Only when there is no other option, says coordinator Carola Wlodarski, do people come to her and her team for consultation: if it hurts, bleeds or itch somewhere.

Before that, the shame of her patients was simply too great.

And the fear of being caught in the air also prevents many from going through the front door of the blue-tiled central medical center in Jena.

Follow the signs past physiotherapy, general medicine and gastroenterology.

That health microcosm that exists in one way or another in medical centers across the country.

But the patients of Wlodarski's team prefer to avoid their treatments.

In the worst case, until there is no longer any chance of recovery.

It is Thursday, 10 a.m. and the start of the consultation hours at the AKST association – the anonymous health insurance certificate in Thuringia.

Red upholstered chairs and colorful flyers in Arabic to Turkish adorn the otherwise sparse waiting room.

The association only recently moved out of the basement rooms of the eye clinic and has found a new home on the third floor of the Jena medical center.

The number of unreported cases is large

This should move the concern of the AKST more into the geographical and social center: the medical care of people without health insurance.

According to figures from the Federal Statistical Office, this affected around 61,000 people in Germany in 2019.

The number of unreported cases is large, some estimates assume 500,000 people are affected.

These are numbers that shouldn't exist in a welfare state based on the principle of solidarity and general compulsory insurance.

And yet the number of people affected is likely to have increased because of the Corona crisis.

As in an ordinary medical practice, the visit for AKST patients begins at reception.

Here coordinator Wlodarski is sitting at the desk.

Without a sterile gown, but with a bowl of cherries.

Her work is exciting, "but also very intense," says the Islamic scholar and sociologist.

Because anyone who comes here for the consultation that the association offers twice a week often has a long history of suffering behind them.

Only the later chapters deal with illness.

According to Wlodarski, the issuing of “sickness certificates” is not really the right term for the work of her association, which has existed in its current form since 2017: “Rather, it’s about advice and arranging treatments,” she says.

It doesn't matter whether people without health insurance come to the AKST with a purulent wound, depression or cancer.

According to preliminary figures, the association was the first point of contact for a total of 145 people in 2021 on their way to the health system.

Mostly in Jena.

But also in the approximately 40 decentralized issuing offices that work together with so-called medical examiners throughout Thuringia.

This nationwide approach is currently unique in Germany.

Similar projects are otherwise more likely to be found locally and in large cities such as Berlin, Hamburg or Leipzig.

Greatest common risk: poverty

But is it really that easy to fall through the cracks in Germany?

"We differentiate our patients according to their origin," says Wlodarski.

That means: German nationals, EU citizens and third-country nationals.

All three groups have their specific problems when it comes to health care.

"Nevertheless, the greatest common risk can be summarized," says the coordinator: "poverty." When this comes up against the thicket of private and statutory insurance, different tariffs and unclear official responsibilities, many people quickly feel overwhelmed.