A city for everyone?

Ulrich Beck took the opening of the "Soziologentag" (German sociologists' annual conference) 2008 as an opportunity to expose the unequal distribution of the global consequences of climate change on a world scale as well as the welfare states’ shielding strategies. In his view, the end of the national class system implies by no means the end of social inequality, but rather aggravates it at national and transnational level. There is a correlation between the merit principle, which legitimises national inequality, and the nation state principle, which legitimises global inequality: 

“With more and more norms of equality globally unfolding, the institutionalised denial of global inequality loses its legitimacy. The rich democracies are carrying the flag for human rights into the most remote corner of the earth without noticing that, in doing so, national borders – which they need to ward off migration flows – lose their legitimacy. Many migrants believe in equality as a human right to mobility, but encounter countries and states which – especially under the impression of increasing domestic inequality – want to end the norm of equality at their armed borders.” (Beck 2008, p. 15)

The following article discusses the consequences of this defensive attitude with regard to health care for people without residential status or sufficient health insurance in Germany, using the example of Berlin.

These people are subject to a special kind of lawlessness, which has consequences in terms of their access to educational and health care institutions, the job market as well as the legal system. In the first paragraph, this group of people is therefore classified as a population group threatened by social exclusion or “Urban Underclass”. The characteristics of social inequality in the health care sector are described based on findings in urban sociology and Public Health.

The existing barriers to health care access for people without legal residential status are the result of a specific form of defensive immigration laws, which cannot be understood without understanding Germany’s transformation from a recruiting to a shielding society. The second and third paragraphs will shed light on this issue.

Based on this foundation, the fourth paragraph explains how the city of Berlin tries to improve   health care for people without residential status or sufficient health insurance. The measures taken in Berlin are put into context with the efforts taken in other German cities. Moreover, the current state of cooperation between representatives of the Berlin Senate and anti-racist groups, humanitarian institutions and health care institutions is presented by means of the “Round Table Health Care for Refugees“.

 

Exclusion, Urban Underclass and social inequalities in health care

A left-wing municipal government‘s objective of securing social security for all residents is based on the observation that poverty structures in the cities have solidified, not only since the introduction of the “Hartz IV” legislation, but already for many years prior.

Based on Anglo-Saxon and French debates, a discourse has established itself which describes a new quality of poverty development by the terms “Social Exclusion” and “Urban Underclass”.

The “Concept of Social Exclusion” denotes structures and divisions, according to which social deprivation is no longer considered a quantifiable condition (e.g. statistics of public assistance), but rather a process of a gradual slide into exclusion and an increasing loss of contact with the majority society.

As shown in the table above, exclusion does not take place via a sudden exclusion from all societal subsystems, but gradually on an axis between economic position and social inclusion. Simultaneous exclusion from and inclusion in different subsystems is possible. The process of exclusion begins with the gradual loss of a stable inclusion and vulnerability, culminating in the exclusion from the job market and social isolation.

The concept of exclusion is to be understood here as a guiding metaphor of social transformation and not as a measurable instrument of social classification.

Based on this concept, “underclass” is a situation in which exclusion from relevant areas of life cumulate in a living condition which is well below average, from which it is objectively difficult to escape, and which is subjectively solidified by the resignation of the individuals concerned or the formation of normative orientations and behaviours which prevent a re-integration into relevant areas of life (Bremer, Gestring 1997). Sarrazin‘s conclusion (by way of tacit reference to US anthropologist Lewis and cultural approaches of the 1980s) that the lifestyle of the poor is the main obstacle for fighting poverty is explicitly wrong. The result is an image of the underclass which is associated with deviant behaviour, such as lack of work ethos, delinquency, promiscuity, etc.

In the context of migrants without legal residential status, the relevant dimensions and indicators are exclusion by public institutions and regulations, exclusion from the legal job market, social isolation, spatial exclusion by segregation, accumulation of marginalisation, and individual reproduction of exclusion (Bremer, Gestring 1997).

