Integrative pressures and bureaucratic entrepreneurs in integration: the emergence of the idea of Regional Health Agencies (ARS)

19From the late 1970s, this historical legacy was called into question by a number of general trends that put pressure on this sectoral configuration and favored the emergence of competing solutions demanding “integration”. The most radical of these, unveiled as early as 1993, aimed at merging state services and the Assurance-maladie into regional health agencies (ARS).

20Managing healthcare expenses was certainly the first challenge. From the 1980s, breaking the inflationary logic of healthcare (dis-)organization became a necessary step, despite being politically risky. Epidemiologically, matters were moving in the same direction. The rise in chronic diseases, which required better care coordination, disrupted the compartmentalized logic of contemporary medicine and the separation of different treatment options. Last but not least, the contaminated blood scandal – the starting point for a series of court cases and other health scandals – cast a harsh light on the collapsing public health system, which had been relegated to the margins of a healthcare system that had been overtaken by the biomedical euphoria of the 1960s and 1970s. In the face of these changes, further integration of the healthcare “system” – integration to create a system – appeared increasingly inevitable. The relationships between the state regulator, the financers/payers, and the healthcare providers had to become tighter. Moreover, each division had to move towards greater integration.

21The healthcare sector had long been neglected by the administrative elite. When a new generation of senior civil servants – graduates of the grands corps d’état and labelled by Patrick Hassenteufel and William Genieys as the “welfare elite” – took an interest in the healthcare sector, they proposed strengthening the power of the state as a priority, via management arrangements that would bring an end to the culture of reverse control exerted on public action by interest groups, professionals, politicians, and members of industry with the (more or less resigned) consent of political decision makers. [26] Making health administration more independent meant first borrowing from the NPM-inspired managerial repertoire. In their view, quasi-markets, subcontractualization, and batteries of performance indicators had to replace the traditional instruments of public action, which would have been swallowed up by the logic of industry. Their criticisms were particularly aimed at healthcare planning, the cornerstone of which – the notion of “healthcare needs” – was perceived as an attempt by healthcare professionals to mask their own interest in medicalizing French society, a medicalization fuelled by the submission of politics to professional strategy. [27] NPM aimed to give regulators the tools that could discipline the professional power of healthcare “production” by obliging it to internalize the political objectives of the state regulator, first of which was controlling costs. Tighter parameters were to be applied to professional autonomy which would be managed remotely, in particular by reworking the means of financing medical activities, but also through the development and implementation of information systems capable of allowing access to the “black box” of medical “production”.

22However, it was not solely through renewing the public action repertoire via managerial instruments that state capacities were reinforced. The same reformers also supported the idea of organizational integration, since interest groups could take advantage of the fragmentation and competition between the state and the Assurance-maladie, or between the different echelons of the administration. Once properly structured, regulation therefore had to become more integrated “from below”. The project of regional health agencies (ARS) was thus set out in 1993 by a planning commission presided over by Raymond Soubie, [28] a high ranking public official in the social sector and a future social advisor to Nicolas Sarkozy. Recognizing the regional level as the only relevant one to direct the provision of treatment, this project set out to challenge the peripheral actors (doctors, hospitals, local officials) with a counter-power capable of creating a global (or integrated) vision of healthcare organization, and with powerful resources of knowledge and action, information systems, or financial incentives, and thus capable of rationalizing the provision of care. Finally, unifying the direction of healthcare in this way would allow for a reallocation of resources between the different portfolios that flanked the dwindling hospital infrastructure. The project of regional health agencies was invented at this precise point in the internal planning of the administrative state.

Incremental integration under strong institutional constraints

23The whole concept of the ARS nonetheless came into immediate conflict with the historical relations of power and competition within the sector. The DDASS and DRASS, and the departmental and regional prefects, defended their position against projects of cooperation and merger of decentralized state administrations, just as the Assurance-maladie fiercely protected its fiefdom (non-hospital private practices). The Juppé Plan of 1995, drawing strongly on the Soubie Report of 1993, thus limited itself to creating regional hospital agencies (agences regionales d’hospitalisation – ARH), “flexible” structures with modest objectives, aimed solely at improving the coordination of state services and the Assurance-maladie in hospitals, a domain which fell under the relatively uncontested control of the state. [29] The new directors of the ARH, appointed within the Council of Ministers, nonetheless exercised a hierarchical authority over the personnel of the DDASS and DRASS for hospital-related matters, which explains the furious reaction of the regional directors of health and social affairs and the regional prefects, who were divested of their powers within the field of healthcare (in other words, planning and allocation of resources to establishments). The regional level was promoted by the state in order to take back control of sectoral governance. The Assurance-maladie network deliberately circumvented this level, preferring the departmental level, and, of course, the national level. In the end, non-hospital private practices remained exclusively under the nationally agreed framework connecting the Assurance-maladie and the private doctors’ unions; whereas medical-social care came under the departments, and hospitals and public health under the state. Integration “from below” and by merger faltered under the weight of the institutional legacy. [30]

