Authors: Matthias Zimmer, Antonia Sahm
Categories: Research, vulnerability, end of life, human right, health insurance, hospice, intersectionality
Source: BMC Medicine
Authors: Matthias Zimmer, Antonia Sahm
People without medical insurance often lack access to medical care, increasing their risk of chronic diseases and reducing life expectancy. This disparity likely extends to end-of-life care, when patients are especially vulnerable. The main research question was whether outpatient and inpatient palliative care facilities regularly treat uninsured patients. Based on the results, the study initiated an ethical reflection on the circumstances of uninsured palliative patients in Germany.
The study ran for 15 months from 2024 to 2025 1494 inpatient hospices, outpatient hospice services and specialized outpatient palliative care (SOPC) in Germany were invited to participate in an online questionnaire. The questionnaire contained questions about the care of uninsured patients with palliative care needs. A univariate descriptive analysis was used. Based on the results, ethical reflections on overlapping vulnerability were conducted, focusing especially on how living without medical insurance and its related circumstances interact from an intersectional perspective.
People without medical insurance, usually aged 40–65 years, received care at 41 (45.6%) inpatient hospices, 63 (29.3%) outpatient hospice services, and 29 (48.3%) SOPCs. Social workers usually made the requests. Funding gaps were reported by 10 (24.3%) inpatient hospices, 18 (8.4%) outpatient hospice services, and 55 (60.3%) SOPCs. 49 (54.4%) of inpatient hospices, 133 (61.9%) of outpatient hospice services, and 37 (61.7%) of SOPCs lacked knowledge about care options for uninsured patients ,. Fewer uninsured patients were cared for than had requested care, although there was a high level of willingness to provide palliative care to people without medical insurance.
The findings suggest that palliative care facilities do not regularly treat uninsured patients in Germany. Access to established palliative care institutions seems more difficult for the uninsured. These results indicate major inequalities in the provision of health care in Germany, especially in phases when patients are highly dependent on caregivers and therefore in need of protection. To address these issues, networking between medical services for the uninsured and palliative care services should be further strengthened. Precise legal regulations are ethically necessary alongside measures to ensure low-threshold access to palliative care and targeted training for medical professionals.
The online version contains supplementary material available at 10.1186/s12916-026-04992-9.
The establishment of palliative care as the standard of care at the end of life is widely regarded as an important achievement of modern medicine. In both inpatient and outpatient settings, palliative care seeks to alleviate symptoms and ensure the best possible quality of life, addressing physical, social, psychological, and spiritual needs [1]. Given their limited life expectancy, palliative care patients find themselves in a particularly difficult phase, in which the involvement and training of relatives and caregivers can be helpful [2]. In many cases, physical vulnerability often coincides with emotional and cognitive vulnerability [3]. Dealing with dying and death therefore requires not only the treatment of somatic symptoms but also social and psychological support for the patients and their relatives [4]. The aim of palliative care is to offer this comprehensive support in one of the most vulnerable phases of life, during which people can be highly physically, emotionally and socially dependent on their environment and in need of protection. Moreover, a central aim of palliative care is the promotion and protection of patient autonomy. Accordingly, palliative care may be understood as a supportive treatment designed to preserve autonomy and enable the highest possible degree of independent living [5]. In terms of ethical considerations the concept of vulnerability can refer to the risk of losing autonomy and being in need of supportive measures [6].
From an intersectional perspective [7], other forms of vulnerability can amplify the risk of physical and cognitive vulnerability associated with serious illness. Structural and institutional forces can intersect with a patient’s multidimensional axes of identity in ways that marginalize the patient [8].
