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Communication to the
Senate Social Affairs Committee
July 2022
Executive summary
In the context of the Court of Accounts’ mission of assistance
provided for by Article
2 of the Organic Act on Budget Acts (LOLF), the Senate’s Social Affairs Committee asked
the Court of Accounts to produce a report on the reform of the 100% Santé health insurance
A reform aimed at reducing out-of-pocket expenses,
to act on the renunciation of care
The 100% Santé health insurance scheme consists of full reimbursement by social
security and supplementary health insurance for a number of hearing aids, eyeglasses and
dental prostheses, combined with a price cap for the goods and services concerned. This
reform was justified by the high out-of-pocket expenses incurred by households, which could
limit their use of such care. However, these out-of-pocket expenses were much lower for
optical care than for dental care and hearing aids, mainly due to the existence of offers
without out-of-pocket expenses for optical care even before the reform.
With regard to dental and hearing prostheses, the 100% Santé scheme has eliminated
out-of-pocket expenses for equipment already used by part of the population. In the optical
sector, the choice was made to create an offer with no out-of-pocket expenses, at a price
level much lower than that of the equipment that was and still is the most widely used.
However, policyholders with no supplemental coverage are not affected by full
reimbursement, although they are more likely to forego care than others. The creation of the
supplemental health insurance scheme
, which took place in parallel with the reform of the
100% Santé scheme, is precisely intended to remedy this situation.
Uneven results by sector, positive for dental care and hearing aids,
down for optical care
Although the results of the reform are difficult to measure, due to the lack of hindsight
and the disruption of health care consumption caused by the Covid-19 crisis, initial analyses
are nevertheless possible. Thus, it appears that the rollout of the reform has not achieved the
same results in the three areas.
In the dental sector, the basket without out-of-pocket expenses represents a large
majority of the prosthetic procedures performed (55%), which translates into an overall
reduction in out-of-pocket expenses for households. It was accompanied by a significant
increase in the number of patients in 2021 (5.16 million, compared to 4.4 million in 2020 and
4.75 million in 2019), which must nevertheless be interpreted in the light of the drop in the
use of care in 2020, due to the health crisis, and the catching up that may have followed in
2021. Among them, the number of new patients appears to be limited (among the 3.5 million
patients who will have had a prosthetic procedure in the first half of 2021, 92% had already
used a dental surgeon between 2017 and 2020 and 70% had used a dental surgeon in
2020). Instead, there is an increase in the number of prostheses per patient.
In audiology, the no out-of-pocket expenses basket represented 40% of hearing aids in
late 2021 and was combined with a strong increase in the number of patients (0.7 million
compared to 0.45 million in 2020), in a sector that has historically been dynamic, with, as in
the dental sector, decreasing out-of-pocket expenses and a trend towards an increase in the
number of devices sold per patient.
In contrast, in the optical sector, the no out-of-pocket expenses basket is still very
rarely chosen, with the exception of beneficiaries of supplemental publicly funded health
insurance, for whom limited options are offered. It represents only 5% of frames and 7% of
lenses, in a sector where there have long been offers with no out-of-pocket expenses, even
before the reform was introduced. The reform even results, contrary to its objective, in an
increase in out-of-pocket expenses, as the introduction of a basket of care reimbursed at
100% is accompanied by a reduction in reimbursements by the health insurance scheme for
equipment in the free basket and, for supplemental organisations, by a reduction in the cap
for the reimbursement of frames, which are not compensated by a sufficient rate of
equipment in the basket without out-of-pocket expenses.
Levers to be mobilised in order to increase rollout
of the reform
Several difficulties are likely to slow down the use of care that the reform seeks to
The implementation of the reform was initially disrupted by the health crisis. Public
awareness of it has been affected. According to the Directorate for Research, Studies,
Evaluation and Statistics (Drees), in 2021, only 53% of those questioned said they knew
about it. In addition, the administration’s audits of the pr
actices of professionals have
revealed certain behaviours aimed at devaluing the content of baskets with no out-of-pocket
expenses. These audits will have to be strengthened in order to remove any ambiguity about
the content of the reform.
The absence of full third-party payment, despite the obligation set out in the Social
Security Financing Act for 2021
, may also explain some of the difficulties faced by patients
with cash flow problems. By design, the implementation of such a system, which brings
together multiple points of contact, is bound to be complex. In addition, the question of the
degree of confidentiality of the health data transmitted has been raised and has not yet been
definitively resolved. Lawmakers did, of course, attempt to respond to this, by means of an
amendment to the PLFSS 2022 giving the Ministry of Health the possibility of providing a
stricter framework for the transmission of information between stakeholders in the context of
third-party payment, but this amendment was rejected as a social rider by the Constitutional
Council. Another legislative vehicle will therefore be needed.
Finally, in the absence of an evaluation questionnaire, it remains difficult to determine
whether the 100% Santé baskets actually meet the needs of the population. Such a
questionnaire is being considered for optical and hearing aids, but work has not yet been
An uncertain cost, a reform difficult to manage
The estimated cost of the reform established by the Social Security Directorate was
€170 million per year, shared equally between the compulsory health insurance and
the supplemental health insurance schemes. The funding was based on a partial offsetting of
the costs resulting from both the increase in the use of hearing aids and the increase in the
Act No. 2020-1576 of 14 December 2020.
reimbursement of dental and hearing aids by savings linked to the use of less expensive
optical equipment. However, the forecast of the cost of the reform was based on optimistic
assumptions regarding the use of the 100% Santé basket for optics. The lack of real sharing
of available information between the ministry, the compulsory health insurance, supplemental
health insurance, and professionals makes it difficult not only to estimate the cost of the
reform in advance, but even more so to monitor it after the fact. This was further affected by
the health crisis, which severely disrupted health care consumption.
In fact, the consumption of care observed in 2021 is different from the forecasts and
health insurance expenditure is lower than expected, in particular due to the drop in the
consumption of optical equipment as a result of the crisis and the lower than expected use of
the 100% Santé basket in this sector.
Based on its own data, supplemental health insurance reports an additional cost, linked
on the one hand to the dynamism of hearing aids and on the other hand to lower than
expected savings in optics. Such a situation is likely to result, unless there is a deterioration
in the guarantees offered (difficult to establish for lack of updated data), in an increase in
policyholders’ contributions, which will vary according to the contracts, the risk profiles and
the financial position of each organisation.
The absence of a tool to regulate expenditure, such as a mechanism to regulate the
price of hearing aids, is not likely to facilitate compliance with the initial expenditure
trajectories and could therefore result in additional costs for the insured. A review will be
worthwhile in 2024, outside the disruption of the health crisis.
Set up data sharing between the compulsory health insurance scheme and supplemental
insurance companies, ensuring that the latter make reimbursement data available, and on
this basis, monitor the expenditure incurred under the reform
(Ministry of Health and
Prevention, CNAM, supplemental health insurance companies)
Revise downwards the limit prices for the sale of hearing aids in the 100% Santé basket
(Ministry of Health and Prevention)
In the context of future negotiations with the dental surge
ons’ unions, include a clause
allowing action to be taken in the event of a slippage in the trajectory of dental prosthesis
expenditure; strengthen controls on the implementation of the 100% health insurance scheme
by dental surgeons
(Ministry of Health and Prevention, CNAM, Unocam)