DS0409 -

Access to benefits, care trajectories and take-up of the Aide Médicale de l'Etat (AME) program – PREMIERS-PAS

First steps

The “First Steps” project aims to investigate the issue of UIs’ health, access to insurance and to healthcare, through collaboration mixing researchers, health and social professionals, and public and associative organizations. From a scientific perspective, this research intends to investigating UI healthcare and insurance trajectories. Several French institutional reports (Legislative Reports, General Inspectorate of Finance, CNAMTS, IGAS, ARS Dauphiné)

The “First Steps” project addresses UI trajectories in terms of access to healthcare services and to health insurance in metropolitan France.

The « Premiers Pas » (First Steps) project addresses Undocumented Immigrants’ trajectories in terms of access to healthcare and to health insurance, from longitudinal and multidisciplinary perspectives. It aims at answering the following questions: <br />- To what extent do undocumented immigrants (referred to as “UI” below) actually access healthcare and health insurance in France? In particular, what factors can explain the use or non-take up of the state funded health insurance for UI (“Aide Médicale d’Etat”, or AME), access to public healthcare providers, private practices, NGO facilities, and alternative treatment? <br />- What are the dynamics of undocumented immigrants trajectories regarding AME, non-insurance, means tested public health cover (“Couverture Maladie Universelle de base: CMU” and “Couverture Maladie Universelle Complémentaire: CMUC”), standard Public Insurance schemes1, and related health care consumptions?

The project is divided into two Work Packages (WP1 and WP2), designed so as to complement each other. WP1 aims to follow immigrants’ healthcare and insurance pathways, as well as ways of self-appropriation of the AME insurance, over a one year and a half period. It will build on socio-anthropological and economic approaches, including qualitative approaches and a multimode survey. WP2 aims to assess the feasibility of a panel of individuals initially insured to AME, from administrative data, and propose first cross-sectional results. Beyond the expected academic outcomes, the project, conducted in a collaboration with Médecins du Monde (MdM), has been designed to be directly productive to policymakers and field workers in the health and social sectors, whether public or associative.
The WP1 qualitative study aims to analyze healthcare trajectories of adult AME beneficiaries. It will describe UI’s perceptions of the AME and account for UI concrete experience of healthcare use in France. It will address the representations and practices of UI, health professionals, social services workers, and stakeholders. This study includes a socio-anthropological study and a medical survey.
The quantitative study aims to construct typologies of UI’s trajectories, in terms of health status, health insurance, and healthcare consumption. These typologies will be described according to UI’s social and family situations, migratory trajectories and personal history.

The WP2 panel shall, over time, monitor a sample of AME recipients, i.e. follow the sequence of their entitlements, on the basis of their national identification number. AME insurance is granted for one year, then renewable; it can also switch to registration to basic CMU or a compulsory scheme or, simply, not be renewed if the insured have waived going through the process again, or have left the country.

Pragmatically, First Steps aims to improve access to healthcare and the rights of UI on several levels:
- Through knowledge production, the project aims to guide national, regional and local health policies tackling health inequalities and enhancing access to the French healthcare system for UI.
- By identification of predisposing factors or factors inhibiting access to effective healthcare and the development of concrete proposals, it seeks to improve the reception and support strategies of dedicated specific systems especially in the city of Bordeaux, e.g. PASS, CASO (Centre d'Accueil de Soins et d'Orientation) of MdM Bordeaux; training sessions for professionals will be implemented via MdM.
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- Through its different phases of implementation, this research will support the training of students in from General Medicine and anthropology at the University of Bordeaux, social work at IRTSA, humanitarian and solidarity action).

The issue of UI access to healthcare in France is a matter complicated by the lack of information and knowledge about the reality of the conditions of access and use of the healthcare system by the resident IU population. The primary objective of the research project is the accumulation of new knowledge to clarify the public debate and propose adjustments to the reception and orientation measures of these people in the healthcare system.
The project's strength lies in collaboration between researchers with a thorough knowledge of the healthcare system and / or immigrant populations, but whose methods and questions are different. Collaboration will forge mainly around the construction of the questionnaire and issues that concern it. The ambition to obtain relevant quantitative clarification of UI healthcare consumption made possible by the integration of knowledge produced by qualitative approaches. Symmetrical patterns that emerge from the quantitative approach will question the singularities described in field observations. The participation of a doctor who is both an actor and a researcher with the study populations is also a key
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element in the genesis of the project and its feasibility. From these points of view, the proposed project immediately meets the objectives of the “Collaborative Research Project” financing instrument.

