While the new French « Immigration Plan » has just been revealed on November 6th, I would like to focus on the changes made to « l’Aide médicale d’Etat » (AME). Sometimes presented as the incarnation of French laxity with regard to illegal immigration, sometimes presented as the gateway to « medical tourism », AME cover the health expenses of undocumented migrants living in France.
The myth of « medical tourism of the migrant », (phenomenon totally marginal according to Médecins du Monde), is a powerful lever of contemporary identity discourses. In reality only 3% of undocumented migrants cite health as a reason for migration and 85% of the patients supported by the association and eligible for the device are unaware of its existence. Beyond individual care, the AME is a real public health tool, one of the sentinels of the national health system that protects the entire society and contrary to the common discourse, the AME could well represent an economy on the total budget dedicated to healthcare. Let’s take a pragmatical look…
Before beginning, a statement. Thinking refugees only as useless consumers of public spending is to deny the fact that many of them work, consume, pay VAT, the first tax in France in terms of tax revenues, while burdening only little on pension benefits and paradoxically and having statistically less use of the care system. In fact, the current discourse, part of the wider rhetoric of the “criminalization of the poor”, makes the figure of the migrant responsible for its own ills but also for social ills. It stigmatizes migrants, making them guilty of their own destiny, and more largely guilty of the loss of speed of the French health system, while in the name of the budget, more than 4200 beds were closed in hospitals in 2018, and that the ambulatory medicine is more and more the standard1.
It’s about restoring dignity to the care system. Migrants do not aim to become « the new burden » of the Republic, but to integrate the country socially and economically, living like everyone else, in peace, in the same way that precarious French people do not want to live on charity and / or assistance system, as evidenced by the symbolic hashtag #pauvremaisdigne on Twitter…
So, does reducing the AME budget really represent an economy for society ? The 2019 AME budget2 amounts to 934.9 million euros, 893.4 million in conventional care, 40 million in emergency care and 1.5 million in « humanitarian » AME, while in 2019 , the budget of the Health Insurance amounts to 200 billion. AME represents 0.5% of the total healthcare budget, a budget that could be put in perspective with the tax gift (100 billion) made to companies through the Crédit d’Impôt pour la Compétitivité et l’Emploi (CICE), for example3…
Why parallelize these issues ? Why are these political choices problematic in the short, medium and long terms ? In the short term because they have a major impact on the national budgets immediately available, in the medium and long term because by decreasing the national budgets and by restricting the credits devolved to the welfare state (health, education, security, transport…), we endanger the future of our society that would need state investment in both classical sovereign areas and in new strategic areas such as innovation, for example, that can not be done without a real policy of education of the active and unemployed. Let us stop on the genesis of contemporary welfare state. Why was it created ? Was the purpose of giving life guarantees to a population of parasites, assisted, held by the hand like children? No, the purpose of the welfare state, in a post-war period (a period of reconstruction, a period of urgency to restart economies sustained by the war effort and to pacify them), was to guarantee companies a strong work force in good health. The challenge for the country was to support global economic competition and support the game of international relations and external domination, especially that of the United States, the big winners of the WW2. This tool has show its effectiveness for several decades. Today the political discourse often insists that the welfare state is expensive for society and that it is responsible for unnecessary expenses. Maybe I am wrong, but it seems to me that it is the progressive abandonment of the welfare state which generates additional expenses for the state but also for companies, in terms of sick leave and international competitiveness… It is a question of economic vision : small permanent investments, against expenses of emergencies when the situation is already no longer controlled.
By analogy, it is the opposition between two ways of thinking : the motorist who has his car repaired when it has an oil leak and the one waiting for the engine to be impacted by this recurrent lack of oil … This is exactly the same issue with the AME and health spending in general.
The question is whether we repair the leak or wait until the car is broken : daily investments or wait for new epidemics to paralyze our economic system, especially the large concentrated poles in which the spread of diseases is much faster than in rural areas.
Restricting the expenses of the AME could actually lead to an increase in emergency costs, these medical services which are becoming real » Miracles Courts », and where the tiredness of staff has become evident… caregivers invested with a public service mission, having chosen by vocation the public hospital and caring the most precarious, with all the marks of extreme poverty : tuberculosis, viral hepatitis, HIV and its opportunist diseases… An explosive cocktail that without health watch, could, coupled with the lack of vaccines in France, lead to significant epidemics among the entire French population.
