1The political debate surrounding the reform of healthcare systems in developed countries essentially revolves around the opposition between state and market. The concepts of “liberalization”, “privatization”, “neoliberalization”, and even “commodification” have been used in a negative light to oppose reform projects aimed at expanding the role of private actors, especially for-profit ones, and at bolstering the logic of competition in “healthcare states” that were established and consolidated after the Second World War and, it is argued, were based both on keeping medicine out of the free market and on maximum nationalization of health cover. The political and social sciences have mirrored these controversies by frequently using the same terms as the public debate. For the most part, this has consisted of identifying the coalitions of public and private actors that express support for privatization and liberalization, and of illustrating the resilience of the sectoral institutions that are legacies of the post-war era.  For a time, it was considered that welfare states were “immovable objects”,  before this literature – which was comparative in the main – turned to an exploration of the incremental processes of change and the introduction of neoliberal logic. 
2However, several authors have suggested that the literature should not limit itself to what appears to be academic “path dependence” exclusively focused on the thesis of neoliberal privatization.  In some ways, the idea of “marketization” can cloud our understanding of more structural changes in healthcare systems, or even send us in the wrong direction in terms of interpretation by single-mindedly defending fragmentation of the market and of competition within a framework of the neoliberal retreat of the state. There are three ways in which this interpretation is open to debate. First, healthcare systems have always been political arenas in which institutions and professional sectors have been embroiled in competition. Second, one only needs to observe the changes currently underway in healthcare systems in order to discredit the picture of market fragmentation, in which smaller units would be in fierce competition. The opposite tendency holds true: the dynamics are more centripetal than centrifugal, more industrial than market-based. Healthcare systems are moving towards greater integration, in which actors are emerging that are both more powerful and are interconnected via denser and more diversified relationships. Third, recent events have not seen the state collapse but, on the contrary, assert itself. The observation made by W. Richard Scott and his team (in response to work by Mary Ruggie) with regard to the US healthcare system applies all the more to the French healthcare system.
[Ruggie […] suggests] “that the policy regime now overseeing healthcare in the United States is not in the process of being dismantled but is shifting its mode of governance from an ‘interventionist’ to an ‘integrative’ regime […] We are in agreement with her general claim that the change we are currently observing does not involve a ‘swing along the axis from state to market… because the introduction of marketlike factors is occurring within a continuing strong framework of government regulation’ […] Market mechanisms have joined, but not replaced, state controls. What we see is a change in rhetoric and in the policy mechanisms that governmental actors employ as they attempt to steer the development of this sector specifically and govern the welfare state more generally.” (343-4) 
4In the healthcare systems model proposed by the heterodox Canadian healthcare economist Robert G. Evans  – one of the main opponents of the pro-market rhetoric of recent reforms of developed healthcare systems  – such systems, which are fundamentally hybrid, combine to varying degrees “remote” commercial relations and more classically hierarchical relations. The main interest of Evans’ work is that it draws critical attention to the pro-market rhetoric that accompanied the enactment of reforms starting in the 1990s. 
5Reforms of the healthcare system cannot, therefore, be reduced to the logic of neoliberalization. It is also possible to understand them as arising from the state’s efforts to integrate particularly fragmented systems, which are the legacy of the turbulent history of this sector. This is the goal of the present article: to make the argument that the concept of “integration” – taken from economic sociology and the theory of the firm – sheds new light on the organizational changes that currently affect the French healthcare system.  Let us first clarify the meaning of the concept of integration within economic sociology, which will enable us to adopt an original perspective on the French health sector. Integration is in opposition to the market as a specific social order:
If we accept that a group is integrated when it cannot be assimilated to the sum of the parts that compose it, understanding the process of its integration means describing the stages that transform juxtaposed and independent individuals into a singular and separate entity, one that cannot be reduced to the sum of their actions. 
