The analysis of the institutions that enabled French and German programmatic action takes as its starting point existing research on programmatic groups in health policy identified by existing studies. In the French case, there is an extensive body of research on the French welfare state elite, which implemented substantial health care reforms between 1990 and 2010 at minimum (Genieys & Hassenteufel, 2001; Hassenteufel et al., 2010). The following steps thus proceed through the formal research protocol for identifying potential programmatic groups in a policy area with the goal of laying the groundwork for identifying the programmatic actors to be interviewed in light of the central research question about the institutions of programmatic action. In doing so, the research steps take into account the identification of programmatic action in France and Germany in existing research.

5.1 Policy Program in French Health Policy

Looking at the laws that were passed and substantially reformed the health care system (Table 5.1), what can be observed as third-order policy change, and thus a major realignment, is the increasing use of a narrative that sees rising health care costs as the main problem and a centralization of competences with a stronger role of the state as the solution to this problem. In the early 1990s, some measures were taken in this direction, based on negotiations between the social partners to achieve a reduction in health care spending.

Table 5.1 Substantial health care reforms in France 1990–2010
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However, these measures largely failed until the adoption of the so-called Plan Juppé, which is a reform that fundamentally restructured the health care system by introducing a universal health insurance system and giving parliament the annual task of setting an expenditure target for the national sickness funds (Bouget, 1998, p. 162; Lancry & Sandier, 1999). The so-called financing laws of the social security (Projet de loi de financement de la Sécurité sociale, or PLFSS) are prepared each year by the DSS; this strengthens the role of the directorate and the state in social security financial decisions. In particular, since the preparation of this law and the DSS is under the double supervision of the health ministry and the finance ministry, this can be considered a key instrument for cost containment (Genieys & Hassenteufel, 2015, pp. 288-289). Other instruments of the Plan Juppé include the establishment of an annual national health conference attended by representatives of sectoral actors to prepare the annual finance law, and an administrative reform of the way the director of France’s largest sickness fund, the CNAMTS, is appointed. This again increased state authority and oversight of sectoral actors. Other specific cost-control measures included the expansion of the social security income base subject to include capital income and the introduction of the “remboursement de la dette sociale”—a 0.5% tax on taxable income explicitly and exclusively intended to finance the deficit (Ruellan, 2015), as well as the creation of the CADES (Caisse d’Amortissement de la Dette Sociale; Social Debt Amortisation Fund) (Ract-Madoux & Gauthey, 2018).

The Plan Juppé met with strong opposition from the physicians’ associations during its preparatory phase, especially because of the envisaged changes to a general practitioner-centered model of health care and an associated reform of physicians’ remuneration (from a free basis to a contractual basis) and fixed budgets. In the course of their protests, the physicians’ associations accused these measures of undermining the principle of “médecine libérale” and thus weakening the role of the physicians as self-employed entrepreneurs in a free economy.

Continuing the reforms that appealed to cost containment, the Douste-Blazy reform employed computerized patient records and a 1€ contact fee for a doctor’s visit, along with charging for specialist treatment without prior consultation with a general practitioner, to control doctor visits and thus reduce costs. The reform also promoted the use of generic drugs, which are less expensive (Bosch, 2004), and created the National Union of Health Insurance Funds (Union Nationale des Caisses d’Assurance Maladie; UNCAM) as the representative body of the three major sickness funds. The director of UNCAM negotiates with the unions of physicians and other health professionals and signs medical agreements to meet health insurance spending targets set by parliament—a task previously assigned to the board of directors of the CNAMTS, whose director is now automatically also the director of UNCAM (Hassenteufel & Palier, 2005, p. 17). Both reforms also shifted decisive power from the social partners to the state, with centralization occurring through the merger of associations and the state’s authority to appoint the directors of associations and thus shape positions of power (Hassenteufel & Palier, 2016, p. 68). These mergers and centralization of processes are often referred to as the solution to the challenge of a fragmented and diffuse nature of interest representation that was previously prevalent in the French health care sector. As a result of these preexisting structures, some policies lacked legitimacy among sectoral actors because they were negotiated and endorsed only by some interest unions but not by others, such as the reorganization of primary care through a “reference practitioner”, a French model of general practitioner-centered health care.

These centralization ideas intellectually can be traced back to a commission chaired by Raymond Soubie, whose report strongly influenced not only the Plan Juppé but also the creation of regional hospital agencies (Agences Régionales de l’Hospitalisation; ARH) and their later successors, the regional health agencies (Agences Régionales de Santé, ARS), created in the course of the later 2009 HPST (Pierru & Rolland, 2016, p. 83). The latter was aimed at reorganizing regional care, particularly hospitals, and has been in preparation since Nicolas Sarkozy took office in 2007. The HPST reform was structurally designed to strengthen the state, primarily by tying hospital directors to the newly established regional health agencies (ARS). These act as an extension of the state and are equipped with the necessary competences to coordinate the regional health services and control related expenses (Grimaldi, 2015; Lopez, 2010, p. 567).

Researching a little deeper into the origins of these health care reforms, it becomes apparent that the reform ideas can be traced back to several working commissions within which these conceptions were worked out and to which the actors driving the reform process belonged. The first is the aforementioned planning commission chaired by Raymond Soubie, which was charged with conducting a prospective reflection on the future of the French health care system, resulting in a report called “Santé 2010” (Soubie et al., 1993). The work was done primarily through working groups led by Anne-Marie Brocas, Robert Rochefort, Christian Rollet/Lise Rochaix, and Aïssa Khélifa (Bras & Tabuteau, 2009, p. 80). In essence, the commission’s report put forward concrete proposals on cost containment, specifically on parliamentary control and the setting of an annual budget target. Related to this, the report also called for a fundamental restructuring of the health care system, in particular with regard to a centralization of the state’s competences and a national administration defining the main lines of health policy and relies on a public institution (Bras & Tabuteau, 2009, p. 85). At the same time, a regionalization of health care and a centralization of decision-making and service provision through the merging of sickness funds and state services, and thus the creation of regional health service agencies, which then negotiate with the providers on prices, quantities, and quality of health care, is proposed (Bezat, 1993).

