Skip to content

Institute of Public Policies

Home » Publications » Report » Refusal of care / denial of care to recipients of the Solidarity-based Supplementary Health Insurance and State Medical Aid

Refusal of care / denial of care to recipients of the Solidarity-based Supplementary Health Insurance and State Medical Aid

Lucie Le Rolland, Pauline Mendras, Delphine Roy, Joyce Sultan Parraud, Léa Toulemon
May 2023
The primary aim of this study is to assess discrimination in access to private healthcare for recipients of the Solidarity-based Supplementary Health Insurance and the Aidant programme , and to analyse the underlying causes as far as possible, whilst also examining the patient’s gender and its impact.
Reference IPP Report No. 43

Quote this publication

Le Rolland, Lucie, Mendras, Pauline, Roy, Delphine, Sultan Parraud, Joyce, Toulemon, Léa (May 2023). ‘Refusal of care / denial of care to recipients of the complementary solidarity health scheme and state medical aid’, IPP Report, No. 43. Institut des politiques publiques (IPP).
Download

Presentation

Whilst the principle of non-discrimination is enshrined in the Public Health Code, it does not prevent a healthcare practitioner from refusing to provide care in certain circumstances that fall within a specific legal framework. It is within this tension between the principle of non-discrimination and the existence of legitimate grounds for Refusal of care / denial of care that disputes may arise. When patients are refused an appointment by a healthcare practitioner on the grounds that they are in receipt of social assistance, there is no doubt that the refusal of care / denial of care is discriminatory. However, discrimination against patients receiving financial assistance can take more insidious forms, particularly when practitioners cite legitimate grounds (lack of availability, conditions not covered by the scheme, etc.) solely in relation to patients receiving financial assistance, for example. At an individual level, it is impossible to know whether such refusals constitute discrimination or whether they are applied to all patients. It is precisely to quantify this phenomenon that the implementation of Testing is necessary.

A public health issue
The refusal of care / denial of care in general practice is problematic both for public health and for the efficiency of healthcare spending, as any delay in seeking care is likely to worsen the patient’s health and may lead to more intensive treatment and hospitalisation, and therefore more costly for the health system. Generally speaking, discrimination in access to care is likely to result in patients foregoing treatment, which is detrimental to their health.

Cette étude vise à évaluer l’existence de discriminations dans l’accès aux soins des bénéficiaires de la complémentaire santé solidaire (CSS) et de l’aide médicale de l’État (AME). The study focuses specifically on general practice across three medical specialities (general practice, paediatrics and ophthalmology). Discrimination is measured by comparing the rates and waiting times for obtaining a medical appointment across different patient profiles.

Key Results

Difficulties in booking initial appointments by telephone
The study highlights difficulties in accessing appointments for everyone: only half of referred patients seeking treatment for non-urgent reasons are able to secure an appointment with a GP or paediatrician. The proportion of appointments secured with an ophthalmologist is higher (nearly 70 per cent), but the waiting times offered are often lengthy (60 days on average after the call).

The chances of securing a medical appointment for CSS beneficiaries are similar to those of reference patients
CSS beneficiaries secure medical appointments at the same rate as reference patients. This finding contrasts with those of previous testing studies on access to care for CMU-C and ACS beneficiaries. CSS beneficiaries nevertheless face explicit discriminatory refusals in 1 to 1.5 per cent of cases.

Discrimination observed against AME beneficiaries
The study’s findings highlight, for the first time, discrimination against AME beneficiaries, who, on average, have to make 1.3 times as many calls as reference patients to secure a medical appointment. Compared with reference patients, AME beneficiaries are between 14 and 36 per cent less likely to secure an appointment with a GP, between 19 and 37 per cent less likely to see an ophthalmologist, and between 5 and 27 per cent less likely to see a paediatrician, regardless of the practitioners’ gender or the sector in which they practise.

Discrimination against AME beneficiaries observed among a minority of doctors but often practised explicitly
Against a backdrop of difficulties in accessing healthcare for all, patients covered by the AME face discrimination, which constitutes an additional barrier to healthcare access for these vulnerable groups. This discrimination is perpetrated by a minority of practitioners, but is of a significant scale and is often expressed explicitly: 4 per cent of requests for appointments by patients covered by the AME with a GP result in an explicit discriminatory refusal, as do 7 per cent of calls for an appointment with a paediatrician and 9 per cent of calls to an ophthalmologist. Overall, nearly one in ten appointment refusals faced by AME beneficiaries is explicitly discriminatory.

Method and Data

Testing

This study is based on telephone testing.

Discrimination is measured by the likelihood of securing an appointment and the time taken between the call and the date of the proposed appointment. The fictitious patients all present themselves as new patients. They cite common reasons for requesting an appointment, all of which are non-urgent in nature. Each practitioner in the sample was contacted by three patients (one covered by AME, one covered by CSS, and one without either CSS or AME, known as a ‘reference’ patient) of the same gender.

The list of doctors to be contacted was randomly selected from the Améli Health Directory from among practitioners practising in mainland France, whether as employees or in private practice, using a stratified sampling method. In total, 3,086 practitioners were reached on three occasions, whilst 3,579 were contacted by at least one of the three patients. More than 34,000 calls were made between March and September 2022 by a team of 10 people.

The study follows on from an initial testing session carried out in 2019 on the refusal of care / denial of care to beneficiaries of the supplementary universal health cover (CMU-C) and the supplementary health insurance payment assistance scheme (ACS), benefits which were replaced by the CSS in 2019.

Testing is a methodology commonly used in the social sciences to measure discrimination in various areas (such as access to employment and housing, etc.). Testing is necessary because the discriminatory nature of a refusal is difficult to determine at an individual level, particularly when legitimate reasons are cited, such as not accepting new patients or having no available places. However, if refusals on legitimate grounds are cited more frequently in relation to social assistance recipients than to patients not receiving such assistance, then discrimination is taking place.

Partners

Défenseur des droits
Last modified: July 21, 2026