Forty-six point five billion euros in mutual insurance contributions in 2024, up more than 8% in a year [6]. A modest retiree devotes nearly 10% of their income to health. A wealthy retiree, 3.9% [1]. The 2027 arbitration is there: maintain this two-tier system of financing, private and regressive, or absorb it into the general scheme by changing the contribution base.
Out-of-pocket costs among Europe’s lowest, but rising
France ranks among the two or three EU countries where households pay the least from their own pockets. In 2024, out-of-pocket costs per capita on health care consumption and medical goods reached 292 euros, compared to 276 euros in 2023 [2]. In international terms, this represents 10.2% of current health spending. The European average is 14.8% [2].
This result is the fruit of sixty years of construction. The share of households’ out-of-pocket costs in health care consumption fell from 9.4% in 2008 to 7.5% in 2017 [2]. The main driver was the expansion of long-term illnesses, which entitle patients to 100% coverage by Social Security.
Since 2023, the trend has reversed. Three movements are occurring simultaneously: the increase in long-term illness cases mechanically raises the public share; certain reimbursements are declining; and the doubling of deductibles and fixed co-payments is raising households’ direct contribution [2].
What the 292-euro average does not say
292 euros is an average. It blends opposite situations depending on age, income, and illness.
The effort rate—that is, the share of income devoted to health by combining mandatory contributions, complementary insurance premiums, and out-of-pocket costs—reached approximately 15% of income on average in 2019, or about 6,800 euros per year. This is more than the 4,400 euros spent on food [1].
But behind this average, this rate ranges from 2.7% for those aged 30-39 to 8.2% for those over 80 [1]. Among retirees, the income-based gap is even more pronounced. The poorest 20% devote nearly 10% of their income to health. The wealthiest 20%, 3.9% [1].
In 2019, 4% of people had no complementary health coverage. This rate rose to 12% among the poorest 10% [4]. Without complementary coverage, the insured person pays the entire co-payment themselves, and budget contracts cover little in terms of fee overages.
Illness widens the gaps equally. An insured person with long-term illness for diabetes bears an out-of-pocket cost of 530 euros on average for expenses outside the long-term illness scheme. Approximately 230 euros concern vision care, hearing aids, and dentistry [14]. Long-term care represents 16% of current health spending but concentrates 37% of total households’ out-of-pocket costs [2]. An elderly patient losing autonomy pays, proportionally, three times more than the national average suggests.
Three successive transfers weighing on premiums
A fundamental mechanism redistributes the burden from the public sector to the private sector, then to households.
First movement: the rise in fee overages. In 2005, they represented 1.9 billion euros. In 2019, 3.2 billion. In 2024, 4.5 billion [10].
The share of specialists in sector 2 rose from 37% to 56% between 2000 and 2024 [10]. More than three-quarters of young specialists now choose sector 2. Among newly trained dentists and rheumatologists, this proportion reached 94% in 2024. Among ENT specialists, 89%. Among surgeons, 88% [10].
The projection from HCAAM is striking. If these trends continue, sector 2 would represent 89% of specialists outside general medicine by 2040. Fee overages could exceed 10 billion euros compared to 4.7 billion in 2025 [11].
Second movement: the transfer of charges from Social Security to complementary insurers. Since October 2023, complementary plans have covered 40% of dental care compared to 30% previously. This transfer represents 500 million euros per year in their expenses [6]. The rollout of 100% Health coverage transferred an additional 2.2 billion euros to them, partially passed on to premiums [5].
Third movement: the pass-through to contributions. In 2024, mutual insurance premiums increased by 8.1% on average [19]. Complementary organizations collected 46.5 billion euros in health contributions. This is an 8.2% increase compared to 2023, the largest since 2012 [6].
A mutual insurance contribution is a flat premium, insensitive to income. This is what distinguishes it from a social contribution. Raising deductibles or letting premiums increase transfers the financing problem to households, hitting first those with the least margin. DREES had warned of this before the doubling of deductibles in 2024: this measure weighs more heavily on households in poorer health [1].