7In this sense, integration falls within the more general work on organization. If examined from the perspective of the theory and history of the firm, integration can be divided into an external dimension (concentrated operations that lead to the constitution of large units) and an internal dimension (densification of the mechanisms of coordination, deployment of a techno-structure in charge of the organization, increasing numbers of managerial innovations aimed at exerting better control over operational units).  In a more operational sense, the process of integration can be identified through at least five characteristics: it leads to verticality and hierarchy; using centripetal logic, it aggregates professional interests and territories that, instinctively, tend to differentiate themselves even further using centrifugal logic; it promotes coordination and transversality; it encourages the formalization and standardization of professional practices; it presupposes the routine production of information; and it creates intermediate managerial spaces.  Obviously, using the concept of “integration” should not suggest a functional, irresistible, and homogenous dynamic. The process takes different paths and forms depending on national institutional configurations.
8The terrain chosen to study these processes is the situation in France: the focus is not on healthcare professionals but on the less-examined area of healthcare administration. The process of integration does not affect only the “producers” of care and the organizations in which they operate. In fact, their dreaded and often hated counterparts – the state and the Assurance-maladie (the national health insurance system) – were also led to coordinate better, work more closely, and finally merge. The creation of regional health agencies (agences régionales de santé – ARS) via the “Hôpital, Patients, Santé, Territoire” (HPST) law of July 2009 – which led to the creation of the unique configuration of state reform constituted by the general revision of public policy (revision générale des politiques publiques – RGPP) – was the outcome of a long period of reflection that began in the 1980s within the upper echelons of the administration, and which sought to give public sector authorities the capacity to “regulate” and “manage” a medical field which prized its autonomy. 
9The dynamics of integration are not studied here as irresistible, mechanical, or unidirectional forces. On the contrary, using the general definition set out as a starting point, we propose distinguishing two paths and two modes of integration: integration “from above” (in other words, the national level) and integration “from below” (for example, local services operated by the state and the Assurance-maladie); and organizational integration operating by reshaping and merging organizations versus “distance” management integration using performance-based steering instruments (contractualization, indicators, and objectives, etc.).
|Integration from above||Integration from below|
|Organizational integration via merger||Merger of central administration||Merger of decentralized services|
|Managerial integration via performance mechanisms||Integration of the network of health insurance funding bodies (caisses d’assurance maladie)||Mutual and insurance healthcare networks|
10The primary aim of this matrix is to encourage reflection on the different features of the processes of integration: in this case, the organizational and managerial features. We are not seeking in principle to set ourselves up in opposition to the mechanisms inspired by New Public Management (NPM) and reforms via merger, as is the wont of some works which consider mergers as belonging to the repertoire of reforms that follow on from and improve upon NPM.  On the contrary, we seek to use empirical cases to think about the ways that reforms focused on the establishment of steering mechanisms based on objectives and indicators, or on forms of contractualization, may connect in different ways to organizational reforms via merger: harmonizing with them, reinforcing them, or constituting an alternative. In contrast with set visions of NPM that depict it as the neoliberal means by which the democratic state is hollowed out and dismantled,  New Public Management can provide a repertoire from which state or para-state actors can borrow to “rearm” the state against the power of industry and reinforce its capacity to integrate. In this hypothesis, NPM would work in tandem with the project to strengthen state capacities  and to make healthcare administration independent of the powerful interest groups that have long dominated the sector.
11This perspective allows for a sociological approach to the processes of institutional integration on three levels. It serves to highlight the modalities of integration and the actual instruments through which they are transmitted (the organizational format of the merger; the managerial mechanisms, etc.). It attaches importance to the actors involved (central administrations, decentralized state services, the medical-social sector, health insurance funding bodies) and to the dynamics of integration. Finally, this approach recognizes the processes of integration as a political dynamic in the classic sense, and also one which encompasses significant political issues, relating to the legitimate definition of good sectoral governance and of the medical professionalism that should prevail there.