People without medical insurance in Germany are a group with an increased risk of vulnerability, as they often have poorer health than insured people do, frequently live in precarious situations and have no access to established care structures [9]. Although medical insurance is legally mandated in Germany, a substantial number of individuals living in the country remain uninsured [10]. Estimates suggest that at least 100,000 individuals lacking adequate medical insurance coverage, with the actual number likely much higher [11–13]. The reasons for the lack of insurance coverage are diverse. The people affected include EU citizens with precarious employment, self-employed people with very low incomes, undocumented migrants, students, and homeless people, among others. Frequently, uninsured individuals are already marginalized by their social position. Despite its diversity, this group is unified by a lack of financial resources to afford medical insurance or access medical care [13, 14]. Associations, initiatives and individual volunteers are gradually closing the gap in care for uninsured people. These organizations include, for example, Armut und Gesundheit e.V [15]., Medinetz [16] Caritas and the Malteser Hilfsdienst e.V [17]. The commitment of those helping is mostly voluntary; the material costs are covered mainly by private donations and only a few state subsidies. A reliable, established non-governmental network to support these individuals does not exist. A lack of vaccinations, preventive check-ups or treatment for acute illnesses facilitates the manifestation of chronic progressive and neoplastic diseases [18]. Limited opportunities for self-advocacy [19] (such as the possibility of effective communication or informed decision making) make medical care more difficult and reduce compliance with treatment [20]. The consequences can include a limited life expectancy in the face of incurable diseases [21]. Even though the human right to health does theoretically guarantee access to the maximum attainable level of medical care for all people, regardless of insurance status [22], aid organizations often do not have the resources to provide this highest possible standard of care [10]. These interrelations indicate that individuals without medical insurance face an elevated risk of vulnerability.
There are currently no reliable data on the number of uninsured patients with terminal illnesses in Germany. The available data show that people without medical insurance are the exception rather than the rule with respect to palliative care [23]. Access to palliative care is likely to be just as challenging as access to primary medical care [12]. In contrast, it is known that approximately 36,400 individuals are cared for in inpatient hospices each year and approximately 82,500 are cared for by specialized outpatient palliative care (SOPC) teams [24, 25]. 95% of the cost of a bed in an inpatient hospice is covered by medical insurance, and 5% are funded by charitable donations [26]. Inpatient hospices are generally not profit-oriented institutions. Most SOPC teams are profit-oriented or partially profit-oriented institutions. Medical insurance companies cover the full cost for insured patients (Book Five of the Social Code para. § 37b SGB V) [27]. Outpatient hospice services are an embodiment of civic engagement. They provide psychosocial and spiritual support to patients and their families. The members of the outpatient services are volunteers and work for charity without pay [4]. The funding of outpatient hospice services is regulated by law in Germany [28].
In Germany, medical insurance provides an entrance in to the healthcare system. All residents are legally required to obtain medical insurance. Nevertheless, there are individuals in Germany who live without any form of insurance coverage, and their access to the healthcare system is severely restricted. These people depend on the support of a few charitable organizations. A generalized statement about the healthcare structures for the uninsured is difficult to make, as there are no standardized or established governmental care systems for this population. Consequently, those without coverage find themselves excluded from the standard healthcare structures, which, together with poverty and precarious living conditions, presents a high risk for vulnerability. Reasons for this exclusion include lack of residence status [29], language barriers, gaps in social legislation, low compliance, unstable living situations, fear of stigmatization [30], and homelessness [31], among others. Another barrier may be the low level of networking between hospice service providers and charities for people without medical insurance. This may also reflect a lack of knowledge about charitable care options for uninsured people.
Data on the care of uninsured people at the end of life in Germany are scarce. Therefore, which health care structures exist for uninsured patients in this vulnerable phase of life, what the quality of the care that is available and the age range of uninsured palliative patients remain unclear.
To address these questions, this study adopts an empirical-ethical approach, exploring the convergence of a lack of insurance and palliative illness and creating a basis for ethical considerations. The aim of this empirical part of the study is to examine whether outpatient and inpatient palliative care facilities regularly treat uninsured patients. In line with empirical ethics, the paper uses empirical findings to stimulate informed ethical reflection and develops a basis for further research [32].This ethical reflection and contextualization of the empirical findings examines the situation in light of two key concepts in medical ethics that, as outlined in the introduction, are pertinent to the circumstances of uninsured palliative ill individuals. These are, first, the concept of vulnerability and, second, the risk of the convergence and amplification of two forms of vulnerability in the life circumstances of uninsured palliative care patients, which can be elucidated through the concept of intersectionality. Given the limited existing research on uninsured patients in palliative care, this study makes an initial contribution and seeks to promote broader ethical reflection on this care context.
