Unequal access to dental care despite the reform that caps the prices of crowns and other prosthetics
The so-called “100% healthcare” or “zero out-of-pocket costs” reform applied to dental care aims to improve access to more expensive treatments (crowns, dentures, bridges, etc.). However, analysis shows, on the contrary, that this reform risks exacerbating inequalities in coverage, both because it excludes those without private health insurance and due to the specific characteristics of dental practice (areas underserved by practitioners, freely set fees, etc.).
Marion Bruna, University of Montpellier
Dental care is among the types of care most frequently affected by healthcare non-take-up—that is, the failure to seek the healthcare services that one’s health condition requires. This trend is observed 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 insurance, and in some cases, such as in Greece, the public health system covers no dental costs at all.
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. Regarding dental care, the “100% Health” reform caps the prices of prosthetics (dental crowns, bridges, dentures), in exchange for increased coverage for routine dental care (treatment of cavities, scaling, etc.).
However, its operation relies on private health insurance (i.e., supplemental health insurance, commonly referred to as “mutuelles” even though not all of them fall under the Mutual Insurance Code, ed.) and on the practices of dental surgeons, which may limit its effectiveness in providing access to oral health care.
Conservative treatment versus dental prosthetics
The main distinguishing feature of dental care is the dual nature of treatment: on the one hand, conservative treatments, which aim to preserve as much of the tooth’s natural structure as possible (such as scaling and root canal therapy), 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 driven by an economic model that favors prosthetic care. This system has been accompanied by a more than 66% increase in out-of-pocket costs for these procedures over the past ten years, contributing 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 the dental profession is that the vast majority of dentists work 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 workload (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 nature 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 National Health Insurance and professional organizations representing dentists. It is based on a two-pronged approach: on the one hand, capping the rates for prosthetic care to limit overcharging, and on the other hand, increasing the reimbursement rates for preventive care (treatment of cavities, 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 set of guaranteed services with no out-of-pocket costs, accessible to everyone 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, as most dentists are in private practice (meaning they set their own fees), and by their uneven geographical 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 without low income.
While existing research on access to healthcare by geographic area has focused 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, which 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 aim 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 contributed to shaping 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% Health” program, and their freedom to set their own rates remains guaranteed.
Dentists provide care within a relationship characterized by an information imbalance: the dentist has more information than the patient about the necessary treatment and the various available options.
In some cases, particularly in contexts 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, mandatory health insurance is the primary source of funding for fixed public rates, these rates remain significantly lower than the actual prices charged by dentists, particularly for dental prosthetics. The role of health insurance is thus constrained by 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 Medicare and private health insurance cover?
- The mandatory health insurance program (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 step with the actual fees charged by dentists, particularly for crowns, dentures, and bridges.
- Supplementary health insurance covers the portion of expenses not covered by mandatory health insurance, but the amounts reimbursed 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” (private health insurance providers) play an essential role in funding dental care reimbursements. The level of coverage they provide varies from person to person, depending on the specific policy held. In fact, the level of reimbursement for costly treatments, such as dental prosthetics, is closely tied to the quality of the policy, which serves to reinforce structural inequalities in access to oral health care.
The “100% Health” initiative thus appears to be a further step toward the privatization of healthcare financing, making supplementary health insurance essential to prevent people from forgoing medical care.
These successive reforms are gradually leading to higher prices for 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 healthcare access programs. 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 necessity of relying on private health insurance.
This article is based on research conducted as part of the project “Equal Access to Dental Care in the ‘100% Santé’ Reform – 100T-Dent,” which received support from the French National Research Agency (ANR), the agency responsible for funding project-based research in France. 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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