The law restricts health care for asylum seekers during the first 18 months of stay to instances “of acute diseases or pain”, in which “necessary medical or dental treatment has to be provided including medication, bandages and other benefits necessary for convalescence, recovery, or alleviation of disease or necessary services addressing consequences of illnesses.” Furthermore, vaccination and “necessary preventive medical check-ups” shall be provided. The law further contains a special provision for pregnant women and women who have recently given birth. They are entitled to “medical and nursing help and support”, including midwife assistance. In addition, the law states that further benefits can be granted “if they are indispensable in an individual case to secure health”.
After 18 months, asylum seekers are entitled to social benefits as regulated in the Twelfth Book of the Social Code (Sozialgesetzbuch). These “standard” social benefits include access to health care under the same conditions that apply to German citizens who receive social benefits. The waiting period of 18 months is a result of the reform of the Asylum Seekers’ Benefits Act in 2019, which had extended the previous waiting period of 15 months by an additional 3 months.
The term “necessary treatment” within the meaning of the law has not conclusively been defined but is often considered to mean only medical care that is absolutely unavoidable. However, the wording of the law suggests that health care for asylum seekers must not be limited to “emergency care” since the law refers to acute diseases or pain as grounds for necessary treatment. Accordingly, it has been argued that a limitation of treatment to acute diseases is not in accordance with the law. If chronic diseases cause pain, they have to be treated as well. There remains a dispute, however, as to what treatment is necessary in these cases, i.e. if the treatment of pain requires treatment of the causes of the chronic disease, or if a more cost-effective treatment option (usually medication) that eliminates the pain, at least temporarily, is sufficient. It has been reported that necessary but expensive diagnostic measures or therapies are not always granted by local authorities, which argue that only “elementary” or “vital” medical care would be covered by the law.
Even if a chronic disease is not causing pain momentarily, asylum seekers might still be entitled to treatment, if it is indispensable to secure health pursuant to Section 6(1) of the Asylum Seekers’ Benefits Act. Recently, some Regional Social Courts have argued that this provision must be interpreted broadly in accordance with the constitution. Thus, apart from a few exceptions, especially in the case of minor illnesses or short stays, a level of benefits must be established that corresponds to regular health insurance.
In general, the practice with regard to access to health care varies between Federal States and at times between municipalities. A common problem in practice is caused by the need to obtain a health insurance voucher (Krankenschein). These vouchers or certificates are usually handed out by medical personnel in the initial reception centres, but once asylum seekers have been referred to other forms of accommodation, they usually have to apply for them at the social welfare office of their municipality. Critics have pointed out that the ambiguity of the scope of benefits under the law leads to varying interpretations in practice from municipality to municipality and may result in bureaucratic arbitrariness by case workers at the social welfare offices, who usually have no medical expertise. The necessity to distribute health insurance vouchers individually also imposes significant administrative burden on the social services.
In response, the Federal States of Berlin, Brandenburg, Bremen, Hamburg, Schleswig-Holstein and Thuringia issue “normal” health insurance cards to asylum seekers, enabling them to see a doctor without permission from the authorities. In some Federal States (North Rhine-Westphalia, Lower Saxony and Rhineland-Palatinate) the health insurance card for asylum seekers has been introduced in principle, but it has only been implemented in a few municipalities. Other Federal States (e.g. Bavaria and Baden-Württemberg, Saxony, Mecklenburg-Vorpommern) have announced that they will not participate in the scheme.
It has to be pointed out, however, that even in a Federal State like Brandenburg, where almost all municipalities are issuing health insurance cards, the policy does not apply to asylum seekers in initial reception centres, which fall under the responsibility of the Ministry of the Interior. Due to the recently extended obligation to stay in these centres, this affects many asylum seekers for a substantial amount of their asylum procedure (see Obligation to stay in initial reception centres). This means that they cannot access a medical professional of their choice as they depend on the medical personnel present in the initial reception centres. While nurses are present daily in initial reception centres Eisenhüttenstadt and Doberlug-Kirchhain, medical doctors are only on site three days a week. A further practical problem reported is the fact that the medical staff is very restrictive in referring patients to medical specialists. This makes it almost impossible for asylum seekers to meet the legal requirements for the proof of medical conditions in asylum procedures, which explicitly requires a qualified certificate from a medical specialist.
