Obtaining the AME : an obstacle course

Céline Gabarro, sociologist

Established in 2000, the State Medical Assistance seeks to guarantee undocumented migrants’ access to healthcare. Numerous members of parliament regularly accuse it of being a pull factor (‘appel d’air’^[1]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 metaphor has become common in public debates and it stands for a ‘politically correct’ version of an invasion.). However, this social benefit is in practice particularly difficult to obtain.

Frequently disputed by some parlia­ment members, in parti­cular during votes on the Amen­ding Finance Laws and by candi­dates during elec­toral campaigns, the State Medical Assis­tance (Aide Médi­cale d’État or AME) is blamed for ‘attrac­ting forei­gners’ to France (read our article on the matter). The AME is scru­ti­nised for being easily obtained and for having an exces­sive and expo­nen­tial cost. Thus, on the 6th of December 2018, Alain Joyandet, a senator affi­liated with the right liberal-conser­va­tive poli­tical party – The Repu­bli­cans (Les Répu­bli­cains or LR) claimed during a sitting : “No one can deny it, we know very well that there are many cases of abuses with this AME, besides, it is a signi­fi­cant indraught (“appel d’air”) for illegal immi­gra­tion”. Tigh­te­ning the condi­tions to obtain the AME and redu­cing the protec­tion to urgent and vital care is often raised during presi­den­tial campaigns. This is presently the case with Valérie Pécresse (LR), Marine Le Pen (far-right, Rassem­ble­ment national) and Nicolas Dupont-Aignan (far-right, Debout la France), who are sugges­ting limi­ting the AME to specific or emer­gency care. Whereas Éric Zemmour (far-right, Recon­quête) wishes to abolish it comple­tely. Never­the­less, as social science research has shown, the AME is not a system that irre­gular migrants are very fami­liar with, nor is it an inhe­rently acces­sible service. The Enquête Premiers Pas (First Step Survey) showed that only 51 % of those eligible for the AME benefit from it. This is the case even when they report suffe­ring from illnesses that require care.

Based on an ethno­gra­phic survey that I conducted for eleven months on both sides of the French public Health Insu­rance coun­ters within the frame­work of a socio­logy thesis^[2]Carried out obser­va­tions in three types of depart­ments of two local Health Insu­rance Funds (Caisse Primaire d’Assurance Maladie or CPAM): at the coun­ters, an AME appli­ca­tion proces­sing depart­ment and a regu­la­tory depart­ment (in charge of trans­po­sing national rules into local direc­tives). Addi­tio­nally, I held informal inter­views … Lire la suite, I wish to clarify these diffi­cul­ties by retra­cing one’s proce­dure for acqui­ring the AME. This paper will argue that the obstacles faced by the appli­cants are caused simul­ta­neously by a system pecu­liar to the AME (an aid service), as well as the orga­ni­sa­tion of work within the local Health Insu­rance Funds (produc­ti­vity injunc­tion) and by the harsher atti­tudes prevai­ling through the rhetoric of suspi­cion towards forei­gners in poli­tical discourses.

To situate the counter and to access it

Follo­wing the crea­tion of the French Universal Health Cove­rage (Couver­ture maladie univer­selle or CMU) and the imple­men­ta­tion of the AME in 2000^[3]The CMU/​AME law was approved on July 27, 1999 and imple­mented on January 1, 2000. The CMU was replaced by the Universal Health Protec­tion (Protec­tion Univer­selle Maladie or PUMA) as of January 1, 2016., irre­gular migrants became dependent on a sepa­rate system : social assis­tance^[4]Until 1993, employed irre­gular migrants were covered by Health Insu­rance like any other employee. Under the Pasqua law of August 24, 1993, access to Health Insu­rance was condi­tional on legal resi­dency. There­fore irre­gular migrants could only rely on a department’s medical assis­tance. This social support service was reformed in … Lire la suite. This is conse­quen­tial on two fronts. Firstly, it gene­rates diffe­ren­tial treat­ment in regards to the welco­ming of AME appli­cants. Undo­cu­mented migrants are being covered by a ‘special’ scheme, thus their proces­sing is different from those who are insured. Further­more, depen­ding on the depart­ment, AME appli­cants can be received either at the usual Health Insu­rance offices (the ones used by insured people), in a speci­fi­cally dedi­cated centre or at social secu­rity coun­ters at the hospital. There­fore, the first chal­lenge consists of knowing where one must submit their appli­ca­tion. Further­more, AME coun­ters’ addresses are not neces­sa­rily indi­cated on the internet. First and fore­most, the appli­cant must go to a Health Insu­rance counter so that they can be redi­rected to the appro­priate struc­ture. Secondly, constant changes within the AME recep­tion and the dispa­ri­ties amongst depart­ments make gathe­ring infor­ma­tion from people who have gone through the steps, diffi­cult and easily out of date.

