Sixteen years after the adoption of Law No. 2009-879 of 21 July 2009, known as the ‘Hospitals, Patients, Health and Territories’ Act, the legal nature of public healthcare institutions remained shrouded in persistent doctrinal uncertainty.
Whilst the 2009 reform had undoubtedly strengthened their ties to the State, it had not expressly settled the question of whether they belonged to the category of State public institutions.
In a landmark judgment of 4 December 2025 (No. 23-10.525), the Court of Cassation appears to have resolved all uncertainty by confirming, in particularly explicit terms, this classification.
The case brought before the High Court originated in a bold legal argument put forward by the Montargis Urban Area Hospital Centre. Relying on the wording of Article L. 6141-1 of the Public Health Code, as amended by the HPST Act, which states that public health establishments are legal persons governed by public law “subject to State control”, the institution argued that it should henceforth be regarded as a public institution of the State within the meaning of Article L. 413-14 of the Social Security Code. It concluded that it was therefore entitled to benefit from the self-insurance scheme for occupational accidents and diseases applicable to certain public State institutions employing a large number of contract staff.
This reasoning indirectly invited the Court of Cassation to rule on an issue that had never really been addressed head-on, either by the ordinary courts or by the administrative courts.
It is true that neither the legislation nor case law had, until then, provided a positive definition of the concept of a public institution of the State. Administrative doctrine, particularly in light of the Council of State’s study of 15 October 2009 on public institutions, traditionally refers to the criterion of affiliation with a public body, distinguishing between public institutions of the State and those falling under the jurisdiction of local authorities. However, this framework had never been explicitly applied to public health establishments by the courts, even though certain decisions of the Council of State had suggested their similarity to state public establishments (see, in particular, Council of State, 1 October 2018, No. 404677).
In its judgment of 4 December 2025, the Court of Cassation dismissed, on the merits, the hospital’s claim. It strictly reiterates that contract staff in public healthcare establishments are subject to a specific legal regime, derived in particular from Law No. 86-33 of 9 January 1986 and Decree No. 91-155 of 6 February 1991, which imposes compulsory membership of the primary health insurance funds for the coverage of occupational risks. In the absence of any express provision, the HPST Act cannot be interpreted as having intended to call into question this derogatory regime. The decision to dismiss the case was therefore inevitable.
The key contribution of the decision, however, lies in a ground whose scope extends far beyond the dispute. In unambiguous terms, the Court states that the hospital in question constitutes ‘a public establishment of the State’. Through this explicit classification, the High Court puts an end to a long-standing uncertainty and establishes, for the first time in such clear and un d terms, that public healthcare establishments belong to the category of public State institutions.
This clarification is not without nuance. The judgment implicitly reveals the profoundly hybrid nature of the status of public healthcare institutions. Whilst their institutional affiliation with the State is now established, they remain subject, in the performance of their duties and particularly in the management of their staff, to specific legal regimes that distinguish them significantly from other public institutions of the State. The recognition of their state nature does not, therefore, in itself entail the automatic application of all the rules applicable to the latter.
Consequently, the decision only partially dispels the initial ambiguity. It establishes an institutional affiliation without drawing all the normative consequences from it, leaving a form of dissociation between the legal classification and the applicable regime. The judgment thus highlights the continuing uniqueness of public health establishments.
It is therefore not certain that the Court of Cassation has definitively settled the debate …