24Nonetheless, healthcare administration (in its broad sense) underwent a slow dynamic of institutional integration starting in the 1990s. This was incremental and often informal, instigated by professional and administrative actors in the field. Attempts were made to connect decentralized administrations as well as to expand the hierarchy within the administrative fabric. New coordinating authorities were set up, and new coordinating instruments were tested. In a nutshell, relations between historically autonomous actors were tightened and hierarchized: after the institutional splintering of the past came an increasingly coherent institutional landscape.

25Integration worked from above, at the national level. By drafting legislation to finance the French social security system (projets de loi de financement de la Sécurité sociale – PLFSS) together with mechanisms for budgetary regulation, the Juppé orders attempted to generalize the global budget to the entire healthcare system. This global budget had been supported by the National Budget Office since the late 1970s and progressively implemented by sectors (excluding non-hospital private practice), while at the same time providing the national level with a powerful instrument for coordinating central administrations around the Social Security Department (Direction de la Sécurité sociale – DSS) which was in charge of developing the PLFSS. [31] The DSS – the “little Bercy” which would soon come under the supervision of the Budget Office, and the center of gravity of the “welfare elite” – increasingly appeared to be a financial administration with an original doctrine, whose function was to hierarchize and regulate the demands of the more “spendthrift” departments, first among which were the Department for Hospitals and Healthcare Organization (Direction de l’hospitalisation de l’organisation des soins – DHOS) and the Directorate General for Health (Direction générale de la santé – DGS). Via the agreements on objectives and management (conventions d’objectifs et de gestion – COG), the DSS also supervised the activity of national insurance offices [caisses nationales]. The regulator thus sought to exercise more influence over the strategies of multiple public and private financers. The DSS position as the “integrating” center of gravity provides a key to understanding its positioning against the future HPST legislation. Again from above, the major reform of the Assurance-maladie in 2004 accelerated the integration dynamic, but on the financers’/payers’ side. The different schemes that operated under the Assurance-maladie were gathered under the umbrella of a National Union of Health Insurance Providers (Union nationale des caisses d’Assurance maladie – UNCAM), whose managing director, who enjoyed broad powers, was also the head of the primary scheme, the National Health Insurance Fund for Employees (Caisse nationale d’assurance maladie des travailleurs salariés – CNAMts). Moreover, the different complementary health insurance actors (mutual societies and health and welfare insurers) were integrated into a Union of Complementary Health Insurance Organizations (Union des organismes complémentaires d’assurance maladie – UNOCAM) to provide better coordination with the obligatory basic plans.

26Nevertheless, this national integration remained incomplete and ambivalent in many ways. The diarchy of state (the regulator) and Assurance-maladie (the financer) remained. Whilst the budgetary instrument led to the creation of transversal logic in administrative functioning, it also contributed to compartmentalizing financing. Thus, each compartment of the healthcare system (non-hospital private practice, hospitals, medical-social institutions, prevention) was given an annual budget. The compartmentalization of financing contributed to reproducing the same systems of action that the reformers claimed were now better connected. This shows how budgetary rationalization both favored and restricted the dynamic of integration.