12In pursuing this path, this article follows in the footsteps of “neo-institutionalist historical” works in order to show how the issue of integration – bearing the “mark of its origins” – has emerged historically within the French healthcare system. This approach also allows us to highlight the nature of the processes that allow the state, under certain conditions and under the constraint of historical forces, to constitute an “integrating agent” within a sector of public action, and thus to acquire a certain relative autonomy by reinforcing its capacity to act upon one aspect of the social world. The process of integration is thus doubly institutional: it addresses the historical institutional fragmentation of the French healthcare sector whilst dealing at the same time with sectoral institutions.
13After showing that the process of integration provides a key to a heuristic reading of the reforms of the healthcare system since the 1980s, we will look at the way in which the specific configuration of the RGPP opened a window of political opportunity that allowed the reform to quickly progress. The creation of regional health agencies served to anchor the integration project in an organizational dynamic focused on merger, which lent the project a material form and seeming irreversibility. This second part of the article closely studies this dynamic of integration through merger, the competing visions of how this might happen, and the way that the institutional legacy limited its scope, in particular at the national level. In the third section, we will return to look in more detail at the three central issues of this process. These represent the political, and not technical, dimensions of the integration of the healthcare sector; the conflicts surrounding the appropriate level of (national and local) regulation and their resolution; and the effects of integration on healthcare professionals and the definition of professionalism in healthcare work.
Turning medical chaos into a “healthcare system”
14If, as Canadian healthcare economist Robert G. Evans suggests, each healthcare system can be evaluated from the perspective of its degree of vertical integration, the case of France is distinct in its “disintegration” or its historical fragmentation. Its actors and operators are both many in number and at best poorly coordinated; at worst they maintain relations of competition or conflict. From the latter half of the 1970s, this splintered institutional configuration would be subjected to pressures both inside and outside the sector. The tensions witnessed in the French healthcare (dis)organization led some prominent figures of the “welfare elite” – as identified by Patrick Hassenteufel and his team  – to flag this as a problem in need of a solution.
The missing “healthcare system”: a historical trajectory of disintegration
15In light of the different dimensions integration may involve, it’s clear that the historical trajectory of the French healthcare system did not favor integration but instead contributed to its fragmentation. Schematically, the French healthcare system can be broken down into three strands that perform different roles: regulation (taken care of by the state for the most part); funding (covered by social security services and complementary medical insurance); and the “production” of care (hospitals, non-hospital practices, medical-social provision). Not only have these three strands had relatively poor and/or conflictual relationships historically, but each division is poorly internally integrated.
16In terms of funding, the choice of a Bismarckian system and the agreement signed in 1945 with the Mutualité meant distancing the regulator (the state) from the financers/payers and led to the manifold increase in the number of public and private financing organizations.  Rivalries developed between the regulator and the many public and private funders, there was weak integration of the network of health insurance funding bodies, a lack of coordination (and tensions) between basic and complementary coverage, and a multiplicity of coverages: a brief panorama which suggests an image of institutional chaos rather than an integrated and regulated “whole”.  In terms of healthcare production, the configuration was hardly more appealing when viewed from the perspective of integration. Patrick Hassenteufel has shown how the French medical profession defined its identity in private practice in opposition to the state (the regulator) and to social security (public financing).  Moreover, non-hospital practices, hospitals, the medical-social sector, and public health each represented different systems of relatively autonomous, if not rival, systems.