Considering these findings, a debate about unequal health opportunities has developed in the healthcare sector. The systematic influences of social determinants like income, education, profession or background on health and the subsequent inequalities of access to healthcare are called inequalities in health (Vonneilich, Trojan 2009). Public Health research has described the correlation as follows: The lower the individual’s position in the socio-economical play of forces, the worse is their health.

The German legislator has reacted by formulating the following in Article 20 of the SGB V (Fifth Social Security Statute Book): “(…) Services of primary prevention are meant to improve general health and are especially designed to contribute to reducing socially constructed inequalities in health” (ibid., p. 12).

Moreover, a compulsory insurance, to be implemented gradually from 2007, was introduced into the German health insurance scheme as part of the “Wettbewerbsstärkungsgesetz für die gesetzlichen Krankenversicherungen (GKV-WSG)” (Competition Reinforcement Law for Public Health Insurance). This was designed to reduce the number of the 211,000 registered residents of Germany without health insurance. By the end of 2009, 45,000 people were still deemed to be without health insurance. Since that time, the number of those who are unable to afford the basic fees of private health insurance and are therefore subject to health-related risks without sufficient coverage has increased as much as the number of people legally residing in Germany, especially from Eastern European accession countries, who, without work permits, have not yet had access to the job market and public health insurance and who have not acquired sufficient coverage in their home countries.

These two groups with no (sufficient) health coverage accompany a group who are denied access to the healthcare system by explicit legal regulations – people without legal residential status.   

As close meshed, sophisticated and elaborate the shielding systems at the borders of the “Fortress Europe” may seem – illegal migration is still a reality in Germany.

Big cities such as Munich, Frankfurt or Leipzig, city regions like the Ruhr or Rhein-Main area, and metropolitan areas like Berlin and Hamburg are preferred centres for people without legal residential status, which is due to their inherent anonymity, established migrant neighbourhoods, and numerous opportunities for illegal employment.  

The health policy objective of integrating people without legal documents into the official healthcare system requires cross-departmental action as well as the inclusion of refugee organisations, especially those which are not linked to governmental bodies. Describing the efforts made in Berlin by the “Round Table Health Care for Refugees”, amongst others, is the purpose of this article.

 

From a recruiting to a shielding society

Migration politics in Germany can basically be subdivided into four phases, of which some are overlapping.

The first phase covers the time of the German “economic miracle” from the early 1950s to the end of the 1960s. Tackling the enormous economic recovery of post-war Germany was impossible without recruiting so-called “guest workers”. Before the short dream of everlasting prosperity (Lutz 1984) ended in the course of the oil crises in the 1970s, labour migration complied with the liberal concept of transnational factor mobility (Wehrhöfer 1998).

The economic situation of the early 1970s, which was rapidly deteriorating, was the onset of the second phase of migration politics and a change in recruitment policy, expressed by the ban of recruitment of guest workers from non EC (European Community) states in November 1973. However, neither the number of non-German workers decreased nor did the guest workers return to their home countries. In fact, due to family reunification, the structure of the immigrant community changed. Immigration as a comprehensive social process came to the fore – the recruiting countries had become immigration countries (ibid.).

The third phase of German migration policy covers the period from the early 1980s until the introduction of the new citizenship law by the Red-Green coalition government in 2000.    These two decades were characterised by a continuous tightening of foreigner laws and restricting the granting of asylum, in Bade’s words: “The dramatic change of mood, which later subsided again, (…) showed clear marks of a transformation from a recruiting to a shielding society. Migrants were plainly referred to as ‘the foreigners’” (Bade 1994, p. 101). An essential element of a government’s shielding strategy is criminal law as a tool for exerting control – not least of its own citizens: “Clandestine trespassers are named “illegal subjects” by the prosecution authorities. Their existence or support is regarded as ‘damaging to society‘“ (Dietrich 1999, p. 301).

