Inadequate health insurance cover in Germany: People’s characteristics, causes and possible solutions - a mixed methods approach

Inadequate health insurance cover in Germany: People’s characteristics, causes and possible solutions - a mixed methods approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Inadequate health insurance cover in Germany: People’s characteristics, causes and possible solutions - a mixed methods approach Christian Dumke, Andrea Kaifie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4492563/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In the German dual health insurance system, almost 1% of German citizens only have an inadequate insurance cover leading to an impaired medical care. The personals characteristics, the causes of their inadequate cover and the associated health effects are largely unknown, so far. The aim of this study was to obtain a comprehensive overview about those with a limited health insurance cover. Methods The study was conducted using a mixed-methods design. Data was used from two private health insurance companies and one statutory health insurance company. In addition, interviews were conducted with experts from clearing centers that supported the return to a full insurance coverage, with the aim of exploring the causes of the current situation, to identify the challenges in trying to regain full insurance coverage and to capture the health effects. Results The PHI dataset comprised a total number of n = 14.312 and the SHI data set n = 95.325 persons. In the private health insurance system, the most affected people were male, over 40 years and self-employed, while in the statutory health insurance system, the most affected were young male between 20 and 30 years, employees and overproportionate non-Germans. Socio-economic factors, lack of health literacy, and inadequate knowledge about health insurance resulted in an inadequate insurance cover leading to an exclusion from the healthcare system. Conclusion There are particular groups with certain sociodemographic characteristics that are more vulnerable to an inadequate insurance cover. It is therefore important to identify and offer support before an insurance downgrade is carried out. Support from health insurance companies in cooperation with clearing centers and state institutions that provide social benefits is necessary. Access to health care Health inequality Defaulting payers Vulnerable Groups Emergency tariff Suspension of benefits Figures Figure 1 Figure 2 Background Germany is characterized by a dual health insurance system, consisting of statutory health insurance (SHI) and private health insurance (PHI). These systems are based on the principle of contributory financing, and they are characterized either by the principle of solidarity, which is applied in the SHI system, or by the principle of equivalence, which prevails in the PHI system. Contributions under the solidarity principle are based on an insured person’s income and employment status. All members receive the same benefits and family members are automatically covered. Contributions under the equivalence principle, on the other hand, are based on criteria such as age, health status and individual insurance contract. In addition, there is a separate contract for each family member. According to data from the Microzensus conducted in 2019, around 88% of the population in Germany is covered by SHI, while 11% are privately insured ( 1 ). In the SHI system, employees make up the largest proportion of the working population, about 93%, while in the PHI system, employees, civil servants, and self-employed are equally represented ( 1 ). Private insurance is only available to certain groups of people: Employees exceeding a defined gross annual income, self-employed or civil servants ( 2 ). Additionally, PHI provides benefits in comparison to SHI, such as a preferred appointment scheduling or a private room in a hospital. However, PHI does not only offer advantages to the insured. For example, switching from PHI to SHI is only possible under certain conditions and is practically impossible after the age of 55 ( 3 ). This can be problematic for insured persons who chose PHI at a young age because of its financial attractiveness - contributions can be lower than in SHI - and who find that the total amount of contributions becomes unaffordable for them as they get older ( 4 ). Since January 2009, insurance has been compulsory in Germany. Citizens are obliged to have health insurance. Since 2007 in the SHI and since 2013 also in the PHI, a restriction of services takes place if a person is not paying the tariffs for two months in the SHI or for six months in the PHI. In the SHI, this is known as the suspension of benefits (SoB), while in the PHI it is known as the emergency tariff (ET). Both tariffs cover the treatment of acute illnesses and pain, as well as benefits during pregnancy and maternity. However, unlike the SoB, the ET does not cover preventive medical check-ups for adults ( 5 , 6 ). It is possible to restore full coverage under both tariffs. This can be done by paying off all debts during SoB or ET, or by applying for state social benefits. By applying for state social benefits, insured under SoB receive subsidies equal to their contributions, whereas those insure under the ET receive a contribution capped at a fixed maximum ( 7 , 8 ). Furthermore, the SHI system offers the option of an installment payment agreement, whereby the SoB ends as soon as a contractual agreement is reached, and the outstanding amount is paid. In 2021, 0.9% of the population was inadequately insured, which corresponds to 1% of all PHI insured persons and 0.9% of all SHI insured persons ( 9 ). According to media reports and government research, the ET mainly affects the self-employed and the elderly ( 9 – 11 ). Given the lack of research on the underinsured in Germany, the aim of this study was to provide a comprehensive overview of the underinsured, the reasons for downgrading, and the challenges associated with regaining full coverage. Our main research questions were: What are the socio-demographic characteristics? What are the causes for downgrading and what factors contributed to remaining in these tariffs? What are the health consequences of downgrading? What challenges arise in trying to restore full insurance coverage? What are potential solutions to prevent inadequate insurance coverage? Methods This study was conducted using an explanatory-sequential mixed-methods design that integrated qualitative and quantitative approaches. Secondary data was requested from the insurance companies and analyzed together with the interview data in order to obtain a holistic picture of the people affected. The results were interpreted using the weaving approach. The study was approved by the Ethics Committee of the Medical Faculty of the University of Aachen (RWTH Aachen) under the number 23–209. All interview participants gave their verbal consent to participate at the beginning of the interview. Expert interviews Interviews were conducted with social workers from clearing centers. These centers provide counseling assistance to uninsured and underinsured individuals to help them regain coverage. In addition, an interview was conducted with a former expert from a clinic. In total, twelve semi-structured interviews were conducted with seven experts from six different institutions (see Table 1 ). Potentially suitable clearing centers were identified via online research and contacted via E-mail. Experts were included in the study, if they were employed in clearing centers or comparable institutions and had knowledge of the clearing process for people with inadequate health insurance. Table 1 Characteristics of the interviewed persons Experts Position of the expert Institution I1 Social worker Clearing center I2 Social worker Clearing center I3 and I4 Social worker Clearing center I5 Social worker Clearing center I6 Social worker Clearing center I7 Former social worker Clinic The interviews were all conducted via video with Zoom, except for one interview which was recorded with a digital recorder. The average duration of an interview was 29 minutes. All interviews took place in August 2023. The semi-structured interview included four similar open questions with sub-questions on each topic of the SoB and the ET. The questions asked were: characteristics of those affected (socio-demographic characteristics), reasons for entering the different tariffs, reasons for seeking help at clearing centers, current composition of those affected after the Covid-19 pandemic and the Ukraine war, the mental state of those affected, the state of health of those affected and coping strategies, return to regular health insurance (process, challenges and obstacles, family members) and evaluation of the ET and SoB (opinion, possible solutions). The semi-structured interview guideline can be found in the supplementary section [see Additional file 1]. The interviews were transcribed by using language and text software and then corrected manually. The transcribed interviews were inserted into MaXQDA2022, and a code system was developed through inductive category formation, which is available in the supplementary section [see Additional file 2]. Insurance data To obtain the data of those affected by the SoB and the ET, 33 of 36 PHI companies offering full health insurance and who are members of the Association of Private Health Insurance Companies were contacted, as well as all major SHI in Germany. The contact and receipt of the data took place between March and September 2023 via e-mail. Three PHI companies and one SHI company provided the necessary data. All insurance companies received a standardized questionnaire with the request to submit anonymized data on the insured people, who had been on the SoB or ET status in the past or still were. Information on gender, age, length of stay in the SoB or ET status, profession and nationality were obtained. Except for the nationality of those affected in the PHI companies, we received all the requested data. One PHI provided data from 2019 to 2022, the second PHI provided data from 2013 to 2023, and the third from 2009 to 2023. Only the data starting from the date of introduction of the ET in August 2013 was considered for the study. Data prior to this date was removed from the final data set. The extracted data from the SHI comprised the period from January 2014 to October 2023. Only people who were in the SoB or in the ET status in the past were included in the final data set. The PHI set comprised a total number of n = 14.312 and the SHI data set n = 95235 persons. Age was categorized ( 6, 6–12, 12–24, 24–48, ≥ 48), analogous to the categorization of the SHI. Since it was not possible for the insurance companies to provide standardized information on the profession of the insured persons, a division into four categories was made. The "employees with benefits" category includes all employees who worked in the public sector and used private health insurance. Correspondingly, the category "employees without benefits" include all employees who had a high annual salary over the benchmark for entering the PHI and all employees below the benchmark. The category "self-employed/voluntarily insured and self-employed" include all self-employed persons in PHI and all voluntarily insured and self-employed persons in SHI. Voluntarily insured persons are those who insured with a SHI company, although they could enter a PHI. The category "others" includes all other professional groups with a negligible share as well as retired persons, children and persons who did not provide any information. Only the SHI companies were able to provide us with information on the nationality of those affected. This information was not recorded by the PHI companies, the information was obtained through the interviews. Microsoft Excel 2023 was used for the descriptive analysis of categorical variables. No statistical tests were carried out. Results Table 2 The characteristics of persons in the emergency tariff or in the suspension of benefits Table 2 The characteristics of persons in the emergency tariff or in the suspension of benefits category Emergency tariff Suspension of benefits % n % n Time span August 2013 until May 2023 January 2014 until October 2023 Gender 14312 95233 Female 22,4 3201 30.9 29382 Male 77.6 11111 69.2 65851 Age 14312 95235 < 15 7.8 1117 0.5 447 15–20 2.7 392 1.0 917 20–30 7.1 1009 40.0 38090 30–40 16.0 2287 24.8 23641 40–50 24.1 3455 17.2 16369 50–60 22.1 3169 11.1 10530 60–66 8.4 1205 2.9 2725 ≥ 66 11.7 1678 2.6 2516 Duration 14312 95235 (Month) < 6 34.4 4919 45.6 43448 6–12 16.5 2365 18.2 17310 12–24 15.9 2275 18.3 17413 24–48 13.4 1921 13.4 12787 ≥ 48 19.8 2832 4.5 4272 Frequency 1 68.7 64.0 2 21.0 21.3 3 7.8 8.4 ≥ 4 2.5 6.3 Professions 14312 95235 Employees with benefits 2.8 400 - - Employees without benefits 13.3 1898 31.9 30331 Self-employed/ Voluntarily insured and self-employed 61.6 8818 19.0 18092 Other 22.3 3196 49.2* 46812 Nationality n = 14312 n = 95235 German -** -** 59.5 56641 Not German -** -** 40.5 38594 Legend: * Other professional groups with an insignificant share; ** The PHI companies were unable to provide data on the nationality of those affected in the ET as this was not documented Legend: * Other professional groups with an insignificant share; ** The PHI companies were unable to provide data on the nationality of those affected in the ET as this was not documented 1. Emergency tariff (ET) 1.1 Information on those affected People in the ET who made use of the services of clearing centers were mainly people of German nationality and in the last third of their working life or older. This group was dominated by former or current self-employed people who have earned a solid income in the past but were currently in a precarious financial situation. The data analysis showed that 62% of the individuals were self-employed and around 66% were 40 years and older (see Table 2 ). Compared to the age group distribution in the SoB group, there was a higher proportion in the age group of children to young adults (under 20 years). In terms of gender distribution, men were overrepresented in this tariff, as well as in the SoB group. "B: One was a retired teacher - I do remember that - otherwise they were all self-employed." (I7) 1.2 Factors for being downgraded to ET One of the main reasons for the downgrade to ET was insufficient income from self-employment. "Most of all, people who used to be self-employed, for example, had a business and then had private health insurance. Then self-employment didn't go so well, they had to give up their business, personal setbacks or something else, and then could no longer pay the contributions to the private health insurance. As a result, they fell into arrears and were downgraded to the emergency tariff."