Cost containment measures had already been advocated by the same Raymond Soubie when he delivered the “Livre blanc sur le système de santé et d’assurance maladie” (White Paper on the Health and Health Insurance System) to then prime minister Balladur in December 1994 (Soubie et al., 1995). By this time, there were already several commissions, all of which had the task of evaluating the future of French policy sectors. Chief among these was a “Commission for the Evaluation of the Social, Economic and Financial Situation of France”, which included bureaucrats and scientific advisors from a variety of disciplines (given the broad range of topics) and which included—in addition to Raymond Soubie—Jean Raynaud, Jacques Barel, Jean-Claude Casanova, Marguerite Gentzbittel, Lucien Israël, Pierre Laurent, Raymond Lévy, Jean Pinchon, Jean-Philippe Ricalens, Simon Rozes, Dominique Schnapper, and Guy Vidal (Treize membres., 1993) and a commission chaired by Alain Minc on “France in the year 2000” (members included Claude Bebear, Jean-Louis Beffa, Michel Bon, Isabelle Bouillot, Luc Ferry, Jean-Paul Fitoussi, Jean-Baptiste de Foucauld, Pierre Guillen, Rene Lenoir, Rene Remond, Pierre Rosanvallon, Raymond Soubie, and Alain Touraine) which proposed that the social partners also be involved in a major reform effort (Seux, 1994). The reports of Raymond Soubie and Alain Minc, as well as that of Philippe Lazar on ambulatory care in the regions, and the ideas of François-Xavier Stasse influenced the reform proposal pushed by Alain Juppé to regionalize health care while centralizing decision-making (Nouchi, 1995).

The HPST continued the ideational line of centralizing decision-making power by empowering hospital directors, as opposed to hospital boards of directors, to meet financial targets (Simonet, 2017, p. 3). One of the main components of the 2009 HPST reform under then health minister Roselyne Bachelot-Narquine was the creation of ARS. The report issued by the rapporteur Philippe Ritter in January 2008, entitled “Rapport sur la creation des agencies régionales de santé” (Report on the creation of regional health agencies), that announces this reform step explicitly refers to the origins of this policy idea. I quote the report (Ritter, 2008, p. 1) (translated):

  • “the Minister has instructed [Philippe Ritter] to set up a mission to prepare for their creation, relying primarily on broad consultation with all the players concerned”;

  • “the result of this consultation, carried out with elected representatives, officials of the ministries concerned and of the health insurance, as well as with representatives of health professionals and users, but also of numerous reports and written contributions, this report presents a summary of the mission’s work”;

  • “its content and recommendations have been the subject of regular discussions in particular with a working group made up of representatives of UNCAM and each of the administrative departments concerned, and with the steering committee for the reform, chaired by the minister, bringing together, in addition to the ministry, parliamentarians, representatives of the ministries of the interior, labour and the budget, and representatives of each of the health insurance schemes”.

Therefore, one can conclude from this document that the policy idea at the core of the HPST reform was in fact the result of long-term preparation around a regularly meeting group of actors from various institutions that belonged directly to the state apparatus. But not only does the trajectory of this reform become clearer; the connection of the HPST reform with previous reform steps, in particular the Plan Juppé, is explicitly outlined in the introductory chapter. “The 1996 reform creating the ARH was a first step, which must now be completed and surpassed. The creation of ARS based on orderly cooperation between the State and the Health Insurance is one of the most important institutional reforms of recent decades” (Ritter, 2008, p. 2).

In addition and related to the creation of the ARS, the HPST included several other measures to facilitate collaboration among health institutions, particularly at the regional level (IRDES, 2018): For example, one or more public health establishments could join together to form territorial hospital communities (communautés hospitalières territoriales, CHT) and, through delegation or transfer of competences and telemedicine, implement a common strategy and jointly manage certain functions and activities. Such an agreement is subject to approval by the directors of the establishments, after consultation with their supervisory boards, and ultimately by the director general of the ARS. Another possibility for collaboration arose through so-called health cooperation and resource groups (groupements de coopération sanitaire de moyens, GCSM), which could be composed of public and private health establishments, medico-social establishments, health centers, and independent medical professionals working individually or in companies. The formation of such groups would, in turn, allow for the joint organization or management of administrative, logistical, technical, medico-technical, teaching, or research activities and would require approval by the director general of the ARS. Finally, private health institutions are now less restricted in participating in public service provision, as this no longer depends on a special status. Under the label of private health establishments of collective interest (établissements de santé privés d’intérêt collectif (ESPIC)), private health institutions can register with the respective ARS either as cancer centers or as private health establishments managed by non-profit organizations (IRDES, 2018, pp. 8-12). In terms of cost containment, this inter-establishment collaboration between public and public, as well as private, facilities allow for more efficient use of resources and more responsive health care planning to regional needs. Overall, health care provision is organized more regionally than before, but it should not be confused with a decentralization of competences, as the ARS bundles various competences in a single institution that serves as an intermediary body to implement national guidelines and thus has only “relative autonomy” (Evin, 2019, p. 109). Nevertheless, policy ideas on the regionalization of health care can be traced back to the “Santé 2010” policy program.

Although many scholars of French health policy see the three reforms described above (Plan Juppé, Réforme Douste-Blazy, HPST) as the fundamental reforms in health care during the period under study, following a coherent vision for the policy sector (Hassenteufel, 2012; Palier, 2008, pp. 96-112; Ruellan, 2015), not all reforms in health policy can be attributed to the policy ideas and fit the substantive vision of the identified policy program. Some reforms did not explicitly pursue the goal of cost containment, but rather were the response to emerging problems, such as increased regulations following a contaminated blood scandal reveal.