Situa­ting the right counter does not induce its access. Coun­ters’ sche­dules can be parti­cu­larly scarce. Thereby, at the time of my research, the hospital units were often open in the morning and not neces­sa­rily every day (this varied from week to week depen­ding on the staff’s work­load). Since these times were not posted in advance, appli­cants would come every day hoping to be admitted. When the agent would arrive at his office at 9 a.m., he would distri­bute tickets to the appli­cants accor­ding to their order of arrival : a dozen if he had meetings sche­duled for the after­noon, twenty if he was avai­lable all day. The others had to come back and try their luck another day, that is if they were able to miss a day of work or if they did not have any work. Having access to a counter could take weeks. Conse­quently, after having failed for several days in a row, some appli­cants came as early as 5 a.m., or even as late as 9 p.m. the night before and slept on site to ensure being received the next day.

To understand a file’s creation

Once access to the counter has been ensured, other types of problems arise for undo­cu­mented migrants. For one to obtain the AME, they must fulfil the three follo­wing criteria : their iden­tity, a stable resi­dency in France and not excee­ding a certain income^[5]This amount is set at 9,041 euros a year per person as of 01.04.2021.. There­fore, they must provide proof of iden­tity and proof of resi­dence (incomes involve self declaration). 

None­the­less, some agents may require further docu­ments : they can ask for a proof of address or a specific resi­dency certi­fi­ca­tion such as an income tax return or rent receipts. Although the appli­cant can justify their resi­dency through other means (entry visa, elec­tri­city bill, etc). The counter staff recei­ving the appli­cants are not in charge of their inquiry report, thus they tend to request further docu­ments than neces­sary as they do not know what type of justi­fi­ca­tion is accepted by the inves­ti­ga­tion department.

“The peculiarity of this social aid service and its constant questioning are the primary impediments to which is added the complexity of the administrative and managerial system and the effects of suspicion toward foreigners.”

Céline Gabarro, sociologist

Further­more, being a social aid service, its regu­la­tion diverges from the Health Insu­rance for which agents have been trained. Hence, counter staff tend to apply to the AME Health Insurance’s regu­la­tions, such as proof of address or a marriage certi­fi­cate, constrai­ning appli­cants to come again although both docu­ments are not required for their file review. Mana­ging to be received, waiting for two months depen­ding on the exis­ting time limits… These many obstacles account for why an appli­cant might take several months to submit their application.

Managerial policy increasing the number of returned files, ergo delaying access to care

Once the appli­ca­tion has been submitted, it is the work orga­ni­sa­tion within the local social secu­rity and in parti­cular, through the produc­ti­vity injunc­tions, that complexi­fies the application’s proce­dure by promp­ting the submis­sion of addi­tional docu­ments. Health Insu­rance staff are subjected to produc­ti­vity controls that impact the way they process cases. Their promo­tions and salary increases vary by reaching specific targets. Agents are evaluated accor­ding to the number of files they process per day and their error rate. The latter is exclu­si­vely assessed on accepted AME files, conse­quently, when the instruc­ting offi­cers have some doubts about a docu­ment, they would rather send the file back to the appli­cant and ask them to provide another one, than accept it. Indeed, due to the frequent deve­lop­ment of AME’s regu­la­tions, as well as an unclear list of accep­table suppor­ting docu­ments, even the inves­ti­ga­ting offi­cers specia­lised in AME cases doubt the value of the suppor­ting documents.

Retur­ning the file, rather than refu­sing it, provides the appli­cant with an addi­tional oppor­tu­nity. However, with a three-month proces­sing time, retur­ning the file means post­po­ning access to the AME by several months. A returned file must go through the entire inves­ti­ga­tion proce­dure again, i.e. another three-month delay, without consi­de­ring the time it can take to recons­ti­tute and send the file.

