Abstract
Disparities in healthcare access persist in European countries for undocumented immigrants and are influenced by political issues. In France, healthcare access for this population is divided between two programs: the State Medical Aid (SMA), which provides broad healthcare coverage, and the Urgent and Vital Care (UVC) program, which is limited to life-threatening conditions for those ineligible for SMA or other assistance. Analyzing hospital admissions and costs related to these programs can provide insights into the implications of restricted healthcare access. This retrospective cohort study used data from the French national hospitalization database between 2013 and 2021. All hospital stays involving undocumented immigrants covered under either the SMA or UVC programs were included. The primary outcome was the average cost per hospital stay for each program. Secondary outcomes included length of stay (LOS) and use of intensive care unit (ICU). Multivariable generalized linear mixed models were employed to adjust for patient and hospitalization characteristics. The study included 197 327 patients under SMA and 40 322 under UVC. Emergency department admissions accounted for 47% of SMA hospitalizations compared to 68% for UVC. The average cost per SMA stay was €3758 (95% CI, €3637–€3883), which was 13% lower than UVC stays (average absolute difference, AAD: €504). UVC patients had a 16% higher probability of ICU admission (AAD: 1.08 days in ICU) and a 19% higher total LOS compared to SMA patients. Undocumented immigrants without comprehensive healthcare coverage under SMA incur higher hospital costs, longer stays, and increased ICU admission rates than those covered by SMA.
Introduction
Health policies for immigrant populations vary across the world and are often sensitive to political issues. Although universal healthcare coverage is associated with improved access to care, disparities persist across European countries for undocumented immigrants [1, 2]. An international legal framework mandates minimum standards for healthcare access for undocumented immigrants, particularly the right to urgent and vital care [3]. The European Union also shares a common core of healthcare coverage, including urgent or essential care, care for pregnant women and children, and, in some cases, the prevention of infectious diseases. However, differences exist in the definition of beneficiaries, imposed waiting periods, restrictions on care pathways, and the scope of the minimum care basket [4–6].
In France, the general population has access to statutory health insurance. In contrast, undocumented immigrants may access State Medical Aid (SMA), which is subject to residency and income conditions (a 3-month waiting period with stable residency and income threshold) [7]. Undocumented immigrants are individuals born in a foreign country who may have had their asylum applications rejected, overstayed their visa, residence permit, or other authorized stay, or entered the country irregularly. SMA provides broad access to care, including out-patient and in-patient services, as well as primary and preventive medicine. It covers healthcare costs. SMA applications must be renewed annually, and expenditure under the SMA program reached €1 billion in 2022 (less than 0.5% of total healthcare expenditure) [8]. However, the complexity of administrative procedures affects undocumented immigrants access to SMA. It is estimated that only half of eligible undocumented immigrants benefit from this scheme [9, 10]. For those who are ineligible, do not apply, or fail to renew their coverage, no other scheme covers routine care—aside from life-threatening emergencies—meaning they must pay out of pocket. This situation is likely to result in delays in seeking usual healthcare.
In exceptional urgent situations, vital care must be delivered to any patient in need, regardless of their social protection or administrative situation. In France, the Urgent and Vital Care (UVC) program covers any essential care provided to foreign patients who are not eligible for any other form of assistance or insurance (SMA, statutory health insurance, or foreign insurance for tourists). This program covers “care whose absence would jeopardize the vital prognosis or could lead to a serious and lasting deterioration in the state of health of the person or the unborn child”—including care for pregnant women and newborns, and care aimed at preventing the spread of infectious diseases to family members or the wider community [7]. To prevent uncollected hospital bills in these situations, the UVC program allows healthcare providers to bill the Health Insurance System instead of charging the patient directly. This is an administrative program applied by healthcare professionals or facilities for specific care episodes. In 2022, UVC-related expenses amounted to 70 million euros (0.02% of total healthcare expenditure) [8].