(I5) Furthermore, some of those affected lacked knowledge of the insurance system, particularly regarding compulsory insurance and the impossibility of switching to SHI after a certain age. "And then, for whatever reason, they found themselves in a situation where they no longer wanted to or could pay their insurance. Partly because of the experience that many years ago it was still the case […] that you didn't have to be insured at all. In other words, there was still more or less a traditional attitude behind it. They just didn't realize when compulsory insurance was introduced." (I1) In the context of the ET downgrade, the analysis of the data also revealed that, similarly to the SoB, around 30% of those affected end up in the ET several times in their life (see Table 2 ). 1.3 Factors for the persistence of the ET status In the interviews, the social workers reported that some people decided to remain in the ET because they were not able to pay the contributions or the contribution debts. "And most of them also say: "Well, I'd rather pay the 100 euros a month and accept that […] I have a minimal entitlement to benefits. Because […] the other one puts me under so much emotional strain when there are these high debts from the normal contribution obligations." (I6) Some people found it difficult to seek help because they felt ashamed. "There are definitely people who find this relatively shameful. […] they often believe that they don't actually have any health insurance. They say: "I don't have health insurance and I need help". That's also something you have to overcome at first, to say: "Okay, I need support with this issue now." (I5)" However, those who wanted to tackle the problem and sought advice from their insurance company were given incorrect advice or were not advised, at all. "And she says: She has been to so many private health insurance employees [she talked to], none of them listened to her, and she just didn't get any real information and we are something like an independent institution that can again provide information." (I6) 1.4 Time span until upgrade to regular tariff Half of those affected remained in the ET for less than one year, while the other 50% remained in the ET for between one to more than four years. In addition, there was an increased prevalence of those affected who were inadequately insured for a period of more than four years compared to those who were in the SoB group (see Table 2 ). 1.5 Knowledge of the German health insurance system There was a lack of knowledge of the PHI system and the ET. Knowledge about compulsory health insurance and the impossibility of returning to SHI was often missing. Some of those affected were in the ET without knowing it or were aware of their situation but without having sufficient knowledge of their legal entitlements. "[...] all the people who come to me in this situation, I first have to explain the system completely. They always come with the hope: "Yes, but I'm 60 now, and if I find a job now, with compulsory insurance, then I can go back into the statutory system." And these are all things that don't work. So, I first have to give them a complete overview of the situation here." (I6) 1.6 Health status The people affected have reportedly often chronic illnesses. "Well, at least they were all chronically ill, I can say that. That means they are constantly dependent on medical treatment, to very different degrees." (I7) In addition, there existed medical issues that required immediate treatment. “Because they only come when they can either no longer bear the pain - pain is a big issue - or when the illness is so threatening that something like an operation or chemotherapy is absolutely necessary, and they somehow can't do it because either there is no cover at all, or the health insurance keeps refusing something and saying: "That's not in the emergency tariff.". So, these are usually serious illnesses […]" (I6) As a result, mental health problems also appeared. "I've often had people sitting here - and I wouldn't be saying this if it hadn't really happened a few times - who say: "I don't really want to live like this anymore. I have suicidal intentions.”” (I6) Social workers reported a delay in seeking medical help. The tariff does not cover preventive medical check-ups or costs of non-acute conditions. This was accompanied by a lack of knowledge regarding the rights and restrictions of the ET, not only by the affected person, but also by the medical facilities. "So, there are always clinics that say: "Well, what tariff is this person on? Emergency tariff?" and are then simply unsure and say that they want clarification before they start treatment. This is often the case with something like chemotherapy […]. In other words, when the costs are very high. I can kind of understand that on the part of a clinic, and on the other hand it is of course frightening that health or clinical pictures are then delayed. This sometimes leads to more life-threatening situations or - yes, especially in the case of cancer - things that can no longer be traced back once the tumor has spread." (I6) 1.7 Mental health status Despair, fear and resignation were observed, in particular in older people, as it was often unclear to them where they could find help or how they can solve the problem. "Well, there […] were case constellations where you meet people who have resigned themselves to their situation and have also ignored their insurance situation. And as a result, they have no resources of their own and no interest of their own because they have simply resigned themselves. That is certainly one strategy that can be found. The other, of course, is also great concern about the upcoming costs, which come on top of the health insurance debts, because of course there is also ignorance in the system, among those affected."(I7) However, some of those affected also experience a certain feeling of well-being in the situation. "It's very different. In the case of Germans, I often get the impression that they are comfortable in the situation and well, if you like - it's always difficult to talk about responsibility and self-responsibility and things like that - but somehow they are a bit self-responsible, that they are at least no longer correctly insured." (I1) 1.8 Challenges and obstacles in returning to the regular health insurance Social workers faced various challenges and obstacles during the clarification process caused by granting or applying for social benefits, working with PHI companies, and working with those affected (see Fig. 1). 1.8.1 Challenges and obstacles associated with social benefits The indebtedness of those affected Debt was in particular problematic for people who could not receive social benefits, as repaying debt was the only way to get out of the ET. As can be seen in Fig. 2, there are only two ways to get into regular insurance cover. The length of time these people remain on the ET therefore depends on how long it takes to raise the necessary funds to pay off their debts. "If the people are entitled to social benefits, then it actually works relatively well. For people who don't, access is possible by tapping into their debts. Not like, for example, in the statutory health insurance system, where an installment payment agreement can be made and then the suspension of benefits stops. And […] since it is often several years where the person has accumulated arrears, it takes time until the arrears are paid off. Exactly, that's why you can say that there is a way for them to get back into the other tariff, but that takes time. But there is sometimes a chance that it will work out if they have enough money to pay it." (I5) The bureaucratic requirements The bureaucratic requirements posed a challenge. This was due to the large number of necessary documents and evidence that must be submitted for the social benefits. This was particularly the case for self-employed people, where providing proof of income and information on the business situation was complex and time-consuming. "The biggest challenges are […] all the bureaucratic paperwork. […] The various applications. Especially when it comes to social benefits, filling out the applications, attaching the supporting documents." (I5) 1.8.2 Challenges and obstacles associated with private health insurance companies Cooperation with PHI companies were perceived as negative by the interviewed social workers. The quality of cooperation depended on various factors. This included accessibility to the insurance companies. The availability by phone or email of the right contact person to address the problems was described as difficult and time-consuming. The legal knowledge of the health insurance contact person also played a decisive role as well as the willingness to actively deal with the insurance problem. "And of course, there is always someone in private health insurance who gives us good advice. But if I were to summarize it in general terms, I would say that it is very negative and tainted with accusations and not legally compliant." (I6) 1.8.3 Challenges and obstacles associated with those affected Covering the costs of treatment Bridging the treatment costs until clarification was perceived as challenging. The costs could be covered by treatment funds or donations provided by individuals, cities or federal states. However, they were not available in all regions of Germany. One of these treatment funds, also mentioned in the following quote, is the anonymous healthcare vouchers (AKS – “Anonymer Krankenschein”) which is financed by certain cities or federal states. The reasons for requiring temporary coverage of treatment costs were when hospitals refused to treat people on the ET due to fears that treatment costs would not be covered. This was particularly the case when costly treatments were pending, such as chemotherapy. "[…] you've probably noticed that in many federal states, sometimes also in city states, there are so-called anonymous healthcare vouchers […]. So, we need money for people who are in the process of clarification, but who need to be treated now because it is simply no longer possible to delay. We need funds for that." (I6) Figure 1 Options to upgrade from the ET to a regular tariff and the associated challenges and obstacles ( 6 ). 2. Suspension of benefits (SoB) 2.1 Information on those affected People with a SoB status were mainly unemployed people, homeless people or migrants. The nationalities of those affected varied. However, it is noticeable in the quantitative analysis that there is a high proportion of non-German affected persons (40.53%) in comparison to the non-German insured persons (approx. 13%) in the SHI ( 1 ). In terms of age distribution, there was huge differences to the people from the ET category, as the entire age spectrum was represented. People often found themselves in precarious living conditions. The SoB was just one of many challenges they faced. Other problems included financial difficulties, homelessness, unfavorable working conditions, or unemployment. The analysis of the data showed that 32% of those affected were employees and around 40% were between the ages of 20 and 30 (see Table 2 ). "And when it comes to the suspension of benefits in the statutory health insurance system, I have fewer solo self-employed people […] but more actually homeless people, migrants who have moved here who are not entitled to social benefits and who used to work. So that's a completely different group, and the group tends to be younger." (I6) 2.2 Factors for being downgraded to SoB An important aspect mentioned was the limited knowledge of the compulsory health insurance in Germany. "If I don't make use of the health insurance card, I don't incur any debts. They don't quite realize that the health insurance continues to run and that there is compulsory health insurance in Germany. And then at some point they are surprised and say "Why should I pay for something I haven't used? I've never been to the doctor. Why should I pay for health insurance now?" (I3). Another important factor was the employment situation. The loss of a job or the end of an employment relationship without taking the necessary steps to maintain health insurance cover could result in a compulsory follow-up insurance, where the contribution costs are generally higher. This transition to the suspension of benefits status often occurred due to a lack of engagement with the issue and non-payment of contributions. "In other words, loss of work for whatever reason. Did not take care, did not apply for unemployment benefit. The insurance was terminated and then automatically continues in the compulsory follow-up insurance. Then the insurance companies send questionnaires to determine the classification. They are not answered, then the maximum rate is calculated directly."(I2) 2.3 Factors for the persistence of the SoB status To a certain extent, those affected did not actively tackle the problem by seeking professional help. "Then I also have clients who are no longer entitled to benefits, so benefits are no longer approved or the application for continued approval has not been completed. This resulted in deregistration. There are clients who are taken care of immediately, and there are clients who only come months later." (I2) There is also a lack of knowledge about where support for the problem could be found and how to get out of this situation. 2.4 Time span until upgrade to regular tariff More than 60% of those affected remained in the SoB less than one year, while the rest remained in the SoB category for between one and more than four years. 