17The third strand – regulation – will be our prime focus here. The state appears weak as a result of its fragmentation. This weakness is the flipside of the stranglehold that powerful interest groups have on the healthcare system. Hospital-university elites, local elected officials, and healthcare industries keep the administration of healthcare at arm’s length, notably through direct access to political decision makers, whose plethora of cabinets tend to duplicate and short-circuit the central and decentralized state administrations. The Ministry of Health is a relatively recent creation (1920), with a fluctuating ministerial affiliation, and for a long time it appeared to be a “general without troops”.  In competition with the network of health insurance funding bodies, it had little in the way of human resources, equipment, and expertise; it did not have large bodies that would allow it to assert itself during ministerial negotiations. At least until the end of the 1980s, the central administrations of the ministry were little respected and the decentralized administrations were both poor and fragmented. The Departmental Directorates of Health and Social Affairs (DDASS), established in 1964 and under the authority of departmental prefects, primarily performed supervision and inspection of health, medical-social, and social establishments. Their regional counterparts, the DRASS, created in 1977 and under the authority of the regional prefect, were essentially tasked with planning and allocating the resources for medical, medical-social, and social establishments. In principle, there was no hierarchy between DDASS and DRASS, as there was no hierarchy between local, regional, and national offices of the Assurance-maladie. The decentralized administration of the state was surrounded on all sides. It did not manage the majority of the financial resources allocated to the healthcare system, which were administered by the Assurance-maladie, but only the hospital system, and was faced with powerful local interests to which it could not stand up, either in a real sense or in a symbolic one. Hospital regulation is political in nature: the arrangements between prefects and local officials obey the model of cross-regulation,  with the most important officials (mayor-deputies, mayor-senators) able to circumvent the financial constraints proclaimed by the Ministry since the early 1980s by calling on their national political networks.  “We must therefore conclude that the under-administration of healthcare in France is the logical condition for survival of a system dominated by the values and interests of medical society”, lamented the former DRASS employee, Bernard Marrot.  Non-hospital practices, on the other hand, were part of the framework of the national agreement, adopted with difficulty in 1971 after negotiations between the Assurance-maladie and the private practitioner unions. They therefore almost entirely escaped the grasp of state regulation, which did not control the main vehicle for the reorganization of healthcare delivery: pricing incentives. The competition between doctors’ unions around issues of private practice, coupled with the rivalry between the Assurance-maladie and the state – with doctors’ unions playing one off against the other – contributed to a “negotiated waste”  that essentially benefited the status quo (persistent devaluing of general medicine in favor of specialized medicine, persistent territorial inequalities in healthcare delivery, and, in recent times, a normalization of the practice of exceeding reimbursement levels).
18Examined from the perspective of any of these three strands, the “healthcare system” was not a system, but more a political arena in which centrifugal forces won out over centripetal ones.
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.  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.  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,  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.  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. 
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.  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.  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. 
RGPP as political opportunity: when integration becomes merger
29The encounter between the project to create the ARS and the General Revision of Public Policy (RGPP) was not without impact on its content. On the one hand, the RGPP allowed this integration by merger to overcome, at least in part, the institutional obstacles that since the mid-1990s had hindered its rapid realization. These rival forces would manifest themselves forcefully once again during the process of developing the HPST law. The Assurance-maladie, as primary financer of the healthcare system, on this occasion promoted a competing project of integration in which financers sought to take over the regulatory function of the state. On the other hand, the idea passed uncontested through the specific configuration of state reform known as the RGPP. The initial objective of achieving better connected and more localized public health policies gave way to more political objectives (bringing an end to the diarchy of state and Assurance-maladie) and budgetary ones (reducing the number of positions, making gains in productivity, and moving towards greater efficiency by pooling services and support functions).
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”.  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.
“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.
“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.  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.  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”,  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.  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  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,  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.  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?
The political stakes of integration of the “healthcare system”
41The controversy that surrounded the merger, albeit muted and somewhat eclipsed by the medical protests against the hospital “governance” section of the law, came from the fact that the merger brought with it a certain number of specifically political stakes and conflicts over what should be good sectoral governance in a healthcare system undergoing the process of integration. We will identify three: the respective place of politicians and technocrats; the redefinition of the relationships between politics and administration implied by the “territorialization” of public policy; and the positioning of professional logic in a more integrated institutional environment.
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.  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.  Johanet’s second term at the head of the CNAMts reinforced the movement that had begun at the start of the 1990s.  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.  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.  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.  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.  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. 