In addition, the process of reducing the laws found under the keyword “santé” has removed from consideration some reforms that were related to other policy areas or specific areas of the policy sector, such as professional training and public health and prevention. However, these reforms may well belong to another policy program, possibly a cross-sectoral program aimed at combining environmental protection and public health, for example. In particular, some of the reforms between 1990 and 2010 also modified the code of public health (santé publique), for example, the “LOI n° 2004-806 du 9 août 2004 relative à la politique de santé publique (1)”. Public health and prevention policies were also put on the agenda in the wake of the COVID-19 pandemic, which reached France in January 2020 and spread across Europe in March through June 2020 (Capano et al., 2020; Schrappe et al., 2020; Weible et al., 2020), although this already concerns the second period of analysis after 2010. Additionally, there are some reforms explicitly related to family and care policies and criminal justice policies, each of which could be indications of an underlying programmatic group.

Without neglecting the existence of other programmatic groups behind these thematic foci, further empirical analysis will focus on the structural reforms of the health insurance system in France, that is, the modification of the code of social security (code de la sécurité sociale), the substantial reorganization of the health care system, whose modifications were aimed at cost containment. This narrative description of the problem (inefficiency, rising costs) and the corresponding solution (setting annual targets for expenses, centralizing responsibility for meeting these targets, narrowing leeway for negotiating contracts between the social partners), which can be found in the reports and legal documents analyzed earlier, will also be kept in mind for the upcoming discourse analysis in search of the actors surrounding this narrative.

5.2 Programmatic Actors in French Health Policy

Tracing policy reforms back to ideational and personal roots allowed for an initial identification of substantial foci of policy reforms toward a potential policy program and the individuals who were mainly active in these ideational processes. This second step serves even more to explore the policy program as it appears not only in formal documents but also in public discourse. Therefore, in this subchapter, such discourse analysis will be conducted in relation to keywords in the public debate on health care policy.

Regarding the selection of media sources for an analysis of public discourse, the French daily newspaper Le Monde is chosen for several reasons: It has a relatively high circulation—next to Le Figaro (ACPM, 2020), but—as opposed to the comparably prominent newspapers—has a quasi-iconic status (Wilcox, 2005). Moreover, existing research analyzing public discourse selects Le Monde as the French newspaper with reference to its dominance in the coverage of political issues (Jacobs & van Spanje, 2020). Even if the fact that it is a center-left newspaper may imply that reports on political issues are written from a left-wing ideological view, the main idea of the discourse analysis is to trace policy ideas independent of their evaluation or frame back to policy actors. And even if the leftist orientation of the newspaper would result in a bias that grants more presence in newspaper to some policy actors but not others (and some ideas but not others), the multi-methodological procedure applied in this study, which also includes the analysis of policy documents and interviews, provides an ideal setting for cross-checking the empirical results of the media analysis. It thereby would enable the identification of actors that are present in the public discourse, but not in the policy process or vice versa.

As a result of the health care reforms 1990–2010 studied, the period between 1 January 1990 and 31 December 2010 is searched for the relevant keywords of health care reforms. The search is performed via LexisNexis (www.nexisuni.com). Specifically, the keywords “social security/health insurance” (sécurité sociale/assurance maladie) and “health policy” (politique de santé) are used as search terms to locate articles dealing with the public debate on health care reform. For Le Monde, these search terms yield 168 hits for the specified study period. The articles are downloaded and transferred to a dataset within the discourse network analysis program DNA. After removing duplicates and articles that do not fit the topic, 84 articles remain in the dataset to be analyzed. The link to the dataset is provided in the appendix.

Once the selected articles are integrated into a dataset, the PAF allows for analysis of their content in light of the assumption that programmatic actors ideationally agree on the content of a policy program and use that program in the struggle for authority in the sector. These connections between policy program elements and actors can be tested using discourse network analyses (Bandelow & Hornung, 2019). This leads to the expectation that indicators of programmatic action are not limited to an observed substantial connection between adopted policies, but also include an assessment that actors who promote these policy programs use the same narrative in the public discourse and share a common view of policy problems and solutions in their sector. Thus, the analysis focuses exclusively on statements that can be directly attributed to individual actors, as the PAF’s perspective is on individual actors. However, actors appearing in the discourse network cannot be compared to programmatic actors. Actors that appear in public discourse are mostly politicians and well-known, memorable individuals, while programmatic actors are sectoral actors that do not follow the media or political logic. The discourse network thus presents an initial indication of a unanimously agreed policy program, but without already revealing programmatic actors.

Figure 5.1 depicts the discourse network resulting from the coding of statements in the selected articles. To allow a comparison of discourse development over time, Fig. 5.1 starts with the discourse network between 1990 and 1999, while Fig. 5.2 presents the discourse network of the second period under study, 2000—2010. The coding procedure is theoretically driven and oriented toward the definition of a policy program as identified problems and corresponding instruments presented as solutions to this problem, as well as the articulation of policy goals (Bandelow et al., 2021; Genieys & Hassenteufel, 2015, p. 282). Thus, the concepts visible in the discourse network are explicitly labeled as problems, solutions, and objectives. To increase the validity of the coding, the procedure was run twice. This results in a final set of 317 coded statements. Not all coded statements are shown in the figures; some actors and concepts were deleted due to redundancy, isolation, or non-specific statements. Since the goal of the discourse networks is to analyze whether actors are connected and which concepts are consensually discussed in the public debate, deleting isolates does not distort the results.

Fig. 5.1
A network diagram for the health policy in France from 1990 to 1999. It has components, consensual concepts, conflictual concepts, academic or advisory actors, political actors, actors from corporatist and self-administrating bodies, and bureaucrats.

Discourse network of health policy in France, 1990–1999. Source: Own illustration, created with the software visone (Brandes & Wagner, 2019). The red outlines emphasize the programmatic content of the discourse

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Fig. 5.2
A network diagram for the health policy in France from 2000 to 2010. It has components, consensual concepts, conflictual concepts, academic or advisory actors, political actors, actors from corporatist and self-administrating bodies, and bureaucrats.

