Focus originally published on the website of the Autonomy Health Ideas Laboratory (LISA), of which we are partners.
There is always a danger in bringing the subject of immigration back to the legislative profession (thirtieth bill since 1980, it seems) because that inevitably arouses bad instincts… The subject ofstate medical aid (AME) is caricatural from this point of view, an obsessive point of fixation for a certain number of parliamentarians.
They did not miss the opportunity once once more: the Senate Law Commission thus adopted an amendment to the Immigration and integration bill providing for the abolition of the AMEreplaced by a ” emergency medical aid [1]”. The senators do not even hide to sacrifice there to some kind of ritual[2].
Why bother in these conditions? Because you never know – today less than ever – what may come out of a parliamentary discussion… and of a joint committee.
The subject is however hackneyed and the solutions brought today by the senators have been regularly judged useless or harmful by quantity of expert reports.
The “advantage” of bringing such a subject back to the fore a hundred times is that there is plenty on the subject: indeed, the public authorities never fail to get away with it by commissioning new reports. So that of the finance and social affairs inspections of October 2019.
We are not naïve; neither are professionals and inspectors: there is fraud, there are channels that organize it, there are optimization practices (in relation to the rules laid down)… but the conclusion is always the same: in terms of public health (which commands not to delay pick-ups) and therefore overall efficiencythe AME device has more than collective benefits only inconveniences and, consequently, it is important not to dismantle it and not to do anything by demagoguery.
It is interesting to come back to the inspection report to put things in perspective. What were they writing?
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That we are faced with not one but two articulated systems: the common law AME and the emergency and vital care system (for which reimbursement of hospital costs is planned, which is not without raising a certain number of management problems);
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That the AME is a social assistance benefit whose eligibility conditions are precise (illegal stay, continuous residence of three months on French territory, resources below a ceiling): illegal stay as a condition of eligibility is of course something counter-intuitive and that is a lot for the sensitivity of the subject;
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That the care basket is quite comparable to that of social security, except for certain drugs and eyewear, dental care and hearing aids;
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That the system has been very regularly scrutinized and adapted but also that it is fairly well managed, given its sensitivity: the inspections did not note any excesses in expenditure over the past years.
The inspections further underlined:
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A strong geographical concentration of expenditure (Ile-de-France and Marseille) but less strong than a decade earlier;
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A high concentration also of the origin of the beneficiaries: two-thirds nationals of North African or sub-Saharan African countries;
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Typical profiles: rather young, without rights holders, mostly male;
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And stable expenditure basket over time, with an overrepresentation of hospital care (even if city care is progressing) and, in terms of drugs, antivirals, drugs related to drug addiction, anti-inflammatories and analgesics. Among the stay profiles, over-representation of childbirth, stays related to cancers, transplants and blood diseases… with a strong suspicion of migration for care with regard to these stays…
Take seriously the problems posed by migration of care
The inspections judged the reintroduction of a moderator ticket or participationwhich is precisely what the senators propose, inefficient and costly (in management), considered very complicated a restructuring of the care basket to give priority to urgent and acute care (which is what “emergency medical aid” corresponds to), which would suppose having a seriously organized course of care and rather favored regulatory devices (reinforcement of the verification of the criteria of eligibility and prevention of nomadism via reinforced authentication procedures).
The characteristics of stay and destination described above make it necessary to take seriously the problems posed by healthcare migration (in terms of bed occupancy in certain hospitals in particular). This requires in particular the identification and control of sectors and a strengthening of relations with the countries of origin, without ignoring the risks of aggravation of the situation linked to the impoverishment of hospital systems in these countries… and to the call of air created by our own difficulties in terms of the demographics of health professionals.
On this subject as on many others, we will gladly follow the editorialist of Le Monde“In short, rather than rushing France into a new incendiary and futile debate, would it not be time for politicians to get out of their ready-to-think disconnected from reality, to help the debate on immigration to go beyond French borders and to seek to implement pragmatic solutions rather What inoperative laws? To listen to researchers in the field and the population rather than instrumentalizing fears and prejudices? “.
Pragmatism and concern for public health plead for reinforced regulatory mechanisms, in conjunction with professionals, rather than for solutions already known to be ineffective.
Stéphane le Bouler, president of Lisa
Notes
[1] Amendment No. 304: http://www.senat.fr/amendements/commissions/2022-2023/304/Amdt_COM-3.html “This amendment aims to replace State medical aid (AME), accessible to foreigners in an irregular situation who have been present in the territory for more than three months and subject to means testing, by emergency medical aid (AMU) centered on the management of the most serious situations and subject to the payment of stamp duty. The Minister responsible for social action would nevertheless retain his ability to grant AMU by individual decision in order to be able to respond to exceptional situations. »
[2] “This mechanism has been adopted several times by the Senate, on the initiative of Roger Karoutchi during the examination in 2018 of the law for controlled immigration, an effective right of asylum and successful integration and more recently of Christian Klinger during the examination of the finance bill for 2023.
