Before being able to assess the impact of institutional on programmatic action, it is necessary to present an overview of the institutions found in French and German health care systems. This allows for performing a systematic analysis of how these play out in policy processes. The subsequent two chapters provide an overview of the institutions of French and German health policy, with a particular focus on the institutions for which the previous chapter has formulated hypotheses.

4.1 Institutions of French Health Policy: Centralization, Education, and Advice

In 2000, the French health care system was recognized by the World Health Organization as the best in the world in terms of quality and provision (Schütte et al., 2018, p. 4). Recent typologies refer to the French health care system as an “Etatist Social Health Insurance type” (Böhm et al., 2013, p. 264), indicating a “technocratic civil service elite” (Freeman, 1998, p. 398) that supports a centralized system of decision-making. Yet, typologies of health care systems tend to represent ideal types that are useful as starting points but do not take into account the fullness of institutional complexity (Burau & Blank, 2006, p. 74). Categorizing the French (or German) health care system into highly simplified structures falls short of achieving a deep understanding of the institutions and processes that organize health care, which is the goal of this chapter.

Despite the frequent label of centralization and hierarchical governance, the French health care system was originally rooted in an organization based on municipal structures without noteworthy state intervention, except for epidemic control and municipal governance failures. The establishment of sickness funds in 1928 and 1930 and a fixed social security system in 1945 presented the first steps toward increased autonomization of health care units. These developments culminated in regulations issued by decree in 1967, through the Plan Juppé 1996, to the 2016 Health System Modernization Act, which placed state actors even more at the center of responsibility for health care (Tabuteau, 2010).

The French health care system is based on a contribution-financed health insurance, co-financed by employers and employees, and provides universal health coverage for all citizens through three main insurance schemes, with the general SHI scheme (Caisse Nationale d’Assurance Maladie des Travailleurs Salariés; CNAMTS) covering more than 90% of the French population. The representative for all sickness funds is the National Union of Health Insurance Funds (Union Nationale des Caisses d’Assurance Maladie; UNCAM) (Chevreul et al., 2015, p. 29). The reimbursement principle and free choice of physician apply. However, since 2004, there has been requirement to consult a primary care physician before consulting a specialist. Failure to do so can result in a drop in reimbursement by the health insurance companies from 70% to 40% (Tinapp & Hesselbarth, 2019, p. 33).

The most important institution in the process of health policy-making is the health ministry and—for formal legislation—the parliament. Within the administrative structure of the ministry, some units appear to be particularly relevant for policy formulation. These are the Directorate of Social Security (Direction de la Sécurité Sociale; DSS), the General Directorate of Health Care Supplies (Direction Générale de l’Offre de Soins; DGOS), and the General Directorate of Health (Direction Générale de Santé, DGS). Finally, the General Inspectorate for Social Affairs (Inspection Générale des Affaires Sociales; IGAS) is a central body. Also located within the ministry’s internal structures, it is regularly tasked with investigating and evaluating policies and administrative structures and is an important source of expert advice to both the health ministry and the public, as its reports are publicly available (IGAS, 2020).

In addition to the health ministry and—to a lesser extent—the parliament, the health policy process is dominated by a variety of advisory bodies and the involvement of expert advice. These include the High Council for the Future of Health Insurance (Haut Conseil pour l’Avenir de l’Assurance Maladie; HCAAM), the High Council for Public Health (Haut Conseil de la Santé Publique; HCSP) (former High Committee for Public Health (Haut Comité de la Santé Publique, HCSP)), and the National Health Conference (Conférence Nationale de Santé; CNS), which regularly issue reports on the health care system on the basis of which key decisions are made, such as the annual social security budget (Chevreul et al., 2015, pp. 23-25). In particular, the HCAAM and the CNS provide an interface between the ministry and the UNCAM. While formally attached to the ministry, they are composed of a range of subsystem actors, including health care providers and payers, scientific institutes, unions, and other public and private health care actors. Moreover, they are essentially involved in the development of ideas and the translation of those ideas into concrete policy proposals, thereby influencing the policy-making process through the health ministry (CNS, 2020; HCAAM, 2020).

It is striking that, apart from the central role of the UNCAM, other health care actors are almost excluded from decision-making processes at the federal level (with exceptions at the regional level). Nevertheless, there is a historically important role of physicians’ associations, which at times have been able to block major reforms (Hassenteufel, 1996). French physicians—comparable to those in other countries—highly value their freedom and professional autonomy, making them a natural enemy of constrained competencies and regulation by the state. Despite this potential veto position, the fragmentation of physicians’ associations has enabled governments to overcome these blockades (Immergut, 1992). Although physicians were able to take back regulations adopted in the mid-1990s, for example on reimbursement for exceeding cost caps, the fragmentation of associations remains not only an impeding factor but also a driving factor for major health reforms (Brunn & Hassenteufel, 2018).