Discourse network of health policy in France, 2000–2010. Source: Own illustration, created with the software visone (Brandes & Wagner, 2019). The red outlines emphasize the programmatic content of the discourse

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When interpreting the discourse network, the first thing that stands out is the general agreement present in the newspaper articles and the presence of certain people and concepts that are highly visible in the network. In terms of people, there is considerable visibility of politicians, particularly prime ministers Alain Juppé, Lionel Jospin, and Edouard Balladur, president Jacques Chirac and health ministers Jacques Barrot, Jean-Louis Bianco, Martine Aubry, and to some extent their state secretaries, Hervé Gaymard and Bernard Kouchner. In the PAF’s understanding, the latter in particular are to be considered as potential programmatic actors, as they are members of the health care administration. Others, such as Jean-Pierre Davant as president of the National Federation of French Mutualities (Fédération Nationale de la Mutualité Française, FNMF), also actively participated in the discourse and agreed with the concepts presented, but were not members of the narrow state apparatus in the strict sense. With respect to the content of the discourse and the elements of a potential program, it can be postulated that there is both coherence and unanimity regarding the problems identified, the desired objectives, and the preferred instruments to solve these problems and achieve these objectives. In line with what the analysis of adopted policies has indicated above, the identified problems are the increasing health care expenditures, which are associated by some actors with a problem of a lack of state competences to control these expenditures. This gives rise to the objective of cost containment, which is to be achieved through the instruments of increased hierarchical control (by parliament) and various hospital restructurings, modified remuneration and reimbursement systems, the expansion of contribution bases, and the reduction of drug costs, for example, through the prescription of generics. In parallel, there is another dominant goal, which is to achieve equal access to care, leading several actors to call for a universal health coverage, which was actually adopted in 2000.

There is little disagreement on specific concepts, for example, from Marc Blondel, who participated in an employment summit organized in Matignon to bring together sectoral actors and align them with the Plan Juppé (Dive, 2016, p. 108), and who as a leading unionist of the Force Ouvrière (FO) and publicly campaigned against the Plan Juppé (also visible in this network). He complained that he had not been sufficiently involved in the process, while others, including Jean-Marie Spaeth, welcomed the fact that Juppé did not give in to the unions’ demands (Bezat & Lemaître, 1997). Despite this disagreement, which was even more present in the articles but not directly linked to identifiable individuals—but to organizations—the problems, objectives, and instruments discussed reflect well the content of the laws previously analyzed. At first glance, this may seem a tautological conclusion—that what is decided is what is talked about publicly—but the discourse network explicitly serves to identify individuals and connect the program to potentially relevant individuals and groups, who are later analyzed with regard to their biographical connections. If these are confirmed, an instance of programmatic action can be assumed. Furthermore, the analysis of media articles along the 1990–2010 timeline also allows for a reconstruction of developments from a long-term perspective:

French health policy at the beginning of the 1990s was characterized by the impression of policy failure, as attempts to decrease health expenditures in previous years had not been successful. The threat of a strike offensive by physicians unwilling to agree to the cost-containment policies favored by the government and the social security system exacerbated the situation. The minister at the time, Jean-Louis Bianco, tried to find a cooperative solution with the physicians’ associations and sickness funds, represented by various unions. However, this failed almost completely, as the agreement reached by the sectoral actors did not contribute to the goal of cost containment but, on the contrary, provided for a short-time increase in health care spending. Moreover, the agreement was not accepted by some unions, partly because the representative corporate actor negotiating with the government did not have a representative mandate to conclude binding agreements for all actors. To achieve the common goal of cost containment, various policy solutions were publicly discussed and debated, sometimes supported by reports from expert committees such as the commission chaired by Raymond Soubie. When the first step of the Plan Juppé was communicated through the media, some of the instruments already in place were highlighted, such as the extension of the contribution base to include capital income and increased parliamentary control of health care spending. The experience of previous years prompted actors already occupying key positions to learn from the past and propose new ideas to contain health care costs.

Following a report by IGAS and other institutions, central savings through a restructuring of the hospital landscape were also proposed in 1994 (Blamont, 1994). Regarding the Plan Juppé, pressure from unions and employers’ associations was so great in some cases that a move away from the parity system was discussed. This would have been the path to a commercial insurance system. During this period, there were also calls for a national health conference involving all stakeholders to discuss the way forward in terms of cost reduction (and ultimately, probably, also implementation of Plan Juppé). The general discussion was also strongly geared toward bringing the various actors together, which was also foreseen in the Plan Juppé, as it ultimately helped calm some of the public protests. This conference was held for the first time in 1996, also to approve the first of the annual financial laws. The Plan Juppé was adopted in several steps, starting with a constitutional reform and followed by several ordinances.

Despite the fierce opposition from sectoral actors, particularly opposition of physicians’ associations to collective liability for exceeding spending targets, and some unions (notably FO), health policy experts such as Jean-Pierre Davant, then head of the French Mutualité, praised the reform for fundamentally restructuring the health care system. Increased oversight of all health care spending was a novum in French health care policy and was therefore frequently discussed. Previous instruments focused largely on controlling reimbursements, but this led to increasing inequality in health care and was detrimental to less affluent citizens. In response to rising claims of inequality in French health care, the 1999 Act Creating the Universal Health Coverage (Couverture Maladie Universelle) (Chauchard & Marié, 2001) under minister Martine Aubry strengthened universal access to health care for all, regardless of social situation. This can also be seen as part of the program of the programmatic group, as it was advocated by the same actors. In an interview with Le Monde, Jacques Barrot, then health minister, paraphrases the policy program, which can best be named “Achieving cost containment by maintaining the main principles of the French health care system”.

Particularly present in the media was the strengthened role of parliament in setting the annual budget for health insurance. When the first report of the High Committee on Public Health (which became the High Council on Public Health in 2004 as a result of the Douste-Blazy reform) was published in September 1996, shortly before the first of the annual conferences to prepare the draft legislation for the parliament, the issue of inequality regained attention in the public debate. A case was made for placing the objective of equal access to health care on equal footing with the objective of cost containment. Besides, there was also increased emphasis on the objective of improving public health and strengthening prevention to reduce health care costs. For example, the 1991 Loi Évin restricted advertising for alcohol and tobacco, partly following a European directive, but also partly inspired by the work of professor Claude Got. As an advisor to the health minister, he substantially influenced government policy toward public health. At first glance, this strongly resembles the logic of policy-making from the perspective of the MSF, with a policy entrepreneur advocating a single policy. However, discourse analysis shows that the reference to public health recurs in the discourse, for example, in the reimbursement of specific cancer screenings for women.