2.5 Knowledge of the German health insurance system There was a lack of knowledge among those affected about the SHI system and the SoB. Those affected were even in the SoB without knowing it. "And everyone who comes here and then tells our doctors or even me: "I'm not insured", then I first have to ask the question: "Which system were you last in? Which health insurance company? And how long ago was that?" And it's actually already clear to me when someone says: "Well, it happened last year." Then I say: "Well, you're actually still in the system. We'll have to call them now.". And then it often turns out: "Yes, of course, they're still a member, but their benefits are suspended." And people don't know that." (I6) In addition, there was a lack of understanding of how the German health insurance system works among people who are not German citizens. This was mainly due to language barriers and the fact that the healthcare system works differently compared to other countries. "[…] I'm talking about the EU foreigners now. Because with Eastern Europeans there really is […] often a lack of understanding of how the German system works. I often hear: "I didn't know that this would continue, and I haven't been to the doctor, and I haven't claimed anything. How can that be?" (I2). 2.6 Health status Social workers indicated the presence of serious medical problem in those affected, similar to the ET. A delay in seeking medical help due to a lack of knowledge of those affected and also the medical staff regarding the rights and restrictions in a SoB status was reported. As a result, medical advice and treatment was also refused by medical staff. This delay could lead to life-threatening situations. "Or diseases that are not treated, such as derailed diabetes or something like that, are very common and can become life-threatening." (I6) It is not only the situation of the SoB that led to physical health problems, but also the complex life situation in which those affected found themselves, for example as homelessness. This also had a negative impact on mental health. "But in the statutory health insurance system, those affected […] are so heavily burdened by their living conditions, by the general circumstances. […] But of course, life on the street makes you absolutely ill. We have a lot, a very high increase in mentally ill people, really seriously mentally ill people with psychoses from the schizophrenic spectrum, which makes it also very difficult to work with them." (I6) 2.7 Mental health status Social workers experienced despair, resignation or panic in those affected. They were under considerable pressure and stress due to their complex life circumstances, such as unemployment, homelessness, addiction or unacceptable working conditions. The SoB was a further burden. "Because health insurance is often only a component. […] or sometimes a consequence of many other problems. And the people are simply in very difficult life situations, whether they are affected by financial poverty, difficult exploitative working conditions, a housing situation or something else. And here, as well, the people are very often helpless and in some cases a bit resigned because they have already visited many different advice centers." (I5) 2.8 Challenges and obstacles in returning to the regular health insurance Social workers faced various challenges and obstacles during the clarification process. These were mainly associated with granting or applying for social benefits, working with the SHI companies and working with those affected (see Fig. 2). 2.8.1 Challenges and obstacles associated with social benefits The bureaucratic requirements Bureaucratic obstacles arised in connection with the submission of necessary documents and evidence by those affected. It shows to be difficult for some to obtain all the documents. "And these administrative obstacles - what do I need to apply to the Jobcenter - are so big that it takes us months. It starts with the fact that many homeless people don't have a valid ID – all these things – that you need to apply for these social transfer benefits." (I6) 2.8.2 Challenges and obstacles associated with the statutory health insurance companies The statutory health insurance companies The quality of cooperation with SHI employees was perceived as a challenge with mixed views experiences. Knowledge on legal issues varied between the different health insurance companies. Some insurance professionals had a good knowledge on the SoB status. Nevertheless, there were gaps in their legal knowledge on the subject. Existing cooperation’s between clearing centers and health insurance companies were mentioned, which allowed an easier exchange of information and made the work more efficient. "As the (name of the clearing center) clearing center, we have our contacts to health insurance companies, where we can make direct phone calls and work together to find a solution and see how we can help the person affected." (I3) The installment payment agreement Payment by installments in SHI has been observed as an advantage compared to the ET. First, the SoB status ends after the first installment has been paid. Furthermore, there is an additional option for people who were not entitled to benefits to get out of the SoB status. However, implementing an installment payment agreement can be challenging. The amount of the installment payment must be sufficiently high, as repayment of the debt must be ensured within a fixed period. The health insurance company may refuse installment payments that are too low. In addition, the person concerned must have sufficient financial resources or access to social benefits to cover the current health insurance contributions. Due to the health situation, those affected were not always able to pursue an employment after medical treatment. This made their financial situation more difficult and, in return, made it more difficult to reach a sufficient installment payment agreement with the health insurance company. "If I now come and have a debt of 2.000 euros to the patient and say: "We'll make an installment payment of 5 euros per month", then that's something the health insurance company can certainly say is too little for us, and that's understandable. But if the patient can't pay any more, then that's the way it is. In other words, it's a process - a negotiation process - that doesn't happen so fast, and it has to be paid [insured persons must be able to pay the installments]." (I7) 2.8.3 Challenges and obstacles associated with those affected The cooperation with those affected, or their relatives was perceived of essential importance for the returning process. The time it took to obtain the necessary documents or attend the necessary appointments with the authorities may have extended the whole process. Social workers emphasized that the individual situation of those affected, such as homelessness, extreme poverty, mental illness, or their employment situation, had a significant impact on compliance. "Then there are another 10% who - in my view - often have no compliance due to their living conditions and mental illnesses, so they don't come to appointments." (I6) Figure 2 Options to upgrade from the SoB to a regular tariff and the associated challenges and obstacles ( 5 ). Discussion In addressing the broad issue of inadequate insurance coverage in Germany, this is, to our knowledge, one of the first studies on this particular subject. In our study, we observed that older people were more likely to be affected by the ET as well as self-employed people (approx. 60%) with low incomes. This is especially interesting since this group makes up only one third of the working population in PHI ( 1 ). Self-employed are therefore more susceptible to falling into the ET. A possible reason for this could be the exemption from compulsory insurance, combined with the financial advantages that healthy self-employed people experience at a young age through membership in the PHI. With regard to the SoB in the SHI, our results show that unemployed young people, migrants and the homeless people are particularly affected by this tariff. This observation shows similarities with data from the Netherlands ( 12 ). Those covered by the SHI system in Germany experience a continuous and uninterrupted payment of health insurance contributions, without direct contact with the health insurers. This begins at birth and continues throughout employment, as contributions are deducted directly from salary. There is no in-depth examination of the health insurance system and the contributions paid, which means that the financing of contributions in the event of unemployment may be neglected. This explains the majority of younger people affected as a result of lacking knowledge on the health care system. In the case of migrants, it is very likely that the language barrier plays a significant role, e.g. in communicating with authorities and health insurance companies and in understanding documents. However, an inadequate understanding of the German healthcare system due to a non-comparable system in the country of origin could also be significant. For example, in some tax-financed systems, all citizens are automatically insured without having to pay contributions, while in other countries, non-payment of contributions leads to exclusion from the health insurance system, which is not possible in Germany context, and leads to payment default ( 13 ). The issue of homelessness is inherently complex. Inadequate or no insurance status is only one of many problems faced affected ( 14 ). Inadequate insurance status has a significant impact on homeless people’s access to health services ( 14 – 16 ). However, this access also depends on the social benefits provided to homeless people by the state. A survey of unsheltered and hidden homeless people in North Rhine-Westphalia (Germany) found that almost 50% of unsheltered homeless people did not receive any social benefits from the state. In addition, 38% of these people did not have a valid health insurance card at the time of the survey ( 17 ). Regardless of the different demographic characteristics of those affected in the ET and the SoB, as well as the different reasons for the downgrading of tariffs, a common basis for the persistence of the situation becomes apparent: a lack of health system knowledge This deficit is also evident in the general population in Germany, especially among the elderly and those with a low social status and a migration background ( 18 ). Nevertheless, other factors could play an important role. For example, administrative barriers associated with the effort required to obtain benefits may have an influence. One study found that a lack of information and the complexity of application procedures were important factors in the non-take-up of social benefits in EU countries ( 19 ). In addition, the fact that social benefits do not fully cover contribution costs may also be a reason for a non-take-up ( 7 , 8 ) With regard to the state of health of those affected, it is difficult to say anything on the basis of the interviews conducted. Chronic and serious illnesses were mentioned, but no precise details or quantitative data were given. Firstly, the degree of severity in this context is a subjective perception and secondly, some of the social workers lack the necessary medical knowledge to make a proper assessment. Further research is therefore needed. In the US, uninsured people were found to have an increased risk of being diagnosed with advanced cancer compared to insured people, especially for diseases that could have been detected early through symptoms or screening, such as colon, breast or bladder cancer ( 20 , 21 ). Uninsured may be less likely to seek preventive care and therefore delay seeking medical care ( 22 ). Second, as a study of the impact of underinsurance on bladder cancer diagnosis found, treatment may also be delayed ( 23 ). It is important to note that the ET does not include preventive check-ups in its benefits ( 5 , 6 ). This means that people on the ET may be denied preventive check-ups even if they want them. Furthermore, the terms "only treatment of acute illnesses" and "pain conditions" are broad terms that ideally depend on the judgment of the attending physician. In addition, initial assessments may be made by the reception staff of a practice or emergency room, who may not have the comprehensive medical knowledge to make an appropriate judgment. There is currently no data on the frequency with which people are turned away with acute emergencies due to insufficient coverage and a lack of medical knowledge among the staff in Germany. Three potential approaches to tackling the problem of inadequate insurance coverage were identified in the interviews conducted. These approaches can be broken down into three simple hierarchical levels: Federal, state and municipal level. One possible solution at the federal level, in order to initially provide equal opportunities and possibilities for those affected in terms of medical benefits and the return to a regular health insurance relationship, is the introduction of a single health insurance system, as has been adopted in the Netherlands. The responsibility for proper insurance has been transferred to the National Health Care Institute (NHCI) who are responsible for maintaining insurance coverage ( 24 ). This has been effective in ensuring continuity of full coverage for (future) patients ( 12 ). In addition, a single health insurance system could also benefit insurers by potentially lowering their contribution rates without reducing physicians' fees ( 25 ). A potentially less complex implementation at the federal level under our dual system could be to establish a mechanism that allows vulnerable people with financial constraints to return to the SHI system after the age of 55. The government has justified this decision by arguing that a transition from the insured from PHI to SHI would be a financial burden for insurers ( 26 ). However, current PHI statistics show that only 0.1% of the population is affected by the ET ( 27 ). Our research suggests that only about 40% of people in the ET are over the age of 50. Further in-depth research is needed. At the state and municipal level, whether within a dual system or a single health insurance system, a concept is needed that would strengthen cooperation between different providers at the municipal level, since the structures for this already exist. This approach should include improved coordination