Similarly, in Bavaria, access to health care is rendered extremely difficult for asylum seekers living in AnKER Dependancen. There is often no general practitioner in the Dependancen and residents have therefore to receive care in the main AnkER building, which can be located miles away. Moreover, the doctor present in an AnKER centre is usually a general practitioner and does not provide medical reports, while access to specialised doctors can only take place following a referral from the general practitioner. As seen above, this problem is not specific to AnKER centres, but also prevalent in other reception centres.
According to Section 1a of the Asylum Seekers Benefits Act, reception conditions can be reduced for reasons defined in the law (see Reduction or Withdrawal of Reception Conditions). Even if benefits have been reduced, however, asylum seekers remain entitled to medical treatment pursuant to Section 4 of the Asylum Seekers’ Benefits Act. However, treatment pursuant to Section 6(1) of the Asylum Seekers’ Benefits Act is not accessible in these cases.
Specialised treatment for traumatised asylum seekers and victims of torture can be provided by some specialised doctors and therapists and in several specialised institutions (Treatment Centres for Victims of Torture – Behandlungszentren für Folteropfer). Since the number of places in the treatment centres is limited, access to therapies is not always guaranteed. In 2019, access to around 40 % of applicants is refused, and others have to wait an average of 7,3 months to start treatment. The treatment centres have to cover most of the costs for therapies (93 %) through donations or other funds since therapies are often not covered by the health and social authorities. Large distances between asylum seekers’ places of residence and treatment centres may also render an effective therapy impossible in practice.
The legal framework for accessing health care has not changed since the outbreak of Covid-19. However, preventive measures such as testing and social distancing was implemented in most reception centres and many services were reduced, which might have affected access to health care as well (see Conditions in reception facilities). All persons residing in Germany, including asylum seekers, are entitled to receive the vaccination against SARS-CoV-2. Asylum seekers living in reception centres were among the priority groups, meaning they were entitled to receive a Covid-19 vaccine from February 2021. However, the organisation of vaccinations have been criticised in some cases. By way of example, the Refugee Council of Lower Saxony reported that no adequate information about the vaccine was provided in reception centres at the start of the vaccination campaign, e. g. that information in other languages than German was missing and that information was not provided systematically. At the beginning, a lack of vaccines also led to delays in the start of vaccination campaigns. In some places, the readiness of asylum seekers in reception centres to get vaccinated has thus been reported to be comparatively low in some reception centres. This was attributed to a mistrust vis-à-vis authorities following the lack of systematic information, but also the at times difficult conditions in reception centres during the first waves of the Covid-19 pandemic and previous experiences of being disadvantaged by authorities.
 Section 4(1) 1st Sentence Asylum Seekers‘ Benefits Act.
 Section 4 Asylum Seekers’ Benefits Act.
 Section 4(2) Asylum Seekers‘ Benefits Act.
 Section 6(1) Asylum Seekers’ Benefits Act.
 However, the reduction of benefits may apply for more than 18 months (i.e. without any time limit) to persons who have “abused the law to affect the duration of their stay”.
 Higher Administrative Court Baden-Württemberg, Decision 7 S 920/98, 4 May 1998.
 Regional Social Court Hesse, Decision L 4 AY 9/18 B ER, 11th July 2018; Regional Social Court Mecklenburg-Vorpommern, Decision L 9 AY 13/19 B ER, 28th August 2019.
 A study published in early 2022 gives an overview of the regulations and practices in place in the Federal States: Katja Lindner, ‘Gesundheitsversorgung von Asylsuchenden In den Bundesländern. Rahmenbedingungen und Reformbedarfe’, MIDEM-Policy Paper 01/22, available in German at https://bit.ly/3inpIgt.
 Information provided by local social workers of Komm Mit e.V. June 2020.
 Section 60(7 in conjunction with Section 60a(2c) Residence Act.
 Bundesweite Arbeitsgemeinschaft der Psychosozialen Zentren für Flüchtlinge und Folteropfer (BAfF), Versorgungsbericht – Zur psychosozialen Versorgung von Flüchtlingen und Folteropfern in Deutschland, August 2019, available in German at: https://bit.ly/2O68bKK, 146-147.