Since the appointment of Michel Barnier’s government, State Medical Aid (AME), this health coverage from which foreigners in an irregular situation can benefit, has once again found itself at the heart of the news. Bruno Retailleau, the new Minister of the Interior, has in fact announced his desire to reform this system.
[Article issu de The Conversation, écrit par Marwân-al-Qays Bousmah, Chargé de Recherche, Ined (Institut national d’études démographiques), Annabel Desgrées du Loû, Directrice de recherche, Institut de recherche pour le développement (IRD) et Anne Gosselin, Chargée de recherche en démographie de la santé, Ined (Institut national d’études démographiques)]
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 discussions surrounding the “immigration” law.
At the time, the government of Élisabeth Borne had first considered abolishing the AME, within the framework of this law, on the basis in particular of the report established by Claude Évin and Patrick Stefanini… before backing down. Note that the conditions for access to the AME had already been tightened in 2019.
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.
A study was recently published based on the “First Steps” survey conducted in 2019 by the Institute for Research in Documentation and Health Economics (Irdes). This study shows that, compared to people eligible but not AME beneficiaries, AME beneficiaries are more likely to consult a doctor’s office or health center than in emergency or association services.
Furthermore, contrary to what is often put forward in the political debate, the so-called “economic” argument is also in favor of the AME. AME does not lead to overconsumption of care and it would minimize costs for the health system by avoiding late and more expensive treatment of pathologies.
In other words: the cost of excluding illegal foreigners 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 an increase in their mortality, access having then been restored in 2016 .
These facts, documented by scientists and widely relayed by caregivers, associations and learned societies, seem to be little taken into account in the current political debate.
Limited access to health coverage for precarious immigrants, despite existing systems
Although they benefit from a right to health protection, immigrants in precarious situations, 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 that hinder “navigation” in the social and health system, discrimination in access to care or even the fear of being reported to authorities and potentially deported.
In France, legal immigrants (including people with refugee status and asylum seekers) are entitled to the general Social Security system. It is immigrants without a residence permit who have been residing on French soil for more than three months who can benefit from the AME, this national free health coverage program set up in 2000.
The AME allows you to benefit from 100% coverage – with exemption from 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”), costs of analyses, costs of hospitalization and surgical intervention, certain vaccinations and certain screenings, as well as costs linked 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 €10,000 per year for a single person).
But in fact, the “First Steps” survey showed that only 51% of eligible people were actually covered by the 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 did not have any health coverage.
The Makasi project: community, 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. Community-based, participatory and interventional research can help address this issue. Here we report the results of a study on the impact of a capacity-building intervention (empowerment in English) in health matters on access to health coverage.
Between 2018 and 2021, we carried out the Makasi project 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 duration of their stay. 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.
The Makasi project brought together the Afrique Avenir and Arcat associations, a group of peers, as well as research teams from Ceped, LEDa-DIAL and ERES. This project had three main dimensions:
- Social work and health mediation carried out routinely by Afrique Avenir and Arcat, in a forward-looking approach;
- An innovative empowerment intervention in health and sexual health offered to eligible people. The Makasi intervention – based on the principles of motivational interviewing 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 even linked to housing (69% did not have stable housing).
Our results first show that the health coverage rates were very low when the 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 First steps survey.
On the other hand, the Makasi intervention 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 the health coverage, for example the length of time since settling in France or mastery of the French language.
Thus, the probability of benefiting from 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 (from 57% before the intervention to 86% six months after).
The “Premiers pas” survey identified the length of stay in France as the main determinant of access to the AME: after 5 years of residence or more on French territory, 35% of people without a residence permit did not benefit from still no 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 regardless of the number of years spent in France – thanks to an intervention byempowerment outside the walls.
Several factors help explain this strong impact of the Makasi intervention: 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 capacity to take action by participants in matters of health, thanks in particular to 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 residence permits. Achieving universal health coverage is however one of the objectives that the European Union has set 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 aimed at guaranteeing better access to health coverage and care for immigrants in Europe.
With the Makasi project, 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.
