Proposition 54K2890

Projet de loi modifiant les articles 2 et 9ter de la loi du 2 avril 1965 relative à la prise en charge des secours accordés par les centres publics d'aide sociale.

General information ¶

Submitted by

MR Swedish coalition

Submission date

Jan. 16, 2018

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

first aid health care health insurance

Voting ¶

Voted to adopt

CD&V Open Vld N-VA MR PP

Voted to reject

Groen Vooruit Ecolo LE PS | SP PVDA | PTB

Abstained from voting

∉ VB

Party dissidents ¶

• Olivier Maingain (MR) voted to reject.
• Isabelle Poncelet (LE) abstained from voting.

Contact form ¶

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Discussion ¶

March 15, 2018 | Plenary session (Chamber of representatives)

Full source

I would like to refer to my written report. I will then speak on behalf of my group.

I will be brief because the debate was extensive in the committee.

There was already a lot to do in the press, today again, but in it I find a slightly wrong reading of what the design exactly means. I have already said it in the committee and I would like to reiterate here clearly that neither this government nor my party is questioning the necessary care for every citizen in this country, illegal or not. This is not included in this draft either. This is not about undermining the necessary care. I say that very clearly to the doctors who apparently sometimes give a different reading in the press about this.

This draft is about a clear allocation of who is responsible and for what in the discussion around the urgent medical assistance. This means that once again it is made clear what the OCMW should do and what the doctor should do in this procedure. Furthermore, this design also provides more time for the OCMWs, upon their request, so that this can be done thoroughly.

However, it cannot be denied that here too, as with most legislation, some abuses have occurred. Therefore, it is ⁇ recommended that control is exercised here too, which in the past was not, or much less, the case. That is all that the design proposes and it is responded to very emotionally, while there are many of those controls within the healthcare sector. I do not understand why this is so sensitive.

It also seems to me unfair that doctors would feel that they should no longer provide certain concerns or that that assessment is so difficult to make. Every doctor knows very well what necessary care is and what is not. As the OCMW chairman, I myself have already seen in my OCMW applications passing by, where one was very clearly on the wrong side of that separation. We remain in favour of this draft, but ask the Cabinet to, as agreed and promised in the committee, in the preparation of the KB which will be clearly explained the concept of "urgent medical assistance" again, absolutely take the input of the medical associations. After all, they are the ones who can deepen this definition.

Mr. Speaker, the Government is represented but I regret that the Minister of Custody is not present since this is a bill.

The reform of the 1965 Act on the Accountability of Rescues by the CPAS – the so-called AMU Act – is undoubtedly a necessity. This aid is currently the subject of a very heavy procedure and constitutes, as Doctors of the World often say, a real course of trials for persons in irregular residence and who do not have direct access to care.

We could expect a lot from this bill. Unfortunately, with the exception of one or another small technical improvement, the core of the project is likely to complicate the situation of these already extremely fragile people by making access to urgent medical assistance even more difficult.

First, the text that is submitted to us is extremely lacunar, referring only to future execution orders of which we obviously did not have the slightest detail on the content. It is a lack of transparency that has, from the beginning, aroused concerns, concerns that Mr. Ducarme confirmed almost instantly.

Mr. Ducarme, this text was first and foremost an opportunity to spread you in the press to say how many abuses in the field of urgent medical assistance were. The statements made in the media in this context have thus enabled us to understand the actual scope that was intended to be given to this project. The speech that was held hit my group. Again, I would say, because it is recurring within this government to want again and again to make the foreigners and the most impoverished of our society pass as profiteers of our system.

Mr. Ducarme indeed dared to say: “Stop comfort care like aesthetic surgery or unnecessary pregnancy ultrasound for people in illegal stay.”

How did the Minister dare to make such false statements? How could he make our people believe that people who are illegally staying in our territory could receive certain care free of charge while citizens with regular residence are not entitled to it?

How dare you think that a refugee fleeing war would come to us to repair his nose or get breast implants?

To these questions, Minister Ducarme answered by leaving his hat what he called a "report": report of the CAAMI doctor-consultant. Without wanting to denigrate the work done, the author defines it himself as a "short analysis". I think this is primarily a personal consideration.

I think other scientific instances could have had a more comprehensive, more scientific view of what urgent medical care is. In its 2015 study, the KCE estimated that in 2013, 10 to 20 percent of illegal residents had applied to the AMU. The KCE also believed that there were no objective elements indicating the abuse of health services by persons in irregular residence.

The speech of Mr. Ducharme has struck us. He also struck the many field associations, which Mr. Minister did not take the time to receive and which, however, accompany daily these vulnerable people in their steps to obtain the medical assistance they need. I think, for example, of Medimmigrant, of Doctors of the World or even of CIRÉ.

The speech struck us, struck the field associations, but also struck the Order of Doctors. According to him, “the medical care provided to foreigners staying illegally in Belgium cannot be limited to immediate and urgent care of vital character, but they must include all the care necessary for a life consistent with human dignity.”

It has therefore seemed necessary, indispensable, to be able to hear their voices during our work in committee. A strong rejection by you, Mr. Minister, supported by the majority in its entirety. This is an incomprehensible attitude.

It is true that during our discussions, we felt a willingness from your part, Mr. Minister, to soften the speech a little, ⁇ pushed by a fraction of your majority who also seems to have trouble living with the position defended. You have thus stated that emergency medical assistance would not be restricted and that if the budget should continue to increase, it would increase; and that as a Democrat, it could not be otherwise. You said it.

Yet, Mr. Minister, the explanation of the reasons of your text says quite another thing. It indicates your willingness to set up a system with counseling doctors who will check if you are still in the field of urgent medical assistance. If we are there, and so, if we are not there.

You mentioned in this regard the necessary, indispensable and essential care and considered it useful to establish a "jurisprudence" in this matter, as you called it. There is therefore no doubt for our group and for the field actors that this will inevitably lead, in the long run, to a restriction on urgent medical assistance.