between the health insurance companies, which are informed at an early stage about defaulting people, the clearing centers, which act as case managers for those concerned, and the state institutions that provide social benefits. The goal is to ensure continuity of coverage and prevent people to falling into debt. In some federal states and cities, special funds have already been set up to provide people with temporary healthcare while their situation is being clarified - one example of this is the anonymous healthcare vouchers in North Rhine-Westphalia ( 28 ). However, these funds are financially limited and subject to political approval, which means that they can potentially be abolished and are therefore not a long-term solution. Limitation The data on SoB is based exclusively on a single health insurance company from one federal state. Despite the fact that a considerable number of people were included in the analysis, it should be noted that the characteristics and results may vary depending on the federal state. Furthermore, it was not possible to assess the morbidity of those insured in SHI or PHI, even though this would have been of great interest in order to draw conclusions about their state of health. A more in-depth analysis with those affected would be beneficial in order to understand their situation. Conclusion The results presented here open up a field of research that has been little explored to date and highlight the need for more in-depth studies. They show that certain groups of people are affected by insurance downgrading, although the reasons for this vary. While some people are able to successfully return to their previous insurance levels, others fail to do so. Therefore, there is a need to support these people and, ideally, to take preventative measures to prevent them from getting into such a situation in the first place. Abbreviations SHI Statutory health insurance PHI Private health insurance SoB Suspension of benefits ET Emergency tariff Declarations Ethics approval and consent to participate Ethical approval was given by the ethics commission of the medical faculty of RWTH Aachen University (23-209). All participants gave informed consent to participate in this study. Consent for publication Not applicable. Availability of Data and materials The analyzed and generated data of the study can be made available on request from the corresponding author. Supplementary Information Additional file 1 Interview guideline.docx, Title: Interview guideline on the ET and the SoB from the perspective of social workers, Description: The interview guideline used for the interviews. Additional file 2 Coding guideline.xlsx, Title: Coding guideline for the ET and SoB interviews, Description: The coding guideline used for the ET and SoB interviews. Competing interests The obtaining of data from a private health insurance company required the conclusion of a contract. Submission of the manuscript was only possible with their consent. The insurance company had no influence on study design and evaluation. Funding This research did not receive external funding. Author’s contributions The Design of the study CD and AK.; The procurement, analysis and the interpretation of secondary data CD; Development of interview guideline CD and AK; Conducting and interpreting the interviews CD; Writing of the manuscript CD; Review of the manuscript AK; Supervision AK; Approval of the published version of the manuscript CD and AK. Acknowledgement Thanks to all the experts who took part in the interviews and to the insurance companies and their employees who provided us with the data. References Statisches Bundesamt. Sozialleistungen Angaben zur Krankenversicherung - (Ergebnisse des Mikrozensus). Fachserie 13. 2019;4(11):1–71. Verband der Privaten Krankenversicherung. Krankenversicherung - Versicherungsbeginn [Internet]. n.d. [cited 2024 May 21]. https://www.pkv.de/wissen/private-krankenversicherung/versicherungsbeginn/ . Bundesministerium für Gesundheit. Wechsel zwischen GKV und PKV [Internet]. 2024 [cited 2024 May 3]. https://www.bundesgesundheitsministerium.de/themen/krankenversicherung/online-ratgeber-krankenversicherung/krankenversicherung/wechsel-zwischen-gkv-und-pkv . Bellmann C, Gehlen R, Asmus J, Süddeutsche Z. 2024 [cited 2024 Apr 21]. Krankenversicherung: So geht’s zurück in die Krankenkasse. https://www.sueddeutsche.de/projekte/artikel/wirtschaft/krankenkasse-private-krankenversicherung-gkv-pkv-wechsel-beitraege-e636264/ . WD 9. Gesundheit, Familie, Senioren, Frauen und Jugend. Ruhen der Leistungen in der gesetzlichen Krankenversicherung bei Nichtzahlung von Beiträgen [Internet]. 2014 [cited 2024 Mar 10]. https://www.bundestag.de/resource/blob/410048/4afed3fb28b52133d7a507353affb568/WD-9-023-15-pdf-data.pdf . Verband der Privaten Krankenversicherung. Allgemeine Versicherungsbedingungen 2013 für den Notlagentarif, Tarif NLT [Internet]. 2022 [cited 2024 Mar 10]. https://www.pkv.de/fileadmin/user_upload/PKV/3_PDFs/ABV_und_MB/AVB-NLT.pdf . Bundesministerium der Justiz. Bundesamt der Justiz. Sozialgesetzbuch (SGB) Zweites Buch (II) - Bürgergeld, Grundsicherung für Arbeitsuchende - (Artikel 1 des Gesetzes vom 24. Dezember 2003, BGBl. I S. 2954) § 26 [Internet]. n.d. [cited 2024 May 3]. https://www.gesetze-im-internet.de/sgb_2/__26.html . Bundesministerium der Justiz. Bundesamt der Justiz. Sozialgesetzbuch (SGB) Drittes Buch (III) - Arbeitsförderung - (Artikel 1 des Gesetzes vom 24. März 1997, BGBl. I S. 594) § 174 [Internet]. n.d. [cited 2024 May 3]. https://www.gesetze-im-internet.de/sgb_3/__174.html . Kurz C. Menschen ohne Krankenversicherung: Ein oft übersehenes Problem. Deutsches Ärzteblatt. 2022;119(41):1738–41. Deutscher Bundestag. Antwort der Bundesregierung auf die Kleine Anfrage der Abgeordneten Dr. Achim Kessler, Susanne Ferschl, Matthias W. Birkwald, weiterer Abgeordneter und der Fraktion DIE LINKE.– Drucksache 19/22329 –. Zugang zur Gesundheitsversorgung im Notlagentarif (Bundestag-Drucksache 19/23095) [Internet]. 2020 [cited 2024 Mar 10]. https://dserver.bundestag.de/btd/19/230/1923095.pdf . Freihold J, Süddeutsche Z. 2020 [cited 2024 Apr 20]. Private Krankenversicherung: Beharren mit System. https://www.sueddeutsche.de/kolumne/private-krankenversicherung-beharren-mit-system-1.4828194 . Van Ginneken E, Rice T. Enforcing Enrollment in Health Insurance Exchanges: Evidence From the Netherlands, Switzerland, and Germany. Med Care Res Rev. 2015;72(4):496–509. Bahnsen L, Kostenbeteiligungen. Wartezeiten, Leistungsumfang - Ein europäischer Vergleich der Gesundheitssysteme. Köln: Wissenschaftliches Institut der PKV; 2022. Omerov P, Craftman ÅG, Mattsson E, Klarare A. Homeless persons’ experiences of health- and social care: A systematic integrative review. Health Soc Care Commun. 2020;28(1):1–11. Kaduszkiewicz H, Bochon B, Van Den Bussche H, Hansmann-Wiest J, Van Der Leeden C. The medical treatment of homeless people. Deutsches Ärzteblatt international. 2017;114(40):673–9. van der Leeden C, Kaduszkiewicz H, Boczor S, Kloppe T, Lohmann B, Mallon T, et al. Medical centres for the homeless in Hamburg – consultation reasons and diagnoses compared to primary care patients in the regular health care system. Arch Public Health. 2023;81(1):190. Brüchmann K, Busch-Geertsema V, Henke J, Schöpke S, Steffen A. Wohnungslose ohne Unterkunft und verdeckt Wohnungslose in Nordrhein-Westfalen: Ergebnisse einer Befragung. GISS; 2021. Schaeffer D, Berens EM, Vogt D. Health Literacy in the German Population. Deutsches Ärzteblatt international. 2017;114:53–60. Eurofound. Access to social benefits: Reducing non-take-up. Luxembourg: Publications Office of the European Union; 2015. Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol. 2008;9(3):222–31. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, et al. Effects of Health Insurance and Race on Early Detection of Cancer. JNCI: J Natl Cancer Inst. 1999;91(16):1409–15. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of Preventive Care Among Adults: Insurance Status and Usual Source of Care. Am J Public Health. 2003;93(5):786–91. Fletcher SA, Cole AP, Lu C, Marchese M, Krimphove MJ, Friedlander DF, et al. The impact of underinsurance on bladder cancer diagnosis, survival, and care delivery for individuals under the age of 65 years. Cancer. 2020;126(3):496–505. Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. Netherlands: Health System Review. Health Syst Transit. 2016;18(2):1–240. Ochmann R, Albrecht M, Schiffhorst G, Institut IGES. Geteilter Krankenversicherungsmarkt: Risikoselektion und regionale Verteilung der Ärzte. 1st ed. Bertelsmann Stiftung; 2020. Deutscher Bundestag. Gesetzentwurf der Fraktionen SPD und BÜNDNIS 90/DIE GRÜNEN Entwurf eines Gesetzes zur Reform der gesetzlichen Krankenversicherung ab dem Jahr 2000 (GKV-Gesundheitsreform 2000) [Internet]. 1999 [cited 2024 May 3]. https://dserver.bundestag.de/btd/14/012/1401245.pdf . Verband der Privaten Krankenversicherung. PKV Zahlenportal - Notlagentarif Ergebnis [Internet]. n.d. [cited 2024 Apr 14]. https://www.pkv-zahlenportal.de/werte/2012/2022/12/pers-nlt/basket/result . 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(1):117. Additional Declarations Competing interest reported. The obtaining of data from a private health insurance company required the conclusion of a contract. Submission of the manuscript was only possible with their consent. The insurance company had no influence on study design and evaluation. Supplementary Files Codingguideline.xlsx Interviewguideline.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4492563","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":307952343,"identity":"618cc412-6516-4feb-b40a-9bea3557b443","order_by":0,"name":"Christian Dumke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYDACCQaGA2CSgcEAxJQzAAsbWBDQkoDQYmzAwAxiS+DVwsCQwADXkrgBrIUBtxb+2b0PD/78YSFvzsC8TerGGZv07ez9Rzf8KJBg4G/vTsBqyZ3jBod5EiQMdzawlUnn3EjL3dlzmO1mD9BhEmfObsCmxUAijeEw0C+MGw7wmEnnfDicu+FGMtsNHqAWA4lcnFoO/kiQsIdq+Z9uANRy8w8BLQeADkuEaLlxIAGk5TY+WyRuAB3GkyaRvOEwW7F1zplkww1nDpvdljGQ4MHlF/4Zacwff9jU2W443rzxds4xO3mD443Pbr75YyPH396LVQsCMKPxefArHwWjYBSMglGADwAAjztjHFghHq0AAAAASUVORK5CYII=","orcid":"","institution":"RWTH Aachen University","correspondingAuthor":true,"prefix":"","firstName":"Christian","middleName":"","lastName":"Dumke","suffix":""},{"id":307952344,"identity":"eab50411-8b86-4012-a894-b23677b33b33","order_by":1,"name":"Andrea Kaifie","email":"","orcid":"","institution":"RWTH Aachen University","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Kaifie","suffix":""}],"badges":[],"createdAt":"2024-05-28 17:47:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4492563/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4492563/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58125402,"identity":"b36e49bb-d650-4fde-92d6-e5b7441f4303","added_by":"auto","created_at":"2024-06-11 13:08:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37791,"visible":true,"origin":"","legend":"\u003cp\u003eOptions to upgrade from the ET to a regular tariff and the associated challenges and obstacles (6).\u003c/p\u003e","description":"","filename":"Figure131.png","url":"https://assets-eu.researchsquare.com/files/rs-4492563/v1/f1f72a30e12e4f1386c986f5.png"},{"id":58125405,"identity":"5b27c152-00d7-41f5-815e-0940d44b047d","added_by":"auto","created_at":"2024-06-11 13:08:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60799,"visible":true,"origin":"","legend":"\u003cp\u003eOptions to upgrade from the SoB to a regular tariff and the associated challenges and obstacles (5).\u003c/p\u003e","description":"","filename":"Figure227.png","url":"https://assets-eu.researchsquare.com/files/rs-4492563/v1/3e27766eb2650eb6ac22d6e2.png"},{"id":58238351,"identity":"b662e2a8-3278-447a-8e54-8c42bbd2cf60","added_by":"auto","created_at":"2024-06-12 23:31:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1072653,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4492563/v1/800558a8-0820-4937-b3a6-a863e0352be4.pdf"},{"id":58125403,"identity":"14670635-039e-47cd-8680-af4ce23bcbf9","added_by":"auto","created_at":"2024-06-11 13:08:43","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":20481,"visible":true,"origin":"","legend":"","description":"","filename":"Codingguideline.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4492563/v1/e0ea7deb1d6b2001811272fb.xlsx"},{"id":58126045,"identity":"d17ac934-8197-4bcf-b138-fee2bc869528","added_by":"auto","created_at":"2024-06-11 13:16:43","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":29274,"visible":true,"origin":"","legend":"","description":"","filename":"Interviewguideline.docx","url":"https://assets-eu.researchsquare.com/files/rs-4492563/v1/9f5515407a1e568f8b593b99.docx"}],"financialInterests":"Competing interest reported. The obtaining of data from a private health insurance company required the conclusion of a contract. Submission of the manuscript was only possible with their consent. The insurance company had no influence on study design and evaluation.","formattedTitle":"Inadequate health insurance cover in Germany: People’s characteristics, causes and possible solutions - a mixed methods approach","fulltext":[{"header":"Background","content":"\u003cp\u003eGermany is characterized by a dual health insurance system, consisting of statutory health insurance (SHI) and private health insurance (PHI).\u003c/p\u003e \u003cp\u003eThese systems are based on the principle of contributory financing, and they are characterized either by the principle of solidarity, which is applied in the SHI system, or by the principle of equivalence, which prevails in the PHI system.\u003c/p\u003e \u003cp\u003eContributions under the solidarity principle are based on an insured person\u0026rsquo;s income and employment status. All members receive the same benefits and family members are automatically covered. Contributions under the equivalence principle, on the other hand, are based on criteria such as age, health status and individual insurance contract. In addition, there is a separate contract for each family member.