France: minimal abuse of free healthcare for undocumented migrants; reforms will undermine public health

A French government enquiry has been unable to substantiate allegations by right-wing politicians that an increase in spending on free healthcare for undocumented migrants is linked to fraud and abuse of the system. Moreover new restrictions on this support will be counter-productive. The measures will discourage individuals from accessing care at the appropriate time, with the result that medical conditions will be aggravated and infectious diseases spread.

The enquiry's findings were revealed by newspapers last week, but it appears that the government had kept the report from public view during parliamentary debate on the controversial reforms. 

There are restrictions in many countries on the provision of healthcare to foreign citizens who have overstayed their visa, entered the country illegally or have been refused political asylum (undocumented migrants). These restrictions are often motivated by fears about ‘health tourism’. Nonetheless there are often procedures and loopholes which allow doctors to provide care, especially to individuals with life-threatening conditions.

France may be unique in having a clearly codified and structured system, allowing access to healthcare to undocumented migrants (les sans-papiers in French). In this system, an individual has to demonstrate that he or she is living in France, has been in the country for at least three months and is very poor (monthly resources of less than €634). The individual (and his or her family members) has access to a wide range of healthcare for one year, after which time he or she must re-apply.

In the system, known as l’Aide Médicale d’Etat, doctors and hospitals are reimbursed by the central government, separately from other channels of healthcare spending.

The system has been under attack from right-wing parliamentarians for a number of years. They point to substantial increases both in the number of individuals covered by the system (from around 143,000 in 2004 to 192,000 in 2009) and in total spending (from €422 million in 2004 to €540 million in 2009).

They allege that this is because the system is subject to widespread abuse and is poorly controlled. They say that there are organised ‘networks’ which are defrauding the system. Specifically, they allege that people abuse the system by getting free prescriptions of buprenorphine opioid substitution therapy, which are then sold on the black market.

In November the parliament voted a number of changes to the system, including an obligatory annual payment of €30 for all applicants.

On the other hand, HIV and health non-governmental organisations say that access to healthcare is a fundamental and universal right, with the beneficiaries of l’Aide Médicale d’Etat (AME) being among the poorest and most socially excluded people in the country. They argue that restrictions to the system will undermine efforts to promote HIV testing and reduce late diagnosis, with consequences both for individuals’ health and for the public health.

Government enquiry

The government asked two official audit organisations, l’inspection générale des finances and l’inspection générale des affaires sociales to analyse the functioning of the system, including a detailed examination of two offices in the Paris region which are responsible for almost half the money spent.

Their report was delivered in November, before the last parliamentary votes on changes to the system. However the government appears to have found its findings uncomfortable and kept the report out of the public view until it was quietly released on 31 December.

The auditors found that the potential for fraud was limited, although a few cases have been identified. The auditors could not find any link between the rise in spending and an increase in fraud or abuse.

They suggest that the risk in the system is not that of abuse, but of individuals abstaining from accessing healthcare. A minority of people who are entitled are enrolled in the AME. Barriers include lack of knowledge about rights, the complexity of the administrative system and the perceived hostility of official bodies.

People generally only enrolled in the system when they were in a very poor state of health and the need was urgent. Most beneficiaries were single men; four-fifths did not exercise their right to enrol family members in the system.

The average cost of their healthcare is no higher than that of French citizens or of foreign citizens with legal residence. Whereas individuals covered by the mainstream insurance system consumed €1580 of services per year, individuals covered by AME consumed €1741. Poor people who had been unable to make insurance contributions consumed more: €2606 a year.

While almost all AME beneficiaries consulted family doctors (and incurred modest expenses there), a minority of beneficiaries were hospitalised and this generated 70% of total spending - a higher proportion than for other healthcare users.

Moreover the high spending in recent years appears to have been driven by a handful of cases of extremely ill individuals. In Paris, 173 individuals (0.3% of all beneficiaries in the city) consumed more than €100,000 of healthcare each and accounted for 18% of the city’s AME spending.

The enquiry found that treatment was medically necessary for these individuals (although there were some irregularities in the way care was provided). Some of the expensive cases involved chemotherapy, neonatal care, neurosurgery or dialysis.

In many cases, unnecessarily long and expensive hospital stays could have been avoided if convalescent care services had been available and the patient could have been discharged.

Moreover, a number of administrative changes were at the origin of the increase in the number of people treated - people who would have previously received healthcare through other channels are now passed on to the AME system.

There has been suspicion that certain types of interventions, such as transplants, are particularly subject to ‘health tourism’. However, the enquiry found that individuals who received transplants had all first applied for the AME (and hence been in the country) at least two years before the operation. Moreover the average waiting period of four years for receiving a transplant would make health tourism unlikely.

Counter-productive reform

The auditors also considered the possibility of reforms to the system, including a €30 annual contribution by beneficiaries. Advocates of this measure argue that it will both raise revenue and make beneficiaries more ‘responsible’.

The enquiry found that this measure could raise €6 million, which would have a minimal impact on the annual spending of over €500 million.

However given that most AME beneficiaries are in extreme poverty, the cost and the extra administrative procedures are likely to deter potential users and further delay their accessing healthcare. In a number of situations, a problem which could have been dealt with by a family doctor or at an out-patient clinic will subsequently aggravate, and admission to hospital will later become imperative.

The auditors make a rough estimate - if 10% of patients delay care in this way, total spending will rise by €20 million.

Moreover, there are risks for the public health. Drawing particular attention to tuberculosis and other infectious diseases which are prevalent among people entitled to AME, the report notes that if individuals avoid engaging with the healthcare system, these infections will spread.

The final report describes this reform as being financially inappropriate, administratively complex and risky for the public health. However the report was not released until the parliamentary debates were over and the measure will come into effect on 1 April.

The HIV non-governmental organisations AIDES, ARCAT, Act Up Paris, Sida Info Service and Solidarité Sida are among those condemning the "scandalous concealment" of the report and calling for the reform to be suspended.