In France, as in many other countries, social assistance programs for undocumented immigrants are frequently debated in public, media, and political arenas. The current trend is toward restricting these schemes, despite opposition from the medical community [11–13]. In 2023, the French Senate approved a proposed bill that would limit SMA to Urgent care only. However, the parliament ultimately amended the bill, postponing further debate on the SMA until the following year. Despite scientific advocacy and evidence showing the benefit of SMA in improving access to healthcare, public and political discussions continue to focus on the supposed attractiveness of the French welfare system and the costs associated with providing care to undocumented immigrants.
There are no specific data on hospital care delivered to undocumented immigrants who are not covered by SMA. The main aim of this study was to analyze hospital admissions in France for undocumented immigrants and to compare the costs and characteristics of hospital stays between those covered by SMA and those receiving care through the UVC program.
Methods
We conducted a retrospective cohort study using the French national hospitalization database (PMSI Programme de Médicalisation des Systèmes d’Information) from 1 January 2013 to 31 December 2021, including public and private non-profit hospitals. This database describes patients’ pathways during their hospital stays and is exhaustive. It contains diagnoses [coded with ICD-10 (International Statistical Classification of Diseases and Related Health Problems - 10th Revision)], medical and surgical procedures, total length of stay (LOS), and LOS in the intensive care unit (ICU), age, sex, location of hospitalization, and type of coverage. Patients are pseudonymized. At the end of the hospital stays, all different stays are grouped by an algorithm into Diagnosis Related Groups.
Inclusion criteria
We included every patient aged 18 years old or over who had at least one hospital admission during the study period. Patients’ healthcare coverage was identified: SMA, UVC, and Compulsory healthcare coverage scheme. We selected and included all stays over the study period for patients on SMA and UVC.
Endpoints
Our primary endpoint was the average cost of stay for each program. Our secondary endpoints were mean total length-of-stay (LOS), use of ICU, and LOS in ICU for each program.
Statistical analysis
Descriptive statistics were presented as means (95% confidence interval) if normally distributed and as medians [interquartile range (IQR)] when appropriate. Categorical data were presented as numbers and percentages.
We described the patients, their stays, and the associated costs for the whole cohort, as well as according to the year and the location of hospitalization (metropolitan France vs. overseas).
We performed multivariable analyses with (i) costs, (ii) LOS, (iii) LOS in ICU according to the healthcare coverage scheme as outcomes, and (iv) the use of ICU as outcome variables. To ensure the comparability of patients and reason for admission, we previously grouped each patient by sex, the first 3 ICD-10 characters, and the fact of being admitted through the emergency department (ED), and did intra-group comparisons using mixed modeling. The only groups compared were those for at least one stay for a patient under UVC. We performed a multivariable generalized linear mixed model relating the outcome variable with the type of healthcare coverage scheme. We used the gamma distribution with a log link function for costs as an outcome variable, as recommended [14]. We used a negative binomial distribution with a log link function for the total LOS and the LOS in the ICU as outcomes. For the use of ICU, we used a binomial distribution with a logit link (logistic regression). The random effect was the patient group, and the fixed effects were the type of coverage, age, transformed into a cubic spline with 4 degrees of freedom [15], and localization of hospitalization (metropolitan France or overseas).
To make the results of regression models more easily interpretable, we only presented the mean and the standard deviation of the exponentiated estimate for the SMA, which is the reference; for UVC, we calculated their marginal effects and confidence intervals to determine the difference with the reference. The full model output is available in the Supplementary Material.
We did not anticipate missing data, as the database is exhaustive. We followed the RECORD guideline to report the findings of this study.
Ethics, reglementary, and data availability statement
This study was approved by the Scientific and the Research Ethics Committee CLEA, an institutional review board, and ethics committee (CLEA-2022-241, 11 March 2022). Due to our missions, our institution (Medico-economic clinical research unit of the Assistance Publique Hôpitaux de Paris) has permanent access to the French national hospitalization database [16]. According to French law, all computer data (including databases, in particular, patient data) are protected by the National Commission on Informatics and Liberty (CNIL), France's national data protection authority. CNIL is an independent French administrative regulatory body whose mission is to ensure that data privacy law is applied to collecting, storing, and using personal data. The data analyzed for this study cannot be shared publicly and could be made available upon request to qualified researchers who have first gained legal authorization from CNIL to access the data.