\u003c/p\u003e \u003cp\u003eAccording to data from the Microzensus conducted in 2019, around 88% of the population in Germany is covered by SHI, while 11% are privately insured (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the SHI system, employees make up the largest proportion of the working population, about 93%, while in the PHI system, employees, civil servants, and self-employed are equally represented (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrivate insurance is only available to certain groups of people: Employees exceeding a defined gross annual income, self-employed or civil servants (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Additionally, PHI provides benefits in comparison to SHI, such as a preferred appointment scheduling or a private room in a hospital.\u003c/p\u003e \u003cp\u003eHowever, PHI does not only offer advantages to the insured. For example, switching from PHI to SHI is only possible under certain conditions and is practically impossible after the age of 55 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This can be problematic for insured persons who chose PHI at a young age because of its financial attractiveness - contributions can be lower than in SHI - and who find that the total amount of contributions becomes unaffordable for them as they get older (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince January 2009, insurance has been compulsory in Germany. Citizens are obliged to have health insurance. Since 2007 in the SHI and since 2013 also in the PHI, a restriction of services takes place if a person is not paying the tariffs for two months in the SHI or for six months in the PHI. In the SHI, this is known as the suspension of benefits (SoB), while in the PHI it is known as the emergency tariff (ET). Both tariffs cover the treatment of acute illnesses and pain, as well as benefits during pregnancy and maternity. However, unlike the SoB, the ET does not cover preventive medical check-ups for adults (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is possible to restore full coverage under both tariffs. This can be done by paying off all debts during SoB or ET, or by applying for state social benefits. By applying for state social benefits, insured under SoB receive subsidies equal to their contributions, whereas those insure under the ET receive a contribution capped at a fixed maximum (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, the SHI system offers the option of an installment payment agreement, whereby the SoB ends as soon as a contractual agreement is reached, and the outstanding amount is paid.\u003c/p\u003e \u003cp\u003eIn 2021, 0.9% of the population was inadequately insured, which corresponds to 1% of all PHI insured persons and 0.9% of all SHI insured persons (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). According to media reports and government research, the ET mainly affects the self-employed and the elderly (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the lack of research on the underinsured in Germany, the aim of this study was to provide a comprehensive overview of the underinsured, the reasons for downgrading, and the challenges associated with regaining full coverage.\u003c/p\u003e \u003cp\u003eOur main research questions were:\u003c/p\u003e \u003cp\u003e \u003col style=\"list-style-type:upper-roman;\"\u003e\n \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the socio-demographic characteristics?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the causes for downgrading and what factors contributed to remaining in these tariffs?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the health consequences of downgrading?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat challenges arise in trying to restore full insurance coverage?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are potential solutions to prevent inadequate insurance coverage?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was conducted using an explanatory-sequential mixed-methods design that integrated qualitative and quantitative approaches.\u003c/p\u003e \u003cp\u003eSecondary data was requested from the insurance companies and analyzed together with the interview data in order to obtain a holistic picture of the people affected. The results were interpreted using the weaving approach.\u003c/p\u003e \u003cp\u003e The study was approved by the Ethics Committee of the Medical Faculty of the University of Aachen (RWTH Aachen) under the number 23\u0026ndash;209. All interview participants gave their verbal consent to participate at the beginning of the interview.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eExpert interviews\u003c/h2\u003e \u003cp\u003eInterviews were conducted with social workers from clearing centers. These centers provide counseling assistance to uninsured and underinsured individuals to help them regain coverage. In addition, an interview was conducted with a former expert from a clinic. In total, twelve semi-structured interviews were conducted with seven experts from six different institutions (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePotentially suitable clearing centers were identified via online research and contacted via E-mail. Experts were included in the study, if they were employed in clearing centers or comparable institutions and had knowledge of the clearing process for people with inadequate health insurance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the interviewed persons\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosition of the expert\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstitution\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClearing center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClearing center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI3 and I4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClearing center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClearing center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClearing center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormer social worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe interviews were all conducted via video with Zoom, except for one interview which was recorded with a digital recorder. The average duration of an interview was 29 minutes. All interviews took place in August 2023.\u003c/p\u003e \u003cp\u003eThe semi-structured interview included four similar open questions with sub-questions on each topic of the SoB and the ET.\u003c/p\u003e \u003cp\u003eThe questions asked were:\u003c/p\u003e \u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\n \u003cspan\u003e \u003cli\u003e \u003cp\u003echaracteristics of those affected (socio-demographic characteristics),\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ereasons for entering the different tariffs,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ereasons for seeking help at clearing centers,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ecurrent composition of those affected after the Covid-19 pandemic and the Ukraine war,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ethe mental state of those affected,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ethe state of health of those affected and coping strategies,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ereturn to regular health insurance (process, challenges and obstacles, family members)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eand evaluation of the ET and SoB (opinion, possible solutions).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e The semi-structured interview guideline can be found in the supplementary section [see Additional file 1]. The interviews were transcribed by using language and text software and then corrected manually.\u003c/p\u003e \u003cp\u003eThe transcribed interviews were inserted into MaXQDA2022, and a code system was developed through inductive category formation, which is available in the supplementary section [see Additional file 2].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInsurance data\u003c/h2\u003e \u003cp\u003eTo obtain the data of those affected by the SoB and the ET, 33 of 36 PHI companies offering full health insurance and who are members of the Association of Private Health Insurance Companies were contacted, as well as all major SHI in Germany. The contact and receipt of the data took place between March and September 2023 via e-mail. Three PHI companies and one SHI company provided the necessary data.\u003c/p\u003e \u003cp\u003eAll insurance companies received a standardized questionnaire with the request to submit anonymized data on the insured people, who had been on the SoB or ET status in the past or still were. Information on gender, age, length of stay in the SoB or ET status, profession and nationality were obtained. Except for the nationality of those affected in the PHI companies, we received all the requested data.\u003c/p\u003e \u003cp\u003eOne PHI provided data from 2019 to 2022, the second PHI provided data from 2013 to 2023, and the third from 2009 to 2023.\u003c/p\u003e \u003cp\u003eOnly the data starting from the date of introduction of the ET in August 2013 was considered for the study. Data prior to this date was removed from the final data set.\u003c/p\u003e \u003cp\u003eThe extracted data from the SHI comprised the period from January 2014 to October 2023.\u003c/p\u003e \u003cp\u003eOnly people who were in the SoB or in the ET status in the past were included in the final data set. The PHI set comprised a total number of n\u0026thinsp;=\u0026thinsp;14.312 and the SHI data set n\u0026thinsp;=\u0026thinsp;95235 persons.\u003c/p\u003e \u003cp\u003eAge was categorized (\u0026lt;\u0026thinsp;15, 15\u0026ndash;20, 20\u0026ndash;30, 30\u0026ndash;40, 40\u0026ndash;50, 50\u0026ndash;60, 60\u0026ndash;66, \u0026ge; 66) as well as the length of stay in months in the individual tariffs (\u0026gt;\u0026thinsp;6, 6\u0026ndash;12, 12\u0026ndash;24, 24\u0026ndash;48, \u0026ge; 48), analogous to the categorization of the SHI.\u003c/p\u003e \u003cp\u003eSince it was not possible for the insurance companies to provide standardized information on the profession of the insured persons, a division into four categories was made. The \"employees with benefits\" category includes all employees who worked in the public sector and used private health insurance. Correspondingly, the category \"employees without benefits\" include all employees who had a high annual salary over the benchmark for entering the PHI and all employees below the benchmark. The category \"self-employed/voluntarily insured and self-employed\" include all self-employed persons in PHI and all voluntarily insured and self-employed persons in SHI. Voluntarily insured persons are those who insured with a SHI company, although they could enter a PHI. The category \"others\" includes all other professional groups with a negligible share as well as retired persons, children and persons who did not provide any information.\u003c/p\u003e \u003cp\u003eOnly the SHI companies were able to provide us with information on the nationality of those affected. This information was not recorded by the PHI companies, the information was obtained through the interviews.\u003c/p\u003e \u003cp\u003eMicrosoft Excel 2023 was used for the descriptive analysis of categorical variables. No statistical tests were carried out.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e The characteristics of persons in the emergency tariff or in the suspension of benefits\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe characteristics of persons in the emergency tariff or in the suspension of benefits category\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eEmergency tariff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eSuspension of benefits\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime span\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eAugust 2013 until May 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eJanuary 2014 until October 2023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e95233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e29382\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e77.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e69.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e65851\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e95235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e447\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e917\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e38090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e23641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10530\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1678\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e95235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e43448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17310\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17413\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u0026ndash;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e19.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e68.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e64.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e14312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e95235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployees with benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployees without benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e30331\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed/ Voluntarily insured and self-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e18092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e3196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.2*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e46812\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;14312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;95235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGerman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e56641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot German\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e38594\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eLegend: * Other professional groups with an insignificant share; ** The PHI companies were unable to provide data on the nationality of those affected in the ET as this was not documented\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLegend: * Other professional groups with an insignificant share; ** The PHI companies were unable to provide data on the nationality of those affected in the ET as this was not documented\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1. Emergency tariff (ET)\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e1.1 Information on those affected\u003c/h2\u003e \u003cp\u003ePeople in the ET who made use of the services of clearing centers were mainly people of German nationality and in the last third of their working life or older. This group was dominated by former or current self-employed people who have earned a solid income in the past but were currently in a precarious financial situation.