549 “You can’t go against the system!”How professionals and patients navigate healthcare access restrictions for asylum seekers in Germany

Abstract PTH 4: Mental Health and Refugees 2, B307 (FCSH), September 4, 2025, 14:00 - 14:48 Aims Healthcare for asylum seekers in Germany is governed by a special legislation designed to deter migration through benefits-based restrictions. Access can be simplified, but many federal states oppose easing procedures, maintaining bureaucratic hurdles where many services must be requested case-by-case from local authorities. We aimed to understand how affected actors cope with these restrictions. Methods We conducted a three-month ethnographic exploration in two refugee clinics, documented 110 cost coverage applications and their outcomes, compiled 40 free-lists, and interviewed 41 professionals (healthcare, interpretation, social work, administration) and 26 severely or chronically ill asylum seekers. Results The analysis shows that legal restrictions impose new roles on actors: for example, patients must provide credible evidence of their need and become petitioners for medical care. Health and social work personnel must familiarize themselves with restrictions, explain access procedures, assist with applications, track funding issues, and often inform patients when services are denied. Administrators without medical expertise and clear guidelines must decide on requests, communicate, and enforce decisions. Actors respond on reflective, affective, attitudinal, and behavioral levels. We will elaborate on their reactions ranging from resignation and over-adaptation to cautious questioning, enabling strategies for access and sometimes resistance. Conclusions The law’s implementation by street-level bureaucrats has many side effects. All actors face uncertainty. Patients often lack awareness of their rights; their care depends heavily on advocates’ goodwill. Professionals display both supportive behaviors and restrictive interpretations influenced by deservingness ascriptions that may include evaluations of flight motives and asylum prospects. Medical care for asylum seekers has become a site of internal border-making, risking professionals becoming enforcers of restrictive migration policies. To allow care staff to focus on the needs of those seeking protection and ensure equal access, we must advocate for the abolition of the special legislation – especially as restrictions have recently been tightened.