All stages of the research were carried out following current guidelines and regulations.
Results
Inpatients characteristics
Between 2013 and 2021, the number of patients with at least one hospital stay benefitting from the SMA and the UVC program was 197 327 and 40 322 patients, respectively. Over the study period, patients had an average of 2.0 and 1.8 stays for SMA and UVC, respectively, accounting for 386 181 and 70 601 stays.
The mean age at inclusion was 38.0 (38.0–38.1) old (yo) for SMA and 38.2 (38.0–38.3) years old for UVC (Fig. 1). Men accounted for 32% of SMA and 46% of UVC patients.
Figure 1.
Distribution of age at inclusion among the different healthcare coverage scheme (years).
The average LOS was 6.3 (6.3–6.3) days for SMA and 8.6 (8.5–8.7) for UVC. Among all stays, 47% of SMA stays began through the ED when it concerned 68% of UVC. The proportion of stays, including at least one day in intensive care or continuous care unit, corresponded to 6.5% of SMA stays and 9.0% of UVC with a mean LOS of 7.6 ± 14.8 and 8.0 ± 13.7, respectively.
Among all stays, 36% were related to obstetrics for SMA and 31% for UVC (Fig. 2). Among obstetric stays, antepartum disorders accounted for 14% for SMA and 19% for UVC, and abortions for 2.7% and 4.1%, respectively. Diseases of the circulatory system concerned 6.3% of SMA stays and 6.6% of UVC, while infectious diseases accounted for 2.6% and 5.4% for SMA and UVC, respectively.
Figure 2.
Distribution of diagnoses among the different health programs over the study period.
Hospital costs
The unadjusted average cost per stay was €969 (€3945–€3992) for SMA and €5005 (€4940–€5071) for UVC.
Multivariable analysis
We created 3982 groups of stays for patients sharing the same clinical characteristics. When considering total LOS, LOS in ICU, and hospital costs, values for SMA stays were lower than UVC (Table 1; Supplementary Tables S1-S5). The adjusted average cost per stay was €3758 (95% CI, €3637–€3883) for SMA. The average additional cost of UVC stays compared with SMA was 13%. The probability of being transferred to ICU during their stay was 16% higher for UVC programs than for SMA programs. On average, the duration of UVC stays was 19% longer than SMA stays.
Table 1.
Hospital cost, LOS, and ICU stay probability for SMA and average absolute difference of UVC with SMA
| SMA | Urgent and Vital Care | N stays | |
|---|---|---|---|
| Total hospital cost (€) | 3758 (95% CI, 3637-3883) | +504 (95% CI, 461-548) | 438 381 |
| Total LOS (days) | 5.79 (95% CI, 5.64-5.95) | +1.08 (95% CI, 1.03-1.14) | 438 381 |
| LOS in ICU (full sample, days) | 0.136 (95% CI, 0.119-0.154) | +0.128 (95% CI, 0.100-0.155) | 438 381 |
|
5.36 (95% CI, 4.98-5.76) | +0.0404 (95% CI, -0.176 to 0.257) | 27 375 |
| Probability of ICU stay (%) | 6.76% (95% CI, 6.08-7.5) | +1.09% (95% CI, 0.899-1.28) | 438 381 |
Discussion
This study is the first to analyze hospital admissions in France for undocumented immigrants and to compare costs and characteristics between patients benefiting from SMA which provides broad access to care and UVC program focused on life-threatening emergencies. The multivariable analysis highlighted extra hospital costs, longer stays, and a higher probability of ICU stay for UVC compared to SMA. SMA and UVC patients have similar demographics and reasons for hospitalization, mostly obstetrical; traumatology and infectious diseases being more frequent for UVC patients than those benefitting from SMA. ED visits were a more frequent admission mode for UVC than for SMA patients.