The introduction of the new citizenship law marks the fourth and so far last phase of migration politics. It overlaps with the third phase without ending it, as the EU’s restrictive border regime remains unaffected by this change within German domestic migration policy. However, the effect of this change on integration policy should not be underestimated.  

The constant change in the perception of unauthorised migration and illegal stay of migrants has therefore been influenced by changing social and especially economic conditions.  However, the government’s desire of controlling migration has gained prevalence, and the perception of illegal migration as a problem prevails. (Schönwälder et al. 2004, p. 7).

Based on the fear for jobs, the following will describe the complexity of various fears of migration and their effect on the social discourse in those organisations which commit to principles of social justice, such as the unions. This description refers to Schönwälder et al. (ibid., p. 8), who have carried out a division of these fears of migration into six dimensions.

In the dimension of fear for jobs, illegal migration is seen as jeopardising jobs and social standards. There is a widespread assumption and fear, even among the unions, that so-called “illegals“ work for dumping wages and, by sabotaging agreements with social partners, push domestic employees out of the job market and challenge the results of the collaboration with social partners. This view stigmatises illegalised migrants as offenders rather than victims of exploitation and degrading working conditions. Already in its annual report of 2004, the Expert Panel for Migration and Integration pointed out that illegal employment notably reveals the inconsistencies in the political and social views on illegal migration. In times of high unemployment, the illegal stay and employment of foreigners is a sensitive issue. Contrary to this criminalisation of illegal migration and the public outrage is the fact that these migrants are well accepted in everyday life, and their services are used without asking about their residential status. Illegal employment meets specific market needs and can only arise and persist if there is demand for it (Expert Panel for Migration and Integration 2004). This is linked to the fear of social costs, which is the assumption that illegal migration leads to a significant financial burden due to unpaid social security contributions, unfair competition as well as public services for the so-called “illegals”.

In view of these complex, problematic views on illegal migration, the expert panel has mentioned the significance of political dealings with illegal migration in its report. It is crucial for the general attitude towards illegal migration that political players manage to deal with this complex issue in a differentiated fashion, thereby reducing complexity and distorted views as much as possible.

No less important is the insight by relevant governmental players that illegal migration can only be reduced but not prevented, which is why keeping legal migration paths open contributes significantly to reducing illegal immigration. Criminalising migration does not only hamper the support for legal migration, but also prevents immigrants from claiming their existing social and political rights in Germany, no matter which residential status they have (ibid.).

 

General conditions of healthcare for people without residential status in Germany

The Asylbewerberleistungsgesetz (Asylum Seekers' Benefit Act) as well as the Sozialgesetzbuch (Social Code) XII provide the right to medical care, for example in cases of serious illness, even for people who do not legally reside in Germany.

The exercise of this right, however, is made difficult by various measures, such as the “Übermittlungspflicht“ (notification obligation) required by article 87(2) of the “Aufenthaltsgesetz“ (German Residence Act), which represents article 1 of the “Zuwanderungsgesetz“ (Immigration Act), adopted in 2004 and entered into force on 1 January, 2005^[1], as well as the provisions of articles 95 and 96 of the Residence Act, which aim at enforcing governmental orders to leave the country. In the words of Bertold Sommer, a former judge at the Federal Supreme Court, these regulations are “unbearably contradictory” (Sommer 2006, p. 2). According to Sommer, the principle must be that “(the) state should not prevent people who help others to exercise their rights from such supportive behaviour by threats of punishment (“facilitation of unauthorised residence”). Furthermore, the state should not impose the obligation to report anyone to the authorities. (…) Exercising fundamental rights, which even people without residential status are entitled to, must not entail the termination of their stay, as this leads to people not claiming their fundamental rights at all and ending up in distress” (ibid.).

 

Even though the Federal Ministry of the Interior and various politicians at state and federal level have correctly observed that the difficulties of the notification obligation have been excessively expounded (BMI 2007, p. 9), and that only few cases have become known in which medical care was indeed refused based on these legal requirements, the construction is a contradiction in itself.  