27Integration also – and primarily – occurred from the bottom-up. The reform of public health in 2004 created regional public health groups, once again in the form of a public interest group (groupement d’intérêt public – GIP) thus bringing together the services of the state, the ARH, the Assurance-maladie, and participating local communities under the authority of the regional prefect. Their aim was to implement regional public health plans, as well as initiating regional health objectives, which were supposed to pool the resources of the ARH and the regional unions of health insurance providers. The local actors tried, for better or worse, to put together integrative solutions capable of overcoming the multiple compartmentalization of the healthcare system and the excessive centralization of health and social administration. The latter appeared to be on the verge of “suffocating”, to borrow the expression of an IGAS (Inspection générale des affaires sociales) and former DDASS employee, and future member of the ARS project group in the ministry. The smaller DDASS, for example, were required to abandon work on certain projects due to downsizing. The absence of hierarchy and the presence of rivalries between DDASS and DRASS, between departmental prefects and regional prefects, found interim solutions in the “regional and interdepartmental technical committees” and de facto hierarchies when strong personalities emerged. [32] Administrative actors thus attempted to invent informal means of coordination, which were particularly time-consuming.

28Integration by small adjustments nevertheless had its limits, in particular in terms of hospital restructuring, which explains in large part how from 2003 the ARS became the object of widening political consensus. Its appearance in the manifestos of the main candidates for the presidential elections of 2007 achieved its political embodiment. Yet the consensus around the acronym was ambiguous. The meaning given to “A”, “R”, and “S” varied widely across the political spectrum. Nonetheless, the acronym ARS became a necessary rite of passage in political discourse. And the long-term project of regional merger came to be “attached” to the RGPP framework, which represented a political opportunity. [33]

The ARS gets on board the RGPP train

30The RGPP was considered to be “a political framework steered by the Élysée Palace, involving the ministers, and aimed at producing political decisions concerning reorganization”. [34] Contrary to what its title suggests, it places greater emphasis on administrative organizations than on public policies themselves. Philippe Bezes has underlined how this very centralized and technocratic mechanism could lead its actors to favor a hyper-rational idea of reorganization that was cut off from the professional cultures and practices of public agents. Finally, the RGPP provided a very welcome framework. It was first and foremost a brand and a framework for political decision-making.

31

“The ARS and HPST were ongoing projects that were integrated into the RGPP. This was a very good thing because it allowed us to use the RGPP organization and governance as well as its political backing to move the project forward. That said, it was not a typical project in the RGPP framework. It was seen as somewhat marginal to the RGPP, which mainly concerned state services. The ARS was, however, one of the biggest projects of RGPP and one that was brought to a conclusion, meeting the deadline as best possible, even if it was a little off. This quick pace was inevitable given the scale of the work to be done. A law had to be drafted. But there was not much political appropriation by those steering the RGPP. It was an important reform for the president of the Republic in that it involved hospitals. It touched on the hospital sector. A lot was said about hospitals, but not much about the ARS.”

32Bolting the idea of the ARS onto the RGPP nevertheless had one major consequence. While they were presented as the means to integrate the portfolios of the healthcare system (care and public health), the future ARS had to respond in particular to the budgetary requirements of the management of public spending and the reduction of public deficit (especially for hospitals). The drafter of title IV of the HPST law relating to the ARS, an IGAS employee previously at the DRASS and who had long reflected on hospital planning, noted with regret the reductions that RGPP backing caused to the project.

33

“It could have happened differently. There could have been two distinct rationales. To avoid replacing one out of every two civil servants, there was no need for the ARS even if the ARS pooled a certain amount of resources. But we could have pooled them without making one ARS, by keeping the ARH system and restructuring the DDASS and the DRASS. Groupings of DDASS and DRASS from the same departmental capital had already formed. I initiated these connections as DRASS. In short, another scenario was possible. It was not inevitable. The questions raised by the RGPP did not cover the full gamut of questions in the healthcare field. These were questions that had been raised for a long time. The creation of the ARS is an old project. There was an old movement that explains how we arrived at the ARS and then a more circumstantial movement that is the RGPP. At a certain point in time these two movements coincided.”

34Two working groups were established within the RGPP, both under the direction of the honorary prefect Philippe Ritter. The first dealt with the “productive apparatus” on the healthcare side. It brought together members of the IGAS and IGF and was responsible for reviewing administrative organizations and their mandates as well as thinking about the pooling of resources; the second dealt more specifically with ARS and was established in the spring of 2007 after the launch of the reform by the new President of the Republic. [35] The new Minister of Health at the time and her combative cabinet leader, whose background was as a prefect, made use of Ritter’s work and subsequent report to try to keep control of the merger project. [36] The idea of a public administrative establishment merging state services and those of the Assurance-maladie in the regions opened up two fronts, shattering the tentative political consensus that had crystallized around the ARS acronym since the early 2000s.