Do you really need to be treated if it is not necessary? In what is covered by compulsory insurance, what health care is in your eyes unnecessary, avoidable, accessory? Do you think there is a distinction, in this context, depending on whether you are a Belgian resident, a beneficiary of compulsory insurance or not, such as homeless people or foreigners without papers? Is there a gradation in the way we look at human beings and their health?

For our group, the right to health care is a fundamental right. One cannot exclude a part of the population only because of its administrative situation of residence under the penalty, as the CIRÉ said, to cause these persons, but also to the whole population, serious risks to public health.

Furthermore, you now also provide for sanctions against health care providers and CPAS who would give this aid incorrectly. Like the field actors, we fear that in the future they will become more refractory in welcoming patients without access to care.

For our group, the current problem of urgent medical assistance is the weight of the investigations, the length of the procedure as well as the difficulties that people in need encounter to access it. Successive studies conducted in this context have never said anything else. And today, you are not trying at all to resolve this. With the project you present to us today, you clearly weigh the procedures and make access to urgent medical assistance even more complex and, above all, try to restrict it at all costs. For all these reasons, we will not support your project.

I will conclude by telling you that we know that tomorrow we will have to adopt a series of execution orders. We could therefore still hope that you will consult the sector and that, finally, you will listen to all the parties concerned, especially all those and those who have tried to make their voice heard, in vain until now. But we also know what this government means by “concertation” and we know what it means in the mouth of ministers. We also have fears in this regard. In order that you do not accuse us of having the intention to make you a bad trial, I see only one possibility: come and present us your arrests after consulting!

Gandhi said, “You can judge the greatness of a nation by the way animals are treated in it.” I wish to paraphrase it by saying that the degree of civilization of a society is also measured, Mr. Minister, in the way it treats the weakest, including those without a fixed home or without papers.

Mr. Speaker, Mr. Minister, dear colleagues, in the preamble, I would like to recall my commitment and that of my group to the notion of urgent medical assistance and, in a general way, to emergency assistance.

Every person who resides temporarily or not in our territory and who is sometimes in an illegal situation has the right to have access to emergency assistance, urgent medical assistance. It is about the dignity of the person. This is our responsibility as representatives. This is a right guaranteed by our Constitution, European law and international law.

As the Minister in the Commission recalled, the number of recipients of emergency aid continues to increase from year to year given the current situation in Europe and our country in terms of migration. This shows that our country has never escaped its responsibilities and will continue to do so. However, field practice has made it possible to highlight certain technical shortcomings and problems, on the one hand, and abuse situations – although marginal – on the other.

Therefore, the proposed reform has as its sole objective to sustain the system of urgent medical assistance in the primary interest of the beneficiaries themselves and to make it more efficient for stakeholders such as CPAS and practitioners.

First, the bill aims to define in a more comprehensive and precise manner not only the role of each stakeholder (CPAS, Auxiliary Fund, care providers, State), but also the scope of the aid.

Secondly, on the basis of an analysis conducted in 2016 by the doctor-consultant of the Caisse auxiliaire, it appears that 6% of cases that could be the subject of an analysis can be considered as abuse.

This is little, but it is enough to be able to reallocate these abused means to other people who feel the imperative and vital need for them. That is why the government intends to strengthen the control capacity of the auxiliary fund, a perfectly competent body, instead of this role that was assigned to the CPAS. This means that the missions of the Auxiliary Caisse are expanded and strengthened, that the function of physician-advisor within the Auxiliary Caisse is created, that measures are taken in case of administrative failure or undue amounts paid, without forgetting that the analysis of the files – this is fundamental – will continue to be done case by case.

Third, this text responds to the criticisms raised by field stakeholders in terms of administrative complexity. Thus, the rule of territorial jurisdiction is extended, as well as the extension of 45 to 60 days of the period preceding the decision of the CPAS. It was appropriate to address these gaps denounced by the sector, which was widely consulted. This text has been the subject of consultations with stakeholders, it is the result of a reform desired by the field actors. It was approved last summer, without being the subject of any criticism, while today, given the context, some have found it good to make an amalgamation of everything and scare the population.

This text aims to strengthen and improve urgent medical care, not to make it more restrictive. In his spirit of effective openness, the Minister, responding to the Health Commission, undertook to consult with the official field actors as part of the drafting of the royal decrees, adopted which will allow to define the procedure of control. We congratulate him and thank him. He committed himself to this publicly, as requested by the Commission. In this context, our group will support this project.

Mr. Minister, dear colleagues, the present bill is primarily a framework that will be clarified and supplemented by KB. The bill clearly contains noble objectives that we can support: administrative simplification, improved control and the prevention of abuse. No one can be against it. Or is it? Despite these noble objectives, this bill has caused concern, both among doctors and among civil society organisations dedicated to people without papers. The open letter published today in the newspapers is proof of this.

We at CD&V have also tried to convey and express these concerns during the first and second reading of the draft in the committee. You understand those concerns. We then called for a broad discussion, with participation. The colleagues referred to it. We think you can take away so much worry. I therefore ask you here once again to reiterate your clear commitment, Mr. Minister, to engage in a very broad consultation in the preparation of the KBs that will implement this bill, in which you will work together with the stakeholders who will develop the KBs. I see you cuddling.

Mr. Minister, the draft law clearly shows that you are more competent for the OCMWs than for public health and the doctors. For the OCMWs, there are several good elements in the bill. Their role is also clear. It is positive that the investigation period for OCMWs is extended from 45 to 60 days and that one OCMW remains competent. You will also provide for a clear role definition and the possibility to impose a sanction on the OCMWs if they conduct their investigations negligently. These are good elements that shone out in clarity.

It is especially among doctors and civil society organizations that mist has been sprayed. There are several concerns there, but I think it is possible and remains to remove those concerns through the various KBs you will be working out. You also brought this reassuring message to the committee.

