The statutory health insurance system (GKV) in Germany has borne a significant financial and administrative burden since 2015 due to the medical care of refugees and asylum seekers, including Ukrainian war refugees since 2022. Based on official reports and studies, the cumulative expenses for healthcare services during this period amount to several billion euros, with costs being reimbursed by the federal government, states, and municipalities. This burden results from the Asylum Seekers' Benefits Act (AsylbLG), which limits benefit entitlement, as well as full GKV access for recognized refugees and recipients of citizen's allowance. The National Association of Statutory Health Insurance Funds emphasizes that there is no direct financial relief for the funds, as expenses are reimbursed separately, but administrative efforts and indirect effects on the health fund are noticeable.
Total migration since 2015 includes approximately 2.5 million initial applications to the Federal Office for Migration and Refugees (BAMF), with a peak of 975,000 individuals in 2015. Medical costs account for about 10 to 20 percent of the total refugee-related expenses, which are cumulatively estimated between 370 and 420 billion euros from 2015 to 2025. The share for healthcare thus amounts to approximately 37 to 84 billion euros, with precise GKV-specific data being fragmented and often linked to social expenditures.
Annual expenditure structure and cumulative estimate for general refugees
Since 2015, the Asylum Seekers' Benefits Act (AsylbLG) has regulated medical entitlement: during the first 36 months (waiting period), benefits are limited to acute illnesses, pregnancy, and aftercare; from the 37th month onwards, full GKV access is granted. Health insurance funds manage this on a commissioned basis, book expenses separately, and receive reimbursement from states and municipalities. Per capita expenses for refugees are between 180 and 200 euros annually, below the GKV average of around 3,000 euros, as many services are outpatient and preventive.
- 2015: With 975,000 refugees and total costs of 21.1 billion euros (ifo Institute), approximately 2 to 3 billion euros were allocated to health, based on a 10 percent share.
- 2016–2019: Expenditures increased with declining numbers (approx. 400,000 per year), cumulatively amounting to 10–15 billion euros for medical care. A study by the German Medical Journal estimates annual additional expenses for recipients of unemployment benefit II (including refugees) at 2–3 billion euros.
- 2020–2021: Higher costs due to pandemic-related tests and vaccinations; cumulatively approx. 5 billion euros.
- 2022–2023: Spending rose to €6–8 billion annually for 486,000 (2022) and 399,000 (2021) individuals, driven by integration and chronic care.
- 2024–2025: Projected €5–7 billion per year, with deficits due to underfunding for recipients of citizen's income (Bürgergeld).
Cumulatively since 2015, this amounts to approximately €40–60 billion for statutory health insurance (GKV). In 2024 alone, €1.2 billion was allocated to asylum-related medical services (state budgets). An analysis by LabNews-Investigativ quantifies the healthcare share of migration costs at 15–20 percent of the total sum of €370–420 billion by 2025.
Specific burden from Ukrainian refugees since 2022
Since February 2022, over 1.1 million Ukrainians have arrived in Germany, of whom around 730,000 are employable. Until May 2022, the Asylum Seekers' Benefits Act (AsylbLG) applied with limited benefits; from June 2022, those in need of assistance receive full GKV access via citizen's income (Bürgergeld) or social assistance, including electronic health cards and long-term care insurance. Those not in need of assistance can opt for voluntary insurance. This led to rapid utilization, with a focus on mental health issues, vaccinations, and chronic diseases.
- 2022: Between June and August, GKV spent €29.3 million (Federal Social Security Office). For the entire year, the Federal Ministry of Health (BMG) estimates approximately €500 million, including reimbursements for war casualties.
- 2023: Annual spending increased to €1–1.5 billion, as 50 percent of refugees receive citizen's income (Bürgergeld), causing underfunding (contributions do not cover full costs).
- 2024–2025 (up to September): Forecast of €1.2–1.5 billion per year, with an additional €50 million in federal subsidies for soldier care until the end of 2025.
Cumulatively since 2022, GKV expenditures amount to approximately €3–4 billion, with additional administrative challenges arising from diverging state regulations. The GKV representative body reports no systemic financial burden, as reimbursements are in place, but the health fund feels the pressure from rising membership to over 75 million.
Impact and need for reform
The cumulative burden highlights systemic weaknesses: While immigrants can provide net relief – from 2013 to 2019, they paid 7.9 percent of contributions with only a 3.5 percent share of expenses – short-term costs from non-working individuals outweigh this. By 2040, the shortage of contributors could burden the GKV by €2–3 billion annually. Experts call for stricter integration requirements and contribution adjustments to ensure stability. Without adjustments, the pressure on contributors will escalate, especially during times of demographic change.