The study with a quantitative, cross-sectional survey design was conducted as identification of the target group, collection of contact details for sending out invitations to participate, creation of a questionnaire to obtain a database, distribution of invitations to participate in the study and data collection, statistical analysis of the collected data, and ethical reflection on the collected data from an intersectional perspective.
The survey was conducted among hospices, hospice services, and SOPC teams in Germany. According to the German Fifth Social Code Book (para. 73b und para. 39a) [27], these providers are responsible for palliative care outside of hospitals. The care of palliative patients is strictly regulated by the provisions of the Fifth Social Code Book. This care is considered a standard benefit covered by both statutory and private medical insurance.
In general most nursing homes are unable to provide adequate palliative care independently [33], which is why they must rely on the SOPC. The costs of the SOPC are covered by medical insurance companies for insured patients. For this reason, nursing homes were not included in the study separately.
Hospitals’ palliative care units were not involved because their primary goal is to stabilize patients so that they can be discharged to their homes, nursing homes, or hospices. Charitable clinics do not exist in Germany, and church-run services do not provide palliative care outside of the official insurance system. In Germany, there is no official national register for inpatient hospices, outpatient hospice services, or outpatient palliative care teams. A review of existing registers of hospice associations and organizations revealed that the available data sets were consistently outdated. Therefore, it was necessary to identify the above institutions through a structured online search. This systematic online search, sorted according by German local authorities (cities, counties, etc.), identified 269 inpatient hospices, 928 outpatient hospice services and 297 SOPC teams in Germany. The search was carried out using the Google search engine (Google LLC, Mountain View). The keywords “hospice”, “hospice service”, “SOPC” and were searched for all 400 districts and independent cities. Separate searches were performed for each keyword. The initial 50 entries for each case were meticulously examined to identify institutions of interest. The use of a Microsoft Excel (Microsoft Corporation, Redmond) to systematically list the duplicates was an effective prevention method.
Three physicians or nurses working in palliative care developed the three questionnaires (hospices, hospice services and SOPC teams). They also provided care to uninsured patients independently of their palliative work. They never contacted each other and remained anonymous. The experts were personally known to the authors of the study and were invited to participate. Moderation between the three experts was handled by an independent moderation. They were instructed to ensure that the questions focused on the care of uninsured individuals, financing, and knowledge of care options for uninsured individuals in hospices, hospice services and SOPC teams. The requested data should refer to 2023. In addition, the questions were to be applicable to each of the three types of institutions. This resulted in three questionnaires, each containing 13 questions. The questionnaires went through several rounds of revisions. The questionnaires went through several rounds of revisions. The process was moderated by another independent person who volunteers to assist people without medical insurance. After each round of revision with all experts, the results were summarized and provided to the participants. The experts reviewed the questions until they were satisfied with the wording and no longer suggested any changes.
We used single-choice, multiple-choice, and free-text responses. “Unknown” was included as an answer option for some questions to avoid distorting the distribution of answers. The questionnaires were in German. The experts were responsible for ensuring that the questions were written in clear and simple language.
The development of three questionnaires was necessary because hospices, hospice services and SOPC teams have different forms of work and financing. Four independent persons tested the questionnaires. The software for data collection was SurveyMonkey. The questions were displayed in a fixed order on the same page without a time limit and could be skipped when answering. There was no final completeness check. All answers could be changed until the end of the questionnaire. Each IP (internet protocol) address could only participate once. Search engines could not index the questionnaire. The data center used was SOC-2 (System and Organization Controls 2) accredited and subject to the provisions of Regulation (EU) 2016/679. Participation in the descriptive study was entirely voluntary. The invitation link directed potential participants to a website with the participation terms and conditions. Only the heads of the contacted institutions were invited. The questionnaire did not inquire about whether the task of completing it had been assigned to subordinate employees. Clicking the Start button signified agreement to these terms. No data were collected that could be used to identify the participating institutions. No personal data were collected, indicating that no ethics vote was required in accordance with the statutes of the Ethics Committee of the Hesse Medical Association. The principles of the Declaration of Helsinki were followed.