First, it is about the legal uncertainty that prevails today among healthcare providers following the draft law. There is great concern among doctors and civil society about the introduction of that financial sanction and non-payment to doctors when they have provided non-urgent medical care. It should not be intended that a financial risk is borne by healthcare providers and this on the cap of people without papers. These people are vulnerable and find it difficult to access medical care. We must not punish them twice. I fully share the concerns of doctors in this regard. They should be able to engage in taking care of people who are sick and not with a financial penalty that potentially hangs above their heads. The KB must provide a solution to this, Mr. Minister. You have committed to this.

Second, the KB should also provide clarity on the definition of "urgent medical care". The investigation underlying this bill found 11 out of 200 cases of abuse. Abuse of urgent medical care is not permissible. Personally, I am also not in favour of allowing circumcision or determining gender through an ultrasound. The control doctor examined whether the assistance was urgent, but the 1996 KB states that urgent medical assistance covers all medical, preventive and curative care. Therefore, it is not just about the most urgent care. If doctors may be financially sanctioned afterwards, can we please ensure that there is a correct definition? I urge you to make this clear to the Hulpkas, the doctors and the midfield. For us, it is about necessary, curative and preventive care. Take, for example, a blood collection. This is not always urgent, but often necessary to detect certain diseases.

Third, there is concern about communication through your cabinet. Particularly in the Dutch-speaking press, your cabinet has made clear that this measure must deliberately have a deterrent effect on healthcare providers. This can absolutely not be for us. I realized that this is not possible for you either. People without papers are already having enough difficulties accessing medical care. To discourage or discourage the attending physician to provide these people with the necessary care, can and should not. In particular, we also pay tribute to the numerous doctors who voluntarily and uninterestingly work out day by day for vulnerable people, as this aspect has been insufficiently highlighted in the present bill.

Fourth, one concern that also prevails, and which we must remove with the royal decision, is the lack of support from the doctors. You have consulted organizations in the sector. You have also heard of the Order of Doctors. He stated that they supported the bill. However, in its press release and its concerns on its website, it explicitly requests that a prior check and no subsequent check by the Helpkas be enabled. Other medical organizations have also jumped into the breakout, such as Domus Medica, the BVAS and the Cartel. They are all very concerned. Therefore, it would be good that you invite them to your cabinet to discuss with them how the royal decree will be fulfilled.

I am confident that you will do so and will take that advice to heart.

Therefore, we approve the bill, though with a recommendation and a condition.

Our recommendation is that you take the Order’s request to heart and develop a pre-check in which the healthcare providers can contact the Helpkas’s control doctor in advance to be sure that the concerns they want to address are urgent medical care. During the first reading, you indicated that you would like to consider, which is a ⁇ good thing. We strongly recommend doing this.

We have repeated our condition several times. That is, you will comply with your commitment to organize a very broad consultation and thus allow some participation. After all, there is concern today, which we cannot deny. Give them participation and bring with them in the Royal Decree clarification and reassurance that urgent medical care for the most vulnerable, such as paperless people, is still possible.

We will continue to follow closely. We hope that good royal decisions will come from the bus.

Mr. Speaker, Mr. Minister, to wind up urgent medical assistance for people without papers, that’s what you are doing. Suspicion of urgent medical assistance, too, that’s what you do with this legislative change. For vulnerable people, who already often, even if necessary, do not find the way to help, you now put another threshold. Because of so-called abuses, you leave the people who need it most in the cold.

Let it be clear, Mr. Minister, if there are abuses, then they must be addressed, with which we fully agree. But it is about twelve irregular cases on 200 investigated files and of those twelve, a large number is still very controversial. Because urgent medical care is not limited to urgent concerns. This clearly comes from a wrong definition. Thus, in these numbers are things that are unfoundedly labeled as abuse. It looks like shooting with a cannon on a mosquito. You can’t take this seriously, right?

It’s not just about the abuse, you say, you also find it too expensive. This represents 0.2% of the total cost of healthcare. This is the second mosquito. In addition, this draft law means quite a bit more overhead costs. I wonder if you mean this seriously?

Hello, Mrs Jiroflée

Please excuse me for interrupting you, but you cannot allow you to say what is not true. You have never pretended that the system costs too expensive. and never. never ever .

At least we had understood that in the committee.

In addition, not only the patient is visited here, but also the treating doctor. In the present draft, the doctor is apparently not considered capable of deciding on his own whether or not a provision is necessary. I ask again, Mr. Minister, if you are serious about this. Doctors will be financially punished if they do not act as the control doctors see. We have also suggested the criteria that the control doctors will use for this, as they are included in a KB to be published. Therefore, the doctor who treats someone without papers will not know in advance whether he will be reimbursed for this. Again, Mr. Minister, is this really serious? That financial penalty will only cause some healthcare providers to hesitate. Speaking of setting a threshold.

Colleague De Coninck and myself in the committee have repeatedly asked you to hear the organizations concerned and the OCMWs, but you have refused to do so. I am surprised to read in the newspaper today that you have seen organizations.

The [...]

I also say what I read, and it is stated that your spokesman has said that you have seen organizations. I wonder why those organizations are asking us and other groups to be heard, please.

I have asked you many times if you are serious. I will give you the answer: this is not serious. For my group, everyone who needs medical assistance should also get help, without thresholds. We clearly disagree on this, Mr. Minister. What the government is doing here is scandalous: you are trying to save a little bit of money on the back of the most weak, in order to be able to show how punishable and strict you are. That is scandalous and populist, and as far as we are concerned, a liberal unworthy.

You are very disappointing, Mr. Minister.

We will vote against this bill.

