As of 2010, the number of undocumented/illegal migrants was approximately 618,000 to 1.1 million (Migration Watch UK, 2010). The main authority responsible for insuring the health of the UK residents is the National Health Service (NHS). The eligible beneficiaries of the NHS are 'ordinary residents' as specified in the 1989 Statutory Instrument No 336. Generally, a person residing more than 3 years in the UK is defined as ordinary resident, and this term normally includes legal immigrants. Ordinary residents are allowed to enjoy free NHS services in all range of care.
For undocumented/illegal migrants, only certain services are provided free of charge, which include (but are not limited to), outpatient emergency care, compulsory treatment under court order, psychosis treatment, treatment for potential public threats (such as cholera, tuberculosis (TB), encephalitis, HIV/AIDS [in England and Scotland, but not in Wales], and influenza), family planning, and treatment for victims of violence.ii Note that maternity care is regarded as secondary care where undocumented/illegal migrants are liable to pay the treatment expense. Doctors are not allowed to delay treatment for patients with urgent needs who are unable to pay the treatment cost, but the incurred debts will be pursued later (Citizens Advice, 2015). In practice, there was still confusion in the NHS guidelines and regulations for dealing with undocumented/illegal migrants.
Some NHS staff were unaware of the rights of these migrants (Piacenti, 2016).
Nevertheless, the NHS attempted to resolve confusions by establishing a hotline service where healthcare staff can check the rights of each patient. Some Primary Care Trusts collaborated with non-profit clinics or charitable agencies in order to help undocumented/illegal migrants have better healthcare access (Cuadra, 2010b).
II. Germany
There were about 8.2 non-German nationals in Germany (~10% of its population). It is estimated that the number of undocumented/illegal migrants might be as large as 1.5
ii There are slight differences in migrant insurance policies amongst countries within the UK; most information in this review is from the English experience.
43 million. The refugee crisis of European region in recent years might have expanded the volume of migrants who applied for asylum by 330,000 (Berens et al., 2008, BBC, 2015).
The main public insurance system in Germany follows the Bismarck concept where social health insurance plays a dominant role. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Germany has a universal multi-payer system where private insurance companies under state regulation are the main insurer (pluralistic system). Contributions are waived in certain beneficiary groups, such as children and pregnant women. The benefit package is comprehensive. Legal migrants are required to make insurance contributions, similarly to German nationals. In summary, the German health insurance system is tightly linked to work and residence status (Gray and van Ginneken, 2012).
Undocumented/illegal migrants’ rights to care are limited to certain services, such as post-natal care and infectious disease treatment (including HIV/AIDS, TB, and sexually transmitted diseases [STDs]). For such services, no charge is incurred by a patient if he/she applies for the Health Card (Krankenschein) with the Welfare Office. The state will issue a Toleration Certificate (Duldung), which guarantees the patient’s right to care while he/she is under a temporary suspension of expulsion. In some local regulations, the coverage of the Duldung also covers delivery and postpartum care. Germany also endorsed the Law of Infectious Diseases, which allows an undocumented/illegal migrant to participate in anonymous disease screening and counselling free of charge without showing his/her legal identity. Undocumented/illegal migrants without the Duldung are still allowed to enjoy emergency care without any charge. Healthcare providers can apply to have the cost of emergency treatment reimbursed by the Social Welfare Office upon the condition that the providers report the residence status of these migrants according to the law (Section 87 AufenthG). This practice indirectly creates barriers to care for some undocumented/illegal migrants who are afraid of being reported to immigration officials (Gray and van Ginneken, 2012).
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III. Italy
Of the 60 million residents in Italy, 3.5 million (~5.8%) are foreign-born (Cuadra, 2010a). The estimated volume of undocumented/illegal migrants was one million. The main insurance system is the Italian Health Service, financed by general taxation.
Insurees are required to register with the local authorities to obtain a Health Card (Tessera Sanitaria). The Health Card holder is eligible to enjoy comprehensive health services, including specialised care/treatment, but there is co-payment at point of care, varying by the beneficiary's income. Certain populations are exempted from co-payment, such as those aged above 65, low-income, prisoners, persons suffering from chronic diseases, and pregnant women. Legal migrants are under the same regulations as Italian nationals (Gray and van Ginneken, 2012).
