three questions on its removal, voted on in the Senate

On Tuesday, November 7, the Senate adopted the abolition of state medical aid (AME) and transformed this public health system, intended for foreigners in an irregular situation, into emergency medical aid (AMU). The measure was not initially provided for in the government’s “immigration” bill, but the latter did not oppose the wish of the senatorial right which voted to remove the system.

However, the measure may not pass the National Assembly stage – where the bill should be examined before mid-December. Long wanted by the right and the far right, the abolition of the AME is widely criticized by health professionals, associations and left-wing elected officials.

How does AME work?

A system introduced by the left in 2000, the AME is granted to foreigners in an irregular situation present in France for at least three months and who receive less than 810 euros per month for a single person. This aid entitles you to 100% coverage of medical and hospital care within the limits of Social Security rates.

This does not mean that the system systematically covers 100% of care: the AME provides support limited to the basic Social Security rates, which is not full coverage. The insured may have out-of-pocket expenses, depending on the procedures performed.

Basic services are thus covered without advance costs, always within the limits of Social Security rates:

• medical and dental care;
• medicines reimbursed at 100%, 65% and 30%;
• the costs of analyses, hospitalization and surgical intervention;
• the main vaccines, certain screenings;
• costs related to contraception and voluntary termination of pregnancy.

Unlike other socially insured people in France, AME beneficiaries do not, however, have the right to certain benefits, such as thermal cures or medically assisted procreation.

Since January 2021, the government has restricted the support of certain non-urgent care and treatments : a period of nine months is now necessary between submitting the AME application and access to certain operations or community care. This is for example the case for cataract operations, procedures for protruding ears or knee or shoulder prostheses.

In 2022, the system had 415,000 beneficiaries for a total cost of 1.186 billion euros, according to a parliamentary information report published in May. Compared to Health Insurance expenditure that same year (247.1 billion euros), the AME represents only 0.47%.

Although the number of beneficiaries and the costs of AME have tended to increase, this proportion has remained stable over the last five years. “It can be assumed that Covid has led to a greater need for medical consultations and recourse to AME over the last two years”explained the report to Parliament on foreigners in France in 2021. The average expenditure per AME beneficiary in 2018 was 2,685 euros (at a stable level over ten years), i.e. less than a social insured person (3,087 euros in 2018).

Why does the Senate want to abolish the AME?

The abolition of the AME is a recurring demand from the right and the extreme right, who see in the system a “a migratory call of air”. Already in December 2022, Senator Christian Klinger (Les Républicains, LR) had adopted during the examination of the finance bill for 2023 a amendment aimed at replacing the AME with a “public health medical aid” focused on serious illnesses, urgent care, pregnancy and vaccination. The objective was to reduce the AME budget by 350 million euros, but the amendment was ultimately not retained in the text adopted by the National Assembly. Two similar amendments had already been adopted by the Senate in 2018 and 2019, without succeeding in passing the Assembly stage.

Taking advantage of their position of strength in the Senate, the Les Républicains group added an article to the “immigration” bill which did not appear in the initial version of the government text. This transforms the AME into emergency medical aid (AMU), with a reduced scope of action and restricted access conditions.

Beneficiaries of the AMU should pay an annual fee, the amount of which will be set by decree, in addition to meeting the current conditions of the AME. The healthcare basket would be greatly reduced.

Article 1^er Bill aims to reserve support without advance payment:

• for the treatment and prophylaxis of serious illnesses and acute pain;
• pregnancy-related care;
• regulatory vaccines;
• preventive medicine examinations.

The government, which needs the votes of the right in the National Assembly to pass its bill, issued an “opinion of wisdom” (neither favorable nor unfavorable) on this article finally adopted, Tuesday November 7, at 200 votes against 136. If several members of the government, including the Minister of Health, Aurélien Rousseau, declared their opposition to this measure, Gérald Darmanin said he “favorable” to LR’s proposal. The Minister of the Interior saw October 7 in The Parisian “a good compromise which combines firmness and humanity”.

Why is this proposal so criticized?

For several weeks, health professionals have been warning against a withdrawal of state medical aid, which would have potentially disastrous consequences from a humanitarian and health point of view.

“Challenging the AME would pose a major risk of disorganization of the health system, worsening of the working conditions of caregivers and significant additional financial costs”denounced more than 3,000 caregivers in a forum at World. “It is preferable to treat a mild illness before it turns into a serious pathology, or before it spreads,” explained the Minister for Health Professions, Agnès Firmin Le Bodo, during the examination of the text in the Senate, evoking “real risks for our healthcare system”.

In 2019, a report from the General Inspectorate of Social Affairs (IGAS) and the General Inspectorate of Finance (IGF) had already looked into the question of a possible reduction in the basket of care covered by the AME. He emphasized that the withdrawal of certain benefits “could prove problematic in terms of health and ultimately lead to postponements to hospital care, which is more expensive”.

The principle of emergency medical aid would amount to waiting for pathologies to deteriorate and only treating them when they become dangerous for the patient. With the risk of ultimately increasing the cost of care.

As for the introduction of an entry fee to the AME, the IGAS and IGF report recalled the experience of the introduction of an entry fee of 30 euros in 2011, Who “encourages great caution”. At the time, the measure led to a drop in the number of beneficiaries and a very slight drop in ordinary law AME expenditure (−2.5%) but was offset by a sharp increase (+33, 3%) of the expenditure on urgent care provided by hospitals to foreign patients in an irregular situation who cannot benefit from the AME. “Hospitals often paid the entrance fee on behalf of their patients to create rights that would allow them to bill for care”, explained the rapporteurs. The franchise was finally canceled after a year, in July 2012.

The idea that the AME would cause migration for care had, for its part, been dismantled by a survey by the Institute for Research and Documentation in Health Economics, carried out in 2019 on a sample of 1,223 foreign people in an irregular situation. This showed that only 51% of people who are eligible benefited from this assistance, suggesting that “most migrants have little knowledge of the AME and do not all have the capacity to master a complex system”. People with regular care needs, such as people with chronic illnesses, frequently appeared uncovered. The rate of non-recourse could be even higher according to Médecins du monde, which assured in a report published in October that 86.5% of patients eligible for AME received in the NGO’s centers in 2022 were not covered by the system.

A new assessment of the system is expected at the beginning of December, just before the examination of the text in the National Assembly. Entrusted to Patrick Stefanini, former director of the campaigns of Valérie Pécresse and François Fillon, and Claude Evin, former socialist minister of health, the report could shed more light on the debates and, perhaps, disperse fantasies.