in health care provision to everyone living in Germany.

Anke Dickmann, Sabrina Kastaun, Marie-Therese Schmitz, Jacqueline Warth

Funding

The MoveCitizenS project was financially supported by the funding program for research projects with citizen participation at the Heinrich Heine University Düsseldorf, Germany.

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript submitted on 8 April 2024, revised version accepted 1 August 2024.

Translated from the original German by Christine Rye.

Cite this as
Dickmann A, Kastaun S, Schmitz MT, Warth J: The health and
medical care of people without regular health insurance—an exploratory cross-sectional study. Dtsch Arztebl Int 2024; 121: 851–2. DOI: 10.3238/arztebl.m2024.0169

References

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2. Ärzte der Welt e. V.: Gesundheitsreport – Krank und ohne medizinische Versorgung in Deutschland; 2023 [Stand: 07.04.2024]. www.issuu.com/arztederwelt/docs/gesundheitsreport_2023_aerztederwelt (last accessed on 21 October 2024).

3. Robert Koch-Institut, Abteilung für Epidemiologie und Gesundheitsmonitoring. Gesundheit in Deutschland aktuell 2019/2020-EHIS (GEDA 2019/2020-EHIS). Scientific Use File 1. Version; 2022.

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