Health data concerning undocumented immigrants are incomplete and difficult to collect [17, 18]. Although some studies report that, due to selection bias, undocumented immigrants reaching the wealthiest countries have a relatively good state of health on arrival, their conditions deteriorate over time [19, 20]. Their social isolation and precarious living and working conditions expose them to significant health risks specific to the most vulnerable populations (traumatology, complex perinatal conditions, and increased risk of maternal death, chronic, transmissible, and psychological diseases) [9, 17, 20–22]. Their low health literacy level, associated with their fear of being reported, leads them to delay seeking care and sometimes to turn to the EDs much later [23–26]. In France, it is estimated that half of all undocumented immigrants eligible for SMA do not ask for it during their first year. This still applies to 35% of them 5 years after arrival, including those with chronic illnesses, who should receive regular medical check-ups and appropriate treatment [9]. Thus, undocumented immigrants are similar in demographic and socio-economic situations when benefitting from SMA or UVC. However, UVC patients are further away from care than SMA patients, who have access to medical and social services.
In France, as in other European countries, social protection for undocumented immigrants has been under constant attacks from far-right politics. The abolition of SMA or other social protection programs is one of their key arguments and campaign slogans for more than 20 years. In France, in the case of SMA clearing, UVC would be the only scheme available to undocumented immigrants with medical issues. The results reported here enable us to provide possible elements for projections on what the needs of this population without access to SMA would be. They show a much higher proportion of stays initiated through the ED, longer stays, and a higher probability of being transferred to ICU. The results also report important extra costs for hospital stays for those who are not entitled to the SMA and are taken care of through the UVC program. These findings complement those of Hraiech et al., who conducted a large cohort study on critically ill patients in France. They reported longer stays in the ICU and higher hospital costs for undocumented immigrants when compared to general ICU patients [26]. The marked difference between SMA and UVC stays highlights the importance of access to the broad healthcare system, particularly primary and preventive care, in avoiding significant overuse and complex hospital admissions linked to additional costs.
SMA is designed to improve healthcare access for patients living in socially deprived conditions [7]. Use of SMA is indeed associated with an increase in the use of primary care rather than EDs, hospitals, or associations for undocumented immigrants [27, 28]. As Evin et al. report, the share of hospital expenditure for SMA spending is on the decline, having fallen from 68% in 2010 to 61% in the early 2020s [28]. The use of outpatient care has also risen steadily in line with health policy priorities [27]. Other studies show similar patterns of healthcare use between SMA beneficiaries and low-income households with similar health insurance coverage [29].
Hospital admissions occurring less frequently from an ED visit for SMA patients than for UVC, suggests an improved care orientation and planning. Access to SMA for undocumented immigrants appears to be a mechanism that increases rational use of the healthcare system for a particularly vulnerable population and its integration into the healthcare system. Indeed, undocumented immigrants not benefiting from SMA (which could have given them access to primary care and preventive medicine), may turn to the EDs as a last resort, an easily identifiable and accessible structure for usual care, or hospital admission when in serious conditions.
In the general population, a low level of social protection is associated with an increase in forgoing care, discontinuation of follow-up or treatment of chronic illnesses, medical complications, increased ED use, and, ultimately, the need for complex and more costly hospital care [17, 30–33, 7–10]. It is also associated with longer hospital stays and higher costs [34]. For undocumented immigrants, the consequences on the healthcare pathway of administrative insecurity are added to those incurred by social deprivation [35]. In Spain, the abolition of social protection for undocumented immigrants has been associated with an increase in their mortality rate, a rise in the incidence of certain infectious diseases, and greater use of EDs [36–38]. These results have led to re-establishing a social protection system for this population.
Similarly, in the United States or Europe, in the interests of collective benefit and rational use of the healthcare system, medical doctors advocate extending the scope of social protection and medical care offered to undocumented immigrants [2, 34, 39]. In France, the medical community has also strongly advocated against SMA restrictions suggested by politicians over the immigration bill since it improves their access to care and helps to maintain public health and limit over use and extra costs of already strained public hospitals [11–13]. The results presented here point in the same direction, highlighting higher costs for the entire community when undocumented immigrants face medical concerns while not benefitting from broad access to health care.