When the weak become strong: the Ministry of Health inflicts defeat on its institutional rivals

35The first (and main) front saw Roselyne Bachelot’s office oppose the Assurance-maladie and its allies and intermediaries within the state. In fact, the Assurance-maladie never stopped obstructing state moves to bring about increased integration at a regional level. It was also less than cooperative with the ARH. Previously undeclared, the war on the Bachelot Project now became an open battleground. Frédéric Van Roeckeghem, chief executive of UNCAM – an engineer by training, and one of the principal craftsmen of the reform of the Assurance-maladie in 2004 when he was a member of the cabinet of Minister Douste-Blazy – sought at all costs to preserve the autonomy of his institution on the basis of its recognized know-how in “managing health-risk”, [37] which was supposedly absent from state services. From the point of view of the Assurance-maladie, entrusting to the state control of all mandates to steer the healthcare system in the regions effectively meant placing one’s faith in a state actor that was both bureaucratic and politically bound up with sectoral interests, especially with the powerful French Hospital Federation representing the groups managing public hospitals. Conversely, the Assurance-maladie made great efforts to demonstrate its independence from these same interest groups. To promote its point of view, the institution had solid connections at the heart of the state (“the social security network”) and in the chambers of parliament.

36The most solid ally was the DSS, which sought to defend its position as integrating center of gravity at the national level (offices and central leadership of the ministry). It did not take kindly to the long-term merger of the state and the Assurance-maladie, which would challenge its primary innovations, especially the objectives and management agreements (COG). This disparaging view of the state’s role in the sector was also shared by some members of parliament, particularly the UMP deputy Yves Bur, who submitted a competing report to the Ritter Report that inspired the ministerial project. [38] Reflecting the personal positions of the commission’s rapporteur, the report was primarily a vehicle for the CNAMts project. Expressing his wariness of a “Gosplan health system” and his critiques of the penchant of senior public officials for institutional reforms aimed (incorrectly) at solving all problems, the deputy proposed dual regional steering. The future ARS would oversee the organization of the healthcare offer, while new regional offices of the Assurance-maladie would oversee regulation and “risk management”. At odds with ministerial doctrine, Yves Bur was removed from his position as a rapporteur for the future HPST law.

37Finally, there were also less “militant” allies. In the cabinet of the prime minister, who was an influential supporter of Roselyne Bachelot, technical advisers who had inspired the reforms of the mid-2000s [39] and/or who came from the social security network, deemed that in some cases merger was not a good idea or, in others, that the schedule for merger was not the right one, since the previous reforms had barely taken hold. One of these advisers felt that this type of institutional reform would bring higher and immediate political costs because of the mobilizations that this type of approach always elicited, in return for hypothetical long-term benefits in terms of regulation of spending and reorganization of the healthcare offer. In their view integration had to take the path of managerial instrumentation instead of institutional integration by merger. However, this disagreement remained between technical advisers, since the cabinet director of the Prime Minister and the Prime Minister himself believed that this reform fell under the discretion of the Minister of Health and Social Affairs.

38The second, less central front opposed the Ministry of Health against the Ministry of the Interior and the prefects. The prefects had fought the creation of the ARH, which relieved them of their main powers within healthcare through the DRASS and DDASS, to give them to senior civil servants who were nominated, like them, to the Council of Ministers. The proposed merger only intensified this dispossession. This time, all their authority in the area of healthcare was to be handed over to to the future directors general of the ARS. The change seemed irreversible, and the prefects could only step aside. There was one subject, however, on which the prefects would not budge: health monitoring and health security mandates. As these matters came under public security and public order (and therefore the departmental prefects), the prefects as a whole hoped to retain the material and human resources needed to carry out these mandates (along with anything related to crisis management) under their remit, in particular the few public health inspector doctors and health-environment technicians.

