Emmanuel Macron's campaign promise, the immigration bill, which will be examined in Parliament from December, was initially not to revisit the terms of access to healthcare for foreign people. But it was a long-standing wish of the right fringe of the hemicycle to modify this point. Republican senators therefore introduced a amendment coming to transform State Medical Aid (AME) into Emergency Medical Aid (AMU) and which has been adopted.
What is it about ? The AME is part of a system offree medical aid for the most vulnerable people which has existed since 1893 in France. For a century, foreigners residing in France could benefit from access to healthcare: if they worked, they benefited from affiliation with general health insurance; otherwise, they could benefit from this Free medical help. In 1993, the "Pasqua Law" comes to impose a condition of legality of stay to benefit from this "universal" aid. Six years later, in 1999, State Medical Aid is created, responding for the Court of Auditors to a humanitarian and health imperative:
“making France one of the only European countries to provide free minimum health coverage for foreigners in an irregular situation.”
The AME is seen as “republican” aid" at a pivotal moment when "universal" aid ceases to really be so. It aims to (re)bring the health system into line with the fundamental values of the Republic, notably inherited from the philosophy of the Enlightenment and which are found today inscribed in the French currency.
Funded by the State and renewable annually, the AME is aimed at illegal aliens able to prove their presence in France for at least three months. Minors can benefit from it upon their arrival on French territory. A resource condition is also posed: the income ceiling not to be exceeded to benefit from it is the same as that for access to complementary health insurance, or around €9 per year for a single person in 700.
The AME allows its beneficiaries to access a supported 100% of their medical and hospital care within the limits of Social Security rates. It also waives the need to advance health costs. Currently, the classic community or hospital medicine care is covered, as well as the majority of treatments, including contraceptives. However, not all health costs are covered by the AME (treatment and accommodation costs for disabled people, costs of preventive oral and dental examinations for children, daily allowances, etc. are excluded), which leads certain associations to talk about second-tier health coverage.
On the contrary, emergency medical aid, as designed by Republican senators, aims to reduce as much as possible access to care for people in an irregular situation to only:
“treatment of serious illnesses and urgent care the absence of which would be life-threatening or could lead to a serious and lasting deterioration in the state of health of the person or an unborn child”.
Savings by removing the AME?
The opposition to the AME was born at the same time as it. Since then, the question of its suppression – or at least its reform – has been a real sea serpent. It is discussed during each new law relating to immigration or the adoption of Social Security financing laws. Its conditions have notably been tightened in 2021.
Like the information report of a Republican deputy filed in 2021, pleading in particular for a refocusing of the AME on urgent care, the critics of the AME rely on an economic argument, regularly claiming an "uncontrolled increase in health spending".
However, the number of beneficiaries has been stable for several years, although we see a slight increase post-Covid – approximately 7% more beneficiaries in 2022 compared to 2020 and its cost is estimated at approximately 0,5% of health spending. Furthermore, as shown by the Court of Auditors in his aforementioned report :
"Analysis of the economic cost of AME is difficult to establish: it would be necessary to be able to measure the costs of avoiding the spread of infectious diseases as well as the cost of vital and urgent care caused by non-care early onset of patients."
Thus, nothing indicates that the transformation of the AME into an AMU would allow a reduction in costs.
A violation of a fundamental right and public health risks
As the professor of public law reminds us Christel Cournil, access to care is a fundamental right which arises from the right to health, guaranteed by the Constitution and by major post-war universalist principles (paragraph 11 of the 1946 Preamble in particular), confirmed by multiple international commitments (Universal Declaration of Human Rights, the European Social Charter, etc.). Furthermore, for the European court of human rights, States must ensure the right to life, which involves in particular the provision of care (positive obligations of Article 2).
In France, since 2003, access to urgent care only for any person has been provided for by common law. (article R.1112-13 of the Public Health Code):
"If the condition of a sick or injured person requires urgent care, the director takes all measures to ensure that this urgent care is provided. He pronounces admission, even in the absence of any civil status documents. and any information on the conditions under which the accommodation costs will be reimbursed to the establishment."
But the provision of only urgent and vital care may seem insufficient: ultimately, this risks leading to a general deterioration in the state of health of these people due to lack of preventive medecine. In a context of hospital overload, many doctors are warning of the risk that people thus deprived of preventive care will present themselves in the emergency room. with ultimately much more serious health problems.
Furthermore, it is the responsibility of the municipal police to ensure public health, which includes public health. However, with the disappearance of the AME, the diseases are likely to be transmitted much more quickly, which could lead to an epidemic that these authorities are responsible for containing.
Multiple associations warn of the risks linked to a transformation of AME into AMU. This is also the case of many doctors who called for its maintenance and to disobedience if the reform was completed. Among other institutional actors, the Defender of Rights, Claire Hédon, joins these protests. Heard by the rapporteurs of the Law Commission of the National Assembly on the bill, she warned about attacks on the rights of foreigners, particularly “in matters of access to health”.
[More than 85 readers trust The Conversation newsletters to better understand the world's major issues. Subscribe today]
Adoption of the government text against suppression of the AME?
Returning to a system contributing to full respect for the fundamental rights of foreigners, the Republicans place this abolition of the AME at the center of negotiations with the Government. This amendment is in fact now at the heart of a political strategy, despite the concrete negative repercussions that it risks generating. In exchange for the adoption of measures proposed by the Government, the Republicans have engraved in the text “a certain number of markers”, in particular “the tightening of the conditions of access to free care for sick foreigners”.
Left-wing parliamentarians seem to have an insufficient majority to reverse the senators' proposal. All eyes are now on the government which can table an amendment at any time during the legislative procedure.
Before taking a position, the government will surely wait for the conclusions of the mission on State medical aid entrusted to the former Minister of Health, Claude Evin, and Patrick Stefanini, honorary State Councilor – expected on December 2, 2023. The pre-report seems to indicate that the AME is neither too expensive nor too attractive. Conclusions corroborating those of the previous public report on the AME, released in 2019 by the General Inspectorate of School Affairs (IGAS). This demonstrated that the AME did not create any draft and that it would be risky – and ultimately costly – to reduce the healthcare basket.