An interrogation of the states‘ interior ministries, carried out by the Federal Ministry of the Interior (Bundesministerium des Innern (BMI)) in 2006, revealed that there were only isolated cases of notifications to the authorities according to article 87(2) Residence Act (ibid., Annex 4). The desired control of migration is therefore not achieved by this provision. However, the effort and the determent they cause prevent the exercise of fundamental health and social rights.  

For this reason, the notification obligation should be waived and the Residence Act amended accordingly. Regrettably, this very sensible reasoning is opposed by the prevailing view in which it is out of the question to abolish the notification obligation as this would lead to an “irresponsible loss of public control” (ibid., p. 43).

 

Volume and structure of unauthorised migration and healthcare access in Berlin

Berlin is a typical immigration city. The integration concept of the Senate of Berlin therefore correctly states that the debate about the question whether Germany is an immigration country ignores the city’s social reality – this question has been answered for Berlin (Senate of Berlin 2007, 2).

When talking about migration and immigration in Berlin, it is not about a negligible minority of society, but a significant part of the city’s residents, as 14% of the residents of Berlin do not have Germen citizenship.

This figure does not include the number of Berliners with German citizenship and a migrant background. 40% of all children and adolescents under 18 years in Berlin have a migrant background (ibid., p. 5). What “migrant background” actually refers to is currently under debate at the integration ministers’ convention, established in 2008.

There are of course no reliable figures when it comes to illegal migration in general and in Berlin in particular, as this kind of migration evades statistics. The numbers publicly discussed vary significantly, they are usually not well-founded, and they may be used for political manoeuvring due to their inaccuracy and controversial background.  

The motives for migration and the paths to Germany and a life of illegality are just as inaccurate as the number and origin of illegal migrants. What is certain is that illegal migrants are neither a homogenous group nor do they all enter Germany as “illegals”. “Economic immigrants, refugees who seek protection from prosecution or wars but are not granted asylum, children and elderly who would like to live with their relatives in Germany, as well as students and au pairs who violate provisions in their resident permits or stay longer than permitted become ‘illegals’. Most of them probably entered Germany legally – as students, tourists, au pairs, seasonal workers“ (Schönwälder et al. 2004, p. 33).

Furthermore, there are people who in various ways are forced to live a life of illegality or in deprived and violent conditions. This could be due to trafficking of humans, particularly of women as wives or maids, or prostitution.  

With articles 232, 233 and 233a, German criminal law arranges for the prosecution of human trafficking for labour or sexual exploitation. According to the “Bundeslagebild Menschenhandel“ (Statistics on Human Trafficking) (German Federal Criminal Police (BKA) 2008), a rise in proceedings against human trafficking for sexual exploitation could be established in 2007. 454 proceedings were completed, which corresponds to an increase of 29% compared to the year before. The key areas here were the states of Berlin and Lower Saxony.   

The EU eastward enlargement has led to a different situation. The majority of foreign victims are from EU countries in Eastern Europe – and they are therefore legal residents of Germany now (ibid., pp. 11 et seq.). In summer 2008, the Berlin Senate reported on its policies against human trafficking and for the protection of victims in a report for the House of Representatives (Senate of Berlin 2008b).

On the whole, however, the “Wissenschaftszentrum für Sozialforschung Berlin (WZB)” (Social Science Research Centre Berlin) is probably right with their statement that coercion and exploitation only make up a small part of illegal migration (Schönwälder et al. 2004, p. 34).

An investigation commissioned by the socialist-managed Senate Administration for Health, Environment and Consumer Protection found that in Berlin, there are 4,000 to 5,000 personal contacts per year between people without residential status and healthcare providers (Maschewsky-Schneider, Hey 2011, p. 16).