However, the point that concerns us most is not in the text. We even appreciate some advances in favour of public centres of social action (CPAS), such as the extension of the deadline for the social inquiry or the abolition of fines. But we share the concern of the field actors, who have clearly expressed their distrust towards the implementation of the control reform. The federations of CPAS, Doctors of the World, ASBL Coordination and Initiatives for Refugees and Foreigners (CIRÉ), the Belgian Grouping of Omnipraticians (GBO), all are suspicious of the upcoming royal decree, which must specify the tasks of the control doctor, whose function you create within the Auxiliary Caisse d’assurance maladie-invalidité (CAAMI). The fact that the majority refused the hearing of these actors in a committee meeting comforts us in the idea that there is a real problem, carpeted in the shadow of this text. We think they are right to be cautious.

Your government’s migration policy gradually shapes a society that lives in constant tension, including with respect to fundamental rights and human dignity. When the chairman of your N-VA partner says that you should choose between social security, on the one hand, and migration and acceptance of the illegal, on the other, he creates tension by manipulating public opinion.

The only social protection that illegals are entitled to is urgent medical assistance (AMU), and still under certain conditions. It seems to be too generous in the eyes of some people.

In order to limit urgent medical assistance, without too much hurting the public opinion, the ground must be prepared. This is what your predecessor did, by broadcasting, since last July, a press release entitled “Solidarity in case of emergency, yes, health care ‘à la carte’, no.” To justify this shock formula and the announcement of the AMU reform, he mentioned an increase in the cost of urgent medical assistance, which is accurate. According to the Federal Centre of Expertise (KCE), which studied the evolution of costs from 2006 to 2013, the increase in AMU average cost per beneficiary is mainly linked to a sharp rise in hospital costs, which we do not find for the population covered by health-invalidity insurance.

It would have been relevant to question this difference observed by several experts, instead of going up to evoking medical tourism. In this regard, KCE experts concluded that there were no reliable data to support this concern. In fact, I imagine that the vast majority of illegal workers have other priorities than getting aesthetic care. Emergency medical assistance accounts for only 0.25% of healthcare spending. According to Doctors of the World, 90% of paperless people never use AMU.

No matter what, you have recently returned to the burden by presenting your project as a way to fight the comfort care offered by complacent doctors. The priority would therefore not be to ⁇ savings, but rather to punish laxist behavior. You mentioned cases of circumcision and breast reduction, about which, however, too little information is available to claim that these are systematic abuses. Your statements have indignated the medical and associative circles, who are well aware of the realities and difficulties of the field. Of course, it is important to identify and punish abuses, however marginal they may be. However, it is not only a question of sanctioning proven abuses, but of mediating them to show that the priority is to put order in practices deemed too lax.

I would like to remind you that, for the experts of the KCE, the problem is not here. They proposed a reform of the AMU in 9 points, in order to "simplify and harmonize administrative procedures, as well as rationalize access to health care and the information system". From the beginning, I had indicated that I did not challenge the presence of advances in your bill. However, we also see an evolution in the interpretation of the very concept of urgent medical assistance, as it is increasingly assimilated to emergency care.

In its lean report of 18 November 2016, the CAAMI counseling doctor announced at the beginning that medical records had been analyzed by applying the following definition: "medical care to be delivered promptly to avoid a risk medical situation for a person or their surroundings." This definition used by the CAAMI is not repeated anywhere. The small report in question refers to the Circular of 24 November 1997 of Ministers Colla and Peeters.

But the latter, which specifies the royal decree of 2 December 1996, contains a broader definition: "By AMU, it must be understood the aid of a strictly medical character whose urgency is attested by a medical certificate. It can be ambulatory or administered in a health care facility and has a preventive or curative character. It is therefore solely up to the doctor to assess the urgency of medical assistance. Emergency medical assistance also means the necessary assistance in order to avoid any medical situation that poses a risk to the person or his/her surroundings.”

The CAAMI has thus taken back only the last words of the definition of the circular in a phrase that limits its scope, which is not serious.

The above elements helped create a climate of distrust around your reform. You may still be able to restore confidence by working together with representatives of all stakeholders, when preparing the royal decree that will implement this draft law on control.

This will be the hour of truth. We will see if despite all your statements in the press, despite those of the President of the N-VA, despite the definition of the AMU held by the CAAMI counseling doctor, you will keep the urgent medical assistance intact. But for now, it is our distrust that remains intact.

Mr. Speaker, Mr. Minister, Colleagues, today there is a bill to be voted in the plenary session that aims to reform the access to medical care for people without papers. I read in this design especially that it is making them even more difficult than it is now.

The media today is full of reactions from angry doctors and those reactions do not come from the least. My group shares the concerns of the ninety signatories of the open letter.

In the committee, we have in vain called for amendments to eliminate some pain points, which I will now overcome.

Mrs. and Mr. Minister, you say that this bill aims, among other things, to clarify the definition of urgent medical care, but you do not, unless Article 5 must continue to do so. Article 5 gives a very large delegation to the King, eliminating parliamentary control entirely. There is a possibility that the urgency will be interpreted restrictively through royal decrees, although we do not now know whether this will actually happen.

I am most upset by the fact that you package this reform with administrative simplification but are also motivated by an alleged abuse. There you go, as other colleagues have said, into the fog. You are based on a 2016 report from one medical consultant, who analyzed 200 medical records and concluded that there were twelve cases of abuse. The colleagues have already said that these twelve cases account for just 6% of the total, which we can call disproportionately mass abuse.

Furthermore, it turns out that that consultant used a wrong definition to analyze those medical records. The correct definition is based on the Royal Decree of 1996. It states that urgent medical care, contrary to what the name suggests, covers all medical preventive and curative care. The KCE report, a thorough expert report on urgent medical care, emphasized this once again. Therefore, it is important not to confuse urgent medical assistance with ordinary urgency, with urgency, which in popular terms is also called urgent medical assistance.

Apparently, that counselor has reviewed neither the royal decree nor the expert report and properly labeled concerns that were not urgent as abuse. Examples have already been cited by my colleagues. I will not repeat them.