Let’s take the example of tuberculosis, a disease that is common among precarious populations and highly contagious, the transmission being carried out by aerial contagion. Tuberculosis can remain in the lungs of an individual in a latent form, with no warning symptoms, until the patient, for whatever reason, is immunocompromised, and that the disease become evident in its contagious pulmonary form. Coupled with the measles immunization deficit, (measles being a disease that seriously undermines the immune system4), one would expect that the spread of tuberculosis goes beyond precarious populations to reach the more favored populations who have contracted a latent form which is only waiting for the immunodeficiency of the previously immunocompetent individuals… It is good to know and to remember that a person with tuberculosis, contaminates on average 10 to 15 people per year, according to the INSERM5 and that an effective treatment requires several months of antibiotherapy associating several drugs… The same goes for HIV patients, whose immune defenses are weakened, which could also lead to epidemics of tuberculosis within administrative holding centre, as we experienced for scabies in 2002, in Nanterre6. Places where promiscuity is extreme, where are gathered undocumented people of all origins, places where the stress is a palpable reality7, stress, which, as we know for a long time now also generates a diminution of the immunity and opens the door to pulmonary infections such as tuberculosis. Reducing the budget of the AME, in the name of budgetary policies, is the end of the prevention and early detection and care of precarious populations at high risk having run away from zones of wars, massacres, poverty and all the evils related to these situations.
Reduce the AME by half, from 12 to 6 months for asylum seekers who de facto remain in France, introduce a waiting period of three months for foreign nationals with a touristic visa, ask the beneficiary to make a physical appearance… everything contributes to reduce the number of beneficiaries. We already know through sociological studies but also through stories collected by caregivers, that refugees, developing a certain fear of being sent back to their country, often prefer to hide themselves rather than resort to the care device to which they can claim by right… This will necessarily lead to a delay in medical care, late treatments, or to a non-care situation. The worsening of pathologies could lead to epidemics and requiring in the long term a more consequent care and expenses of health. This is showed by studies realized in Sweden, Germany and Greece on the prevention and screening of arterial hypertension and pre-natal care8.
By developing such practices of inhospitality, society losing its own dignity puts itself in danger, it exposes itself to the return of evils that it had succeeded in eradicating thanks to the establishment of a strong Providence State covering the territory in its entirety. This is not worthy of France, the country that prides itself on being the home of human rights.
Instead of opposing and dividing the poor through xenophobic discourse accusing the foreigner of increasing social security spending, instead of opposing AME beneficiaries, (whose fraud is estimated at number of 54 for the year 2014 and 38 in 2018 out of a total of 311,310 beneficiaries in 2019), and beneficiaries of the « protection universelle pour la santé9 » (PUMA) and the « Complémentaire Santé Solidaire10 » (CSS) replacing the CMU-C since November 1, 2019, (5.6 million in 2019, for a total number of patients in the Health Insurance of 62 million), instead of accusing patients of overcrowding emergency services, while a new study has shown that only 6% of emergency room visits are abusive11, it would probably be appropriate to reflect on the refusal of care faced by the most precarious12, some liberals doctors judging the repayment deadlines of Health insurance too long, and above all, it would be high time to wonder about the price of drugs that growing constraints on the budget of the Health Insurance.
The role of the health system is not to reach a balance between care and support for the economic development of private actors. The aim of the health system is to ensure the fundamental right to health for all and not to put the Care after industrial remuneration and after the economic development of pharmaceutical laboratories.
It is an ethical question that is being played out in the economies targeted by the budget reforms, an ethical question that is at the heart of the deep malaise experienced and described by hospital caregivers tired of not having the possibility to achieve their mission, a mission of public service.
Caregivers that are fed up with having to carry out a work of accounting savings to the detriment of the dignity and sometimes of the own life of their patients13, and that are fed up with the « TINA discourse » which, by destroying all the forms of solidarity, jeopardises the entire healthcare system.
K.Bozorgmehr, O.Razyum : « Effect of restricting access to healthcare on health expenditures among asylum seekers and refugees : a quasi-experimental study in Germany, 1994-2013 »
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