In line with his television announcements, new French Interior Minister Bruno Retailleau intends to reform the Aide Médicale d’Etat (AME, or State Medical Aid). The scheme, which provides care for immigrants—including illegal ones—costs the French state more than a billion euros a year. As he is unable to count on a majority in the National Assembly to do so, he plans to use the regulatory route. That might not be enough to succeed.
State Medical Aid covers around 500,000 people every year. The estimated annual cost is €1.2 billion—a low estimate, according to Le Figaro, because a lot of expenditure that actually comes under AME is not accounted for under this heading. At the very least, an additional €500 million would have to be added to this budget, according to calculations made by an MP in charge of a parliamentary report on state aid, published in spring 2023. This would include, for example, the specific medical expenses incurred by foreigners in the Mayotte archipelago and those of immigrants placed in administrative detention centres pending deportation.
The figures in the report leave one wondering. According to the report, 80% of applications for AME are from people who have been in France for more than three years. The ‘average basket’ of healthcare costs per person is estimated at more than €2,800 per year. In twenty years, the number of AME beneficiaries has increased by 134%.
The AME was created by Lionel Jospin’s socialist government in 1999. At the time, migratory flows were nowhere near the levels we see today. Today, the financial burden represented by this aid is no longer justifiable, which explains why the AME is now singled out by the Right as a key budget item to be cut to help the state in its desperate quest to control public spending.
But for some, the AME has acquired an almost sacred status. To touch it would not only be tantamount to calling into question the mantra of ‘France, land of asylum,’ but also pose a significant health risk to the entire French population by potentially denying medical care to immigrants who may carry serious illnesses.
Unable to obtain its legislative repeal, Retailleau is exploring regulatory avenues to reduce expenditure on the AME. One possibility is to reduce the range of care covered. The problem is that the decision-making authority in this area lies not with the Ministry of the Interior, but with the Ministry of Health. However, the Health Minister is resistant to any reform of the AME. The Prime Minister therefore has to arbitrate between these conflicting priorities, even though he was in favour of abolishing the AME altogether when he was considering running for president.
Another solution could involve reintroducing the provisions aimed at regulating the AME through legislation. These provisions were originally included in the immigration law passed at the initiative of the previous minister, Gérald Darmanin, in December 2023. At the time, the Senate successfully included in the law its proposal to transform the AME into emergency medical aid (AMU), focusing on the most serious situations. However, the bulk of this was struck down by the Constitutional Council on purely formal grounds.
The upper house is already working on a new text, with common-sense corrections, to supervise and restrict the AME without symbolically abolishing it. A Senate report, for example, recommends “reserving the status of beneficiary of a person entitled to AME to minor children only,” to prevent spouses, cohabitees, or others from piggybacking on the rights of a lucky beneficiary to take advantage of undue benefits. Another common-sense approach is to combat fraud by increasing scrutiny of eligibility criteria and verifying identities rigorously.
Computerisation of the beneficiary’s card could also be very effective in preventing certain types of fraud. Similarly, the report proposes “excluding from the AME benefit people who have been expelled from the country for reasons of public order.”
Reading these recommendations, it is hard to imagine why they have not already been applied. The reform of the AME will be an excellent test for the Interior Minister and his ability to embody a change of direction on migration issues.