That was also the reason why we submitted an amendment in the committee, to replace the word "urgent" with "necessary". In the committee this was rejected, but supported by CD&V. So I think this is something we need to think about thoroughly. By the way, it is also one of the goals in your design to specify this. So I think you leave a chance here, but it can still be included.

The conclusion is that the care provided by Belgian doctors is well in line with the legal framework, but what worries me and the Doctors of the World and the signatories of the open letter is that the report of a medical consultant, who uses a wrong definition, gained much more weight in the press than a solid expert report of the KCE that used a validated methodology.

Another misconception is that medical costs are an excessive cost item. You have indeed denied that in the committee, but it has been questionably spread around in the media. As my colleagues have already said, it ultimately represents only 0.2 % of the total budget. Furthermore, it appears that the individual costs of people using urgent medical assistance are 24,5 % lower than that of an ordinary insured Belgian citizen.

Mass abuse and medical tourism by people without papers?

In 2013, only 10 % to 20 % of non-legal residents used medical care, compared to 90 % of the Belgian population.

What is difficult is that you not only do not follow the recommendations of the KCE, but also that you have not heard the Doctors of the World, despite their repeated questions. It is absolutely important that you sit around the table with them for further steps. What the Doctors of the World just like me don’t understand is that a doctor’s judgment to decide if someone should get medical care would be checked post-hoc. Why Why ? The story of the abuses is not true, that we have all denied here. There seems to be a lack of confidence in the judgment of doctors.

With other words, you understand that eleven fractions will againststemmen. Of het gaat om control van misbruiken of dat het in werkelijkheid draait om en wijziging van de definition van dringende medische hulp, dat is us not so clear. There are many indications for the second, therefore we can say the design is not supported.

Mr. Speaker, if you allow me, I will remain on my bench because of my minor mobility concerns.

Some aspects of your bill are problematic. The first element was even precursor to the debate in the House. Indeed, in advance of the filing of your bill, your predecessor and you had decided to light the thread with shock statements. Your predecessor spoke of “medical tourism”. You yourself highlighted abuses, which you strongly insisted on in the press. You talked about abuse, but also “comfort care,” such as aesthetic surgery or unnecessary pregnancy ultrasounds.

Abuse of language? The Minister of Health is at your side. She will be able to remind you that aesthetic surgery obviously does not receive any refunds, unless it is therapeutic. In your statements, you said that people in irregular residence abused the system by collecting refunds for cosmetic surgery. However, there is no refund for aesthetic surgery, for anyone. From language abuse to shock statements, you had planted the setting before arriving in the Room.

I will not be too long on the substance of your bill. I will point my finger on a few things. The first is the way in which you try, in all possible and imaginable ways, to narrow the field of intervention to what is merely urgent, in the vital sense of a medical intervention. But the legal framework, Mr. Minister, does not aim at that. The law expressly provides that persons in illegal residence, whose fragility and vulnerability is known by definition, receive the necessary health care. It is not only people who have a heart attack that can be taken care of. Emergency medical assistance is not limited to emergency in the sense of vital care. You are trying by all means to narrow the field of intervention.

I was interested in reading a very recent press release from your party, in which it was stated that access should be given, given abuse, only to urgent care.

So it is true, the name of the law is indeed misconceived, miswritten. But what matters is not the title of the law, it is its content. It is very clear; it is not only aimed at urgent care, and even less only the care that would be vital.

You highlight the few abuses that can always occur and we obviously cannot accept them. You provided the figure of twelve abuses, including aesthetic surgery. I can’t agree with you because, if it’s not a therapeutic care, it’s not reimbursed anyway. This could not have happened or then it was not aesthetic surgery but rather therapeutic.

We hardly hear you, however, Mr. Minister, for example, about young pregnant women who do not have the opportunity to benefit from the three ultrasound scans, however necessary during pregnancy. We do not hear you about this study – which I pointed out –, demonstrating in fact that only 14% of people in irregular residence actually access health care, on the one hand because of a whole series of administrative burdens, but also because of problem of interpretation and sometimes too large restrictions in the level of decisions of some CPAS.

You choose, in your bill, to introduce an additional mechanism a posteriori. You know as well as I do, that when a doctor finds himself confronted with a patient, he is deontologically obliged to provide him with medical or surgical assistance – no matter. He must act this way and he will continue, I hope, to intervene. Introducing a mechanism a posteriori is a danger, since there is a greater risk of narrowing and diminishing access to care.

It is always easy, on the medical level, to re-diagnose a posteriori! But when the patient arrives, I’ve already told you in the commission, he doesn’t come with a diagnosis written on his forehead. It comes with symptoms. He comes with a difficult medical situation. Your control a posteriori, it will obviously be easy since we already have the diagnosis, but the risk for the doctor, is that he will all the time wonder: "If I do this for the hospital, a posteriori, they will interpret things differently." It risks at that time, as you introduce in addition to sanctions, to progress towards increasingly restrictive access.

Many field actors reacted: from associations, caregivers, doctors, to the Order of Doctors. On a topic like this, it does not happen so often that the Order of Doctors recalls its position. The least we can say, Mr. Minister, is that you were until now everything except listening when it was necessary to be, that is, first and above all, ahead of this bill. This concertation, this respect for the field actors, this respect for the care actors, despite their constructive proposals, you have not paid any attention to it.

I find in addition that the proposal coming from field actors, especially doctors, when it was still time, not from a mechanism a posterori but to stay – even with a doctor via the CAAMI, etc. –, in an a priori approach, was a very interesting and very constructive proposal that I continue to support. You wiped this from a reverse of your hand. I regret it. I believe that in this matter, you have demonstrated that you were absolutely not open to dialogue and above all that you wanted to move forward in this text not by being right, that is, by saying no to abuses when there are, but by being especially attentive to issues of dignity and to issues of care and medical or surgical intervention in patients ⁇ fragile and vulnerable.

