Unequal Access to Dental Care Despite the Reform That Caps Prices for Crowns and Other Prosthetics
The reform known as “100% healthcare” or “zero out-of-pocket costs,” as applied to dental care, aims to improve access to more expensive treatments (crowns, dentures, bridges, etc.). However, analysis shows that, on the contrary, this reform risks exacerbating inequalities in access to care, not only because it excludes those without “supplementary health insurance,” but also due to the specific nature of dental practice (areas with a shortage of practitioners, freely set fees, etc.).
Marion Bruna, University of Montpellier
Dental care is among the types of care most often affected by health care non-use—that is, the failure to seek the health care services that one’s health condition requires. This observation holds true throughout Europe, where dental care is generally not well covered by public health insurance systems. Across all OECD countries, less than one-third of dental expenses are covered by public health insurance, and in some cases—such as in Greece—the public health system covers none of the dental costs.
In France, it has been estimated that dental care accounts for nearly half of all cases where people forgo medical care for financial reasons. The “100% Health” reform is intended to address this issue. With regard to dental care, the “100% Health” reform caps the prices of prosthetics (dental crowns, bridges, dentures), while increasing coverage for routine dental care (cavity treatment, scaling, etc.).
However, its operation relies on private health insurance (that is, supplemental health insurance, commonly referred to as “mutuelles” even though not all of them fall under the Mutual Insurance Code, editor’s note) and on the practices of dental surgeons, which may limit its effectiveness in providing access to oral health care.
Conservative Treatment vs. Dental Prosthetics
The main distinguishing feature of dental care is the dual nature of such care: on the one hand, conservative treatments, which treat the tooth while preserving as much dental tissue as possible (scaling, root canal treatment, etc.); and on the other hand, prosthetic treatments, which involve the fabrication and placement of a prosthesis.
The 2018 dental agreement highlights an imbalance in dental care practices, largely influenced by an economic model that favors prosthetic care. This system has been accompanied by an increase of more than 66% in out-of-pocket costs for these procedures over the past ten years, which contributes to high out-of-pocket expenses for patients. This pricing structure leads practitioners to choose treatment strategies that are more oriented toward prosthetic care than toward conservative care, which is less profitable.
Another distinctive feature of dental care is that the vast majority of dentists are in private practice (83.2% of practitioners in 2024). The income of dentists in private practice is based on a fee-for-service system and therefore depends directly on their activity (the number of procedures performed).
However, since dental surgeons can charge additional fees depending on the type of care they provide, their income also depends on the mix of their practice and their pricing strategy. In 2018, while prosthetic care accounted for 10% of the procedures performed by dental surgeons, according to Drees calculations, it represented two-thirds of their fees.
The "100% Health" dental program suffers from the uneven distribution of dental practitioners
This is the system that the 2018 dental agreement sought to reinstate; it sets the rates applicable to dental care following negotiations between the Health Insurance Fund and professional organizations representing dental surgeons. It is based on a two-pronged approach: on the one hand, capping the rates for prosthetic care to limit out-of-pocket expenses, and on the other hand, increasing reimbursement rates for restorative care (cavity treatment, scaling, etc.).
At the same time, the “100% Health” reform has established, for certain particularly costly medical services—including prosthetic dental care (crowns, removable dentures, etc.)—a package of guaranteed care with no out-of-pocket costs, accessible to all under certain conditions.
This approach has helped reduce the number of people who forgo dental care for financial reasons. However, it is hampered by the structure of the dental profession—where dentists are primarily in private practice (meaning they are free to set their own fees)—and by their uneven geographic distribution, which results in areas with a low density of dental practitioners. In fact, in areas with a severe shortage of dentists, the risk that a person with low income will forgo care (of any kind, dental or otherwise) is 23 times higher than for a person who does not have low income.
While existing research on access to care by geographic area focuses primarily on general practitioners, this issue is a genuine concern for dental surgeons. The Ministry of Health has therefore established a zoning system for dental surgeons that indicates that 70.8% of French municipalities and districts are severely underserved in terms of dental surgeons, and that only 3% of them are areas with an ample supply of dental surgeons (figures for the year 2024).
Since 2015, incentive programs implemented by the National Health Insurance system have aimed to encourage dentists to set up practices in health centers in areas with a severe shortage of dental care. Nevertheless, the initial trends in practice establishment may have helped shape a geographic distribution of dental care that persists despite recent incentive policies.
Dentists' freedom to set their own fees remains guaranteed
The implementation of the “100% Health” program also faces resistance from a profession with significant market power—that is, one with a strong ability to influence prices—as well as flexibility in how they implement the provisions they are required to follow. For example, they have the option to refuse to apply the “100% Santé” program, and their freedom to set their own rates remains guaranteed.
Dentists provide care within a relationship characterized by an information asymmetry: the dentist has more information than the patient about the necessary treatment and the various available options.
In some cases—particularly in a context where oral health is improving, as is the case in Norway—this relationship can lead to demand-induced phenomena, that is, the provision of more care than is necessary.
The Rise of "Mutual Insurance Companies"
Another limitation of the “100% Health” reform is that its approach relies entirely on funding from supplemental health insurance (the “mutuelle,” ed.). This assumes that the patient has supplemental health insurance, which is a prerequisite for the system to function. Access to supplemental health insurance therefore remains central to receiving dental care.
While in France, the mandatory health insurance system is the primary source of funding for fixed public rates, these rates remain significantly lower than the prices actually charged by dentists, particularly for dental prosthetics. The role of the health insurance system is therefore constrained by its limited regulatory authority, giving way to market forces when it comes to the placement of a dental crown or dentures.
Crowns, dentures, bridges: What do “Sécu” and “mutuelle” cover?
- The mandatory health insurance system (known as “Sécu”) offers the same reimbursement amount to everyone, based on the “Sécu rates” it has set. However, these rates are sometimes out of line with the actual fees charged by dentists, particularly for crowns, dentures, and bridges.
- Supplemental health insurance covers the portion of expenses not covered by mandatory health insurance, but the amounts it reimburses vary depending on the policy.
In 2019, out-of-pocket expenses for dental prosthetics accounted for 36.8% of total spending on this type of care. “Mutuelles” (which are private health insurance plans) serve as essential sources of funding for dental care reimbursements. They provide coverage that varies from person to person, depending on the policy held. In fact, the level of reimbursement for costly treatments, such as dental prosthetics, is closely linked to the quality of the policy, which serves to reinforce structural inequalities in access to oral health care.
The “100% Health” program thus appears to be another step toward the privatization of healthcare financing, as it makes supplementary health insurance essential to prevent people from forgoing care.
These successive reforms are gradually leading to an increase in the cost of supplemental health insurance. They are also contributing to the exclusion of a segment of the population—those without “mutuelles” or solidarity-based supplemental health insurance—from systems providing access to care. This amounted to 2.5 million French people in 2019, according to the Institute for Research and Documentation in Health Economics (Irdes).
An analysis of this reform thus suggests that its inclusive nature in terms of access to dental care could actually exacerbate inequalities “by design”— due, on the one hand, to more complex issues, such as how practitioners adapt their practices in response to new economic incentives, and, on the other hand, to the essential reliance on private health insurance.
This article is based on research conducted as part of the project “Equal Access to Dental Care under the ‘100% Santé’ Reform – 100T-Dent,” which received support from the National Research Agency (ANR), the French agency that funds project-based research. The ANR’s mission is to support and promote the development of basic and applied research across all disciplines, and to strengthen the dialogue between science and society. For more information, visit theANR website.
Marion Bruna, Postdoctoral Researcher in Economics, University of Montpellier
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