39The political involvement of Roselyne Bachelot, [40] who was very close to Prime Minister François Fillon (whose political influence was very important at the time), the combative nature of her cabinet director, the prefect Georges-François Leclerc, and the part played by the RGPP mechanism in facilitating the decision allowed the Ministry of Health and Social Affairs to win the inter-ministerial battle on these two points. At this point, mature intellectual reflection reconnected with short-term political action. The architect of the “Health 2010” plan – the first to mention the ARS – Raymond Soubie, had in the meantime become the social adviser for the new President of the Republic, Nicolas Sarkozy. Under the very centralized and political configuration of the RGPP, having an ally of that stature carried weight. Moreover, the very “prefectural” conception of the ARS was spontaneously supported by several prefects in decision-making positions. While the Assurance-maladie and its allies suffered a chastening defeat, opposition to the Ministry of the Interior was removed through compromise. If a health crisis occurred, all the ARS resources dedicated to health monitoring and security would come under prefectural authority in order to maintain the unity of command. Once the first negotiations were over, a long road still lay ahead with the law still needing to be drafted, while the clock was ticking. A group dedicated specifically to the ARS project was established, at the head of which was named the new general secretary of social ministries, specially recruited to implement the merger process successfully. This was the chief counsellor at the Court of Auditors, Jean-Marie Bertrand, who was familiar with these operations, in particular because he had implemented the reform of the French railway network. [41] Once again, the existence of this type of project group bears witness to the involvement of political actors in the reform. The administration gave itself specific resources to achieve the merger under the very short deadline set by the executive branch.

40To reveal, as we have just done, the institutional competition and conflicts that presided over the merger (a rather banal phenomenon in terms of organizational rearrangement) remains, however, insufficient. This account only provides the most visible political dimension of the reform, the “politics” of merger. As it happens, integration happened more as a result of competition between political, bureaucratic, and professional segments of the sector than because of simple market pressure. However, beyond the territorial (or even personal) conflicts, this competition was the vehicle for substantial political stakes that we must now explain. What political form would this integration take?

What is the place of politics in the process of sectoral integration?

42As we have seen, the main conflict created by the project of merger opposed the state and the Assurance-maladie. Beyond questions of personalities and turf wars, this conflict developed from the confrontation of two conceptions of the integration of the healthcare sector, weighing politics against technocracy. [42] To better understand this situation, we have to go back (briefly) in time to pinpoint the precise moment when these two ideas were dialectically defined: one was centralized and technical because it was inspired by neo-management and supported by the Assurance-maladie; and the other was more “political” (even if it did not shy away from drawing on the managerial repertoire) and decentralized, and promoted by the state. The creation of the ARS marks the victory of the latter, but it is not a total victory: the Assurance-maladie mostly succeeded in defending its turf and its vision of integration thanks to the deployment of performance management mechanisms and contractualization.

43We know that the creators of the French social security system hoped that it would be the “property” of its stakeholders – in other words insured persons and companies – in the context of “social democracy”. Each office was autonomous, governed by private law and run by a management board on which the union representatives elected by those with state health cover occupied three-quarters of the seats, with the remaining quarter for representatives of employers. However, this “social democracy” was soon revealed to be a failure. Moreover, with the increasing emphasis placed on controlling healthcare spending, the social partners revealed themselves to be very reluctant to take on the political costs of budgetary restraint, leaving the state to do the “dirty work”. The social movement of November-December 1995 in reaction to the Juppé Plan turned out to be the last stand of the unions in relation to social security. Thereafter, “social democracy” began an irreversible decline, at least for the Assurance-maladie. A new legitimacy was then required to replace the political legitimacy of “social democracy”. The notion of “health risk management” provided its philosopher’s stone. More generally, the institution underwent a managerial conversion starting in the late 1990s.

44Initially a relatively vague notion that appeared in the early 1980s, “risk management” was gradually adopted and promoted in order to differentiate between the visions of the Assurance-maladie and the state. In the 1990s, the arrival of a new generation of medical officers who were inclined to assert their public health expertise over and above their traditional role monitoring persons receiving social assistance (sick leave in particular) coincided with the first term of the Master of the Court of Auditors Gilles Johanet at the head of the CNAMts. [43] Johanet’s second term at the head of the CNAMts reinforced the movement that had begun at the start of the 1990s. [44] Essentially, the director of the CNAMts wanted to bring into his institution the techniques of risk management developed by insurers. In re-establishing its legitimacy, the Assurance-maladie thus began to borrow from managerial sources that allowed it both to rival the claims of insurers and, above all, to make health administration seem “obsolete”. At the same time, the senior management of the CNAMts initiated the move towards centralization and hierarchization of the network of offices, taking care to circumvent the regional level that was supported by the state. [45] The Assurance-maladie network – which for a long time had consisted of relatively autonomous offices (and with private law status for the non-national offices) – underwent a process of intense integration, which saw its higher echelons (the national offices) tighten their control over the bottom rungs (the local offices), through the deployment of management instruments.