Findings from this investigation state that these people without papers are usually young to middle-aged patients between 20 and 40 years, and that the gender distribution is fairly balanced. “The results of the quantitative analysis show that the range of diagnoses varies widely. Most of the 42 interrogated medical practitioners indicated that people without legal status seek assistance in case of acute illnesses, infectious diseases, chronic conditions and emergencies. (…) According to expert statements in interviews, most patients are consulting a medical doctor if they have complex and acute symptoms, which are often due to protracted infections or other illnesses which have become acute or where complications have appeared. Some also have severe mental issues such as anxiety, insomnia, and exhaustion with chronic pain symptoms, irritability and depression. These ailments may be exacerbated by a life of illegality, which can affect a number of physical symptoms. A large part of patients also seek medical assistance because of work-related injuries“ (ibid., p. 17).

 

Improving healthcare services for people without legal residential status within and alongside the existing healthcare system in Berlin

As illegal migration constitutes a significant part of migration reality in Berlin, the red-red coalition (of Social Democrats and Socialists) commits to its adopted integration concept and “(to) the responsibility for those who live in our city without residential status. It is an important governmental principle to prevent foreigners from illegality. On the other hand, it is the state’s duty to alleviate social problems which have arisen from illegality and to ensure the compliance with human rights for this group of people” (Senate of Berlin 2007, p. 83 et seq.). Based on this, the objective was established that people living in Berlin without residential status “(obtain) real access to all human rights which are every person’s rights. These include the rights to freedom of personal development, to life and physical integrity, to freedom of speech, to association and to petition, which are all anchored in Germany’s constitution” (Senate of Berlin 2008a, p. 3). With reference to the rights to education and adequate housing, which are anchored in the constitution of Berlin, the exercise of these rights has to be made possible without regulatory sanctions (ibid.).

The division of powers at federal level, however, limits the implementation of the aforementioned objectives (exercising social and political rights by people without residential status) within the state government of Berlin.  

The activities of the state government of Berlin are subject to the German Residence Act and hence subject to the contradiction between residence and criminal-law regulations on the one hand and ensuring minimum social and legal standards on the other.

As a “city-state”, i.e. both a federal state and a municipality, the state of Berlin has greater leeway than cities like Munich or Frankfurt, which have developed their own systems for improving healthcare, but which are subject to the local municipal surveillance systems and cannot act on their own behalf in the Bundesrat (German Federal Council), unlike Berlin and Bremen.

The decision taken by the Senate’s Administration for Health, Environment and Consumer Protection in 2007 to make healthcare for people without residential status a subject of political activity was based on the Senate’s integration concept, but also on the expectation of non-governmental networks that a health administration managed by the Socialist party DIE LINKE was supposed to make this issue a priority.

The non-governmental network for healthcare for people without residential status and those without sufficient insurance, which has been around Berlin for several years, essentially consists of four key anchor points:

1. The “Büro für medizinische Flüchtlingshilfe“ (Bureau for medical refugee aid) was established in 1996 based on anti-racist projects. At that point in time, it became evident that following the effective abolition of the right to asylum, there would emerge a relevant group of people without residential status, for who access to healthcare was not secure. This institution, also known by the abbreviation “MediBüro” is headquartered in the autonomous centre “Mehringhof” in the district of Kreuzberg. Twice a week, they connect patients to doctors of various disciplines, midwifes and physiotherapists who are willing to treat them anonymously and free of charge. Incurred costs are mainly covered by donations. MediBüro has so far rejected any governmental funding to preserve its independence. It does not provide its own healthcare, only placement of patients within the existing structures of healthcare. This is not only an organisational issue, but part of MediBüro’s general policy. Rather than caring for patients by establishing parallel health structures, MediBüro wants to promote the permanent and unlimited medical care for “illegal” people within the existing healthcare structures. MediBüro is part of the network “No human being is illegal” and collaborates closely with the Refugee Council Berlin. With an “Anonymous Healthcare Card”, MediBüro has cleft a possible way of healthcare for people without residential status under the conditions of the existing Residence Act, which will be addressed below.
2. Unlike the MediBüro, the “Malteser Migranten Medizin“ (MMM) (Order of Malta Migrant Medicine) is a healthcare contact point for people without residential status or health insurance, founded in Berlin in 2001. Emergency care in case of sudden illness, injury or pregnancy is carried out anonymously. Currently there are MMM centres in the cities of Cologne, Munich, Darmstadt, Frankfurt, Hanover, Munster and Hamburg. According to their own testimony, 13,000 people have been treated so far in case of pregnancy, accidents, acute dental diseases, tumours and infectious diseases at these healthcare points. The MMM have been awarded numerous times and receive public funding alongside donations in cash and kind.
3. The “Öffentliche Gesundheitsdienst“ (ÖGD) (Public Health Service) of Berlin consists of twelve district offices and five citywide “Centres for Sexual Health and Family Planning” as well as a tuberculosis centre. According to Berlin healthcare law, these health offices offering socio-medical services, including the centres, perform their tasks on a subsidiary basis and guided by the principles of compensation. They are, particularly as regards the centres, a widely used contact point for people without residential status or health insurance. For tuberculosis treatment, residential status or health insurance is not relevant. However, the Centres for Sexual Health and Family Planning or the health offices, for instance, have to refer children without residential status or insurance to resident doctors for vaccinations.  As these centres have no medical mandate of their own, they do not have appropriate instruments, devices or funds for adequate medical care. The employees perceive this as a concern, even in dramatically understaffed conditions. According to their self-conception as social medicine practitioners and public health players, they regard it as natural to help especially those who do not have access to medical care in the public system.
4. The Medical Association Berlin (Ärztekammer Berlin, ÄKB) is the independent self-administration of the licensed medical practitioners in Berlin. A Human Rights Committee in the ÄKB pools those medical doctors who carry out medical care for refugees. It addresses the need for improved healthcare for this group of people by means of press releases and motions at the ÄKB’s congresses.

It was always evident that improving healthcare for the above mentioned groups of people must be addressed on several levels. A purely administrative action without any cooperation with existing network structures would have little effect and would make little sense.

Cooperation between non-governmental organisations or institutions and political administrations implies taking into account different types of logic and different perceptions of the shape and speed of processes. This was anticipated from the beginning, although disappointment could not always be prevented, as the example of the “Anonymous Healthcare Card” shows.  

 

“Anonymous Healthcare Card”

The objective of this system is to achieve the integration of people without residential status into regular medical care by means of the protected placement of healthcare cards (anonymous healthcare card). The initiators of this system referred to a similar system in Italy, which existed up until 2009, and in which public municipal healthcare centres (Agenzie Sanitarie Locale) issued a code, with which people without legal residential status could access regular healthcare. The latest Berlusconi government blocked this option as part of a tightened law concerning foreigners.  

According to this model, the anonymous healthcare card is supposed to be issued by health authorities and public healthcare bodies under medical supervision. The issue of this card shall be subject to a previous means test according to articles 4 and 6 of the Asylum Seekers' Benefit Act (AsylbLG). To carry out this test, a cooperation agreement with the social welfare office is intended, as the health authority performs the social welfare office’s duties on its behalf.

Due to the medical supervision, the issuing body is obliged to confidentiality. It shall perform the function of a “gate keeper”. By including legal advice, options for legalisation could be discussed. A “hotline” to the foreigners’ authority, with which cases could be discussed in advance, would enable the assessment of different options together with the people involved. It is possible that by these means, people who have so far avoided revealing themselves to an authority could be convinced to legalise their residential status. This idea is based on experiences in Munich. The procedure, which has become known as the “Munich Model”, arranges for legalisation advice for people without residential status with the Munich Office for Health and Social Welfare in cooperation with the foreigners’ authority. Only in cases where the range of options does not allow for (temporary) legalisation, i.e. residential status, one could resort to existing municipal funds to enable medical care. It is important to note, however, that the number of cases in Munich is far less than in Berlin, for instance. Moreover, the healthcare card model intends for the issuing body to perform the function of a “case manager”, in which it arranges doctor’s appointments for patients and recommends practitioners or medical institutions specialising in the respective ailments. With the anonymous numbered healthcare card the persons concerned may use existing healthcare structures without discrimination (MediBüro 2009, p. 3).