Undocumented/illegal migrants are eligible to acquire a 'Temporary Residing Foreigner Code', with a 6-month validity. This serves as a guarantee to enjoy a variety of essential services. In general, the benefit includes treatment for infectious diseases, HIV/AIDS, TB, occupational injuries and maternal and child care (Cuadra, 2010a). However, there are subtle differences in the interpretation of scope of ‘essential service’ between regions. Healthcare providers are not obliged to inform immigration control or the police about the presentation of undocumented/illegal migrants, except where they suspect that the patients are involved with criminal activity (Brindicci et al., 2015).
IV. France
France is composed of 64.7 million residents. About 3.6 million of them are foreign-born (~5.8%). The volume of undocumented/illegal migrants is approximately 300,000-500,000 (~0.7%) (Gray and van Ginneken, 2012). French public health insurance is operated under the Universal Coverage Act. Employees and employers must pay contributions to the Social Health Insurance, controlled by the Ministry of Social Security. The contributions are exempted in some populations, such as pregnant women and children, and persons with a yearly wage less than €6,600.The benefit package is comprehensive. For outpatient care, a patient must pay for the treatment first but up to
45 70% of the total expense can be later reimbursed from the scheme (Gray and van Ginneken, 2012).
The benefit package comprises primary care, secondary care, maternity and child care, emergency care, vaccination, family planning, public health threat treatment (including HIV/AIDS and TB), but migrants need to apply for the State Medical Assistance Certificate first (Aide Médicale d'Etat: AME). Evidence required for the AME application consists of birth certificate, expired passport and proof of residence and monthly income. The French healthcare system classifies the benefit for undocumented/illegal migrants into three tiers according to length of stay in the country.
For the first three months of residence, the patients can access only emergency care free of charge. After three months, the benefit package is expanded to cover secondary care and high-cost items, with some exceptions, such as prostheses and corrective lenses. If the patient has been residing in France for at least three years, they can be eligible for 'home medical assistance' (Assistance Médicale à Domicile), and other services, which are almost similar to French nationals.
In 2004, the French government established a special fund for indemnifying unpaid debts of health facilities incurred from providing emergency care to uninsured patients (including undocumented/illegal migrants). The Caisse Nationale d’Assurance Maladie (CNAM) is the governing body of the fund. Requests for reimbursement are considered on a case-by-case basis. Facilities must provide evidence to the CNAM to show that that the patient is uninsured and the treatment is really related to an emergency condition (Gray and van Ginneken, 2012, Hasuwannakit, 2012a).
V. Japan
Japan is one of the top destination countries for migrants in East Asia, with about 2.2 million immigrants according to the IOM report (2010). However, the volume of undocumented/illegal migrants in Japan is much smaller than in other developed countries in the western world. Fujimoto (2013) suggested that the size of
46 undocumented/illegal migrants in Japan was around 67,000, and most of them were Chinese and Korean.
The Japanese health insurance system is based on the Bismarck model, where employers and employees are required to pay contributions. There are four main sub-schemes, that is, (1) Social Health Insurance for large companies/enterprises, contributed by employers and employees, (2) Social Health Insurance for small-scale companies/enterprises, financed by tripartite contribution (employers, employees, and the government), (3) Citizens’ Health Insurance for the self-employed population, financed by an individual contribution plus the government's subsidy, and (4) Long-term Care Insurance for those aged over 75, subsidised by the central government with part of the budget cross-funded from the above three main schemes. The benefit package of all schemes is comprehensive but there is a co-payment at point of care of around 30% of the total expense (except for the elderly where exemption is applied) (Ikegami et al., 2011). Legal migrant workers are required to pay contributions to the Social Health Insurance like Japanese citizens.
The insurance system for undocumented/illegal migrants is not well established.
However, there were some attempts to endorse laws that provide a safety net for these migrants, for instance, the Infectious Diseases Law ratifying the rights to TB treatment for everybody in Japan (this does not include HIV/AIDS), or the Tertiary-Level Emergency Care Unpaid Bill Reimbursement scheme, which aims to subsidise unpaid debts to the health facilities that provide complicated treatment for uninsured patients.
Nonetheless, requests for reimbursement are considered on a case-by-case basis, and the system is effective only in some regions (such as Kanto region) (Calain-Watanabe and Lee, 2012, Parikh, 2010). The Mother and Child Health Law also provides pregnant women and their newborns rights to maternity care regardless of their immigration status, with the benefits including antenatal care, postnatal care and vaccination.
However, some officials in welfare centres opposed the idea of providing care to undocumented/illegal migrants, and this situation created inconsistency in the provision of care across provinces (Calain-Watanabe and Lee, 2012, Parikh, 2010).
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