Alors que le “immigration” bill arrives this Monday, December 18 in the joint committee, the question arises of what fate will be reserved for State Medical Aid (AME), this health coverage from which foreigners in an irregular situation can benefit.
The AME indeed finds itself at the heart of the current legislative sequence. This right to access to care and protection of the health of people residing on French territory without a residence permit has been seriously threatened since the start of the examination of the “Bill to control immigration, improve integration”.
On November 7, the Senate voted on suppression of the AME to replace it with simple emergency medical aid, much more restrictive and conditional on the payment of an annual fixed rate fixed by decree, while the conditions of access to the AME have already been tightened in 2019.
She is then restored by the Law Committee of the National Assembly on November 29.
Will the AME be called into question by the joint committee made up of senators and deputies, knowing that the government has made a commitment to reform it on the basis in particular of report prepared by Claude Evin and Patrick Stefanini ? Note that other fundamental devices, such as the residence permit for medical reasons issued to sick foreigners requiring care, are also threatened.
A political debate that relies little on scientific knowledge and the words of specialists
The arguments in favor of access for foreigners in an irregular situation to community medicine, and not just emergency medicine, are numerous: to better guarantee the fundamental right to health for all, to avoid overcrowding emergency services, allocate resources more efficiently, or even better prevent and control communicable diseases.
And contrary to what is often advanced in the political debate, the argument says " economic " is also in favor of the AME. She does not lead to overconsumption of care and would minimize costs for the health system by avoiding late and more expensive treatment of pathologies. In other words: the cost of excluding illegal aliens from routine care would be higher than the cost of inclusion. Finally, the example of Spain is there to remind us of the dangerousness of such measures: introduced in 2012, the restriction of access to healthcare for migrants led to a increase in their mortality, with access subsequently restored in 2016.
Limited access to health coverage for precarious immigrants, despite existing systems
Although they benefit from a right to health protection, immigrants in a situation of precariousness, particularly those without a residence permit, often have no effective health coverage. Among the most common causes are legal and administrative obstacles, financial difficulties, language barriers and communication problems which hinder “navigation” in the social and health system, discrimination in access to care or the fear of being reported to authorities and potentially deported.
In France, immigrants in a legal situation (including people with refugee status and asylum seekers) are entitled to the general regime of Social Security. It is immigrants without a residence permit residing on French soil for more than three months who can benefit from theAME, this national free health coverage program established in 2000.
The AME allows you to bénéficier 100% coverage – with waiver of advance costs and within the limits of Social Security rates – for medical and dental care, medicines reimbursed by Social Security (except those “of low medical benefit” "), analysis costs, hospitalization and surgical intervention costs, certain vaccinations and certain screenings, as well as costs related to contraception, voluntary termination of pregnancy, etc. To benefit from the AME, people must provide proof of (i) identity, (ii) continuous residence in France for at least three months, and (iii) low financial resources (around €10 per year for a single person).
Investigation First steps conducted by the Institute for Research in Documentation and Health Economics (Irdes) in 2019 showed that only 51% of eligible people were actually covered by AME. This alarming observation applies more particularly to immigrants in precarious situations, like those followed in the Care and Orientation Reception Centers (CASO) of Médecins du Monde in France: in 2021, 81% of eligible people followed in CASOs had no health coverage.
The Makasi project: community-based, participatory and interventional research
Guaranteeing better access to health coverage for the most precarious immigrants, often poorly informed of their rights, therefore represents a major societal and public health challenge. There community-based, participatory research et interventional can help address this issue. We report here the results of a study on the impact of an intervention strengthening the capacity to act (women empowerment in English) in health matters on access to health coverage.
Between 2018 and 2021, we carried out the project Makasi with immigrants from sub-Saharan Africa in precarious situations residing in Île-de-France, a marginalized and vulnerable population, whose state of health deteriorates with the length of stay in France. This population also tends to be excluded from the French health system due to a lack of health coverage and limited access to care and prevention.
“Makasi” means “strong, sturdy, resistant” in Lingala, a language spoken in both Congos.
Social work and health mediation carried out routinely by Afrique Avenir and Arcat, in an approach ofmove towards ;
A intervention innovativewomen empowerment in terms of health and sexual health offered to eligible people. The Makasi intervention – based on the principles ofmotivational interview and associated with active guidance and a personalized sexual health assessment – consisted of a 30-minute interview with a mediator in one of the associations’ trucks;
Research work based on data collected by questionnaire at the time of inclusion in the study, then 3 and 6 months later as well as a qualitative component based on observations and repeated interviews with participants.
An Ile-de-France program that improved access to AME for participants
This approach allowed us to reach people in very precarious situations – often excluded from health surveys: administrative precariousness (75% did not have a residence permit), food insecurity (45% had experienced food deprivation during of the month preceding the survey) or linked to housing (69% did not have stable housing).
Our results first show that health coverage rates were very low when participants were included in the study (i.e. before the implementation of the intervention): only 57% of between them were effectively covered, echoing the low rates highlighted in particular in the survey First steps.
On the other hand, the intervention Makasi has clearly contributed to improving participants’ access to health coverage. Without detailing the methodological aspects, available elsewhere, it is important to specify here that we have given ourselves the means to measure the specific impact of the intervention, that is to say independently of other factors influencing access to health coverage, for example the duration since settling in France or mastering the French language.
Thus, the probability of having health coverage increased by 18 percentage points three months after receiving the intervention (from 57% before the intervention to 75% three months after), and by 29 percentage points six months after receiving the intervention (increasing from 57% before the intervention to 86% six months after).
Investigation First steps had identified the length of stay in France as the main determinant access to the AME: after 5 years of residence or more on French territory, 35% of people without a residence permit still did not benefit from the AME.
In this regard, our results are all the more important because they show that a significant improvement in access to health coverage can be obtained in a short time – in our case from three to six months, and independently of the number years spent in France – thanks to an intervention bywomen empowerment outside the walls.
Several factors help explain this strong impact of the intervention Makasi : the active orientation of participants towards the social and health services best able to meet their needs in terms of social protection, but also the strengthening of participants' capacity to act in matters of health, thanks in particular to a better tools in terms of knowledge of social and health resources.
Guarantee and strengthen access to health coverage for the most precarious immigrants
Health coverage is, by definition, not universal if it excludes migrants without a residence permit. Achieving universal health coverage is however one of the objectives that the European Union has set for itself in order to address global health challenges.
Proposals aimed at restricting, or even eliminating, access to health coverage for illegal aliens are not based on any scientific basis. On the contrary, scientific expertise on the issue points to the need to identify strategies to guarantee better access to health coverage and care for immigrants in Europe.
With the project Makasi, we have shown that a forward-looking community intervention to strengthen the capacity to act in health matters can largely improve health coverage among immigrants from sub-Saharan Africa in precarious situations.
Marwân-al-Qays Bousmah, Post-doctoral student in economics and public health, Ceped, Research Institute for Development (IRD); Annabel Desgrées du Loû, Research Director, Research Institute for Development (IRD) et Anne Gosselin, Researcher in health demography, National Institute for Demographic Studies (INED)
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