The study ran from August 1, 2024, to October 31, 2025, and participation was possible during that time. The identified institutions received an e-mail twice at three-week intervals with a link to the online survey. Two weeks later, they received a postal invitation to participate. The questionnaire was available for three months.
The data collected was analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, USA) and BiAS Version 11.06 (epsilon-Verlag, Frankfurt am Main, Germany. A univariate descriptive analysis was used. The mean and standard deviation were specified for cardinally scaled data and the median was specified for ordinally scaled data. The response rate was estimated based on a standard sample size using a finite population correction (93% confidence level, 10% margin of error, p = 0.5). We expected a response rate of at least 20% per type of institution [34].
Ninety (33.3%) providers of inpatient hospice services, 215 (23.2%) providers of outpatient hospice services and 60 (20.2%) SOPC teams participated in the study. They came from 15 out of 16 federal states in Germany. The percentage of users who finished the survey and users who agreed to participate (completion rate) was 100%. The Valid N for all items was 1,157 for inpatient hospices, 2,795 for outpatient hospices, and 764 for SOPC teams. The missing rate for all items were 1.1% for inpatient hospices, 0% for outpatient hospices, and 2.0% for SOPC teams. Some of the participating institutions have received requests to treat uninsured patients and guests (Table 1).
Social workers made the most requests (Table 2). On average, 1.2 ± 1.1 enquiries were made per year. The running costs and financing of care varied among inpatient hospices (Table 3). Thirty (33.3%) of the 90 hospices indicated that they would not want to accept uninsured people.
Table 1Services and potential services offered by participating institutionsInpatient Hospicesn = 90Outpatient hospice servicesn = 215SOPC teamsn = 60institutions that ever received a request58 (64.4%)72 (33.5%)37 (61.7%)institutions that ever provided care41 (45.6%)63 (29.3%)29 (48.3%)institutions of those who would provide care again. Only institutions that were already providing care were asked.35 (85.3%)63 (100%)17 (58.6%)Age range of the people for whom palliative care was requested. Multiple answers possiblen = 41n = 63n = 29under 18 years-3 (2.7%)-18 to 39 years2 (2.2%)4 (3.6%)1 (3.7%)40 to 65 years37 (41.1%)39 (35.5%)20 (74.1%)over 65 years8 (8.9%)30 (27.3%)6 (22.2%)Unknown-7 (6.2%)-Age range of the people for whom palliative care was requested. Multiple answers possiblen = 41n = 63n = 29under 18 years-3 (2.7%)-18 to 39 years2 (2.2%)4 (3.6%)1 (3.7%)40 to 65 years37 (41.1%)39 (35.5%)20 (74.1%)over 65 years8 (8.9%)30 (27.3%)6 (22.2%)Unknown-7 (6.2%)-
Table 2Which groups submitted requests to participating institutions for care for an uninsured person? multiple answers possibleHospices, n = 90Outpatient hospice services, n = 215SOPC teams, n = 60Physicians31 (34.4%)16 (7.4%)11 (18.3%)Social workers48 (53.3%)32 (14.9%)19 (31.7%)Volunteers who support the person without medical insurance3 (3.3%)11 (5.1%))5 (8.3%)Family members / friends of the person without medical insurance16 (17.8%)24 (11.2%)14 (23.3%)The affected person in a palliative situation without medical insurance6 (6.7%)16 (7.4%)2 (3.3%)
Table 3Costs and financing of careinpatient hospicesn = 41outpatient hospice servicesn = 72SOPC teamsn = 29If you have already cared for one or more guests without medical insurance, how was the financing secured? Multiple answers possiblegeneral donations24 (26.6%)--donations specifically for this guest11 (12.2%)-3 (5.0%)family, friends or uninsured person2 (4.8%)-4 (13.8%)government agencies25 (27.8%)-14 (23.3%)free care (pro bono)3 (7.3%)-15 (25.0%)If you have already cared for one or more people without medical insurance, were there gaps in financing?**Yes10 (24.3%)18 (8,4%)^#^55 (60.3%)cost of care, median interquartile range€2,947€1,463n = 10--n = 0€1,612€2,350n* = 10funding gap, medianinterquartile range€2,250€425--n = 0€1,800€2,805^#^Outpatient hospice services are based on civic engagement. Medical insurance companies only finance the coordinator of the outpatient hospice service on a fixed basis if a minimum number of accompaniments are carried out per year.