This should have been your guide, but it has not been. There is still a long way to go, as there is the law but also the royal decrees. I insist that you take the effort to move forward, listen and co-build these royal stops with the field actors. The first damage from this non-listening will have already been done, at least on this control a posteriori at the level of the bill. It is a pity that you have not followed this constructive proposal from the caregivers.

When it comes to royal stops, lines can still move. I dare hope, Mr. Minister, that your attitude will be completely different. But given the concerns related to this bill and the total lack of information on how you are going to model them in royal decrees, we will not support this bill.

Mr. Minister, I urge you to change your attitude in the coming weeks as part of the royal arrests. It is in any case a missed opportunity, at the level of the bill, to do things in a respectful, positive, constructive way and with one goal: no abuse but above all a minimum of dignity and health interventions necessary for these people by definition fragile and vulnerable.

Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker, Mr. Speaker. It is to make it seem that all these populations, who already have enormous difficulties, who have fled their country and who are very precarious, benefit from our social security. We are really in an ideological framework, in a will to polarize the population. That is the purpose. The president of the N-VA says this clearly, but it is regrettable to see MR play in it. It is trying to make people, who already receive too little from social security, believe that there is a huge amount of abuse. The purpose of the political manoeuvre is quite clear. Many people feel the consequences of austerity applied to the level of social security and have frustrations. There is therefore a political attempt to channel this anger to other categories of the population that are obviously not responsible for this hole in social security. This is one of the reasons why the PTB will not be able to support this bill.

The minister wanted to give the press the impression that abuse is the daily bread, with a full of stories more flattered than the others. A very clear report from the Federal Center for Healthcare Expertise (KCE) found that the amounts in question amounted to 362,000 euros over two years – just enough to pay some parliamentary salaries, including that of the House President, over the same period. Stop pointing the finger at all those abuses that are not. This amount corresponds to 0.33% of the emergency medical assistance during these two years. We can therefore ask ourselves serious questions as to whether the control that is imposed here is proportionate to these numbers. We do not think so.

That is also why this morning 100 doctors wrote in an open letter in The Morning that there is no mass abuse at all. Moreover, the famous report of the RIZIV rapporteur, according to the doctors, assumes a misdefinition of urgent medical care.

The truth, dear colleagues, is that it is often difficult to get the necessary medical interventions. We have gathered many testimonies in this regard. Only 10 to 20 percent of paperless people have the opportunity to find this help, even if it is needed. As clearly demonstrated and denounced by the Netwerk tegen Armoede, CIRÉ and Doctors of the World, the right to urgent medical care is already often unjustly denied to persons in illegal residence. The mountain of complicated procedures and controls explain this lack of access to medical care.

A lot of time and money is wasted by preventing doctors from helping people. This is why the 2015 KCE report has not been applied. If it had been, a huge simplification would have resulted.

Many associations of doctors have attacked the bill: the Belgian Grouping of Omnipraticians, the Belgian Association of Medical Unions, the Order of Doctors, Domus Medica and the Dutch-speaking medical unions. As they have so well stated, providing medical assistance to anyone who needs it is a duty of every doctor. There should be no differences between patients.

By this bill, the government intends to intervene in this mission and even – in certain circumstances – prevent it, because it is purely inspired by a logic of savings.

Dear colleagues, anyone who is not deliberately blind sees that the entire sector disagrees with this bill. However, the majority has once again decided not to listen to the real experts because the question of hearings has rejected them.

That is why, dear colleagues, the PTB will vote against this bill.

A simplification and improvement of the administrative provisions relating to the use and use of emergency medical assistance was indeed long expected. And, in its report on this topic, the KCE had also suggested changes and simplifications.

These measures are positive, Mr. Minister. We have supported them in the committee. Unfortunately, one cannot “weigh” your bill on the basis that it contains positive articles, others that one cannot support and, ultimately, abstain after making the balance. What is not right is not really right. And since this is really not the case, one cannot support, even through an abstention, the content of certain provisions.

I can’t help but remember how you introduced this project. In fact, you wanted to present it as a race against terrible abuses. The comfort care offered to the illegals is over! There are abuses. Religious circumcision is one of them. It will be finished!

As a result, you have thrown a form of discredit on this population that needs care and which appeared to benefit from a system at the expense of the Belgian citizens.

We wanted you to do so and, as far as I am concerned, I always regret you for introducing your bill in this way.

On the occasion of your committee interventions, you corrected the shot and said that your goal was, in fact, to encourage the recourse to urgent medical assistance of this population because you want them to be healthy and have real access to care. You still talk about abuse.

To illustrate these abuses, you showed us a report from medical counselors, the CAAMI of MediPrima, etc. I have to admit that I am still not coming back. It is not possible that doctors who have a scientific training, who have a professional conscience, who are brought to consider a population, the care requested, the care provided, the analysis of this care, the dialogue with doctors, hospitals, and then draw conclusions, can transmit a four-page report, written with the data as they are presented.

Either his report was scratched and you showed us a summary of 3 or 4 pages, or there’s really something I can’t understand from a consultant in writing this report.

A little correction!

The report was communicated to you in its entirety. Do not try to induce in this debate that we would have rid him of his report, please!

So, it is even more serious than I thought! I am not concerned that you present to us the summary of a report. We just have to assume that it is. But if a report makes three pages written in this way, it’s not okay. I’m not sure if anyone in the CAAMI assumes such things. This is an impression that I give you. This is an appreciation, beyond the impression. If I were a minister, I would not accept a report written and delivered in this way. I would ask for more.

It shows from this report that it meets your assumption, according to which there is abuse. If there is abuse, the examples given in this report do not constitute a sufficient basis for demonstrating it. It is anything! There is a plastic surgery and an ultrasound questioned, and five or six other acts that are considered not to be care that can enter the category. Frankly, this is not what can allow you to talk about abuse. I will return to another category of care later, because it is of a different nature.

Mr. Minister, you are therefore starting from this principle to amend your bill, while saying that you want people to use more care so that they are healthier and have confidence.

