No abstract

In France, Germany, Spain, and the United Kingdom, the decades from the late 1980s to the present have witnessed significant change in health policy. Although this has included the spread of internal competition and growing autonomy for certain nonstate and parastate actors, it does not follow that the mechanism at work is a "neoliberal convergence." Rather, the translation into diverse national settings of quasi-market mechanisms is accompanied by a reassertion of regulatory authority and strengthening of statist, as opposed to corporatist, management of national insurance systems. Thus the use of quasi-market tools brings state-strengthening reform. The proximate and necessary cause of this dual transformation is found in the work of small, closely integrated groups of policy professionals, whom we label "programmatic actors." While their identity differs across cases, these actors are strikingly similar in functional role and motivation. Motivated by a desire to wield authority through the promotion of programmatic ideas, rather than by material or careerist interests, these elite groups act both as importers and translators of ideas and as architects of policy. The resulting elite-driven model of policy change integrates ideational and institutionalist elements to explain programmatically coherent change despite institutional resistance and partisan instability.

Germany, France and the Netherlands all have specific 'Bismarckian' health insurance systems, which encounter different and specific problems (and solutions) from those of national health systems. Following a relatively similar trajectory, the three systems have gone through important changes: they now combine universalization through the state and marketization based on regulated competition; they associate more state control (directly or through agencies) and more competition and market mechanisms. Competition between insurers has gained importance in Germany and the Netherlands and the state is reinforcing its controlling capacities in France and Germany. Up to now, continental health insurance systems have remained, however, Bismarckian (they are still mainly financed by social contribution, managed by health insurance funds, they deliver public and private health care, and freedom is still higher than in national health systems), but a new 'regulatory health care state' is emerging. Those changes are embedded in the existing institutions since the aim of the reforms is more to change the logic of institutions than to change the institutions themselves. Hence, structural changes occur without revolution in the system.

To what extent have the recent re-enforcement of the EU budgetary competences lead to a stronger capacity of the EU to prescribe welfare state reforms in France? To answer this question, we compare the situation before and after the regulatory changes at the EU level. We first analyse long-term trends in French welfare reform since the early 1990s until 2009. We underline a strong consistency between EU recommendations and French reforms, despite an absence of explicit reference to EU guidelines when French politicians are presenting the reforms. Governments were afraid that referring to Europe would reinforce opposition to already unpopular welfare reforms. Second, we focus on the reforms adopted when France has been subjected to Excessive Deficit Procedure (in 2009 and since 2013). French authorities have (re)-discovered that the EU has gained two means of pressure: first, the need for deficit reduction is now explicitly integrated into French political discourses and policies (thus having a strong impact on control over social spending) and, second, the EU is able to demand evidence of reform. Finally, we show that France has maintained some flexibility on the timing and content of the reforms. Because, on the one side, welfare state reforms need to be negotiated domestically and, on the other side, of growing market concern about public debt, it remains difficult to claim that Brussels is the main driver of welfare state reform

Germany, France and the Netherlands all have specific 'Bismarckian' health insurance systems, which encounter different and specific problems (and solutions) from those of national health systems. Following a relatively similar trajectory, the three systems have gone through important changes: they now combine universalization through the state and marketization based on regulated competition; they associate more state control (directly or through agencies) and more competition and market mechanisms. Competition between insurers has gained importance in Germany and the Netherlands and the state is reinforcing its controlling capacities in France and Germany. Up to now, continental health insurance systems have remained, however, Bismarckian (they are still mainly financed by social contribution, managed by health insurance funds, they deliver public and private health care, and freedom is still higher than in national health systems), but a new 'regulatory health care state' is emerging. Those changes are embedded in the existing institutions since the aim of the reforms is more to change the logic of institutions than to change the institutions themselves. Hence, structural changes occur without revolution in the system.