This system is supported by the fact that under the conditions of the current Residence Act, there has not been any suitable proposal for ensuring medical care for foreigners without health insurance. The latter do not only include so-called “illegals”, but also migrants from new EU member states who often neither have health insurance in their home countries nor in Germany, even though they have legal residential status. They are not entitled to any benefits according to the Asylum Seekers' Benefit Act. Only in emergencies, they may receive medical care according to Social Code XII. Regular healthcare for these groups of people remains an unsolved problem of the discrepancy between freedom to travel on the one hand and denied access to the job market and social security systems on the other.

During one year of bilateral discussion, the Senate Administration for Health and the MediBüro assessed the framework conditions for this anonymous healthcare card model and adjusted the latter by drawing from experiences with the Munich model.

As it was evident from the beginning that the implementation of such a model would require cooperation between different administrations, in particular the Senate Administration for Interior Affairs as well as for Social Affairs and Integration – blanking out district competencies –, the bilateral discussion was extended by the establishment of a “Round Table”. This “Round Table” proved to be a suitable tool for the cross-institutional agreement on improving healthcare for the target groups, but it did not achieve the establishment of the Anonymous Healthcare Card, in spite of the relevant players being present and active.  

The implementation of the Anonymous Healthcare Card has so far failed on the grounds of the Senate’s position that this model would undermine the objective of “illegals” revealing themselves. Even though this scheme provided for legal advice, it would enable people to claim healthcare services without any effort for legalisation on their own part. This would perpetuate solidifying undesired structures of illegality. While there is agreement on the fact that the existing provisions of the Residence Act, such as the notification obligation, are dispensable and should be abolished, there is a difference in opinion whether the anonymous healthcare card is the most convincing scheme for exercising rights to healthcare or whether it creates wrong incentives which are diametrically opposed to the social-liberal views on legalising people without papers. The – not entirely smooth – agreement on the latter position (the Senate’s position) was a rather frustrating experience for the representatives of the MediBüro and supporters of the Anonymous Healthcare Card. Even if that position was generally considered correct – which it is by no means – the question remains how non-discriminatory access to healthcare can be achieved under conditions of illegality, which are enshrined in law.

 

Round Table Health Care for Refugees

After the Senate Administration for Health at state secretary level had discussed the implementation of the Anonymous Healthcare Card with MediBüro for about one year, both players agreed that it would be advisable to open this debate. The “Round Table” was deemed to be a suitable tool for achieving agreement on policies to improve healthcare for people without residential status or health insurance, starting from different positions.

The Round Table is moderated in a way that both sides are on equal terms – the Secretary of State of the Senate Administration for Health on the one hand, and the representatives of MediBüro on the other. This agreement was based on the common understanding of the independence of MediBüro, in other words: Just by taking part in the Round Table, MediBüro is not expected to take the views of the Senate. Its independence remains intact, and likewise the Senate or the Senate Administration for Health do not exploit their discussion with MediBüro in terms of “gloating over” MediBüro. Besides MediBüro and the Senate Administration for Health, the participants of the Round Table are the Senate Administrations for Interior Affairs and Sports as well as for Integration, Employment and Social Affairs, the Regional Office for Health and Social Affairs (being responsible for asylum seekers and refugees), representatives of the Medical Association Berlin, MMM (including former Federal Health Minister Andrea Fischer from the Greens), the Refugee Council Berlin, and district health offices. The objective of this Round Table, which does not exist in any other German state – is to moderate the fundamental debate about the non-discriminatory access to health care for the mentioned target group, with the aim to agree on appropriate schemes, and to achieve concrete improvements of the status quo by means of individual cases. The discussion at the Round Table is characterised by mutual respect, which is partly due to the equitable moderation by Health Administration and MediBüro and the implicit code of cooperation. At the same time, cooperation can never be free from tension, as background, rationale, criteria for success or failure and the evaluation of the political limitations are too different.