In doing so, you set up a system that can contain positive arrangements, such as the registration of the service via MediPrima, which will also simplify the procedures for people, who will have access to procedures and care.

At the same time, and you did not give me any reassuring answer, using a recording system such as that, there will be the possibility not only to record the care provided but also to identify the people and even geolocate them via an address or a place where they will be located.

Given the type of population and your willingness to “increase confidence and promote the use of care” as you say, I raise doubts because these people are illegally staying, that, in the discussions around your project, it is about home visits and also because of your government’s position to expel people who are illegally staying with us.

How can you ensure sufficient confidence to go for treatment when you are at risk of being identified and localized?

To that, you did not answer me. You told me that access to personal and medical data will be preserved (secret of the medical record), but my question does not fall within that record. I would really like to receive clarifications from you in order to know whether I should continue to be worried or if I can be reassured about what is likely to happen.

Finally, regarding the a posteriori assessment of the CAAMI consulting doctor, I agree with the criticisms made by the colleagues before me, because the a posteriori assessment will necessarily be subjective. A doctor who deals with a person with symptoms, disease, anxiety, etc. He is obliged to provide and provide the care he considers necessary.

He cannot ask himself the question of what care he can or cannot give, nor be put into a situation where he will have to take a position, so as not to be punished because that care might not be sufficiently vital, important or urgent. It is impossible for a doctor, in the face of a patient, to position himself like this. This is impossible because it is contrary to the deontology and the mission to which doctors and caregivers have subscribed.

Mr. Minister, either you assume until the end and you affirm your will to limit the access of these people to these care (vital care, emergency care which you will have to define in this case) or you withdraw your provisions that may make it seem that certain care will be considered as care to which the person does not have a right.

I have introduced an amendment, already at a committee meeting. We reintroduced it, my colleague Anne Dedry and myself, in the plenary session. This was intended to change the designation "urgent medical aid" (AMU) and replace it with "necessary medical aid", in order to verify the intention of the aid, stick to the reality and remove this confusion, due to the adjective "urgent". This request was rejected at a committee meeting. You explained that you wanted to develop a jurisprudence, which would determine which care is acceptable or not. In other words, you add a layer of insecurity to the insecurity that your text already contains. If your goal is not to eliminate care, then you should accept this terminological change: “Necessary Medical Aid” instead of “urgent”. Otherwise, you must assume what you do not say but do.

I would like to use the presence of Mrs De Block, Minister of Health, to raise a problem.

I questioned the minister in a committee meeting on a category of care, pointed out by the doctor-consultant who made this famous report relating to cases of non-medical circumcision, which he considered as abuses. However, a parliamentary commissioner asked the minister about the refunds for non-medical circumcision care. The Minister announced, and I share her position, that it was important to be able to reimburse these interventions, even if they were not medically necessary. In fact, these must be carried out in all conditions of safety, hygiene and health to avoid infections and negative consequences. We can therefore deduce that, for all persons in the Belgian territory, there is a refund of this act. If this is the case, we cannot consider it to be abuse in the specific case of those persons who are in irregular residence.

Either you really want to remove them, and you make it clear, or you consider that these treatments are valid for everyone – therefore also for those people – and you stop listing them in the list of abusive benefits. I would like the Minister of Health and you yourself to give a clear answer on this subject.

The royal decrees that must be taken should have been explained in commission so that we could understand your intentions and stop asking you these questions, to which we still have no answers. You said you were going to deepen and finalize the texts with the field actors. We did not have the opportunity to hear these actors in the committee, but they fed us widely, from the CPAS to the doctors, through the caregivers and associations working with people in irregular residence.

I hope that you will work with them and that, doing so, you will agree to use, to value the arguments they will explain to you. I hope that eventually, you will return to us by proposing changes that will improve your text, if the intention is to allow the best possible access for those people in situations of excessive fragility.

You will have understood, we will have to vote against this project, given the content and criticism that my colleague Anne Dedry and myself have just made.

Mr. President, thank you very much.

As I have already said in the committee, the government is fundamentally attached to urgent medical care. We do not question the definition of urgent medical care.

We do not question the definition of emergency medical assistance.

Since the issue has been stunned by some, I would like to return to some essential budgetary aspects. I have heard that this government would not lead a decent or generous policy in the field of urgent medical care. I cannot let that be said and I must, in this case, let the numbers speak. Between 2014 and 2016, the number of recipients of emergency medical assistance increased by 8.9%. The allocated amounts increased by 27.31%, reaching 57.4 million euros. Therefore, this government is increasingly investing in emergency medical assistance. It is therefore not intended to reduce its contribution if the needs relating to this vulnerable category should continue to grow. We must naturally ensure – this is a commitment not only legal but also moral – that this fragile group can access care. That is our will.

I would like to refer to some of the points of the draft law that have brought us together. We have had a long discussion. Two committee readings were held, several fruitful exchanges took place, while others were harder. In any case, what this project brings in terms of administrative simplification – which is in the right line of the recommendations of the KCE and the reform of MediPrima, for the benefit of the practitioners and beneficiaries of the AMU – was able to gather us at the time of the vote of several articles.

I think in particular of this measure which increases from 45 to 60 days the period prior to the decision to take care of the CPAS in the context of emergency medical care. This gives the CPAS more time to conduct the social survey, so that it can take place in better conditions. This was a request from the CPAS Federation.

I also think of another important measure, which relates to the continuity of care. In the existing system, in a number of cases, care should be interrupted depending on the possible change of the recipient’s reference address. We take steps to ensure the AMU beneficiary continuity of care.

It is clear that the bill also specifies the role of the different stakeholders of the AMU, whether it is the State, the CPAS, the care providers or the CAAMI.

I have heard the arguments presented on other aspects. Some of them I cannot subscribe. Colleagues refer to the KCE report. This study is fundamental in the device. The SPP Social Inclusion was associated with this survey, in which the CAAMI actively participated. I have heard Mr. Hedebouw; he does not seem to know this matter well. Many of the study’s recommendations have been implemented. Anyone who has worked on this issue or on this issue knows that. I will take for example one of the measures aimed at separating the social component for the CPAS and the medical component for the CAAMI.