The UNCAM has considerable power in setting drug reimbursement prices and negotiating contracts with providers, particularly physicians’ associations. Nevertheless, this power is formal rather than de facto, as the ministry has the authority to decide on the admission of drugs and as the reimbursement rate is also subject to a decree by the minister (Grandfils, 2008, p. 18). Although these decisions are based on the advice of the National Health Authority (Haute Autorité de Santé; HAS) (Goujard, 2018, p. 32) and are guided by the evaluation criteria of evidence-based medicine, the health ministry intervenes regularly (Ansaloni et al., 2018). Thus, following the French centralist state model, decision-making is highly hierarchical. The main structures of decision-making in French health policy are shown in a simplified form in Fig. 4.1.

Fig. 4.1
A block diagram of institutions in the decision-making process. It has H A S, I G A S, H C A A M, and C N S that advises the health ministry, which is linked to the parliament. H A S and H C A A M advises U N C A M.

Institutions with direct access to decision-making processes in French health policy. Source: Simplified and slightly modified overview on the basis of Chevreul et al. (2015, p. 21)

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In summary, the French health care system, like the political system, is characterized by hierarchical structures of policy-making with a remarkably high degree of institutionalized and regular exchange among actors directly involved in health care and combined with a high level of expertise.

4.2 Institutions of German Health Policy: Self-Governance and Corporatism

Although the French and German health care systems are considered prototypes of Bismarckian, that is, contribution-based health insurance systems with compulsory health insurance and universal coverage, the two Bismarckian systems differ considerably. This is not only because the German system is a divided insurance system with the co-existence of statutory and private health insurance. In particular, the history and path dependencies of the two systems differ with regard to the different involvement and organization of medical interests and health insurance actors, the much greater relevance of the employee-employer conflict in France compared to Germany, and the centralized versus decentralized modes of decision-making (Steffen, 2010, pp. 145-148). Comparing the institutional setting of German health policy with the previously elaborated French health care system, these institutional differences become even more apparent. The relevant German health sector institutions are shown in Fig. 4.2.

Fig. 4.2
A block diagram of institutions in the decision-making process. It has D K G, K B V, and G K V S V that are represented in G-B A. S V R-G advises the health ministry that is linked to Bundestag, which is interconnected to Bundesrat.

Institutions with direct access to decision-making processes in German health policy. Source: Simplified and modified overview on the basis of Busse and Blümel (2014, p. 18)

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Although the health ministry and the parliament, with their formal legislative power, play as central a role in Germany as they do in France, and although there are several expert bodies that inform health policy decisions, the institutional conditions under which health policy is made are different. First, because of the German political system, the Federal Council has veto power over health policy decisions that affect subnational competences. These competences lie primarily in the organization of inpatient care, with a central role of hospital planning committees. Even when there are no formal competences in certain areas, the subnational states exert an influence on health policy. Their own ministries and the coordination of health ministries at the subnational level can take the form of think tanks and preparatory as well as experimental laboratories for certain policies before they are placed on the party-political or federal ministerial agenda (Bandelow et al., 2012). Some sickness funds are also subject to subnational rather than federal supervision, which allows subnational states to set different rules than at the federal level (Orlowski, 2008).

In addition to the stronger role of the subnational level, the corporatist structures of the German health care system also differ from the French health care system. The German health care system is characterized by a specific role of self-governance, its multilateral negotiations, and resulting binding decisions among actors of the self-governance. The status of the associations of sickness funds types and the associations of medical professions has grown historically and the state has deliberately given them the remit to guarantee the provision of health care services (Sicherstellungsauftrag), which in the corporatist tradition trades increased responsibility for the need for negotiating consensus. As a consequence, a substantial role for physicians’ associations is foreseen. Since the introduction of selective contracts, the role of sickness funds and physicians’ associations has been further strengthened by granting them the right to negotiate local health care contracts (Jacobs, 2020). The SHI Peak Association (GKV-Spitzenverband, GKV-SV) has a special role in negotiating prices for health care provision and pharmaceuticals (Schnorpfeil & Gassner, 2020) with the Federal Association of Sickness Fund Physicians (Kassenärztliche Bundesvereinigung; KBV) at the federal level.

The most important decision-making body of self-governance is the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA). Excluding its impartial members, the providers (hospitals and physicians, German Hospital Association (Deutsche Krankenhausgesellschaft, DKG) and KBV) and payers (health insurance funds) of health care each have five votes and, by definition, oppose each other. The G-BA is responsible for selecting the range of services to be reimbursed by the SHI system, evaluating methods according to the criteria of evidence-based medicine, and promoting innovative forms of care through the Innovation Fund (G-BA, 2020). While the individual benches sometimes represent very strong interests that are reflected in debates about problems and adequate solutions for German health policy, the institution of the G-BA itself is a decision-making and implementation body that rarely promotes certain reform proposals on its own initiative and as a unit—not least because the G-BA cannot represent uniformly determined positions.

The most prominent advisory body to German health policy with regard to the systematic involvement of scientific advice is the Council of Experts on the Assessment of Developments in the Health Care System (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, SVR-G). Formally located at the health ministry, it produces expert reports that analyze challenges and propose solutions for important developments in the health care system. Its members often comprise health economists and physicians. Since they are based in the health ministry, they have a direct link to the decision-making structures.