Limits
Despite the significant contributions of this study in understanding hospital use by undocumented immigrants in France, it is important to acknowledge certain key limitations that might influence the interpretation of our findings. First, the absence of specific markers of socioeconomic deprivation in our dataset limits our ability to distinguish and separate the effects of immigration status from those associated with poverty. The reported differences in hospital admissions and associated costs may not be only attributed to immigrant status but could also be heavily influenced by socioeconomic deprivation factors. This distinction underscores the need for more nuanced approaches in health policy design to address vulnerable populations’ needs.
Second, our study exclusively focuses on patients accessing inpatient care, excluding patients using exclusively outpatient care or without any healthcare use. This focus may introduce a selection bias, thus limiting the generalizability of our conclusions to all undocumented immigrants in France. Individuals not seeking hospital services may have different health profiles, care pathways, and needs than those observed in our sample. Consequently, our findings reflect a portion of the complex reality of healthcare access for undocumented immigrants.
These limitations highlight the importance of further research in this area, incorporating broader indicators of economic and social deprivation and extending the analysis to populations that do not necessarily access hospital services. Such studies would provide a complete comprehensive understanding of healthcare access dynamics for undocumented immigrants and better target interventions to improve their health and well-being.
This study analyzed and compared the characteristics and costs of hospital stays for undocumented immigrants benefitting from SMA and UVC. We report similarities between SMA and UVC patients regarding demographics and reasons for hospitalization, with obstetrical reasons at the forefront. For similar patients and reasons for hospital admission, hospital costs associated with the UVC program were higher than for stays associated with SMA. The results highlighted longer stays and a higher likelihood of ICU stay for UVC patients than those benefitting from SMA. For undocumented immigrants, the consequences on the healthcare pathway of administrative insecurity are added to those incurred by social deprivation. Undocumented immigrants not entitled to the broad health care system are associated with higher hospital costs than patients having only access to urgent care.
Supplementary Material
Acknowledgements
The authors want to thank Paul Dourgnon for his insights and comments.
Contributor Information
Kevin Zarca, DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris, Paris, France; Service de santé publique, Henri Mondor-Albert-Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France.
Zakaria Bekkar, LIEPP, Sciences Po, Paris, France.
Thomas Rapp, LIEPP, Sciences Po, Paris, France; LIRAES (URP 4470), Université Paris Cité, Paris, France.
Isabelle Durand-Zaleski, DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris, Paris, France; Service de santé publique, Henri Mondor-Albert-Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France; INSERM UMR 1153 CRESS, Paris, France; Université Paris Est Créteil, Créteil, France.
Anne-Laure Feral-Pierssens, LIEPP, Sciences Po, Paris, France; SAMU 93—SMUR—Urgences, Hôpital Avicenne, Assistance Publique Hôpitaux de Paris, Bobigny, France; LEPS (UR 3412), Université Sorbonne Paris Nord, Bobigny, France.
Supplementary data
Supplementary data are available at EURPUB online.
Conflict of interest: The authors declare no conflict of interest related to this research.
Funding
Z.B. benefited from a scholarship funded by the Laboratoire Interdisciplinaire d'Evaluation des Politiques Publiques Sciences Po Paris via Idex Université Paris Cité (ANR-18-IDEX-0001).
Key points.
Little is known about differences in hospital admission characteristics and costs between healthcare scheme and programs dedicated to undocumented immigrants in France.
The State Medical Aid (SMA) provides broad healthcare access for undocumented migrants while the Urgent and Vital Care (UVC) program is limited to vital care for those not eligible for other assistance or insurance.
Hospital stays for UVC patients are associated to higher costs, longer lengths of stay, and higher probability of ICU admission than SMA patients.
Access to comprehensive healthcare is associated with lower hospital costs and reduced need for intensive care compared to UVC. Restricting access to SMA could lead to increased healthcare costs.
References
- 1. Dourgnon P, Pourat N, Rocco L. European immigrant health policies, immigrants' health, and immigrants' access to healthcare. Health Policy 2023;127:37–43. [DOI] [PubMed] [Google Scholar]
- 2. Kumar BN, Bhopal A, Blanchet K et al. Priority setting and migration health policies for European countries. Lancet Reg Health Eur 2024;41:100804. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. UN Convention on Economic, Social and Cultural Rights, European Convention on Human Rights, European Social Charter, Charter of Fundamental Rights, 1946. Constitution. https://www.echr.coe.int/documents/d/echr/convention_eng (23 February 2025, date last accessed).