I would like to highlight one point that seems to escape a number of parliamentarians who take back some points of the KCE report that arrange them and not others that do not arrange them. I remind you that we are following one of the key recommendations of the KCE in this project, namely the fact of entrusting the control device to a CAAMI control doctor. I draw the attention of opposition parliamentarians to the fact that it is not always necessary to subtly sort between the recommendations that arrange them and those that disturb them!

If we set up a control doctor within the CAAMI, it is by following the recommendation of the KCE report. It is important to indicate it.

I will return to a fundamental point.

Do we need control at the end? In such a system, should controls be removed? In any system, there is a need for control. This control already existed and was operated at the beginning of the CPAS. The controls were carried out on care at several levels, in different ways depending on whether one is in one CPAS or another. For some CPAS, doctors operated the control and for others, administrative officers operated the control.

With the system we are putting in place, with regard to general and hospital doctors, it will no longer be an administrative – whose profession is not in the field of health care – who will operate the control. Now a doctor will talk to a doctor! I think that is a progress. Some members of the opposition expressed this in the framework of the discussions we had in the committee.

We need control. These will not be checks carried out by administrative or variable geometry CPAS. No, there will be a type of control at the CAAMI level with a doctor who will talk to another doctor. When I say “talk” it’s intentionally. I said that in the committee. I also hope that we can, as part of the contact between this control doctor and the general practitioner or hospital practitioner, articulate a dialogue and not just a strict control. With the establishment of royal arrests, that’s where I want to go. I have already repeated it.

I hear a number of criticisms about the report of the CAAMI doctor-controller. I am not a control doctor. I don’t want to allow myself to burn down a report like this, as I’ve heard some MPs do. Indeed, in this report, this doctor-controller tells us that 6% of the care does not fall within the scope of urgent medical care and that for 52% of the files on which he would have wanted to obtain information, he was unable to do so because the legal framework related to the exchange of information between his function and the hospital or generalist doctor did not exist. Therefore, we are setting up a legal framework that will enable this exchange of information. It is essential.

Madame Fonck, we have listened! I assure you that once in two, when I listen to you, I fall from the clouds, so much you can, it seems to me, disguise the facts! There have obviously been a number of consultation meetings with the CPAS federations, with the Order of Doctors that we have already seen several times.

Mrs. Van Hoof, I reiterate the commitment made in the committee. These consultations are essential and will of course continue as part of the implementing measures.

I undertake to organize a broad consultation as part of the preparation of the royal decrees. We will have the order of the messages. I will talk to the CPAS Federation. I received a number of requests. They are very offensive and very harsh in relation to this project; I think of Doctors of the World, whom I will also listen to in all the comments that this association has to formulate.

My will is to operate a settlement that is balanced and fair. Yes, we must continue to send a clear signal, Mrs. Gerkens. I really want to reassure you about this.

You know, the MediPrima reform allows pre-registration. This allows people eligible for urgent medical assistance to go to their CPAS in order to pre-register before even having a medical need, so that their dossier is already prepared in perspective of when they will need medical care.

I know that there is still a form of fear, among these vulnerable people, to go to the CPAS in order to proceed, for example, to this pre-registration.

We assure them that they can go there without any fear, all information concerning them is confidential. They do not take any risk by taking this approach, which they are entitled to, Mrs. Gerkens – it is important to repeat this. I have said this several times before in the committee.

We have had very long discussions in the committee, twice. Our will is clear. Some opposition representatives even mentioned it. I think of Ms. De Coninck who has local experience in social policy.

Yes, there are abuses. They are extremely marginal, but they exist. Would it be too politically incorrect to relay this information that is found in the report of the CAAMI doctor-consultant? I do not believe it. We also have the responsibility to monitor this issue, while also indicating that we wish, for this vulnerable group, that urgent medical assistance be the most widely available, offered, in terms of their health care needs. It is not incompatible to communicate on this aspect of things in a fair manner.

To conclude my speech, I reiterate my will for concertation, which remains full and complete, in relation to the establishment of these royal decrees.

I will not ask Minister Ducarme for additional information, but I would have wanted to obtain a response from Ms. De Block, Minister of Health, regarding the report of the doctor-consultant of the Caisse auxiliaire d’assurance maladie-invalidité, which considers that circumcision for non-medical reasons is abuse. In my speech, I made a link with his remarks at a committee meeting. Indeed, according to her, it is interesting that the INAMI reimburses these acts for reasons of security guarantee, non-infection, etc. This principle must therefore apply to any resident on Belgian soil. I would have liked to receive his appreciation on this subject.

Mrs Gerkens, as I have had the opportunity to say repeatedly, the INAMI does not distinguish between circumcision for medical and non-medical reasons. These acts are taken under the same nomenclature. No initiative is planned to change this rule. We need to know how to proceed. This measure applies to very young boys. What is the risk if this operation is no longer refunded? It would be to create a new chain of circumcision in the kitchens and bathrooms, with all the possible complications, injuries, urinary problems, etc.

Madame Fonck, it is more expensive. We are agreed. This could be more expensive but also really ruin the future of many little boys. On this side, like on all sides, I like them to be healthy. I want to avoid not only spending on social security but also all the misery that can go hand in hand. However, it is known that injuries in these areas can be very serious for boys and then for men.

This does not happen every day, but I think that exceptionally, the whole Parliament follows you on the last sentence. The last word goes to Parliament.

We are all concerned that everything is going well.

I fully agree with your analysis and position. I had to repeat this in the committee where you had brought this answer. This means that these services cannot be considered to be abuses by the nature of the service. Therefore, this is not yet a case-law but it will in any case appear in the reports of the Chamber to the attention of the CAAMI counseling doctor.