PIERRU Frédéric

IRISES (institute for research in sociology, economics, and political science), University Paris-Dauphine

The paradoxical restructuring of the French health state

Between transnationalisation, europeanisation and individualisation

Recent social and political science works have evidenced the dialectics of closure and openness of health care spaces. While the periods of foundation and reform of health care systems were contemporaneous to growing extraversion processes from policymakers, their expansion coincided with a trend towards closure within national boundaries. For example, at the end of WW2, the founders of “modern systems” of health insurance focused on Bismarck and Beveridge-inspired models and weighed their pros and cons before developing their own models according to the socio-political contexts they are faced with. However, once institutional options were taken, of health care systems expanded according to each country’s path dependence. The golden age of the welfare state was also that of the national closure of debate and public policy orientations.

The involvement of international (OECD, World Bank) or supranational (European Union) organisations in the health sector and the establishment of transnational networks of experts and academics made comparatism common practice. National health care systems were then compared through public health and economic science modelisations. This extraversion process emerged at the same time as the dissemination of government knowledge.

I will then show how state capacity building in France was largely influenced by foreign, especially North American experiments on the basis of new government knowledge designed in other countries. The growing weight of state actors is in keeping with new public management. In the health insurance sector where curbing health care costs has always been a priority of the policy agenda, a “management coalition” made up of economists and health managers gradually gained ground and knew their climax when the Juppé health care plan was issued in 1995. Health economics, a discipline in which Anglo-Saxon countries had a preeminent place, prevailed over law and became popular in France among reformers. These reformers ambitioned to provide the state with instruments and recipes for public action with a view to see the general interest prevail over numerous and powerful private interests (payroll workers’ unions, professional doctors, pharmaceutical industry, locally elected members, etc.). After many health scandals broke out, public health administration was revamped and many health agencies – the new organisational form emblematic of new public management – were set up in the late 1980s.

Nowadays, individual responsibility occupies a central place in the health sector. The failure of the management coalition due to the resistance of private interests, led to the underground restructuring of health insurance and the gradual withdrawal of state funding because of soaring social deficits. Instead, individuals have to rely on their private health insurance in the name of “financial responsibility” and “freedom of choice”. Basically, the state seeks to promote the figure of a rational, informed health care consumer who makes the right choices thanks to the information at his/her disposal.