 

Achieved results (as of autumn 2011)

In coordination with the Interior department (managed by the Social Democrats) and the Health department (managed by the Socialists), the Berlin Senate Administration for Interior Affairs and Sports established a new procedure for the treatment of pregnant women without legal residential status for the foreigners’ authority in summer 2008. The essential passage reads as follows: “(…) The obligation to leave the country or detention must not be enforced three months before the expected delivery nor three month after delivery (…)” (Berlin Senate Administration for Interior Affairs and Sports 2008, p. 1).

Thus, an interpretation was brought forward, which boiled down to specify the scope of the notification obligation in winter 2011. The basic idea behind this procedure is the assumption that building bridges to legalisation requires incentives for paperless people to reveal themselves.

To relieve the hospitals in Berlin from the uncertainty whether they are obliged to report on “illegal” patients according to article 87 of the Residence Act, the Socialist-managed Health Administration stated in a circular letter in 2008 that public hospitals or hospitals performing public duties are relieved from the notification obligation (Senate Administration for Health, Environment and Consumer Protection 2008).

Together with the Berlin Hospital Society, the Senate Administration for Social Affairs has adjusted the regulations for billing of medical cases in which sufficient personal data are missing. This has led to improved financial framework conditions.

The cooperation between the Senate Administration for Health and MediBüro has increased the readiness of staff in public and not-for-profit hospitals, at least informally, to tackle the problems of this group of patients – which is part of everyday reality in hospitals anyway.

Health authorities in Berlin, in particular the five Centres for Sexual Health and Family Planning, are important contact points for the above mentioned target group. The state of Berlin contributes to the “Gemeindedolmetschdienst” (community interpreter service) by providing public funds. This service is located at the “Fachstelle für Prävention und Gesundheitsförderung” (Disease Prevention and Health Promotion Unit) and offers a basic service, which, however, often reaches its practical and financial limits.

Since early 2011, the state of Berlin funds the medical care of people without (sufficient) health insurance with 50,000 € by means of the MMM. By including these funds into the “Integrierte Gesundheitsprogramm” (IGP) (Integrated Health Programme), which has an annual budget of 11 million €, the MMM has obtained planning security in the medium term over a time span of five years, which can be increased with funds from the operating budget, if necessary. With regard to the high demand, this is a political necessity and should be ensured in upcoming budget discussions.

Initiated by the Secretary of State for Integration and Employment from the LINKE (Socialist) party, the Berlin Integration Authority has submitted a motion for a helpdesk concerning foreigners with the Integration Commissioner as part of the project “Gesundheitsversorgung von Illegalen” (Healthcare for Illegals), which is meant to be discussed at the Round Table, and which is based on the Munich approach (Berlin Commissioner for Integration and Migration 2011).

These administrative improvements and existing services of communal health offices and institutions such as MediBüro or MMM are no doubt a step forward compared with the situation before. They are, however, not a solution. One of the frustrating aspects of the trust built up during the goal-oriented cooperation with the Round Table is that fundamental changes, i.e. the abolition of discriminating rules with regard to healthcare access, cannot be achieved this way. There is leeway for the improved exercise of social and political rights, which need to be made use of, but this leeway has structural limits and will only allow complimentary services to regular healthcare as long as progressive political forces at federal level, supported by a social majority and social discourse, contribute to tackling social inequalities and abrading the walls of the “Fortress Europe”.

 

References

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This article was published by: Andrej Holm/Klaus Lederer/Matthias Naumann (Ed.), Linke Metropolenpolitik. Erfahrungen und Perspektiven am Beispiel Berlin, Münster, p. 161-182

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[1] Gesetz zur Steuerung und Begrenzung der Zuwanderung und zur Regelung des Aufenthalts und der Integration von Unionsbürgern und Ausländern (German Residence Act), BGBl. I S. 1950 (2004).