After the completion of the Plan Juppé, and thus the first major part of the policy program, the discourse turns from increased state control, parliamentary oversight of spending, universal health coverage, and the extension of contribution bases to include capital income, all of which were still being implemented in the 1990s, to the centralization and regionalization of health care, as already called for in Raymond Soubie’s report. These demands also go hand in hand with an aspiration to increase patient participation in health policy, which many policy actors publicly refer to as health democracy (see, e.g., Bernard Kouchner in an interview with Le Monde on 28 March 2001). In 1998, a reference doctor system was introduced, in which reimbursements were reduced for patients who did not choose a physician they would consult before seeing another doctor (usually a specialist). This system was replaced by the “treating physician” in 2004 (Barnay et al., 2007). Parliamentary oversight of health care spending, however, did not lead to significant improvements. The ONDAM was missed annually, and physician and hospital strikes led to the health ministry caving in to spend even more money. Despite these negative experiences, there was strong support for the parliamentary oversight of budgets, and thus for a strengthened role for parliament and the state in setting overall health policy guidelines. The problem was clearly in the implementation of these measures. This is where the second period picks up:

In contrast to the discourse network of the first period, this second discourse network appears much denser and more integrated. Initially, this indicates a stronger interconnectedness among health policy actors. Some actors have remained in the public discourse, for example, Jean-Pierre Davant and Bernard Kouchner, while others have joined because they were given important offices, such as Jean-François Mattei as health minister and Nikolas Sarkozy as president. It is also interesting to note that actors who were familiar from the commissions in the early 1990s, including Claudine Herzlich, Christian Rollet, and Jean de Kervasdoué, now entered the public discourse and advanced the instruments they had previously developed. Specifically, the problem of rising health care expenditures remained, but was partly addressed with other instruments, as some instruments had already been implemented (e.g., cost control by parliament). The discourse then evolved in the direction of calling for increased cooperation between the state on the one hand and the regions and corporate actors on the other, often combined with calls for new institutions to be created. In addition, the issue of improving public health gained attention in the public discourse and was often met with calls for strengthening prevention.

The centralization and pooling of competences and the assignment of clear responsibilities to actors of the health care sector became a central concern. The Douste-Blazy reform succeeded in tying corporatist and sectoral actors to health policy governance by merging representative bodies and establishing, for example, the UNCAM as the main representative and steering body of national sickness funds and HAS. These developments culminated with the Plan Hôpital 2007, the preparation of the HPST. It established regional health agencies that were consecutively entrusted with the task of implementing the nationally set targets and objectives at the regional level.

The analysis of media articles, similar to the analysis of legislative texts already carried out, showed that the identified policy program, which was pushed over several years, did not prevent certain policies from being put on the agenda that were not directly linked to the policy program. An example of the non-implementation of proposals that were on the table is the privatization of health care, which was called for in part in conjunction with the introduction of competition in health care. However, these initiatives did not make it into the core of the reform programs.

The networks make it clear that a program becomes entrenched over time as the public shares and openly communicates program’s narrative. While the general objectives and identified problems, as well as instruments to address them, remain stable over time, some instruments become more focused than others once the initial reforms are passed. For example, after cost control by parliament was adopted as part of the Plan Juppé, this specific instrument faded from spotlight, while other instruments of state control, such as the regionalization of health care combined with increased responsibility for meeting targets set at the federal level, gained more attention.

This does not mean that all individuals who are in the discourse network are also part of the programmatic group. A true programmatic group can only be identified if, beyond discourse networks, biographical connections between actors who collectively relate to the program are also identified. At the same time, discourse networks show that public media coverage is often dominated by certain types of actors, including primarily journalists, academics, and politicians. While public discourse reflects the narratives found in policy proposals and intellectual documents and reports, it is clear that it is political rather than administrative actors who appear in newspapers. This is partly because administrative actors largely operate behind the scenes and follow a different logic than politicians, whose primary goals include seeking office and votes.

Consequently, politicians also use media attention to gain exposure among their constituents and attract potential voters. In terms of the PAF, it becomes visible that the promotion of a particular policy program, which may also be associated with a programmatic group hidden from media attention, may well lead to appointment as a minister. Thus, politicians can be part of programmatic groups and use policy programs to gain offices in key positions of government. Interestingly, a discourse network analysis also reveals the possibility that some politicians may publicly change their minds on certain issues in response to polls and approval of a policy among actors in the policy process. Hence, a discourse network analysis of a public media discourse provides a small but important aspect to the larger picture of a programmatic group behind the publicly discussed policy program. To gain deeper insight into the formal roles and networks of potential programmatic actors, it is essential to look more closely at the formal and informal actor positions that play a role in policy-making and the biographical connections that link them.

5.3 Biographies and Identities of French Programmatic Actors

Formally, Dominique Libault clearly occupies a central position as director of the DSS between 2002 and 2012, when both the Douste-Blazy reform and the HPST were adopted. He replaced Pierre-Louis Bras, who had headed this directorate for the previous two years but had been a central adviser in the cabinets of Claude Évin (1988–1991) and Martine Aubry (Le Monde, 2000). Before Bras, Raoul Briet had headed the directorate, and he had served on the Soubie Commission, which elaborated the health policy program. The divisions of the health ministry thus emerge as a central—and formal—position of power where programs are elaborated and programmatic actors sit.