A demographic wave that changes the scale of the problem
In 2021, 12 million people suffered from a chronic illness recognized as long-term illness. Prevalence rose from 14.6% in 2008 to 17.8% in 2021. Annual growth in diabetes has reached 5% since 2010 [9].
CNAM projects a structural shift. The number of long-term illness beneficiaries could rise from 14.1 million in 2023 to 18 million in 2035 [9]. The average spending for a long-term illness patient reaches 9,560 euros per year.
Outside long-term illness, it falls to 1,230 euros [14]. CNAM projects that spending for long-term illness patients could represent 75% of reimbursed spending by 2035 [9]. Without new measures, the Social Security deficit could reach minus 41 billion euros by 2030 [9].
What this figure masks is its cause. The growth in long-term illnesses comes from aging, better screening, and medical progress that transforms illnesses once fatal into manageable chronic diseases. Reducing the scope of long-term illnesses to compress the deficit amounts to having the sickest patients finance the very success of the medicine that keeps them alive.
Thinking about chronic health financing as a question of distribution between generations, rather than as a problem of individual irresponsibility, is a position defended by economists working on life courses, notably Hippolyte d’Albis [16]. This requires broadening the base of contributors without having the adjustment weigh on the most vulnerable.
What 100% Health coverage proved, and where the limit emerges
The 100% Health reform, rolled out between 2019 and 2021 for vision care, hearing aids, and dentistry, offers a first concrete case. Social Security data show a decline in care forgone for financial reasons across all three domains between 2018 and 2024. The decline reaches 34% in dentistry, 27% in hearing, 22% in vision [15].
But 38% of beneficiaries were still unaware in 2024 of the existence of a 100% Health quote. The Court of Accounts notes an average 6% increase in free-market prices for vision care: pricing pressure shifted toward higher-tier offerings [15].
In mental health, the My Mental Health Support scheme is progressing but remains partial. It now offers up to 12 reimbursed sessions per year, at 50 euros each [8]. Direct payment for the Social Security portion is planned starting October 2026 for these sessions. But the scheme does not cover severe psychiatric disorders, suicide risks, or addictions. For intensive care with a sector 2 psychiatrist without solid complementary coverage, the out-of-pocket cost remains largely uncovered [8].
Financial protection for patients has progressed, but gaps remain, particularly for low-income people and chronic illness patients, as WHO Europe notes [7].
Absorbing complementary coverage into the general scheme, changing the contribution base
Complementary health insurance has become a second health insurance system. It is private, it collects 46.5 billion euros [6], and it reimburses what the first tier decided no longer to cover. Its premium is flat: it weighs the same amount for the modest retiree at a 10% effort rate as for the executive at 3.9% [1]. It is this architecture that transforms illness protection into a regressive levy.
The 2027 arbitration is as follows: progressively merge mandatory complementary coverage into Social Security, and finance this shift by broadening the base of social contributions to capital income. The general social contribution (CSG) already exists as a beginning of a response, but it has never been assumed as a substitute for private insurance premiums. A chronic illness is a collective certainty. It is financed through the broadest possible pooling [16]. The explicit trade-off is the following: complementary organizations cease to be the second payer for outpatient care and long-term illness.
This choice eliminates the main mechanism that finances fee overages. Without complementary reimbursement to absorb them, the dynamics of sector 2, projected to exceed 10 billion euros by 2040 [11], changes in nature. Regulating supply without a second payer then becomes a separate issue, which goes beyond merely revising the medical procedures nomenclature.
What opens up: current regressivity disappears by design. The 12% of modest households without coverage [4] enter the general scheme without additional procedures or out-of-pocket costs.
What closes and what costs: the mutual insurance market for routine care, which represents the bulk of the 46.5 billion collected, ceases to exist [6]. The contribution based on capital income rises. The takeover of company collective contracts, which currently cover 30 million salaried workers, must be organized without loss of rights. The political risk is real facing mutual groups and insurers. It is the price of coverage finally independent of income.