- 4. European Council. European Convention on Human Rights. 1950. https://www.echr.coe.int/fr/european-convention-on-human-rights (23 February 2025, date last accessed).
- 5. European Counsil. Revised European Social Charter. Right to Social Protection or Social Assistance. 1999. https://rm.coe.int/168007cf94 (23 February 2025, date last accessed).
- 6. Cuadra B. Right of access to health care for undocumented migrants in EU: a comparative study of national policies. Eur J Public Health 2012;22:267–71. [DOI] [PubMed] [Google Scholar]
- 7. République Française. Code de l’action sociale et des familles. Article L251 et 254-1. 2019. https://www.legifrance.gouv.fr/codes/article_lc/LEGIARTI000041474140 (23 February 2025, date last accessed).
- 8. République Française. [Projets annuels de performances–Santé]. https://www.budget.gouv.fr/documentation/documentsbudgetaires/exercice-2022/le-projet-de-loi-de-finances-et-lesdocuments-annexes-pour-2022/budget-general/sante https://www.coe.int/fr/web/european-social-charter/article-11#:∼:text=Pour%20se%20conformer%20%C3%A0%20l, n%C3%A9cessaires%20en%20cas%20d’%C3%A9pid%C3%A9mie (23 February 2025, date last accessed).
- 9. Jusot F, Dourgnon P, Wittwer J et al. [Access to state medical aid by undocumented immigrants in France: first findings of the “Premiers Pas” survey]. Question de Santé 2019;245:1–8. [Google Scholar]
- 10. Dourgnon P, Jusot F, Marsaudon A et al. Just a question of time? Explaining non-take-up of a public health insurance program designed for undocumented immigrants living in France. Health Econ Policy Law 2023;18:32–48. [DOI] [PubMed] [Google Scholar]
- 11. Cailhol J, Vignier N, Vandentorren S et al. French political bargaining over undocumented migrants' health. Lancet 2024;403:140–1. [DOI] [PubMed] [Google Scholar]
- 12. Féral Pierssens AL, Castan B, Cordel H et al. The French Medical Community united against cuts to State Medical Aid. Health Policy 2024;143:105037. [DOI] [PubMed] [Google Scholar]
- 13. Feral-Pierssens AL, Charpentier S, Dumas F et al. Il ne faut pas restreintre ni supprimer l'aide médicale d'Etat. Ann Fr Med Urg 2023;13:277–9. [Google Scholar]
- 14. Ramsey SD, Willke RJ, Glick H et al. Cost-effectiveness analysis alongside clinical trials II—an ISPOR good research practices task force report. Value in Health 2015;18:161–72. [DOI] [PubMed] [Google Scholar]
- 15. Harrell FE. Regression Modeling Strategies: With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis. New York: Springer International Publishing. 2015, 582 pp. [Google Scholar]
- 16. CNIL. [Studies Requiring Access to PMSI and/or RPU Data by Healthcare Establishments and Hospital Federations]. https://www.cnil.fr/fr/declaration/mr-005-etudes-necessitant-lacces-aux-donnees-du-pmsi-etou-des-rpu-par-les-etablissements (23 February 2025, date last accessed).