On average, 1.2 ± 2.1 requests were made per year for uninsured people and 1.0 ± 2.2 requests for their relatives. As part of the civic hospice movement, outpatient hospice services were unable to provide any information on costs, as they are voluntary organizations whose members receive no payment (Table 3). Only one organization claimed to have incurred financial losses as a result of caring an uninsured patient.
A total of 212 (98.6%) providers of outpatient hospice services would provide care for an uninsured person at the end of life and their relatives. A total of 166 (77.2%) outpatient hospice care providers reported that people without medical insurance would have difficulty accessing them. The most common reasons given were lack of networks, lack of information for those affected because of reduced contact with the healthcare system, fear of costs and a high sense of shame.
On average, 1.0 ± 1.2 requests are made per year. Twenty-nine (48.3%) SOPC teams would accept an uninsured guest. However, the costs incurred can vary considerably (Table 3).
Forty-nine (54.4%) of the providers of inpatient hospice services, 133 (61.9%) of the providers of outpatient hospice services and 37 (61.7%) of the SOPC teams lacked knowledge about palliative care options for uninsured patients (Table 4).
Table 4Are you aware of any options for providing care to people without medical insurance who are in a palliative situation? multiple answers possibleInpatient Hospicesn = 90Outpatient hospice servicesn = 215SOPC teamsn = 60Yes, inpatient15 (20.0%)27 (12.6%)6 (10.2%)Yes, outpatient12 (13.3%)58 (27.0%)6 (10.2%)No12 (13.3%)14 (6.5%)10 (16.9%)Unknown49 (54.3%)133 (61.9%)37 (62.7%)
Ethical reflections were undertaken based on the collected data, drawing on the philosophical concepts of intersectionality and vulnerability. Particular attention was given to the interaction between living without medical insurance and its accompanying circumstances in palliative care settings from an intersectional perspective, as well as the resulting impact on affected individuals.
Uninsured patients represent only a small proportion of the palliative patients in the surveyed institutions. Most care requests were initiated by physicians, social workers, or volunteers, and the respondents demonstrated a high willingness to provide care for uninsured patients. Nevertheless, a gap existed between the number of care requests and the actual delivery of palliative services. Uninsured patients receiving care were consistently under 65 years of age across all three settings. Given the number of participating institutions and the range of responses, the data likely provide an approximation of the reality of life for people in need of palliative care.
The reason for the discrepancy between requests and care for uninsured patients is difficult to determine. However, it can be assumed that the unclear cost coverage is one of the causes, since, as the survey shows, there is no standardized procedure for cost coverage, and the costs have to be borne in some cases by patients or institutions. Financial constraints may further marginalize an already highly vulnerable group of patients. The data do not allow precise national estimates of total uncovered costs. While the vast majority of voluntary hospice groups would accompany uninsured patients, the commercially organized SOPC teams (795 million euros total cost in 2021 [35]) are less willing to provide care. A bias with regard to the general willingness to provide palliative care to people without medical insurance cannot be ruled out. Participants who agreed to take part in the study may have had a heightened awareness of the circumstances faced by uninsured individuals.