45The reform of the Assurance-maladie in 2004 was a key moment in the crystallization of the institution’s managerial identity. [46] This reform was prepared by the advisers of Minister Philippe Douste-Blazy, primarily Frédéric Van Roekeghem and Thomas Fatome (who moved to the DSS after a period spent in the cabinet of the CNAMts), and strengthened the powers of the director general of the CNAMts and, beyond it, of the future UNCAM, while limiting the possibilities of its dismissal by political decision makers (clearly the fate of Johanet weighed heavily here). The new director general of the new UNCAM – none other than Frédéric Van Roekeghem – thus appeared almost as a “pro-consul” or a “second Minister” of Health given the extent of his powers, while social partners were relegated to a supervisory council limited to providing (discretionary) advice. It was he who monopolized negotiations with private health professionals. “Risk management” was definitively sanctioned as UNCAM’s core business and distinctive resource. [47] This notion took three forms: promoting efficiency, the quality and safety of treatment, and maintaining financial restraint. While risk management was the concern of only 10% of the staff of the Assurance-maladie – essentially the body of medical officers, which was very hierarchical and reported directly to the director general – it represented 90% of the concerns of the directors of a network overtaken by a managerial culture which presented clear lines of decision-making and strong operational capabilities, and proceeded on the basis of quantified goals defined at the national level. The dominant professional culture was focused on performance, on results, and on quick savings. [48] This managerial idea of how to conduct health policy – in other words, short term, technocratic and focused on financial results – was far removed from the professional culture of state officials, a culture based on legal authority and mastery of the mechanisms of healthcare planning. The merger was also a clash of professional cultures. [49]

46More profoundly, what was at stake in the conflict between the state and the Assurance-maladie was the legitimate definition of good sectoral governance. For a fraction of the welfare elite, which was very critical of the role played by local and national political actors, political action should be de-politicized and technologized as far as possible, so as to neutralize the inflationary consequences of a political decision that was inevitably “appropriated” by interest groups (the French Hospital Federation, private doctors, etc.) in a context that dramatized deficits and public debt. [50] The rationalization of the sector, a politically difficult task, should thus be entrusted to technocrats who could not be removed from office during a given period, and who should enjoy free rein within the framework of a roadmap defined at the political level. The steering of healthcare policy should be unified, not to the benefit of a state that was seen to have shown its managerial shortcomings and political weaknesses, but towards a “technical” national health agency, an ANS that – for better or worse – would be based on the UNCAM. This agency, situated at a remove from politics, would lead the rationalization/integration of available care – non-hospital, hospital, medical-social and public health – starting from the national level, which would set objectives based on performance indicators and subcontracts with the insurance offices (caisses) at regional and local level. It is symptomatic that this neomanagerial, top-down vision of integration, highly critical of politics, found a voice among several members of parliament: political actors had also been won over by this “managerial spirit” [51] that spread after the LOLF (Loi organique sur les lois de finances). In this managerial framework, political deliberation is sidestepped or neutralized in pursuit of efficiency. [52] Sectoral integration must come from an “enlightened despot” [53] who is free, at least for a time, from political pressure.

47This concept of integration – technocratic, authoritarian, and focused on the rationalization of costs – did not prevail in the drafting of the HPST Law, with Roselyne Bachelot declaring that she “would not be the minister to close Avenue de Ségur [headquarters of the Ministry of Social Affairs and Health]”. [54] The ambivalence of political actors can be glimpsed here: although concerned by the political cost of controlling health spending, they could not completely walk away from the project, since ultimately they were held responsible for it by the actors in the public debate and the population itself. Questions of controlling spending must, from this point of view, fit with other objectives, such as the financial and geographical accessibility of care – inequalities in access to care are the least tolerated by the French public – or improvement in the major indicators of public health. Thus, for the Minister, healthcare had to remain an affair of the state, and therefore a political matter, but in a configuration more integrated “from below”: the regional health agencies were required to take the form of public administrative establishments, combining the healthcare sections of the decentralized state and Assurance-maladie services. They were granted the status of legal entities, and benefited from significant autonomy to achieve the reorganization of healthcare provision. In this regard, the HPST law represented the “return leg” of the 2004 reform of the Assurance-maladie, which was heavily influenced by the actors of the “social security network”.