Suspicion of fraud against foreigners tightening the conditions for obtaining benefits

Beyond mana­ge­rial rules, debates at the National Assembly and in poli­tical discourses weigh on obtai­ning the AME. These discourses focus on the abuse of forei­gners and their lack of legi­ti­macy in bene­fi­ting from the French social system. Health insu­rance workers are not neces­sa­rily insen­si­tive to the latter. There­fore, they can be zealous when exami­ning cases. For instance, some may ask for the original passport to check that the person has not left the country during the proce­dure or for the origi­nals of the docu­ments provided. Yet, this is not obli­ga­tory, however, it propels appli­cants to return or resubmit their application.

“Through their denunciations and the unravelling of the AME, successive governments are questioning both a social system that responds to the issue of equal access to care and a public health system that ensures better health for the whole community.”

Céline Gabarro, sociologist

The suspi­cion of fraud against forei­gners is also present in the tools used to guide the work of agents. At the counter, the ‘AME inter­view’ form allows the agent to ‘verify’ that the person is not lying about their resources^[6]Given that irre­gular migrants are not allowed to work, public sector workers may not require them to provide pay slips and shall be satis­fied with a decla­ra­tory state­ment on their resources. by asking the person verbally about his or her monthly expenses for rent, food, etc., and by compa­ring the declared amount of expenses with the number of resources.

Finally, the suspi­cion of fraud against AME appli­cants leads to a tigh­te­ning of regu­la­tions. As some members of parlia­ment perceive the AME as a system inci­ting ‘indraughts’, they decided to make it more compli­cated to obtain by revi­sing the condi­tion of resi­dence in France. Whereas appli­cants formerly had to demons­trate that they had been resident in France for more than three months, since January 2021^[7]Decree 2020–1325 of 30 October 2020 on State Medical Aid and the condi­tions for bene­fi­ting from the right to cove­rage of health costs for insured persons who cease to be legally resident in France. they need to prove that they were resi­ding ille­gally during this period of time^[8]In other words, a person arri­ving in France with a three-month resi­dence visa will have to wait six months to obtain the AME : three months in a regular situa­tion (visa) + three months in an irre­gular situa­tion (once the visa has expired).. Thus, it is no longer only the dura­tion of their resi­dence but their admi­nis­tra­tive status at that time that is inves­ti­gated. Proving irre­gu­la­rity of resi­dence is not so straight­for­ward. In addi­tion, a waiting period of 9 months from the date of obtai­ning the AME has also been intro­duced for certain non-urgent care.

Conclusion

While the AME is described by some members of parlia­ment as gene­ra­ting an ‘indraught’ due to its requi­re­ments for obtai­ning it, the appli­cants’ jour­neys, marked by multiple obstacles, depict a comple­tely different reality. The latter is further explained through the Enquête Premiers Pas assess­ment on the low rate of AME cove­rage of irre­gular migrants in France. The pecu­lia­rity of this social aid service and its constant ques­tio­ning are the primary impe­di­ments to which is added the complexity of the admi­nis­tra­tive and mana­ge­rial system and the effects of suspi­cion toward foreigners.

Through their denun­cia­tions and the unra­vel­ling of the AME, succes­sive govern­ments are ques­tio­ning both a social system that responds to the issue of equal access to care and a public health system that ensures better health for the whole commu­nity. Discourses contes­ting the legi­ti­macy of irre­gular migrants to be treated free of charge by the health system impact on how health care^[9]Bévière, B., & Duguet, A. (2011). Access to Health Care for Illegal Immi­grants : A Specific Orga­ni­sa­tion in France, Euro­pean Journal of Health Law, 18(1), 27–35. doi : https://​doi​.org/​1​0​.​1​1​6​3​/​1​5​7​1​8​0​9​1​1​X​551899 provi­ders perceive these patients, as shown by studies on the refusal of care and on discri­mi­na­tion in health care accor­ding to origin^[10]Riven­bark, J.G., Ichou, M. Discri­mi­na­tion in heal­th­care as a barrier to care : expe­riences of socially disad­van­taged popu­la­tions in France from a natio­nally repre­sen­ta­tive survey. BMC Public Health 20, 31 (2020). https://doi.org/10.1186/s12889-019‑8124‑z.