Life Without Health Insurance

Causes, Living Situations, and Medical Care—a Qualitative Study

According to the microcensus, or “small population census”, of the German Federal Statistical Office, around 61 000 people in Germany were living without health insurance coverage in 2019 (1). However, those living illegally, and others, are not captured by this statistic, so it must be assumed that there is also a large number of unreported cases; estimates put this figure at a total of 0.5 to 1 million people in Germany without health insurance protection (2). Till now, studies from Germany have only reported from the standpoint of experts (3), while those affected have no say in the matter. This is where the present study comes in. From the perspective of those affected, it explores their living situation, potential causes for absence of health insurance, as well as restricting and supporting factors for ensuring medical care and (re)acquisition of health insurance coverage.

Methods

A qualitative study involving ten individuals living in Germany who currently, or in the more recent past, had no health insurance, pursued the following questions:

• What is the living situation of those affected like?
• Which barriers do they encounter with respect to medical care?
• Which positive factors help in coping with the living situation and facilitate reacquisition of regular health insurance coverage?
• Which obstacles stand in the way of changing the insurance situation?
• What are their aspirations regarding their future health insurance situation?

Data acquisition was conducted using problem-centered, semi-structured, face-to-face interviews (05/2021–02/2022). Participants were recruited via so-called gatekeepers, namely, employees of aid organizations and social counseling centers. The interviews were conducted in either German or English, recorded on tape for evaluation, and then transcribed verbatim. Data analysis was performed using MAXQDA, based on anonymized transcripts and following the principles of content-structuring qualitative content analysis as reported by Kuckartz (4). For this purpose, main categories were first derived from the key questions of the interview guide which were then, in a second step, supplemented with subcategories based on the written material. The written material was discussed in a number of interprofessional coding sessions and subjected to several coding loops until no further relevant categories could be identified and all aspects pertinent to the research questions had been coded.

Results

The interviews lasted an average of 32 minutes (23–49 minutes) and were conducted with seven men and three women (Table). Based on the key questions of the interview guide, five main categories and 30 subcategories were developed to address the research questions (Box).

Box

Main categories of the category system with sample quotations

Table

Sociodemographic characteristics of the ten interview partners

Living situation: The life circumstances of the interviewees were varied and often precarious. Most of them had a history of flight or migration, many were living in monetary poverty or in precarious housing conditions, all of which had a direct effect on their health situation. Respondents without legal residence status reported experiencing considerable psychological distress due to living in constant fear.

Barriers to health care access: Reported reasons for having no insurance included lack of knowledge about the German health insurance scheme, bureaucratic hurdles, unemployment, and absence of valid identity documents. In order to receive medical assistance, those affected accessed, for example, MediNetz, i.e., a non-governmental nonprofit organization that arranges medical care for people with no legal residence or health insurance status free of charge. The idea was also mentioned of borrowing a health insurance card from acquaintances, but the photos printed on the cards make this impossible. Self-medication and obtaining services on private prescriptions were also reported. In many reports it was clear that this meant funding by a third party and a subsequent relationship of dependency.

Positive factors for coping with the living situation: Key resources for dealing with the situation were spirituality, faith, and a positive attitude to life. Those affected received support in everyday life in particular from aid organizations, friends, state institutions (for example, social welfare offices), and lawyers for legal advice.

Obstacles to coping with the living situation: A lack of knowledge about their own potential options was reported by some as a key obstacle to gaining health insurance coverage. Further obstacles included language barriers, financial issues, and fear of deportation for illegal immigration. Only a few of those affected mentioned direct rejection by a health insurance company.

Aspirations regarding health insurance status: Those interviewed expressed the need for reliable access to health care for themselves and their families. They expressed their hope for improvements to the insurance system and suggested temporary insurance schemes involving, for example, coverage for specific services. A strong desire for stability and independence from others was apparent, for example, by returning to working life and gaining official residence status.

Discussion

The personal living circumstances of people with no health insurance play a decisive role in their ability to cope with their situation. Although the possession of identity documents is a precondition for health insurance coverage, it is not the only criterion—for example, financial means, language skills, social networks, and awareness of help that might be available are also key factors. These results are in line with the outcomes of previous studies examining expert views, as are the identified barriers to accessing medical services. In this regard, staff working for voluntary organizations also mentioned poverty, insecure livelihood conditions, precarious housing conditions, and lack of social support as key barriers (3).

The present study is a supplement to current research by providing a direct view of those affected and underlining the fact that tailored strategies for improvement are needed. Barriers preventing the various groups of involved individuals from accessing health care should be recognized and dismantled in a way specific to each target group. This requires, in the first instance, quantitative research to demonstrate needs, together with an evaluation of existing approaches (for example, anonymous treatment vouchers enabling access to healthcare without regular insurance). This is the only means to ensure inclusive and equitable healthcare.

Frauke Heinrichs, Klaus Weckbecker, Eva Münster, Christine Kersting

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 17 April 2025, revised version accepted on 22 July 2025

Translated from the original German by Dr. Grahame Larkin

Cite this as:
Heinrichs F, Weckbecker K, Münster E, Kersting C: Life without health insurance: Causes, living situations, and medical care—a qualitative study. Dtsch Arztebl Int 2025; 122: 558–9. DOI: 10.3238/arztebl.m2025.0140

References

1. Statistisches Bundesamt (Destatis): Sozialleistungen. Angaben zur Krankenversicherung (Ergebnisse des Mikrozensus). 2019. Fachserie 13, Reihe 1.1. Artikelnummer 2130110199004. Erschienen am 28. Juli 2020, korrigiert am 15.09.2020. www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Gesundheitszustand-Relevantes-Verhalten/Publikationen/Downloads-Gesundheitszustand/krankenversicherung-mikrozensus-2130110199004.pdf?__blob=publicationFile&v=9 (last accessed on 6 August 2025).

2. Kurz C: Menschen ohne Krankenversicherung: Ein oft übersehenes Problem. Dtsch Arztebl 2022; 119: A-1738

3. Stötzler M, Kaifie A: Healthcare for individuals without health insurance in Germany—a mixed-methods approach to assess the situation and ­current challenges. Int J Equity Health 2023; 22: 117

4. Kuckartz U: Qualitative Inhaltsanalyse: Methoden, Praxis, Computerunterstützung. Weinheim, Basel: Beltz Juventa, 2012.