The uninsured patients who received palliative care were younger than 65 years old in all three areas. These data can be explained by other studies that have shown that health literacy, understood as the ability to maintain or restore one’s own state of health [36], rare among uninsured people and that therefore no or insufficient prevention can be carried out [37, 38]. People without medical insurance usually only seek medical help when they have severe symptoms and when the disease is at an advanced stage. The triggers for care seeking are very high levels of psychological distress or even an emergency situation [23]. A lack of preventive care [24], difficulty in accessing early treatment and precarious living conditions therefore have an impact on life expectancy and the early death of the uninsured [25].
While insured patients can rely on a relatively dense palliative care network [39], people without medical insurance depend on the few nonpalliative care services available in their area [10, 23]. The consequences of this inadequate or absent care in the last phase of life can be understood as a lack of pain management, poor quality of life and, moreover, a shortened lifespan with palliative illnesses [3] Taken together with existing research as cited here, these findings suggest that uninsured individuals rarely receive palliative care and that their already heightened vulnerability due to terminal illness may be further amplified by gaps in care, thereby introducing an additional dimension of vulnerability. These findings indicate that health care disparities are likely to increase in palliative stages of illness because of the coexistence of multiple aspects of vulnerability [40].
Ethical reflection based on the survey findings may be directed toward vulnerability-particularly overlapping vulnerabilities - in situations where palliative care is not adequately provided and individuals have previously lived in precarious life circumstances. In medical ethics, the convergence of multiple forms of vulnerability is increasingly being examined through the lens of intersectionality, a concept originating from feminist theory [6]. The concept highlights that different risks for vulnerability may reinforce one another.
Although uninsured patients are a heterogeneous group, they often experience poverty, social invisibility, and limited political representation, rendering them socially salient [29]. Their lack of medical insurance, despite Germany’s statutory requirement, underscores the structural marginalization and disadvantage they face [16, 17, 21]. Limited access to state healthcare structures and official registration [13, 14] reflects structural factors that can lead to exclusion and vulnerability, deeply shaping the identities of the affected individuals. Additionally serious, incurable, or life-limiting illnesses, can profoundly disrupt to a patient’s identity and psyche. The potential loss of autonomy, physical abilities, or psychological capacities as described, can create a vulnerable situation [6, 24]. Such vulnerability does not manifest equally for all patients, but the risk of vulnerability is heightened in these groups. The main advantage of an intersectional perspective on the situation of uninsured palliative patients is that it makes these compounded vulnerabilities more visible and communicable. As uninsured individuals often avoid state institutions and therefore remain largely unseen, their needs are not represented in public deliberation to the same extent as those of other groups are. This relative invisibility is further reinforced by the fact that uninsured patients frequently have few or no material resources and thus limited capacity to influence the practices and structures through which care is shaped and delivered. From a normative perspective informed by Fricker’s concept of epistemic injustice, this constitutes a systematic marginalization of their knowledge and lived experiences of the uninsured [41]. Intersectional analysis further highlights how multiple, overlapping vulnerabilities—such as socioeconomic disadvantage, health status, and migration background—interact to exacerbate these epistemic harms. Attending to these intersections not only illuminates forms of exclusion but also provides an ethical imperative to address and strengthen epistemic justice in health care.
Considering the ethical obligations of physicians, specific conflicts arise in relation to the situation of uninsured patients in Germany. The German Medical Association’s Charter for the Care of the Severely Ill and Dying in Germany calls for a dignified death with nondiscriminatory access to palliative care [42]. The Charter makes no reference to insurance status. In particular, the Charter refers to effective legal protection in the German welfare state, which does not apply to the uninsured [42]. The authors of the Charter may not have had uninsured patients in mind because, when the Charter was written, in 2010, the issue of uninsured people was much less in the public eye than it is today.