\u003c/p\u003e \u003cp\u003eThe data analysis showed that 62% of the individuals were self-employed and around 66% were 40 years and older (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Compared to the age group distribution in the SoB group, there was a higher proportion in the age group of children to young adults (under 20 years). In terms of gender distribution, men were overrepresented in this tariff, as well as in the SoB group.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"B: One was a retired teacher - I do remember that - otherwise they were all self-employed.\" (I7)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Factors for being downgraded to ET\u003c/h2\u003e \u003cp\u003eOne of the main reasons for the downgrade to ET was insufficient income from self-employment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Most of all, people who used to be self-employed, for example, had a business and then had private health insurance. Then self-employment didn't go so well, they had to give up their business, personal setbacks or something else, and then could no longer pay the contributions to the private health insurance. As a result, they fell into arrears and were downgraded to the emergency tariff.\"(I5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFurthermore, some of those affected lacked knowledge of the insurance system, particularly regarding compulsory insurance and the impossibility of switching to SHI after a certain age.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And then, for whatever reason, they found themselves in a situation where they no longer wanted to or could pay their insurance. Partly because of the experience that many years ago it was still the case [\u0026hellip;] that you didn't have to be insured at all. In other words, there was still more or less a traditional attitude behind it. They just didn't realize when compulsory insurance was introduced.\" (I1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn the context of the ET downgrade, the analysis of the data also revealed that, similarly to the SoB, around 30% of those affected end up in the ET several times in their life (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e1.3 Factors for the persistence of the ET status\u003c/h2\u003e \u003cp\u003eIn the interviews, the social workers reported that some people decided to remain in the ET because they were not able to pay the contributions or the contribution debts.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And most of them also say: \"Well, I'd rather pay the 100 euros a month and accept that [\u0026hellip;] I have a minimal entitlement to benefits. Because [\u0026hellip;] the other one puts me under so much emotional strain when there are these high debts from the normal contribution obligations.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome people found it difficult to seek help because they felt ashamed.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"There are definitely people who find this relatively shameful. [\u0026hellip;] they often believe that they don't actually have any health insurance. They say: \"I don't have health insurance and I need help\". That's also something you have to overcome at first, to say: \"Okay, I need support with this issue now.\" (I5)\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, those who wanted to tackle the problem and sought advice from their insurance company were given incorrect advice or were not advised, at all.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And she says: She has been to so many private health insurance employees [she talked to], none of them listened to her, and she just didn't get any real information and we are something like an independent institution that can again provide information.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Time span until upgrade to regular tariff\u003c/h2\u003e \u003cp\u003eHalf of those affected remained in the ET for less than one year, while the other 50% remained in the ET for between one to more than four years. In addition, there was an increased prevalence of those affected who were inadequately insured for a period of more than four years compared to those who were in the SoB group (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1.5 Knowledge of the German health insurance system\u003c/h2\u003e \u003cp\u003eThere was a lack of knowledge of the PHI system and the ET. Knowledge about compulsory health insurance and the impossibility of returning to SHI was often missing. Some of those affected were in the ET without knowing it or were aware of their situation but without having sufficient knowledge of their legal entitlements.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"[...] all the people who come to me in this situation, I first have to explain the system completely. They always come with the hope: \"Yes, but I'm 60 now, and if I find a job now, with compulsory insurance, then I can go back into the statutory system.\" And these are all things that don't work. So, I first have to give them a complete overview of the situation here.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1.6 Health status\u003c/h2\u003e \u003cp\u003eThe people affected have reportedly often chronic illnesses.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Well, at least they were all chronically ill, I can say that. That means they are constantly dependent on medical treatment, to very different degrees.\" (I7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn addition, there existed medical issues that required immediate treatment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because they only come when they can either no longer bear the pain - pain is a big issue - or when the illness is so threatening that something like an operation or chemotherapy is absolutely necessary, and they somehow can't do it because either there is no cover at all, or the health insurance keeps refusing something and saying: \"That's not in the emergency tariff.\". So, these are usually serious illnesses [\u0026hellip;]\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAs a result, mental health problems also appeared.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I've often had people sitting here - and I wouldn't be saying this if it hadn't really happened a few times - who say: \"I don't really want to live like this anymore. I have suicidal intentions.\u0026rdquo;\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e(I6)\u003c/h2\u003e \u003cp\u003eSocial workers reported a delay in seeking medical help. The tariff does not cover preventive medical check-ups or costs of non-acute conditions. This was accompanied by a lack of knowledge regarding the rights and restrictions of the ET, not only by the affected person, but also by the medical facilities.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"So, there are always clinics that say: \"Well, what tariff is this person on? Emergency tariff?\" and are then simply unsure and say that they want clarification before they start treatment. This is often the case with something like chemotherapy [\u0026hellip;]. In other words, when the costs are very high. I can kind of understand that on the part of a clinic, and on the other hand it is of course frightening that health or clinical pictures are then delayed. This sometimes leads to more life-threatening situations or - yes, especially in the case of cancer - things that can no longer be traced back once the tumor has spread.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e1.7 Mental health status\u003c/h2\u003e \u003cp\u003eDespair, fear and resignation were observed, in particular in older people, as it was often unclear to them where they could find help or how they can solve the problem.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Well, there [\u0026hellip;] were case constellations where you meet people who have resigned themselves to their situation and have also ignored their insurance situation. And as a result, they have no resources of their own and no interest of their own because they have simply resigned themselves. That is certainly one strategy that can be found. The other, of course, is also great concern about the upcoming costs, which come on top of the health insurance debts, because of course there is also ignorance in the system, among those affected.\"(I7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, some of those affected also experience a certain feeling of well-being in the situation.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It's very different. In the case of Germans, I often get the impression that they are comfortable in the situation and well, if you like - it's always difficult to talk about responsibility and self-responsibility and things like that - but somehow they are a bit self-responsible, that they are at least no longer correctly insured.\" (I1)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e1.8 Challenges and obstacles in returning to the regular health insurance\u003c/h2\u003e \u003cp\u003eSocial workers faced various challenges and obstacles during the clarification process caused by granting or applying for social benefits, working with PHI companies, and working with those affected (see Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e1.8.1 Challenges and obstacles associated with social benefits\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eThe indebtedness of those affected\u003c/h2\u003e \u003cp\u003eDebt was in particular problematic for people who could not receive social benefits, as repaying debt was the only way to get out of the ET. As can be seen in Fig.\u0026nbsp;2, there are only two ways to get into regular insurance cover. The length of time these people remain on the ET therefore depends on how long it takes to raise the necessary funds to pay off their debts.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"If the people are entitled to social benefits, then it actually works relatively well. For people who don't, access is possible by tapping into their debts. Not like, for example, in the statutory health insurance system, where an installment payment agreement can be made and then the suspension of benefits stops. And [\u0026hellip;] since it is often several years where the person has accumulated arrears, it takes time until the arrears are paid off. Exactly, that's why you can say that there is a way for them to get back into the other tariff, but that takes time. But there is sometimes a chance that it will work out if they have enough money to pay it.\" (I5)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eThe bureaucratic requirements\u003c/h2\u003e \u003cp\u003eThe bureaucratic requirements posed a challenge. This was due to the large number of necessary documents and evidence that must be submitted for the social benefits.\u003c/p\u003e \u003cp\u003eThis was particularly the case for self-employed people, where providing proof of income and information on the business situation was complex and time-consuming.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The biggest challenges are [\u0026hellip;] all the bureaucratic paperwork. [\u0026hellip;] The various applications. Especially when it comes to social benefits, filling out the applications, attaching the supporting documents.\" (I5)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e1.8.2 Challenges and obstacles associated with private health insurance companies\u003c/h2\u003e \u003cp\u003eCooperation with PHI companies were perceived as negative by the interviewed social workers.\u003c/p\u003e \u003cp\u003eThe quality of cooperation depended on various factors. This included accessibility to the insurance companies. The availability by phone or email of the right contact person to address the problems was described as difficult and time-consuming. The legal knowledge of the health insurance contact person also played a decisive role as well as the willingness to actively deal with the insurance problem.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And of course, there is always someone in private health insurance who gives us good advice. But if I were to summarize it in general terms, I would say that it is very negative and tainted with accusations and not legally compliant.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e1.8.3 Challenges and obstacles associated with those affected\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eCovering the costs of treatment\u003c/h2\u003e \u003cp\u003eBridging the treatment costs until clarification was perceived as challenging. The costs could be covered by treatment funds or donations provided by individuals, cities or federal states. However, they were not available in all regions of Germany. One of these treatment funds, also mentioned in the following quote, is the anonymous healthcare vouchers (AKS \u0026ndash; \u0026ldquo;Anonymer Krankenschein\u0026rdquo;) which is financed by certain cities or federal states.\u003c/p\u003e \u003cp\u003eThe reasons for requiring temporary coverage of treatment costs were when hospitals refused to treat people on the ET due to fears that treatment costs would not be covered. This was particularly the case when costly treatments were pending, such as chemotherapy.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"[\u0026hellip;] you've probably noticed that in many federal states, sometimes also in city states, there are so-called anonymous healthcare vouchers [\u0026hellip;]. So, we need money for people who are in the process of clarification, but who need to be treated now because it is simply no longer possible to delay. We need funds for that.