- 17. De Vito E, de Waure C, Specchia ML, Ricciardi W. Public health aspects of migrant health: a review of the evidence on health status for undocumented migrants in the European Region. World Health Organization. Regional Office for Europe. 2015. https://iris.who.int/handle/10665/326342 (23 February 2025, date last accessed). [PubMed]
- 18. Editorial. How to address migrant health inequity in Europe. Lancet Reg Health Eur 2024;41:100939. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Antecol H, Bedard K. Unhealthy assimilation: why do immigrants converge to American health status levels? Demography 2006;43:337–60. [DOI] [PubMed] [Google Scholar]
- 20. Hargreaves S, Rustage K, Nellums LB et al. Occupational health outcomes among international migrant workers: a systematic review and meta-analysis. Lancet Global Health 2019;7:e872–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Vignier N, Moussaoui S, Marsaudon A et al. Burden of infectious diseases among undocumented migrants in France: results of the premiers pas survey. Front Public Health 2022;10:934050. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Tapie de Céleyran F, Astre H, Aras N et al. Nationwide survey on the characteristics of migrants attending the health service access points in France in 2016. Bull Epidemiol Hebd 2017;19-20:396–404. [Google Scholar]
- 23. Hacker K, Anies M, Folb BL et al. Barriers to health care for undocumented immigrants: a literature review. Risk Manag Healthc Policy 2015;8:175–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Winters M, Rechel B, de Jong L et al. A systematic review on the use of healthcare services by undocumented migrants in Europe. BMC Health Serv Res 2018;18:30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Ortega A, Fang J, Perez V et al. Health care acces, use of services, and expériences among undocumented Mexicans and other Latinos. Arch Intern Med 2007;167:2354–60. [DOI] [PubMed] [Google Scholar]
- 26. Hraiech S, Pauly V, Orleans V et al. Undocumented migrants in French intensive care units in 2011-2018: retrospective nationwide study. Int Care Med 2022;48:290–9. [DOI] [PubMed] [Google Scholar]
- 27. Marsaudon A, Jusot F, Wittwer J et al. Patients like any others? Providing coverage to undocumented migrants in France: effects on access to care and usual source of care. Eur J Pub Health 2024;34:1157–62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Evin C, Stefanini P. [Report on State Medical Aid]. 2023. https://sante.gouv.fr/IMG/pdf/rapport_ame-decembre-2023.pdf (23 February 2025, date last accessed).
- 29. Petit S, Wittwer J, Dourgnon P et al. [Insured people like everyone else. An analysis of healthcare consumption by people covered by state medical aid]. Questions de Santé 2023;284:1–6. [Google Scholar]
- 30. Stringhini S, Sabia S, Shipley M et al. Association of socioeconomic position with health behaviors and mortality. JAMA 2010;303:1159–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Sánchez-Santos MT, Mesa-Frias M, Choi M et al. Area-level deprivation an d overall and cause-specific mortality: 12 years' observation on british women and systematic review of prospective studies. PLoS One. 2013;8:e72656. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Wickham S, Taylor P, Shevlin M, Bentall RP. The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust. PLoS One. 2014;9:e105140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Pujades-Rodriguez M, Timmis A, Stogiannis D et al. Socioeconomic deprivation and the incidence of 12 cardiovascular diseases in 1.9 million women and men: implications for risk prediction and prevention. PLoS One. 2014;9:e104671. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Mathy C, Bensadon M. [The impact of patients' social deprivation status on short-stay hospital admissions]. Mission PMSI. 1999. http://www.departement-information-medicale.com/wp-content/uploads/2009/05/rapport-prec_dec_1999.pdf (23 February 2025, date last accessed).
- 35. Stevenson K, Antia K, Burns R et al. Addressing migration and health inequity in Europe. Universal health coverage for undocumented migrants in the WHO European region: a long way to go. Lancet Reg Health Eur 2024;41:1000803. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Juanmarti Mestres A, López Casasnovas G, Vall Castelló J. The deadly effects of losing health insurance. Eur Econ Rev 2021;131:103608. [Google Scholar]
- 37. Prats-Uribe A, Brugueras S, Comet D et al. Evidences supporting the inclusion of immigrants in the universal healthcare coverage. Eur J Public Health 2020;30:785–7. [DOI] [PubMed] [Google Scholar]
- 38. Peralta-Gallego L, Gené-Badia J, Gallo P. Effects of undocumented immigrants exclusion from health care coverage in Spain. Health Policy 2018;122:1155–60. [DOI] [PubMed] [Google Scholar]
- 39. Santos PM, Shah K, Gany F et al. Health care reform and equity for undocumented immigrants—when crisis meets opportunity. N Engl J Med 2023;388:771–3. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.