Caroline Izambert, historian
The State Medical Assistance, a health care system for irregular migrants, has been at the centre of public debates for over 20 years. Despite the consensus of experts and scientists on its relevance to Public Health.
Established in 1999, the State Medical Assistance (Aide Médicale d’État or AME), enables the access and the coverage of the so-called ‘city’ care, such as medical consultation with private practitioners and hospitals for irregular migrants that are able to prove three months of presence on French territory. The Health Basket is noticeably reduced in comparison to the Complementary Health Insurance Also known under Subsidised Supplementary Health Insurance Program. (Complémentaire Santé Solidaire or CSS Used to be the Universal Complementary Health Insurance Coverage (Couverture Maladie Universelle Complémentaire or CMU‑C); which consists in free of charge complementary health insurance for low income individuals.). In 2020, approximately 383 000 people have benefited from the AME and the expenses were up to 878 million, thus less than 0.5% of total health expenditures in France (results provided by DREES Directorate for Research, Studies, Assessment and Statistics). Funded by the State budget, the AME is annually discussed by the Parliament during the vote on the State Budget Act (Projet de Loi de Finance or PLF), thereby contributing to the politicisation of the debate on this service. Nevertheless, the growing body of data and research demonstrates its value for health and public finances.
A service that is scrutinised by public expertise
The AME is a particularly studied social aid service. Since its creation, it has been the subject of four reports by general inspectorates (the French Government audit, evaluation and inspection office for health, social security, social cohesion, employment and labour policies and organisations (Inspection Générale des Affaires Sociales or Igas) in 2003 ; General Inspectorate of Finance (Inspection générale des finances or IGF) and Igas in 2007, 2010 and 2019) and of an investigation by the National Assembly’s committee for the Assessment and Monitoring of Public Policies (Comité d’évaluation et de contrôle des politiques publiques), conducted by deputies Claude Goasguen and Christophe Sirugue in 2011. An analysis of the Igas public reports shows that only child welfare services have frequently been the subject of missions since 2000.
“Debates on the AME illustrate the poor interaction between expertise, scientific production and public debate on immigration-related issues.”
Caroline Izambert, historian
Despite the nuances, all of these studies conclude that abolishing the AME would not result in savings. Without any health coverage, people would present themselves at a more advanced stage of their illness in hospital emergency departments. Because the higher prevalence of certain diseases, such as HIV or tuberculosis, in immigrant populations, would represent a threat to public health. One question runs through all of this work : does the existence of State Medical Aid give rise to ‘therapeutic immigration’, sometimes even referred to by the oxymoron ‘medical tourism’? Neither the methodology nor the means of investigation make it possible to provide a conclusive answer to this question, which is at the heart of the public controversy over the AME. This leads politicians and experts to turn to social sciences and epidemiology to find answers.
The ‘therapeutic immigration’ hypothesis versus the certainty of the ‘healthy migrant effect’
While the subject has been neglected in France, the recent period has enabled us to increase our knowledge of the health status of immigrant populations. The ANRS-Parcours survey has shown that between one-third and half of the people born in sub-Saharan Africa and living with HIV become positive on French territory. This overexposure to HIV is directly linked to the precarious living conditions that immigrants are subjected to in the first few years of their arrival in France. The growing body of data shows that the health profile of immigrants in France is no different from that of immigrants in other northern countries.
Immigration is a selective phenomenon, healthy people are more likely to migrate and people generally arrive with a significantly better health status than the population of the country of origin and the host country. This is known as the healthy migrant effect. However, this condition deteriorates extensively after spending several years in the host country. Without tackling head-on the question of the existence or otherwise of medical immigration and the measurement of its extent, the scientific results demonstrate that the phenomenon has little structural value in accounting for the health of immigrants and the reasons for migration.
Misuse of scientific data
Between the widely shared conviction that the openness and ‘generosity’ of the healthcare system is a source of immigration, and the production of data highlighting other realities of the relationship between health and immigration, there is a strong incitement from public expertise to hold a biassed reading of scientific productions.
This is how, in 2019, the authors of the latest Igas report on the AME integrated the preliminary results of Premier Pas, a survey conducted by ISPED, IRDES and the University of Paris-Dauphine among 1,223 people in an irregular situation. Thinking that they had the coveted proof that the AME would provoke an ‘indraught’ (‘appel d’air’An ‘appel d’air’ translates into an ‘indraught’. It is a technical term used by firefighters, it describes an air flow that stimulates combustion. The term is used by right and far right parties to associate immigrants with flames that deprive the French of air. The metaphor has become common in public debates and it … Lire la suite), they claimed that 25.8% of people came to France for health reasons.
“Immigration is a selective phenomenon, healthy people are more likely to migrate and people generally arrive with a significantly better health status than the population of the country of origin and the host country. This is known as the healthy migrant effect.”
Caroline Izambert, historian
The use of this study’s figures, which have been extensively used in public and parliamentary debate, led the survey’s researchers to clarify the methodological framework : for AME beneficiaries alone, health was mentioned by only 9.5% of respondents, and for half of them, health reasons were associated with other reasons, mainly economic. The researchers pointed out the complexity of the migration phenomenon for which the motivations are rarely reducible to one variable. They also stress that the major result of their study has been overlooked : in the sample studied, the rate of non-use of the AME reached 49%.
Misuse of scientific results
Debates on the AME illustrate the poor interaction between expertise, scientific production and public debate on immigration-related issues. The incident mentioned above reveals the gap between the questions asked by scientists and those for which politicians and public experts require answers. It calls for the strengthening of dissemination strategies of scientific knowledge on immigration.
- Desgrées du Loû A. et al., 2015. “Sub-Saharan African Migrants Living with HIV Acquired after Migration, France, ANRS PARCOURS Study, 2012 to 2013”, Eurosurveillance, vol. 20, n° 46. DOI : 2807/1560–7917.ES.2015.20.46.30065
- Perronnin, M., Pierre, A., Rochereau, T., 2011. Complementary Health Insurance in France : Wide-Scale Diffusion but Inequalities of Access Persist.
- Cleiss., 2022. The French social security system for salaried workers. URL : https://www.cleiss.fr/docs/regimes/regime_france/an_index.html [Accessed in July 2022].
About the author
Caroline Izambert is a doctor from the EHESS.
|Also known under Subsidised Supplementary Health Insurance Program.
|Used to be the Universal Complementary Health Insurance Coverage (Couverture Maladie Universelle Complémentaire or CMU‑C); which consists in free of charge complementary health insurance for low income individuals.
|Directorate for Research, Studies, Assessment and Statistics
|An ‘appel d’air’ translates into an ‘indraught’. It is a technical term used by firefighters, it describes an air flow that stimulates combustion. The term is used by right and far right parties to associate immigrants with flames that deprive the French of air. The metaphor has become common in public debates and it stands for a ‘politically correct’ version of an invasion.
Cite this article
Caroline Izambert, “The State Medical Assistance : Inaudible expertise, inevitable politicisation”, [trad. Victoire Hernandez], in Betty Rouland (Ed.), Issue “State Medical Assistance and the making of a fake problem”, De facto [Online], 31 | February 2022, [English] published online in February 2023. URL : https://www.icmigrations.cnrs.fr/en/2022/07/26/defacto-031–03/
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