Sources
[1] DREES, “Health Spending: An Effort Rate Progressive for the Employed, Lower for Wealthy Retirees and Very High for Some Modest Households,” Studies and Results No. 1345, August 2025, https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse/250828_ER_depenses-de-sante (accessed 14/08/2026).
[2] DREES, “Health Spending in 2024 (Results of Health Accounts) 2025 Edition,” DREES Panoramas, September 2025 (corrected December 2025), https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse-infographie-documents-de-reference/250930-Panorama-depenses-de-sante (accessed 14/08/2026).
[3] DREES, “Health Spending in 2023 (Results of Health Accounts) 2024 Edition,” DREES Panoramas, November 2024, https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse-documents-de-reference/panoramas-de-la-drees/241120-Panorama-CNS24 (accessed 14/08/2026).
[4] DREES, “Complementary Health Insurance: Actors, Beneficiaries, Coverage: 2024 Edition,” DREES Panoramas, July 2024, https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse/panoramas-de-la-drees/240710_Panorama_ComplementaireSante2024 (accessed 14/08/2026).
[5] DREES, “100% Health Reform: What Effects to Expect on Complementary Health Contract Premiums?,” Studies and Results No. 1338, April 2025, https://drees.solidarites-sante.gouv.fr/sites/default/files/2025-04/ER1338-MEL%20(3).pdf (accessed 14/08/2026).
[6] DREES, 2025 Report on the Financial Situation of Complementary Organizations Providing Health Coverage, December 2025, https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse-documents-de-reference/rapports/251218-rapport-organismes-complementaires (accessed 14/08/2026).
[7] WHO/Europe, “Are Health Care and Services Financially Accessible? New Evidence on Financial Protection in France,” April 2024, https://www.who.int/europe/fr/news/item/22-04-2024-out-of-pocket-payments-for-health-care-are-low-in-france–but-gaps-persist-for-people-with-low-incomes–new-who-report-reveals (accessed 14/08/2026).
[8] WHO, “2024 Global Report on Health Spending,” December 2024, https://www.who.int/fr/news/item/12-12-2024-new-who-report-reveals-governments-deprioritizing-health-spending (accessed 14/08/2026).
[9] CNAM, “Presentation of the Annual Report on Charges and Income for 2026,” June 2025, https://www.assurance-maladie.ameli.fr/presse/2025-06-24-cp-presentation-rapport-charges-et-produits-2026 (accessed 14/08/2026).
[10] HCAAM, “Fee Overages of Physicians: State of Play,” report, October 2025, https://www.securite-sociale.fr/files/live/sites/SSFR/files/HCAAM/2025/Rapport%20DH%20Etat%20des%20lieux%20Hcaam.pdf (accessed 14/08/2026).
[11] HCAAM, “Fee Overages: An Exception to the Principle,” Health Insights No. 3, June 2026, https://www.strategie-plan.gouv.fr/files/files/Publications/2026/2026-06-23%20-%20HCAAM%20-%20Décryptage%20santé%203/ (accessed 14/08/2026).
[12] Social Security, “Health Insurance Spending for Insured Persons with Long-Term Illnesses,” REPSS Illness Edition 2025, https://evaluation.securite-sociale.fr/home/maladie/1.7.2.-D%C3%A9penses-d%E2%80%99assurance-mala.html (accessed 14/08/2026).
[13] Social Security, “100% Health Scheme for Vision, Hearing and Dentistry,” REPSS Illness Edition 2025, https://evaluation.securite-sociale.fr/home/maladie/245-dispositif-100–sante-en-opt.html (accessed 14/08/2026).
[14] Hippolyte d’Albis, work on the economics of life courses, demography and generations (PJSE/Paris 1).
[15] Mutualité Française, “Increases in Health Spending, Charge Transfers: 2024 Contributions,” https://www.mutualite.fr/actualites/hausses-des-depenses-de-sante-transferts-de-charges-revalorisation-des-salaires-et-honoraires-pesent-sur-les-cotisations-des-mutuelles-en-2024/ (accessed 14/08/2026).
