Médecins du Monde : "We tell undocumented, sick people : Don’t go to the hospital."

Dr Zoubida Djelali, coordinator of Médecins du Monde’s French Mission in Paris

What is the biggest roadblock to health care, for foreigners?

The right to health is incorporated into the French constitution. But access to health care is not free. There is a problem if you don’t have money and you aren’t on social security. For AIDS as for any other health issue.

In principle, French and documented non-French both benefit from social security, or, if social security is not an option, from state-sponsored "medical aid" and personal health insurance. Together, they assure that care is fully reimbursed by the social security system. Medical aid is, basically, a substitute for health insurance (1).

So if you don’t have social security, the question is : Do you have the right to medical aid ? This is where a distinction between French and non-French - but also between foreign residents whose administrative situation is "regular" and those whose situation is "irregular" (ie, the undocumented) - is introduced.

When you are a foreign resident, you are asked about your administrative situation. That is : Do you have valid residency papers ? If you do, you have the same rights as a French person, as long as you’ve been a resident for at least three months.

Political refugees and asylum seekers who have a leave to remain in France for at least three months are automatically taken on by social security.

What are the options for someone who doesn’t have papers?

Your right to medical aid if you are undocumented depends on the length of your residency in France. If you can prove that you’ve been in France for over three years, you can, in principle, apply for and get medical aid. How do you "prove" you have been a resident ? If you have school-going children, and you can produce their school papers, that will do. As will the date of entry stamped in your passport, if you still have it. You can also ask people who know you to testify for you. But doing so may become more difficult with impending legislation which criminalizes helping the "illegals".

If you’ve been in France for less than three years, then you do not have the right to medical aid. There is one exception : in cases of emergency - which means a life-threatening emergency (2) - no hospital can refuse to admit you.

Also, somebody who develops AIDS (being HIV+ is not enough, as being HIV+ is not the same as being sick) has the right to a specific form of medical aid which includes follow-up by a social worker from the hospital. This follow-up, along with all medical prescriptions, will be paid for by the hospital (which will itself get reimbursed by social security).

Over two years after the Pasqua Laws, what has changed?

These laws paradoxically and in a very limited way "bettered" the situation for foreign, documented residents (3). Before these laws, even documented residents had to wait three years before they could ask for medical aid. Today the delay is three months. the organizations which worked on the issue of access to health care - groups like MDM, Médecins Sans Frontières, etc. - had met to discuss the situation. We agreed that there is no justification for a three-year waiting period for legal foreign residents.

Have you been able to document cases of undocumented people who went to request medical aid and were turned over to the police?

No, we haven’t been confronted with that, but we know it can happen. Unfortunately, denouncing people who are undocumented is legal... (4)

What is MDM’s position toward attempts to criminalize aid to undocumented people?

The Interior Ministry responded to a letter from MDM’s president, assuring us that they wouldn’t touch health care. To the extent that the law is vague, we can be denounced as an organization, because everyone knows that some of the people who use MDM’s services are undocumented. It is too early to know what will happen with this law.

Beyond the legal framework, what happens to people?

A sick person is unlikely to know his or her rights, and neither is the doctor. This a problem of information. Once you know your rights, you can fight to obtain them.

Everything is going to take time. Every sick person is going to lose time because the necessary administrative steps take so long. You need a certain number of documents : a passport or other proof of identity (or a photocopy, even if it is outdated), a lodging certificate (certificat d’hébergement),... Otherwise, there is no possibility of getting health care outside of emergencies.

For medical aid, you have to go to your Town Hall’s social aid bureau, to drop off your paper work. You have to do this paperwork, for nothing will happen by itself. In an emergency, where the hospital will be the one to request medical aid. But then the hospital will be the one asking for papers (5).

We tell people who come to see us what their rights are, and what they have to do to obtain them. We also tell them there is a risk of denunciation, of harassment, even deportation. We have to tell them that. But ultimately they are the ones to make the decision. In general, if they are seriously ill, they take the risk.

We ask for medical aid for French and documented foreign residents. On the other hand, we generally do not do so for people who are undocumented, even if they have been in France for more than three years. Or even if they’ve been here for over 20 years, which happens. We cannot make people take that kind of risk.

We ask people : are you willing to take this risk to get care ? And discuss it with them at length. This does nothing to stop the police from coming to pick up people as soon as they are out of the hospital.

(1) Medical aid pays for the health care of people with little or no economic resources. To get 100% coverage, an individual must also get a "personal insurance", which is the functional equivalent of social security.

(2) Yet, the latest legislation about medical aid insists that "medical aid in cases of care dispensed in a health care institution" extends to "medical prescriptions, including those prescribed in outside consultations."

(3) Specifically, article 38 of Law 93-1027 (24 August 1993) rewrote almost the whole of article 186 of the Family and social aid code. The "improvement" [sic] in the law consisted of widening the gap between "legal" and "illegal" residents, by making of the administrative "regularity" of residency a precondition for equality with French citizens in social rights.

(4) However, denunciation is clearly a violation of medical confidentiality, the right to anonymity of the patient, etc. In other words, it is a violation of the constitutional right to health. The Charter of the Hospitalized Patient clarifies these rights. In principle, this Charter is supposed to be distributed to every patient. (Charter annexed to the circulaire ministérielle 95-22, 6 May 1995).

(5) Yet, a circular from the Minister of Health clarifies that the condition of "uninterrupted residence in metropolitan France for at least three years" must be verified "without the person concerned having to justify of one of the documents required as proof of legal residency for people of foreign nationality" (Circular DAS 95-16, 8 May 1995, concerning the social rights of foreigners residing in France).