Since migration is a risk factor for a lack of insurance, the topic is of current relevance in the context of refugee situations, which makes it clear how global framework conditions and political regulations also affect medical care in Western countries. The ethical and legal requirement for uniform, highest possible level of care, as named in the Declaration of Human Rights [22], is not currently being implemented in Germany. In this way, a conflict arises between the universal human right—in this case, the right to health—and the rules of the nation state [43]. It is the task of medical ethics to uncover and identify these gaps and contradictions in the regulations and ethical demands. Guided by the codified professional ethos [44–46], physicians working in palliative care would face a conflict of values if they refused to care for terminally ill patients at the end of their lives. Moreover, as the results clearly show, regulations that provide the financial basis and means to ensure that human and material resources are available to enable this care are lacking. How these ethical and legal claims can ensure the care of this vulnerable group in everyday life remains unclear. The overlap of the risks of vulnerability among uninsured palliative patients has been hidden because uninsured patients, such as those who receive temporary care, are not accounted for in the concrete regulation. An ethical reflection grounded in the concept of intersectionality can help to reveal vulnerabilities that are often overlooked and remain invisible [47].
Strategies for addressing this issue in the future might encompass a multimodal approach to counteracting these intersectional effects, as proposed in the concept of inclusive palliative care [48]. Charitable organizations for people without medical insurance should familiarize themselves with the palliative care options available in their area before encountering their first patient in a palliative care situation. The early establishment of a network based on this concept should make it possible to find solutions that might not be identified under the acute time pressure of a patient in immediate need of care. In this way, some of the vulnerability of people who have had no prospects could be alleviated from the very first contact. Palliative care professionals could adapt the existing Charter for the Care of the Seriously Ill and Dying to raise consciousness about the previously marginalized group of uninsured people.
In addition, nationwide clearing centers could help people without medical insurance to regain coverage, preferably before need for palliative care arises. The isolated, state-funded clearing centers support their uninsured clients with a high success rate [11, 49]; these clients are not only able to obtain medical insurance through this service but also experience a certain level of empowerment. Improving the coverage of this type of service would reduce the vulnerability of this population in the future.
With regard to patients already in a palliative situation, the introduction of an emergency fund or a basic medical care system to finance palliative care comparable to the Anonymous Treatment Voucher [50] or the French Aide médicale de l’État [51]. If low-threshold, basic access to the health system could be created in this way, the course of life-shortening diseases could also be changed [52].
Hospitals were not considered in this research because their primary role in palliative care is to stabilize patients for subsequent discharge to other care facilities. Nevertheless, the hospitalization of people without medical insurance is generally a major problem in Germany [53]. This may result in bias due to unplanned hospital admissions. In addition, the extent to which physicians in private practice try to provide free care to uninsured patients at the end of their lives is unknown. The participation rate may introduce bias into the results because only the most committed institutions may provide free care. Participants who agreed to take part in the study may have had a heightened awareness of the circumstances Finally, due to the descriptive nature of the data, long-term comparisons and comparisons between regions are not possible. The characteristics of the participants and institutions were not surveyed. The legal form, sponsorship, and size of the participating institutions were not surveyed. The required anonymization resulted in the loss of geographic information. Consequently, an analysis from an economic geography perspective was not possible.
The results of this study, together with an ethical discussion grounded in the current literature, highlight a lack of adequate care for uninsured patients with palliative illnesses in Germany. This study thus confirms the findings of other studies that have shown that uninsured people have a shorter life expectancy and that health care disparities are likely to be increased by the coexistence of multiple aspects of vulnerability. The data enable an ethical debate guided by intersectionality, focusing on the convergence of vulnerabilities related to illness requiring palliative care and a lack of insurance.
Further research into the care of the uninsured at the end of life is needed, although it is important to be aware that the collection of data is difficult because of the heterogeneity of this group and their lack of access to institutions. This combination of factors carries the risk that these needs are not recorded and are pushed into invisibility. This raises the risk that the overlap between conditions requiring palliative care and a lack of insurance cover will be overlooked in ethical and political considerations. Precise legal regulations are necessary to protect the uninsured, particularly in the vulnerable phase at the end of life, as are low-threshold access to palliative care and training for medical staff.
Below is the link to the electronic supplementary material.
Supplementary Material 1