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;1\u003c/b\u003e Options to upgrade from the ET to a regular tariff and the associated challenges and obstacles (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e2. Suspension of benefits (SoB)\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e2.1 Information on those affected\u003c/h2\u003e \u003cp\u003ePeople with a SoB status were mainly unemployed people, homeless people or migrants. The nationalities of those affected varied. However, it is noticeable in the quantitative analysis that there is a high proportion of non-German affected persons (40.53%) in comparison to the non-German insured persons (approx. 13%) in the SHI (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In terms of age distribution, there was huge differences to the people from the ET category, as the entire age spectrum was represented.\u003c/p\u003e \u003cp\u003ePeople often found themselves in precarious living conditions. The SoB was just one of many challenges they faced. Other problems included financial difficulties, homelessness, unfavorable working conditions, or unemployment.\u003c/p\u003e \u003cp\u003eThe analysis of the data showed that 32% of those affected were employees and around 40% were between the ages of 20 and 30 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And when it comes to the suspension of benefits in the statutory health insurance system, I have fewer solo self-employed people [\u0026hellip;] but more actually homeless people, migrants who have moved here who are not entitled to social benefits and who used to work. So that's a completely different group, and the group tends to be younger.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Factors for being downgraded to SoB\u003c/h2\u003e \u003cp\u003eAn important aspect mentioned was the limited knowledge of the compulsory health insurance in Germany.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"If I don't make use of the health insurance card, I don't incur any debts. They don't quite realize that the health insurance continues to run and that there is compulsory health insurance in Germany. And then at some point they are surprised and say \"Why should I pay for something I haven't used? I've never been to the doctor. Why should I pay for health insurance now?\" (I3).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother important factor was the employment situation. The loss of a job or the end of an employment relationship without taking the necessary steps to maintain health insurance cover could result in a compulsory follow-up insurance, where the contribution costs are generally higher. This transition to the suspension of benefits status often occurred due to a lack of engagement with the issue and non-payment of contributions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"In other words, loss of work for whatever reason. Did not take care, did not apply for unemployment benefit. The insurance was terminated and then automatically continues in the compulsory follow-up insurance. Then the insurance companies send questionnaires to determine the classification. They are not answered, then the maximum rate is calculated directly.\"(I2)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e2.3 Factors for the persistence of the SoB status\u003c/h2\u003e \u003cp\u003eTo a certain extent, those affected did not actively tackle the problem by seeking professional help.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Then I also have clients who are no longer entitled to benefits, so benefits are no longer approved or the application for continued approval has not been completed. This resulted in deregistration. There are clients who are taken care of immediately, and there are clients who only come months later.\" (I2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere is also a lack of knowledge about where support for the problem could be found and how to get out of this situation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003e2.4 Time span until upgrade to regular tariff\u003c/h2\u003e \u003cp\u003eMore than 60% of those affected remained in the SoB less than one year, while the rest remained in the SoB category for between one and more than four years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e2.5 Knowledge of the German health insurance system\u003c/h2\u003e \u003cp\u003eThere was a lack of knowledge among those affected about the SHI system and the SoB. Those affected were even in the SoB without knowing it.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And everyone who comes here and then tells our doctors or even me: \"I'm not insured\", then I first have to ask the question: \"Which system were you last in? Which health insurance company? And how long ago was that?\" And it's actually already clear to me when someone says: \"Well, it happened last year.\" Then I say: \"Well, you're actually still in the system. We'll have to call them now.\". And then it often turns out: \"Yes, of course, they're still a member, but their benefits are suspended.\" And people don't know that.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn addition, there was a lack of understanding of how the German health insurance system works among people who are not German citizens. This was mainly due to language barriers and the fact that the healthcare system works differently compared to other countries.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"[\u0026hellip;] I'm talking about the EU foreigners now. Because with Eastern Europeans there really is [\u0026hellip;] often a lack of understanding of how the German system works. I often hear: \"I didn't know that this would continue, and I haven't been to the doctor, and I haven't claimed anything. How can that be?\" (I2).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Health status\u003c/h2\u003e \u003cp\u003eSocial workers indicated the presence of serious medical problem in those affected, similar to the ET.\u003c/p\u003e \u003cp\u003eA delay in seeking medical help due to a lack of knowledge of those affected and also the medical staff regarding the rights and restrictions in a SoB status was reported. As a result, medical advice and treatment was also refused by medical staff. This delay could lead to life-threatening situations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Or diseases that are not treated, such as derailed diabetes or something like that, are very common and can become life-threatening.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIt is not only the situation of the SoB that led to physical health problems, but also the complex life situation in which those affected found themselves, for example as homelessness. This also had a negative impact on mental health.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"But in the statutory health insurance system, those affected [\u0026hellip;] are so heavily burdened by their living conditions, by the general circumstances. [\u0026hellip;] But of course, life on the street makes you absolutely ill. We have a lot, a very high increase in mentally ill people, really seriously mentally ill people with psychoses from the schizophrenic spectrum, which makes it also very difficult to work with them.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Mental health status\u003c/h2\u003e \u003cp\u003eSocial workers experienced despair, resignation or panic in those affected. They were under considerable pressure and stress due to their complex life circumstances, such as unemployment, homelessness, addiction or unacceptable working conditions. The SoB was a further burden.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Because health insurance is often only a component. [\u0026hellip;] or sometimes a consequence of many other problems. And the people are simply in very difficult life situations, whether they are affected by financial poverty, difficult exploitative working conditions, a housing situation or something else. And here, as well, the people are very often helpless and in some cases a bit resigned because they have already visited many different advice centers.\" (I5)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.8 Challenges and obstacles in returning to the regular health insurance\u003c/h3\u003e\n\u003cp\u003eSocial workers faced various challenges and obstacles during the clarification process. These were mainly associated with granting or applying for social benefits, working with the SHI companies and working with those affected (see Fig.\u0026nbsp;2).\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003e2.8.1 Challenges and obstacles associated with social benefits\u003c/h2\u003e \u003cdiv id=\"Sec32\" class=\"Section3\"\u003e \u003ch2\u003eThe bureaucratic requirements\u003c/h2\u003e \u003cp\u003eBureaucratic obstacles arised in connection with the submission of necessary documents and evidence by those affected. It shows to be difficult for some to obtain all the documents.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And these administrative obstacles - what do I need to apply to the Jobcenter - are so big that it takes us months. It starts with the fact that many homeless people don't have a valid ID \u0026ndash; all these things \u0026ndash; that you need to apply for these social transfer benefits.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section4\"\u003e \u003ch2\u003e2.8.2 Challenges and obstacles associated with the statutory health insurance companies\u003c/h2\u003e \u003cp\u003e \u003cb\u003eThe statutory health insurance companies\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe quality of cooperation with SHI employees was perceived as a challenge with mixed views experiences.\u003c/p\u003e \u003cp\u003eKnowledge on legal issues varied between the different health insurance companies. Some insurance professionals had a good knowledge on the SoB status. Nevertheless, there were gaps in their legal knowledge on the subject. Existing cooperation\u0026rsquo;s between clearing centers and health insurance companies were mentioned, which allowed an easier exchange of information and made the work more efficient.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"As the (name of the clearing center) clearing center, we have our contacts to health insurance companies, where we can make direct phone calls and work together to find a solution and see how we can help the person affected.\" (I3)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eThe installment payment agreement\u003c/h3\u003e\n\u003cp\u003ePayment by installments in SHI has been observed as an advantage compared to the ET. First, the SoB status ends after the first installment has been paid. Furthermore, there is an additional option for people who were not entitled to benefits to get out of the SoB status.\u003c/p\u003e \u003cp\u003eHowever, implementing an installment payment agreement can be challenging. The amount of the installment payment must be sufficiently high, as repayment of the debt must be ensured within a fixed period. The health insurance company may refuse installment payments that are too low. In addition, the person concerned must have sufficient financial resources or access to social benefits to cover the current health insurance contributions.\u003c/p\u003e \u003cp\u003eDue to the health situation, those affected were not always able to pursue an employment after medical treatment. This made their financial situation more difficult and, in return, made it more difficult to reach a sufficient installment payment agreement with the health insurance company.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"If I now come and have a debt of 2.000 euros to the patient and say: \"We'll make an installment payment of 5 euros per month\", then that's something the health insurance company can certainly say is too little for us, and that's understandable. But if the patient can't pay any more, then that's the way it is.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eIn other words, it's a process - a negotiation process - that doesn't happen so fast, and it has to be paid [insured persons must be able to pay the installments].\" (I7)\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003e2.8.3 Challenges and obstacles associated with those affected\u003c/h3\u003e\n\u003cp\u003eThe cooperation with those affected, or their relatives was perceived of essential importance for the returning process. The time it took to obtain the necessary documents or attend the necessary appointments with the authorities may have extended the whole process. Social workers emphasized that the individual situation of those affected, such as homelessness, extreme poverty, mental illness, or their employment situation, had a significant impact on compliance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Then there are another 10% who - in my view - often have no compliance due to their living conditions and mental illnesses, so they don't come to appointments.\" (I6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;2\u003c/b\u003e Options to upgrade from the SoB to a regular tariff and the associated challenges and obstacles (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn addressing the broad issue of inadequate insurance coverage in Germany, this is, to our knowledge, one of the first studies on this particular subject.\u003c/p\u003e \u003cp\u003eIn our study, we observed that older people were more likely to be affected by the ET as well as self-employed people (approx. 60%) with low incomes. This is especially interesting since this group makes up only one third of the working population in PHI (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Self-employed are therefore more susceptible to falling into the ET. A possible reason for this could be the exemption from compulsory insurance, combined with the financial advantages that healthy self-employed people experience at a young age through membership in the PHI.