Besides the formally important health ministry, the overview of the French health care system (Fig. 4.1) identified other institutions that are directly involved in the decision-making processes of French health policy. One of these is the representative body of the sickness funds, UNCAM. Since UNCAM was only founded in 2004, it makes sense to include the National Health Insurance Fund (Caisse Nationale de l’Assurance Maladie; CNAM) in this sample as well. The other institutions identified as formally relevant to the decision-making processes of French health policy according to Fig. 4.1 include the IGAS, the HAS, the HCAAM, and the CNS, some of which were created as recently as the early 2000s. Given that the creation of new institutions can be seen as a key element in the long-term stability of a policy program, a closer look at these institutions can also shed light on the actors who then occupied leading positions in these bodies based on their affiliation with a programmatic group. The formal analysis here starts from a thorough overview of who the actors were who occupied these positions between 1990 and 2010.

Table 5.2 lists the respective individuals occupying key positions in these institutions. Regarding the CNS, due to its more than 72 members over the years in the period studied, it is difficult to provide a concise representation of members. Moreover, the CNS is not a formal professional position, but rather it is the professional position that leads to participation in the CNS. Thus, it is an indicator rather than a manifestation of relevant individuals. In addition, the legal basis of the CNS has changed substantially, with the creation of regional health councils in 2002 and a new CNS with a larger number of members in 2005. Nevertheless, the annual compositions have been scanned (Brodin, 2000, 2001; de Paillerets, 1999; Menard, 1996) and selected individuals are presented as examples to substantiate their role in French health policy because of their involvement in the public discourse and the CNS. For example, Richard Bouton (with 11 statements) and Joël Menard (with 3 statements) were already visible in the discourse networks and active in the public debate, and both participated in the first national health conference in 1996; Menard even chaired it (Menard, 1996). Richard Bouton occupies a central position as president of a physicians’ association, the French Federation of General Practitioners (Fédération Française des Médecins Généralistes, MG). Joël Menard was included as a professional expert. Other experts included in the CNS and also visible in the discourse network were Alfred Spira and Jean-Marie Bertrand, who was explicitly requested as an expert for the drafting of the HPST law (Secrétariat de la Conférence Nationale de Santé, 2010, p. 21).

Table 5.2 Occupied positions in key institutions of French health policy
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According to the PAF research protocol, the analysis of professional actor biographies proceeds starts from the analysis of formal and informal actor positions. The first step was to identify all individuals who held these positions during the period under study. The second step is to analyze who the “long-timers” (Darviche et al., 2013) in these positions are, not in the sense that they have occupied the same position for several years, but that they have made their career in the health care system. Once these individuals have been identified, a more detailed analysis looks at their individual biographical files. This allows both a revelation of individual careers as targets of programmatic action and of biographical intersections as roots of programmatic action.

In French health policy between 1990 and 2010, several of the actors originally involved in generating and promoting the ideas that were later translated into policy actually climbed the career ladder. Referring directly to the members of the commissions mentioned in Sect. 5.1, Raymond Soubie himself became social policy advisor to president Sarkozy until 2010. His was succeeded by Jean Castex, who had previously been head of Xavier Bertrand’s cabinet, former health minister (2006–2007), and labor minister (2007–2008), and even made it to prime minister in 2020 (Ficek & Godeluck, 2020). Raoul Briet, who had already been a member of the Soubie Commission, became director of the National Old-Age Insurance Fund for Salaried Employees (Caisse nationale d’assurance-vieillesse des travailleurs salaries; CNAVTS) immediately after the report was published (Juillard, 1994). Two years later, he was promoted to director of the social security (directeur de la sécurité sociale), and in 2012, he became president of the first chamber of the Cours des Comptes (Court of Auditors), one of the most important institutions in the French administrative system (Cour des Comptes, 2020). His key role in the Plan Juppé has also been reflected in media reports (Bezat & Lemaître, 1997).

Apart from the DSS, the discourse network has uncovered some actors of the Soubie Commission who remained or returned to the public spotlight, including Claudine Herzlich, Christian Rollet, and Jean de Kervasdoué. Jean de Kervasdoué and the then director of the CNAM, Gilles Johanet, were also associated with the program developed in the Soubie Commission (Hassenteufel, 2008). Other commissions formed, for example, for the preparation of the HPST, which was mainly inspired by a commission chaired by Gérard Larcher, had as advisors Edouard Couty, Jean-Pierre Davant, Jean de Kervasdoué, and Guy Vallancien (Ministère des Solidarités et de la Santé, 2008), who were already active in the discourse network.

In order to outline how the biographies of actors coincide, and to use this as a further indication of the presence of programmatic action as revealed step by step in the previous steps, the following biographies serve as anchoring examples. They were selected either because of their occupation of formal power positions or because of their appearance in the media as a result of their participation in the Soubie Commission. The source of all biographical files is the biographical database of the Société Générale de Presse (2020).

Anchoring Example: Pierre-Louis Bras (selected positions)

  • 1982–1984 Student at the National School of Administration l’Ecole Nationale d’Administration, ENA)

  • 1988–1991 Policy officer in the office of the Minister of Solidarity, Health and Social Protection (Claude Evin)

  • 1991–1993 Director of the cabinet of the general budget rapporteur at the National Assembly (Alain Richard)

  • 1993–1994 General Manager of the Mutualité de la fonction publique (Civil Service Mutual Insurance)

  • 1994–1997 Director of the local authority market at Société Générale

  • 1997–2000 Adviser in charge of social protection in the office of the Minister of Employment and Solidarity (Martine Aubry)

  • 2000 Deputy Director of the Private Office of the Minister for Employment and Solidarity (Martine Aubry), responsible for Social Security, Social Protection and Health

  • 2000–2002 Director of Social Security at the Ministry of Employment and Solidarity then (May 2002) under the joint authority of the Ministry of Social Affairs, Labour and Solidarity and the Minister of Health, Family and Disabled Persons

  • Since 2003 Inspector General of Social Affairs (external tower)

  • Since 2015 Chairman of the Pension Guidance Council, Prime Minister’s Office

  • Since 2015 Chairman of the steering committee of the technical agency for information on hospitalization

Anchoring Example: Anne-Marie Brocas (selected positions)

