State Medical Assistance : Inaudible expertise, inevitable politicisation

De facto > Issue 31

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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^[1] Also known under Subsi­dised Supple­men­tary Health Insu­rance Program. (Complé­men­taire Santé Soli­daire or CSS^[2] 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^[3] 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’^[4]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.

Further readings

• 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/​d​o​c​s​/​r​e​g​i​m​e​s​/​r​e​g​i​m​e​_​f​r​a​n​c​e​/​a​n​_​i​n​d​e​x.html [Accessed in July 2022].

About the author

Caro­line Izam­bert is a doctor from the EHESS. 

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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