How Private Health Insurance in France Became a Market? (Cyber-conférence)

This communication focuses on the transformations of the French private health insurance. This sector was seen, at the beginning of the 1980s, as legitimately reserved and managed by non-profit actors, themselves holding a position of privileged partners of the State. This state-of-play reflected the status-quo during the first four decades of the post-war period and shaped the representations of most French people up to this day. Indeed, most of the population keeps referring their private health insurance contract as their « mutual », deriving from the dominant position mutual institutions (non-profit institutions) still hold on this market. Nevertheless, the health private insurance sector is now mainly ruled as a market with a fair competition between for-profit and non-profit actors. This is partly due to the implementation of European directives, starting in the 1990s, but also to a game of power between European and national actors. Using a sociological approach, we will demonstrate that formal categories of actors must be deconstructed to explain this game. For example, not all the general directorates of the European Commission have the same perspectives about these evolutions, and the same applies to the French State or private actors. We will so describe the advocacy coalitions committed to the evolution of the legal framework. By analysing the way French private and public actors faced or anticipated these transformations, we'll answer few questions strongly linked to the place of the Welfare State in financial times: how the market could be used to complete health policy goals? Is the European Union law a trigger of the financialization process in fields such as health? How financialization lead for-profit and non-profit institutions to act more and more the same way? Actors' attitude towards financialization and marketization varies widely, some seeing them as goals while others relying on them only as means for other policy goals. For example, the Health Ministry or a part of mutual institutions claimed that stronger insurers in a clearly market-driven field could bring higher access to the health system for everyone and guarantee limitations of medical extra-fees. For-profit insurers and Ministry of Economy would see the marketization of health insurance as a goal for itself. Such legitimation speeches must be questioned and faced with how these mechanisms actually worked these last two decades. Financialization in this process appears through stricter prudential rules introduced by European law, notably the 1990's Insurance directives (introduction of mandatory provisioning of engagement by insurance companies) and Solvency II (higher standards of capital and solvability requirements), and their indistinct implementation on both for-profit and non-profit institutions. It can be argued that one of the effects of these laws is to drain money dedicated from social protection to financial markets through the constitution of provisions firstly aimed at consumers' protection. Although the amounts are far less than in the case of private pensions, the effects on actors are significant and adversarial on non-profits actors, despite holding most market shares. Indeed, through compliance and adaptation, their internal process, governance and strategies have changed when facing increased competition (both due to lower market barriers for competitors and expansion of new market segments such as occupational schemes) and ill-fitted regulation (due to directives being crafted around the classical for-profit insurance company). This led to a large concentration process of non-profit organizations into larger entities and their adoption of behaviours inspired by for-profit institutions. To illustrate that, we must go away from a legal point of view and describe the socio-historical patterns they experimented. In the end, even if the terms still differ, the gap between for-profit and non-profit organizations is narrower than ever.