  • 1980–1982 Student at the National School of Administration l’Ecole Nationale d’Administration, ENA)

  • 1990–1991 Technical Advisor to the Office of the Minister Delegate for Health (Bruno Durieux)

  • 1991–1992 Deputy Director of the Office of the Minister Delegate for Health (Bruno Durieux)

  • 1992–1994 Deputy Director of Health Insurance in the Social Security Directorate of the Ministry of Health

  • 1992: Chairwoman of the Workshop “Financial Perspectives of the Health System” held at the Commissariat au Plan within the framework of the health system prospective group

  • 1994–2000 Head of department, assistant to the director of social security, at the Ministry of Social Affairs, Health and Urban Affairs

  • 1999 in charge of the coordination of the Etats Généraux de la Santé (General Health Assembly)

  • 1999 General Rapporteur of the Social Europe Group at the French Planning Commission (Commissariat au Plan)

  • 2006–2012 Director of Research, Studies, Evaluation and Statistics on Health and Solidarity, under the joint authority of the Ministry of Labour, Employment and Health and the Ministry of the Budget, Public Accounts and State Reform

  • Since 2012 Inspector General of Social Affairs (appointed on 1 September 2013)

  • Since 2014 President of the High Council for the Future of Health Insurance (HCAAM)

Anchoring Example: Dominique Libault (selected positions)

  • 1985–1987 Student at the National School of Administration l’Ecole Nationale

  • 1987 Second class civil administrator, assigned to the Ministry of Social Affairs and Employment. Head of the Office Al-Scope, Contributions, Other Receipts—at the Sub-Directorate for Administrative and Financial Affairs of the Social Security Directorate

  • 1993–1995 Secretary general of the conseil supérieur de la mutualité

  • 1993–1995 Technical adviser in the office of the Minister of State, Minister of Social Affairs, Health and Urban Affairs (Simone Veil)

  • 1995 Sub-Director of Access to Care, Social Security Directorate, Ministry of Solidarity between Generations

  • 1995–2000 Deputy Director of Social Security Financing and Management in the Social Security Directorate, Ministry of Employment and Solidarity

  • 1999 Reappointed Director, representing the Minister for Social Security, of the Caisse d’amortissement de la dette sociale (CADES)

  • 2000–2002 Head of Department, Deputy Director of Social Security, at the Ministry of Employment and Solidarity, then (May 2002) under the joint authority of the Ministry of Social Affairs, Labour and Solidarity and the Ministry of Health, Family and the Disabled

  • 2002–2012 Director of social security, under the joint authority of the Ministry of Labour, Employment and Health and the Ministry of the Budget, Public Accounts and State Reform

  • Since 2012 State Councilor (external tour)

  • Since 2012 Vice-Chairman of the High Council on the Financing of Social Protection

  • Since 2012 Director General of the Ecole Nationale Supérieure de Sécurité Sociale (EN3S)

Anchoring Example: Didier Tabuteau (selected positions)

  • 1982–1984 Student at the National School of Administration l’Ecole Nationale d’Administration, ENA)

  • 1985–1987 Student at the National School of Administration l’Ecole Nationale d’Administration, ENA)

  • 1988–1991 Technical adviser in the office of the Minister of National Solidarity, Health and Social Protection (Claude Evin)

  • 1992–1993 Director of the Cabinet of the Minister of Health and Humanitarian Action (Bernard Kouchner)

  • 1997–2000 Deputy Director of the Office of the Minister for Employment and Solidarity (Martine Aubry)

  • Since 1999 State Councilor

  • 2000 Adviser to the Minister for Employment and Solidarity (Martine Aubry), in charge of preparing the bill on patients’ rights and the modernization of the health system

  • 2001–2002 Director of the Office of the Minister Delegate for Health (Bernard Kouchner)

  • 2008–2012 Director of the Centre d’analyse des politiques publiques en santé, Ecole des hautes études de santé publique (EHESP)

  • Since 2017 Deputy president of the social section at the Council of State

Whether the biographies of actors associated with the policy program actually overlap and can be traced back to common working occasions is best assessed when tracing them back to commissions like the Soubie Commission, which presents a central starting point for programmatic actors who later occupied key positions in various newly created agencies. The members, including above all Raoul Briet, Anne-Marie Brocas, Jean de Kervasdoué, and Raymond Soubie, subsequently held central positions that were central in the further course of French health policy. This applies, for example, to the Larcher Commission, but also to the DSS in the Ministry of Health, which was significantly strengthened in its competencies by the reforms of the policy program. It can thus be seen here that the actors, who are biographically linked to each other, have themselves attained positions that they have strengthened through their own program. The further biographical connections here also show a strong network between the central actors in health policy, who were also already present in the discourse network and were repeatedly mentioned as essential figures in the political process.

5.4 Continuous Programmatic Action in French Health Policy After the Financial Crisis

Looking more closely at the period after 2010 (see Table 5.3), both with regard to the content of health care reforms and the actors involved, we can see that the programmatic group was active during that period as well. With regard to health care reforms, the legislation through 2013 adjusted measures that had already been passed, such as the HPST act. In 2011, regulations on the use of medicines not yet approved were tightened and a new agency was created, the National Agency of Medicine and Health Products Safety (Agence nationale de sécurité du médicament et des produits de santé; ANSM). These policies followed the scandal around the Mediator drug, which was prescribed for patients suffering from diabetes and obesity but apparently caused up to 2000 deaths because it had not been banned by the responsible French agency following indications of questionable value and scientific evidence for its safety (Mullard, 2011), and another such quality-related incident involving breast implants (Emmerich et al., 2012; Lochouarn, 2012).