Should integration from below lead to integration from above?

48The merger implemented by the HPST law only concerned the regional level; it left the national level relatively unchanged. Some tactical considerations prevailed: in terms of objections raised to the regional merger – especially those of the Assurance-maladie – it was difficult to open a second front, which would have been particularly dangerous. Nonetheless, the architects of the reform viewed keeping the status quo as impossible: the future regional agencies couldn’t have fourteen people giving orders working separately. It was therefore subsequently necessary to develop at least minimal coordination at the national level. [55] While the approach was empirical, the result was unexpected. It took the form of a National Steering Council (Conseil national de pilotage – CNP) to oversee the entire structure, presided by the Minister of Social Affairs and Health as well as the Budget Minister, [56] the directors of the central administrations of the Ministry [57] and the directors of the different insurance offices. The ministers excepted, the other members of the CNP – which met every other week – could not send representatives. Since it was supposed to approve all instructions sent to the ARS, it worked by consensus – implying a significant amount of work by the General Secretary in preparation – and bartering (give-and-take). Effectively, it was unable to drive forward a healthcare policy in the sense of hierarchical objectives constituting a national healthcare strategy. It acted as a “fair broker” destined to “find common ground” and elicit a global, transversal approach to problems. This set-up gave the Assurance-maladie something like veto power, and it was able, at least during the first years, to use it as an opportunity to deploy its strategy of obstruction.

49While the national level saw some progress in the sense of better coordination in the form of the CNP, it remained less integrated than the lower levels. [58] Yet less integration did not mean less control, since those in charge at the national level were unwilling to let the merged entities in the agencies have free rein, even though the latter were supposed to have some margin for maneuver to decompartmentalize and “territorialize” healthcare policy. Effectively, each central administration endeavored to rebuild its network of interlocutors on the regional level. It should be noted that in their daily operation the ARS resembled decentralized services whose margins for action were strictly defined by restrictive and compartmentalized financial instruments (Objectif national des dépenses d’assurance maladie, ONDAM), human resource management controlled at the national level, instruments of public action also defined at the national level, and a plethora of instructions. [59] The ambiguity of the position of the ARS general director was emblematic of the shift back and forth between the advertized decentralizing format and the unofficial centralizing dynamic. Via two decisions on 12 December 2012, the Council of State thus highlighted the “functional duplicity” of the ARS general directors, contracted senior officials named in the Council of Ministers. The minister therefore had the power to instruct all authorities exercised in the name of the state: power was truly hierarchical. Oversight power only applied to executive missions. Moreover, for the Council of State, policies should vary little from one ARS to another, which implied harmonization mechanisms. [60] Finally, because of the persistence of national silos, the regional agencies – through a phenomenon of coercive isomorphism [61] – tended to reproduce the boundaries that they were supposed to combat in the way they actually functioned: “we remained organized in silos so that we received what should be received”, explained an ARS deputy general director. In the end, the segmented interventionism at the national level tended to nullify the benefits of merger in terms of public policy rationality (achieving a more transversal functioning of the administrative components of the regulator).

50Once again, however, explaining this rampant centralization in terms of institutional struggle is necessary but insufficient. It is also a result of the RGPP branding of the new ARS. In effect, the issue of “territorialization” presupposed the passage from classic cross-regulation to policies described as the institutionalization of collective action, in which the administration assumes its political role. [62] If we follow the reasoning of Patrice Duran, by pursuing dual integration – both vertical (bringing together resources and competencies in a homogenous way) and horizontal (improving possible intra- and interorganizational articulation between services and actors involved in the same problem) – then “administrative organizations [must] be thought of as reservoirs of resources and not as repertoires of solutions to public problems”. [63] The RGPP, far from influencing public policy, was in fact polarized around institutional construction. Moreover, it was never truly a question of giving the ARS the financial, legal, and human resources to implement constitutive policies capable of institutionalizing collective action in the territories in relation to healthcare problems. On the contrary, the effects of the tight framing of the autonomy of agencies by the national level were reinforced by the choices made by the ARS general directors in terms of infra-regional organization: the regional offices, whose constituencies were essentially administrative, often did not have the (financial, expert, or temporal) resources or teams capable of mobilizing and maintaining relationships with local systems of action. In fact, regional integration in the form of an agency barely impacted how roles were divided between the political and the administrative: decision-making remained with the national political actors, while the ARS were limited to implementing public policies along traditional administrative lines. Moreover, within these “shared homes”, which the ARS were supposed to be, the inertia of professional routine as well as that of the modes of relationships between the national and regional level contributed to the reproduction of compartmentalization against the stated goals of decompartmentalization/integration of the architects of this administrative format.

