Benefits vs. Ethics? Re-Assessing Healthcare Access for the Undocumented in France – Stéphanie Larchanché
IRIS-EHESS and Centre Françoise Minkowska, Paris
In March 2010, the French National Assembly voted to further limit healthcare access to the undocumented. Since 2001, State Medical Aid (AME) has provided undocumented immigrants living in France with free healthcare coverage. To be eligible for AME, one must provide proof of residence in France for a minimum of three months and evidence of limited monthly income (below 634 euros). Soon after this arrangement was created, however, additional restrictions were added as requirements for access to AME including presentation of a valid government-issued ID, presentation of a housing certificate – which can only be received via specific state-mandated social services – and a mandatory minimum service fee for health services. On March 2nd, 2010, following discussions on budget restrictions, center-right Assembly representative Dominique Tian proposed still more limitations on AME, including the addition of a 30 euro application fee and additional restrictions on covered healthcare services. According to Tian, «If one is willing to pay several thousands of euros to come to France, I doubt that a 30 euro application fee will prevent one from accessing care.»
Beyond the current economic strains that drive budgets cuts in various social welfare programs in France, restrictions on healthcare access for the undocumented also relate to local social constructions of illegitimacy, which portray the undocumented as less deserving of benefits than French citizens. These social constructions of illegitimacy result from intangible factors, such as long-standing racial prejudices, economic insecurities, and social fears, which together generate concrete negative consequences in daily social interactions. For example, undocumented immigrants often are accused of taking advantage of the generosity of the French healthcare system by fraudulently using their access to AME for medical interventions deemed costly and superfluous, such as assisted fertilization techniques, or for using their benefits to cover ineligible extended family members. Although the AME budget increased by 14 percent in 2009 – partly as a result of the massive rejections of asylum status applications in that year and the need to provide care to those refused asylum – the French Observatory on the Health of Foreigners (ODSE) has underlined that it still represents only 0.3 percent of the country’s total social security budget.
Beyond the obvious moral objections expressed in terms of health ethics, such restrictions also have dangerous public health consequences. Although the addition of a 30 euro application fee may have a small impact on budgets (1.25 percent of the AME budget, according to Médecins du Monde), such savings may be offset by increasing costs in emergency care. More specifically, MDM mentions first, biomedical risks such as increased infectiousness among TB infected individuals whose lack of access to healthcare could lead them to infect 10 to 20 persons each year, and second, increased viral loads among HIV patients who may no longer be able to access combination therapy.
Discourses of fear and suspicion have performative weight which, I believe, anthropologists are best suited to identify and document. Ethnography as a research method is particularly adapted to teasing out such intangible factors, especially in tracing how they become channelled into subjective feelings of «undeservingness» – either on the part of institution officials or on the part of undocumented immigrants – which in turn inform social behavior (for example, by leading institutional actors such as administrative tellers or healthcare professionals to refuse undocumented patients access to care, or by leading to delayed healthcare-seeking or avoidance of healthcare institutions altogether).
In fact, this French case echoes efforts, on a global scale, to penalize and criminalize undocumented immigrants by stereotyping them as immoral, benefit-seeking individuals, as if they were a different category of people deserving different standards of living and liable to a different set of ethical responsibility on the part of “the documented.” As politicians know well, this perspective easily captures citizens’ imaginaries (in particular with the use of statistics, for instance, involving healthcare costs), and it narrows the framing of blame by leading us to overlook the macro forces of an economic system that pressures even the most socially-oriented healthcare systems to compromise on their most basic ethical mandates.
Stéphanie Larchanché, PhD is a post-doctoral researcher at IRIS-EHESS in Paris, and she carries out applied research at a mental health care center specifically catering to immigrants and asylum seekers (Centre Françoise Minkowska, Paris). As a medical anthropologist, her research interests include immigrant health (with a particular focus on mental health and issues of “cultural competence”), health inequalities, and health policies.
Larchanché, Stéphanie 2010. Benefits vs. Ethics? Re-Assessing Healthcare Access for the Undocumented in France. AccessDenied: A Conversation on Un/authorized Im/migration and Health. Accessed (date) at https://accessdeniedblog.wordpress.com/2010/12/08/benefits-vs-ethics-re-assessing-healthcare-access-for-the-undocumented-in-france-–-stephanie-larchanche/