Out-of-pocket payments for health care are low in France, but gaps persist for people with low incomes, new WHO report reveals (2024)

According to the report, “Can people afford to pay for health care? New evidence on financial protection in France”, the country had one of the lowest levels of catastrophic health spending in the EU, affecting 2% of households (around 800 000 people) in 2017, the latest year of data available. People who experience catastrophic health spending may not be able to pay for other basic needs such as food, housing and heating.

Reducing hardship for low-income households

However, the report shows that catastrophic health spending is much higher than the national average in households with low incomes. In 2017, 10% of households in the poorest fifth of the population experienced catastrophic health spending. The main drivers are out-of-pocket payments for outpatient medicines and medical products such as hearing aids, glasses and dentures. Levels of unmet need for dental care are above the EU average and especially high for people with low incomes.

“France has made significant progress in strengthening financial protection, but more can be done to protect people with low incomes and chronic conditions from out-of-pocket payments,” said Dr Natasha Azzopardi-Muscat, Director of the Division of Country Health Policies and Systems at WHO/Europe. “The report identifies actions that can reduce financial hardship, particularly for people with low incomes, including exempting them from all co-payments, limiting balance billing and phasing out retrospective reimbursem*nt.”

The report highlights 3 features of health coverage policy in France that help to make health care affordable for many people and offer examples of good practice for other countries:

• Entitlement to health care financed by the social health insurance (SHI) scheme does not depend on payment of SHI contributions; as a result, all residents are automatically covered for life, including people with precarious jobs.
• People with any of 32 chronic conditions (known as affections de longue durée), which affect around 18% of the population, are exempt from user charges (known as the ticket modérateur) for the treatment of those conditions.
• Undocumented migrants with low incomes who have been in France for at least 90 days have access to benefits similar to residents, without user charges, through the state medical aid scheme (aide médicale de l’État (AME)).

Financial hardship and unmet need persist in low-income households due to weaknesses in some aspects of SHI scheme coverage – for example, insufficient protection from heavy and complex co-payments (including balance billing) and limited dental care benefits.

Complementary health insurance (CHI) covering co-payments is not a panacea

CHI improves financial protection for around 95% of the population, in part because households with very low incomes have it for free or with a subsidy, but it does not fully address the problems caused by co-payments and comes with many challenges:

• CHI is a highly regressive way of financing the health system, imposing a heavy financial burden on the poorer half of the population; in 2017 CHI premiums accounted for 6% of all spending in households with lower incomes, compared to 2.5% in the richest households.
• Financial and administrative barriers to accessing good quality CHI continue to be an issue for many households with low incomes.
• Relying so heavily on CHI to provide financial protection involves significant transaction and financial costs for the government and employers.

Making health care more affordable for all

Since 2000, the Government of France has tried to strengthen financial protection by improving access to SHI and CHI and, more recently, by reducing balance billing for medical products (including for dental care, optical care and hearing aids) through the 100% Health (100% Santé) reform phased in between 2019 and 2021.

Building on this, the government can improve affordable access to health care in the following ways:

• reducing SHI co-payments by exempting people with low incomes and people with chronic conditions from all co-payments, setting an annual income-based cap on all co-payments for the whole population, limiting balance billing and phasing out retrospective reimbursem*nt;
• replacing percentage co-payments (the ticket modérateur) with low, fixed co-payments;
• reducing the regressivity of CHI by removing financial and administrative barriers to free or subsidised CHI for people with low incomes and linking subsidies for CHI for employees to income;
• improving SHI coverage of dental care; and
• improving access to the AME scheme for undocumented migrants by simplifying and automating administrative procedures.

“The government has made consistent efforts to expand access to CHI in the last 2 decades, but our analysis shows that the poorest households are still the least likely to have access to CHI,” said Damien Bricard, researcher at the Institute for Research and Information in Health Economics (IRDES) and lead author of the WHO/Europe report. “Even when households with low incomes have CHI, it may not be sufficiently protective and it imposes a heavy and unfair financial burden on them.”

About the report

Produced in collaboration with a researcher from IRDES, the report assesses the extent to which people in France experience financial hardship when they use health care, and unmet need caused by financial barriers to access. It covers the period 2011–2024, using microdata from household budget surveys from 2011 and 2017 (the latest available year), data on unmet need for health care up to 2022 (the latest available year) and information on coverage policy (population coverage, service coverage, user charges and voluntary health insurance) up to March 2024.

More information about this report is available on UHC watch, a new platform tracking progress on affordable access to health care in Europe and central Asia.

The report and UHC watch benefited from financial assistance from the European Union through the EU4Health programme.

About WHO/Europe’s work on financial protection

WHO/Europe monitors financial protection through the WHO Barcelona Office for Health Systems Financing, using regional indicators that are sensitive to equity. Financial protection is central to universal health coverage and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals, part of the European Pillar of Social Rights, and at the heart of the European Programme of Work, WHO/Europe’s strategic framework.

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