The project includes conventional valuation and conventional dissemination:
- A scientific valuation component, through publication in refereed journals and participation in national and international conferences
- Production vulgarized through publications of IRDES and MdM
- Several final conferences in Paris and Bordeaux to a wide audience including politicians, media and actors in the field, and researchers.
- A Policymakers targeted communication strategy (especially toward parliamentary representatives)
- University and post-graduate education
- Local debates: ARS, CPAM, city of Bordeaux, associations, etc. (e.g. I participated in an ARS symposium on access to healthcare of Aquitaine residents in December).
Scientific analyses produced as part of the research will also be integrated into the teaching areas led by members of the consortium (Master 2 Pro anthropology “Health Immigrations Mediation”, university diploma “precarious health” at the University of Bordeaux, social work diploma at the IRTS Aquitaine, medical education). The post-doctoral funding request is part of the professional integration process of young doctors in the fields of applied research, applying scientific analysis to the d research, applying scientific analysis to the concrete needs in the field.

The presence of MdM and IRTSA in the consortium and the WP1study framework, similar to intervention research, promote interaction with the actors in the field, which will highlight the strengths and limitations of the current systems and contribute to the construction of new systems.. Thus, the results of research will be directly transferable to institutions and professionals in the field (conferences, biannual seminar) through the development of collaborative recommendations from exchanges and by providing tools made collaboratively (fact sheets and good practices, statistics, audiovisual and digital support).

The « Premiers Pas » (First-Steps) project addresses Undocumented Immigrants’ trajectories in terms of access to healthcare and to health insurance, from longitudinal and multidisciplinary perspectives. It aims at answering the following questions:

- To what extent do undocumented immigrants (referred to as “UI” below) actually access healthcare and health insurance in France? In particular, what factors can explain the use or non-take up of the state funded health insurance for UI (“Aide Médicale d’Etat”, or AME), access to public healthcare providers, private practices, NGO facilities, and alternative treatment?
- What are the dynamics of undocumented immigrants trajectories regarding AME, means tested public health cover (“Couverture Maladie Universelle: CMU” and “Couverture Maladie Universelle Complémentaire: CMUC”) Public Insurance, non-insurance, and related health care consumptions?

The project is divided into two Work Packages (WP1 and WP2), designed so as to complement each other. WP1 aims to follow immigrants’ healthcare and insurance pathways, as well as ways of self-appropriation of the AME insurance, over a one year and a half period. It will build on socio-anthropological and economic approaches, including qualitative approaches and a multimode survey. WP2 aims to assess the feasibility of a panel of individuals insured to AME, from administrative data, and propose first cross sectional results. Beyond the expected academic outcomes, the project, conducted in a collaboration with Médecins du Monde (MdM), has been designed to be directly productive to policymakers and field workers in the health and social sectors, whether public or associative.

The WP1 qualitative study aims to analyze healthcare trajectories of adult AME beneficiaries. It will describe UI’s perceptions of the AME and account for UI concrete experience of healthcare use in France. It will address the representations and practices of UI, health professionals, social services workers, and stakeholders. This study includes a socio-anthropological study and a medical survey.

The quantitative study aims to construct typologies of UI’s trajectories, in terms of health status, insurance, and healthcare consumption. These typologies will be described according to UI’s social and family situations and migratory trajectories and personal history. The survey will be conducted in Aquitaine and Ile de France regions. Participants will be enrolled among public health service users (PASS and CPAM especially), in Médecins du Monde healthcare facilities, medical practices, and possibly non-medical facilities. We will test and possibly implement “snowball” or “respondent driven” sampling methods to reach non-taker immigrants through other participants.

The WP2 panel shall, over time, monitor a sample of AME recipients, i.e. follow the sequence of their entitlements, on the basis of their national identification number. AME insurance is granted for one year, then renewable; it can also switch to registration to basic CMU or a compulsory scheme or, simply, not be renewed if the insured have waived going through the process again, or have left the country. We will seek to collect information on the use of health services from administrative claims. This will include ambulatory care (Source: Health insurance DCIR) and hospital care (Source: PMSI), including the use of hospital emergency departments and care provided in psychiatric facilities (Source: Rim-P).

Project coordinator

Monsieur Jérôme Wittwer (Equipe Economie et Management des Organisations de Santé (U1219 de l'Inserm/UB))

The author of this summary is the project coordinator, who is responsible for the content of this summary. The ANR declines any responsibility as for its contents.

Partner

Inserm/UB Equipe Economie et Management des Organisations de Santé (U1219 de l'Inserm/UB)
Passages UMR 5319 PASSAGES CNRS/Université de Bordeaux
GIP-IRDES GIP-Institut de recherche et documentation en économie de la santé

Help of the ANR 483,593 euros
Beginning and duration of the scientific project: September 2016 - 36 Months

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