\u003c/p\u003e \u003cp\u003eWith regard to the SoB in the SHI, our results show that unemployed young people, migrants and the homeless people are particularly affected by this tariff. This observation shows similarities with data from the Netherlands (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThose covered by the SHI system in Germany experience a continuous and uninterrupted payment of health insurance contributions, without direct contact with the health insurers. This begins at birth and continues throughout employment, as contributions are deducted directly from salary. There is no in-depth examination of the health insurance system and the contributions paid, which means that the financing of contributions in the event of unemployment may be neglected. This explains the majority of younger people affected as a result of lacking knowledge on the health care system.\u003c/p\u003e \u003cp\u003eIn the case of migrants, it is very likely that the language barrier plays a significant role, e.g. in communicating with authorities and health insurance companies and in understanding documents. However, an inadequate understanding of the German healthcare system due to a non-comparable system in the country of origin could also be significant. For example, in some tax-financed systems, all citizens are automatically insured without having to pay contributions, while in other countries, non-payment of contributions leads to exclusion from the health insurance system, which is not possible in Germany context, and leads to payment default (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe issue of homelessness is inherently complex. Inadequate or no insurance status is only one of many problems faced affected (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Inadequate insurance status has a significant impact on homeless people\u0026rsquo;s access to health services (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, this access also depends on the social benefits provided to homeless people by the state. A survey of unsheltered and hidden homeless people in North Rhine-Westphalia (Germany) found that almost 50% of unsheltered homeless people did not receive any social benefits from the state. In addition, 38% of these people did not have a valid health insurance card at the time of the survey (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegardless of the different demographic characteristics of those affected in the ET and the SoB, as well as the different reasons for the downgrading of tariffs, a common basis for the persistence of the situation becomes apparent: a lack of health system knowledge This deficit is also evident in the general population in Germany, especially among the elderly and those with a low social status and a migration background (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Nevertheless, other factors could play an important role. For example, administrative barriers associated with the effort required to obtain benefits may have an influence. One study found that a lack of information and the complexity of application procedures were important factors in the non-take-up of social benefits in EU countries (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In addition, the fact that social benefits do not fully cover contribution costs may also be a reason for a non-take-up (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWith regard to the state of health of those affected, it is difficult to say anything on the basis of the interviews conducted. Chronic and serious illnesses were mentioned, but no precise details or quantitative data were given. Firstly, the degree of severity in this context is a subjective perception and secondly, some of the social workers lack the necessary medical knowledge to make a proper assessment. Further research is therefore needed.\u003c/p\u003e \u003cp\u003eIn the US, uninsured people were found to have an increased risk of being diagnosed with advanced cancer compared to insured people, especially for diseases that could have been detected early through symptoms or screening, such as colon, breast or bladder cancer (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUninsured may be less likely to seek preventive care and therefore delay seeking medical care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Second, as a study of the impact of underinsurance on bladder cancer diagnosis found, treatment may also be delayed (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). It is important to note that the ET does not include preventive check-ups in its benefits (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This means that people on the ET may be denied preventive check-ups even if they want them.\u003c/p\u003e \u003cp\u003eFurthermore, the terms \"only treatment of acute illnesses\" and \"pain conditions\" are broad terms that ideally depend on the judgment of the attending physician. In addition, initial assessments may be made by the reception staff of a practice or emergency room, who may not have the comprehensive medical knowledge to make an appropriate judgment. There is currently no data on the frequency with which people are turned away with acute emergencies due to insufficient coverage and a lack of medical knowledge among the staff in Germany.\u003c/p\u003e \u003cp\u003eThree potential approaches to tackling the problem of inadequate insurance coverage were identified in the interviews conducted. These approaches can be broken down into three simple hierarchical levels: Federal, state and municipal level. One possible solution at the federal level, in order to initially provide equal opportunities and possibilities for those affected in terms of medical benefits and the return to a regular health insurance relationship, is the introduction of a single health insurance system, as has been adopted in the Netherlands. The responsibility for proper insurance has been transferred to the National Health Care Institute (NHCI) who are responsible for maintaining insurance coverage (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This has been effective in ensuring continuity of full coverage for (future) patients (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In addition, a single health insurance system could also benefit insurers by potentially lowering their contribution rates without reducing physicians' fees (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA potentially less complex implementation at the federal level under our dual system could be to establish a mechanism that allows vulnerable people with financial constraints to return to the SHI system after the age of 55. The government has justified this decision by arguing that a transition from the insured from PHI to SHI would be a financial burden for insurers (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, current PHI statistics show that only 0.1% of the population is affected by the ET (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Our research suggests that only about 40% of people in the ET are over the age of 50. Further in-depth research is needed.\u003c/p\u003e \u003cp\u003eAt the state and municipal level, whether within a dual system or a single health insurance system, a concept is needed that would strengthen cooperation between different providers at the municipal level, since the structures for this already exist. This approach should include improved coordination between the health insurance companies, which are informed at an early stage about defaulting people, the clearing centers, which act as case managers for those concerned, and the state institutions that provide social benefits. The goal is to ensure continuity of coverage and prevent people to falling into debt.\u003c/p\u003e \u003cp\u003eIn some federal states and cities, special funds have already been set up to provide people with temporary healthcare while their situation is being clarified - one example of this is the anonymous healthcare vouchers in North Rhine-Westphalia (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). However, these funds are financially limited and subject to political approval, which means that they can potentially be abolished and are therefore not a long-term solution.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThe data on SoB is based exclusively on a single health insurance company from one federal state. Despite the fact that a considerable number of people were included in the analysis, it should be noted that the characteristics and results may vary depending on the federal state. Furthermore, it was not possible to assess the morbidity of those insured in SHI or PHI, even though this would have been of great interest in order to draw conclusions about their state of health. A more in-depth analysis with those affected would be beneficial in order to understand their situation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results presented here open up a field of research that has been little explored to date and highlight the need for more in-depth studies. They show that certain groups of people are affected by insurance downgrading, although the reasons for this vary. While some people are able to successfully return to their previous insurance levels, others fail to do so. Therefore, there is a need to support these people and, ideally, to take preventative measures to prevent them from getting into such a situation in the first place.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSHI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatutory health insurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePHI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrivate health insurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSoB\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSuspension of benefits\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eET\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency tariff\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was given by the ethics commission of the medical faculty of RWTH Aachen University (23-209). All participants gave informed consent to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analyzed and generated data of the study can be made available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional file 1 Interview guideline.docx, Title: Interview guideline on the ET and the SoB from the perspective of social workers, Description: The interview guideline used for the interviews.\u003c/p\u003e\n\u003cp\u003eAdditional file 2 Coding guideline.xlsx, Title: Coding guideline for the ET and SoB interviews, Description: The coding guideline used for the ET and SoB interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe obtaining of data from a private health insurance company required the conclusion of a contract. Submission of the manuscript was only possible with their consent. The insurance company had no influence on study design and evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Design of the study CD and AK.; The procurement, analysis and the interpretation of secondary data CD; Development of interview guideline CD and AK; Conducting and interpreting the interviews CD; Writing of the manuscript CD; Review of the manuscript AK; Supervision AK; Approval of the published version of the manuscript CD and AK.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to all the experts who took part in the interviews and to the insurance companies and their employees who provided us with the data.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStatisches Bundesamt. 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Int J Equity Health. 2023;22(1):117.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Access to health care, Health inequality, Defaulting payers, Vulnerable Groups, Emergency tariff, Suspension of benefits","lastPublishedDoi":"10.21203/rs.3.rs-4492563/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4492563/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn the German dual health insurance system, almost 1% of German citizens only have an inadequate insurance cover leading to an impaired medical care. The personals characteristics, the causes of their inadequate cover and the associated health effects are largely unknown, so far. The aim of this study was to obtain a comprehensive overview about those with a limited health insurance cover.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was conducted using a mixed-methods design. Data was used from two private health insurance companies and one statutory health insurance company. In addition, interviews were conducted with experts from clearing centers that supported the return to a full insurance coverage, with the aim of exploring the causes of the current situation, to identify the challenges in trying to regain full insurance coverage and to capture the health effects.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe PHI dataset comprised a total number of n\u0026thinsp;=\u0026thinsp;14.312 and the SHI data set n\u0026thinsp;=\u0026thinsp;95.325 persons. In the private health insurance system, the most affected people were male, over 40 years and self-employed, while in the statutory health insurance system, the most affected were young male between 20 and 30 years, employees and overproportionate non-Germans. Socio-economic factors, lack of health literacy, and inadequate knowledge about health insurance resulted in an inadequate insurance cover leading to an exclusion from the healthcare system.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere are particular groups with certain sociodemographic characteristics that are more vulnerable to an inadequate insurance cover. It is therefore important to identify and offer support before an insurance downgrade is carried out. Support from health insurance companies in cooperation with clearing centers and state institutions that provide social benefits is necessary.\u003c/p\u003e","manuscriptTitle":"Inadequate health insurance cover in Germany: People’s characteristics, causes and possible solutions - a mixed methods approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 13:08:38","doi":"10.21203/rs.3.rs-4492563/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a15f7fbb-84f9-4b22-9264-f045eee0aaae","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-20T05:48:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-11 13:08:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4492563","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4492563","identity":"rs-4492563","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}