How does the medical profession position itself in a more integrated institutional environment?

51As we have said, the final objective of the welfare elite was to discipline professional power by forcing it to internalize some of its objectives, in particular the budgetary ones. Integration of the institutional environment of the medical profession aimed at preventing the representatives of the latter from manipulating and defying an administration that was both balkanized and weak in terms of material, human, and expert resources. More generally, with the creation of the Regional Health Agencies, the regulator was supposed to gain more autonomy from all sectoral interest groups and, by the same token, be capable of taking back control of healthcare provision, which was influenced by political (local elected officials), professional, and corporatist (hospital and private unions) rationales that were seen as inflationary. By drawing on the NPM repertoire – albeit in a less systematic and radical way than proposed in the project supported by the Assurance-maladie – the new Regional Health Agencies should be able to counteract the centrifugal tendencies of deepening divisions in medical labor. They should also be able to espouse an overall vision of the “healthcare chain” so as to be able redeploy resources, especially budgetary ones, primarily to benefit the areas in the periphery of the hospital sector (in preventive, non-hospital, and medicalsocial healthcare). The organizational forms and the instruments of public action promoted since the 1990s all share this coordinating and integrating rationale. Consequently, it is easier to understand the medical protests against the reforms. They saw the reforms not only as an attack on their professional autonomy but also a perversion of clinical logic: from a strictly medical point of view, designating “homogenous groups of patients” from billing to treatment (Tarification à l’activité, T2A), [64] or hubs (the integration of hospital services in larger organizations) has no epistemological foundation (they mix apples and oranges). Thus a large part of the medical critiques of the regulatory power consisted of deconstructing the operations of aggregation and integration the regulators promoted.

52The HPST Law constituted the pinnacle of medical opposition to the rising influence of the regulator’s desire for integration. In effect, this reform was not limited to the merger of healthcare administration (the “PST”). Symptomatically, it had a “hospital governance” section (the “H”) radicalizing the integration of hospital organization under its existing leadership, now promoted to “company bosses”. The RGPP moment, and its concern to draw clear lines of command, had the merit of clarifying the main issue in integrating the medical world: establishing the pre-eminence of those in organizational roles over practitioners, who were seen less as members of a profession than as managers – at a senior level, naturally – whose loyalty must first be to their “company”. This symbolic and practical demotion could only raise the ire of the Parisian hospital-university elite. Its protests were as much an avowal of weakness as they were unprecedented, since this elite ordinarily benefitted from direct access to the centers of political decision-making: in the spring of 2009, “mandarins” could be seen for the first time marching alongside the unions of administrative and paramedical personnel in the streets of Paris. [65] Their protests were also defeated, as the RGPP configuration had neutralized the access points and possibilities for veto in the processes of elaboration of the reform. At the same time, the unions of private doctors worked to have parliament withdraw those propositions of the draft law that were the most contrary to the sacrosanct “medical freedoms”, in particular the freedom to set up a practice and set prices. With the government making efforts for strategic reasons not to open two fronts at once, this private mobilization met with success, even leading to the departure of Roselyne Bachelot, replaced by Xavier Bertrand, who was seen as more amenable to the demands of organized private medicine.

53The struggles over the HPST law attest to the state of the power relationships between the bureaucratic and medical fields. More precisely, integration of the bureaucratic field in the healthcare sector was refracted in the conflictual integration of the medical field. It contributed to reworking the power relationships that structured the medical field. It is not by chance that the most strident opponents of HPST were a diabetologist and a psychiatrist, two representatives of medical specialties that do not lend themselves well to industrial rationalization, given their highly discretionary nature. [66] In point of fact, these reforms could not have a hold over the medical world solely because they reshuffled the cards between specialties but also within them. [67] The reformers could definitively count on the support of some representatives of the “dominant” biomedical specialties (whose activity was accentuated by the T2A for example) as well as some of the “dominated” who saw it as a way out of relative indignity. The political dimension of integration arose because it openly challenged the power relations between social fields and within these fields. In particular, it enlivened professional competition and struggles.