Table 5.3 Substantial health care reforms in France 2010–2020
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In 2013, a national health strategy was announced by then health minister Marisol Touraine to guide the health reforms under the label of reducing inequality, strengthening regional and local initiatives including ARSs and primary care, and overall increasing the efficiency of the health care system (Touraine, 2014). In her major reform to modernize the health system in 2016, the trend toward territorialization, which had been inherent since the Plan Juppé, is further reinforced. The law creates regional hospital groups (groupements hospitaliers de territoire, GHT) to replace CHTs. Since the latter were formed on a voluntary basis and the GHTs are mandatory entities that must work closely with the ARSs to ensure access to health care across the landscape, this is a new form of territorial organization of health care in medical deserts (Tourmente, 2016). The path of territorialization taken, which began with the creation of ARSs, thus gained relevance in the 2010s. The 2016 law also introduced the possibility for physicians to register as territorial practitioners, which granted them financial benefits and allowed for special contracts with physicians who chose to work in underserved areas (Hassenteufel et al., 2020, p. 49).

This path of territorialization continues after 2016. The national health strategy “Ma Santé 2022” (My Health 2022) (République Française, 2018) elaborated further programmatic measures, some of which have already been translated into concrete reforms. For example, the 2019 reform on the organization and transformation of the health care system strengthened the role of the ARSs in determining the number of students trained in medical professions, taking into account local needs. It also required the ARS to approve territorial professional health communities (communautés professionnelles territoriales de santé (CPTS)) projects and explicitly promoted regional health projects aimed at increasing efficiency (and thus reducing costs) in the organization of local health care.

Another large part of the ongoing policy program concerns digitalization. The Douste-Blazy reform in 2004 already created a digital health space for patients in the form of a digital health record. This was further extended and access was made easier in the 2019 reform mentioned above. The same reform also expanded telecare and telemedicine capabilities, as well as the storage of health data to improve research. It is likely that the COVID-19 pandemic will initiate further steps toward digitalized health care.

The analysis of the actors connected to these reforms via a discourse network analysis yields mixed results. In general, the coverage of the health political discourse ebbed away in the 2010s, which is why the results of the media analysis are only reported, but not visualized. Looking at the actors publicly referred to in Le Monde, the debate centered mainly around political elites, such as the presidents Emmanuel Macron and François Hollande, and the health minister Marisol Touraine. However, Dominique Libault also appeared in the media in 2020 and is thus a sign for continued influence of the programmatic group.

With regard to the content of the discourse, the financial crisis worsened the financial situation of French health policy, which was communicated publicly. Health expenditures rose again and the contribution-financed health care system suffered from a decrease in revenue due to increased unemployment. The introduction of remuneration for general practitioners based on public health objectives (Rémunération sur Objectifs de Santé Publique; ROSP) has led to an increase in the general practitioners’ payment. Nevertheless, they went on strike on the occasion of the health care reform by Marisol Touraine in 2012/2013, because the principle of reimbursement should be replaced by the principle of payment in kind (tiers payant). Her 2016 reform modernized the health care sector by strengthening the information given to patients, introducing a central phone number for patients to receive medical care, and further improving regional health care by following the reform path previously taken in the direction of the ARSs (Casassus, 2015).

In 2018, the care of elderly people moved in the focus of attention as the consent of old-aged persons to be housed in care homes varied. The ethics committee and policy advisors suggested the introduction of a fifth branch of social security, which to that point had not yet been established. In 2020, surprisingly, the outbreak of COVID-19 and the following pandemic dominated the public discourse. It shed light on the problems of the health care system, including the missing focus on public health, and the low salaries that employees in system-relevant professions gained. Several measures were adopted to fight the consequences of the pandemic and to contain the infection dynamics in France. These had been summarized under the label of the Ségur de la santé, but criticized with regard to their lacking consideration of the territorial specificities of health care provision—particularly the hospital landscape—and concerns. The increased turn to a territorialized health policy with the ARSs implementing the nationally set centralized guidelines (and budgets) has furthermore proved less promising than initially thought. The ARSs are said to have not enough competences—above all regarding the control of budgetary means—to ensure a territorially appropriate health care, and are limited in their actions to research, innovation, employment, and training.

Although the discourse analysis of French health policy in 2010–2020 reveals a less dense public debate compared to the previous two decades, the content of the policy program and the actors involved continue to have a major impact on health care reforms. In describing the key evolution in the governance of social security, programmatic actor Dominique Libault points to three key elements of the restructuring of French health policy. In addition to financial oversight of the budget by parliament, and the changing relations between the national and local levels and between state and social security actors, he proposes the creation of councils to guide the future of health policy by bringing together experts, social partners, and members of the administration (Libault & Minonzio, 2015). The establishment of such councils to give direction to health policy allows for the combination of expertise with sectoral and political-administrative actors, ensuring a long-term strategy of health policy for a programmatic group.

With respect to the biographical actor networks, it can also be noted that programmatic action lives on in France. The HAS serves as a source of personnel for higher positions in government and administration, as in the case of Alain Cordier, who was appointed as a special advisor to Christophe Devys, the director general of the ARS in Paris (ARS Île de France, 2018). Anne-Marie Armanteras-de Saxcé becomes an advisor in the president’s bureau (Hospimedia, 2020). Figure 5.1 shows how the existing network of programmatic actors has expanded to include other agencies. The origin of this network remains the Soubie Commission. It visualizes how the programmatic group has used the newly created structures to place its members in these power positions and manifest its influence and ideas in these institutional structures. Today’s key players, such as Thomas Fatome and Nicolas Revel, as well as Jean Castex and Franck van Lennep, have risen through the old network structures to take the places of Dominique Libault, Pierre-Louis Bras, and Raoul Briet. They are still interconnected through the very institutions through which they gained influence. This network is also created on the basis of the qualitative findings from the interviews, just as the nodes between the core group are depicted based on this information.

The COVID-19 pandemic has not just dominated the media discourse of French health policy, it has also affected the actor networks in the health sector. Responses toward the Corona crisis had been in the French tradition of centralized measures, yet at first without a substantial consideration of regional specificities given that the ARSs are basically implementing national measures at a local level. With increasing turn to decentralized crisis management, COVID-19 can be seen as an accelerator of the previously taken paths toward territorialization and adaptation of measures to local settings, an endeavor in which the programmatic group is ever more visible (Hassenteufel, 2020).