What state medical aid really costs

2024-01-18 17:19:25

In December 2023, the “immigration” bill was finally adopted, excluding the section dedicated to State Medical Aid (AME). But the then Prime Minister, Élisabeth Borne, had promised, in a letter sent to the President of the Senate, to initiate a reform of the AME in the first quarter of 2024. The question is whether this commitment is still relevant. with the arrival in Matignon of a new prime minister, Gabriel Attal.

The “immigration” bill illustrates how the ideas defended by the extreme right are today finding a new audience even in the presidential majority.

A non-automatic and complex right to obtain

The AME allows undocumented immigrants to benefit from coverage of medical costs for a renewable year if they can prove their presence in France for at least 3 months and if their resources do not exceed 810 euros per month.

The AME only concerns a portion of migrants, the most precarious by their administrative status and the poorest. This is a questionable right (you have to ask for it), which is particularly complex to obtain due to the cumbersome administrative procedures for people in financial and linguistic difficulties who fear being reported to the authorities and deported.

Replace AME with emergency medical aid presented as less expensive

In the “immigration” bill which was finally adopted in December 2023, there is no longer any mention of the AME. But a reform of the AME was integrated into a previous version proposed by the Senate. It aimed to “transform” AME into emergency medical aid (AMU) to reserve it for vital care. It remains to be seen whether this system might be modified on this basis in 2024.

If the reform of the AME were to follow the recommendations of the Senate, primary care would no longer be covered by Health Insurance and one would have to wait until one is at the point of death to be able to receive treatment at the ‘hospital. The AMU already exists. It is therefore not a question of transforming the AME into an AMU but quite simply of removing the AME.

The AME is 0.5% of annual health expenditure

It is a recent parliamentary report which is at the origin of the project to replace the AME with an AMU. According to this report, the AMU would only cost 70 million euros compared to 1.1 billion euros for the common law AME from which 350,000 patients benefited in 2021.

However, the AME as such only represents a drop in the bucket in health expenditure, i.e. 0.468%. So we can wonder if it is really its cost that poses a problem, or if it is not rather the patients concerned who are targeted, that is to say undocumented immigrants.

To obtain this percentage of almost 0.5%, the expenditure of 1.1 billion euros corresponding to the AME is compared to all health expenditure which stood at 235.8 billion euros for the year 2022.

The amount of 1.1 billion is considered too high to save migrants. But for comparison, according to certain estimates, policyholders pay, for example, 3 billion euros per year in excess fees at the hospital or at the town doctor (we speak of “excess fees” when care is billed at rates that exceed those set by Health Insurance).

Furthermore, if we have to wait until patients are seriously ill to treat them, health care costs will not only be deferred, they will be increased. Patients will be treated in more critical situations which will require heavier and therefore more expensive care. The community always has an interest in treating patients early, both in the name of public health but also in the name of public finances.

The risk of worsening the overload of services dedicated to the most precarious

This is particularly the case for undocumented immigrants whose life in France is particularly difficult due to precarious income and dilapidated housing which substantially increase the probability of being ill. There is little understanding of what the community stands to gain from allowing physical and mental health problems to worsen. The health of some also depends on that of others.

Transforming AME into AMU would not eliminate the disease. It would only prohibit the coverage of health costs if the vital prognosis is not engaged. By removing the AME, we would organize the renunciation of care and we would plan for the delay in care. The risk would be to worsen the slump in the hospital, exhausted by the Covid crisis.

We would thus program an unsustainable overload of the Permanent Access to Health Care dedicated to poor people (PASS) and the Reception and Emergency Services (SAU) already saturated. This would also lead to increased mortality among migrants as shown in the Spanish case.

Undocumented immigrants with AME do not go to the doctor any more

The hospital, and in particular its emergency services, would be impacted by a removal of the AME due to the arrival of sick people in more degraded health situations. However, we must not lose sight of the fact that it is community care, sessions with the general practitioner, which are targeted by this measure.

The Institute for Research and Documentation in Health Economics IRDES compared the consumption of care in community medicine of a sample of the population beneficiary of the AME with a sample of the population covered by the complementary universal health coverage (the CMU-C, which is today called Complementary Solidarity Health, is intended for people with low incomes in a regular situation).

The comparison is carried out with the same age and gender characteristics, the same income criteria to be eligible (less than 810 euros per month) and on a basket of care with identical coverage, which excludes dental care from the study. and optics which are less well supported by the AME than by the CMU-C.

It appears that for both populations, health insurance above all allows access to general practitioners before arriving at the hospital or emergency room when things are aggravated, which is precisely what the bill wants to eliminate.

There is no additional consumption of care by undocumented immigrants. In other words, undocumented immigrants who benefit from the AME do not go to the doctor any more than people in a regular situation whose life situation is comparable. It is not the residence permit that dictates consumption but the state of health.

Nearly one in two eligible people does not have the AME

The myth of the “call for air” nevertheless dies hard. It would be to stay at the Avicenne hospital in Bobigny in Seine-Saint-Denis, or elsewhere in France, that the migrants would take to the sea on makeshift boats. They would decide to cross the Libyan desert, confront the smugglers and risk their lives to cheerfully rush to the counters of the French administration and face the administrative labyrinth increased tenfold by the deterioration of public services.

The reality is quite different. How might the AME decide on migrations when migrants do not ask for it? Even though they are falling ill on French soil? Indeed, one of the essential characteristics of the AME is that it is subject to an exceptional non-recourse rate of 49%. Even following five years or more of residence in France, 35% of people without a residence permit do not have the AME.

The myth of the “call for air” debunked by scientific studies

The thesis of medical tourism or the call for air is absurd. According to a Comede report (2019), in most cases (70% for all pathologies), migrants discover their illness following arriving in France. Nothing in scientific work corroborates the thesis of the pull of air.

No study has shown that migrants come to France for health reasons. On the contrary, health is a secondary reason. There is no medical justification to support the removal of AME. On the contrary, doctors see it as an attack on what gives pride to their profession. The debate on the AME is an example of the inability of scientists to shake up the speculations of dogmatists.

Immigrants contribute to social budgets

While there is no specificity to migrants’ health, the provision of their care is systematically raised as a distinctive political issue. All this because behind the denunciation of the AME, it is immigration which is attacked by brandishing a fantasized AME fueled by numerous misinformation listed by Médecins du monde.

Immigrants are net contributors to social budgets (they contribute more than they receive in social benefits). Active immigrants, aged 25 to 54 and representing around 50% of the immigrant population on average between 2016 and 2022, do not initially generate any costs in terms of education or social benefits upon their arrival in France.

In good health, due to the strict entry requirements of the French Office of Immigration and Integration (OFII), these foreign workers contribute and have a low impact on the expenditure of social security funds. Immigrants aged 55 and over, representing around 30% of immigrants on average between 2016 and 2022, indirectly contribute to reducing health spending in France.

AME: a problem of integration into the health system, not of immigration

The problems of the AME are not those of immigration but those of the absence of integration. The AME is an administrative system parallel to Social Security and a failure in the universalization of health protection. The entire history of Social Security has been regarding allowing all residents to benefit from the same basic coverage.

By isolating undocumented immigrants from others, it becomes easy to point the finger at them to express the resentment of a part of the population whose health costs are increasing, due to health privatization strategies.

The absence of a common regime allows people without a residence permit to be removed from society as if they were not equals or similar. On the contrary, it is the merger of the AME into the general Social Security system which will guarantee an inalienable right to health care, protecting the dignity of every human being.

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