Social health insurance systems : what makes the differences ? The bismarckian case in France and Germany
Résumé
The article concentrates on a single theoretical model, the Bismarckian social health insurance system, and examines its functioning in the two major cases of application, France and Germany. The comparative results demonstrate that the “same” institutional model can differ substantially. They reveal the weakness of classification principles that ignore the differences in the system of actors and in the political context. The first section provides an account of basic similarities and differences between the two cases. The second section shows how the national architecture shapes reform trajectories in cost containment, emphasizing finance, access, and the implication of the medical profession. The third section concentrates on the key element of the model, the management capacity of social health insurance that sharply differentiates the two cases. The fourth section interprets the comparative results. It argues that both systems are hybrid, and that hybridization should be considered as a normal and unavoidable process. Finally, it characterizes the German case as “renewed social risk management”, and the French case as “liberal universalism”. The latter concept, although seen as contradictory in welfare state theory, not only explains the French system; it may also provide a perspective for theorizing new types of public/private arrangement developing in advanced healthcare systems.
Domaines
Science politique
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