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.  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”  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.  Sectoral integration must come from an “enlightened despot”  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]”.  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.  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,  the directors of the central administrations of the Ministry  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.  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.  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.  Finally, because of the persistence of national silos, the regional agencies – through a phenomenon of coercive isomorphism  – 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.  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”.  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),  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.  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.  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.  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.
Conclusion: from visible integration by technocrats to invisible integration by the market? 
54Hospital mergers and/or closer working relationships, the concentration of medicalsocial establishments, the development of pluri-professional surgeries and healthcare centers on the ruins of the individual private cabinet, the concentration of the complementary health insurance sector more closely linked to basic coverage, the hierarchical integration of the network of health insurance funding bodies, the growing cooperation between the different basic regimes, the creation of the ARS, the rise of information and management systems: within the three strands – financing, regulation and production – of a “healthcare system” that increasingly deserves the name, actors have emerged that are both more significant and that have established dense and diversified relations with actors within the other two strands. Long a non-integrated sector fragmented into smaller actors with relative autonomy, it has thus progressively become a real system where sizeable collective actors exchange information capital, economic capital, and also political capital.
55While pressures in favor of increasing integration of the sector have seemed unavoidable (and far from solely budgetary), we have shown that integration does not just take a single form. It can be more or less technocratic (instead of political), more or less authoritarian (instead of public), more or less “professionalized” (in the sense that professional logics and actors can occupy a more or less pre-eminent or subordinate place).
56Our approach via the concept of integration also allowed us to take a different perspective on the dynamics of transformation of healthcare systems, which all too often depend on commercialization, liberalization, or even privatization. It may well be that these notions only skim the surface of the dynamics at play or, worse, draw analysts into what ultimately proves to be merely the rhetoric legitimizing the reforms. The recourse to market instruments is certainly not absent from reforms, but the development of logics of competition and pseudo-markets can also be seen as a way of reaching a more fundamental end: greater integration of the provision of treatment. For example, in terms of financing, it was shown that social security withdrew from the financing of routine care – thus reduced to complementary health insurance  and, very recently, to complementary company insurance, in the context of the interprofessional national agreement of 2013 – to focus more on “major risk” (long term treatment, hospital care). No one would see this as an edifying example of privatization. However, this analysis is insufficient because, at the same time, public authorities were attempting to better “regulate” the sector of complementary health insurance, which was moreover increasingly reliant on public funds, and to coordinate it more closely with so-called “basic” coverage. In one sense, we could speak of the increasingly public nature of “private” actors, who became para-state actors. The involvement of private financers was not just to satisfy an accounting objective (to transform public spending to satisfy the demands of financial markets and the European Union in terms of public spending and debt); this public/private transfer also had another motive: to minimize the political blame related to the reorganization of privately practicing doctors, who were furious with the public authorities. Moreover, these complementary health insurances, faced with fierce competition and the new European requirements of solvency, underwent an accelerated process of concentration from which new and powerful formally private financers emerged. This is why the unions of private practitioners tried to change sides: they began to ask the state to protect them from challenges against the sacrosanct “medical freedoms” in the context of mutualist or insurance “healthcare networks”. These formally private and increasingly large financers are the mask of a state that does not want and/or cannot intervene openly. It is less about burying the healthcare state than concealing it: the healthcare state is just as present – strengthened even – but it acts remotely, through supposedly independent organs. This is characteristic of a “private social policy approach”  and “delegated governance” which, while in step with neoliberal injunctions, are intrinsically inegalitarian.  To put it another way, the market is used here as a powerful incentive to integrate; it is not an end in itself.
57Under similar “objective” pressures (rationalization and cost control, epidemiological transition and growing prevalence of chronic illnesses, increased demands for continuity and quality of care, etc.), all healthcare systems in developed countries are subject to the dynamics of integration, but – in accordance with the teachings of neo-institutionalist work – they are subject to these dynamics in ways which vary in intensity and between nations. In the liberal systems of health insurance (United States), the insurance industry is at work, inventing for each circumstance organizational frameworks and managerial instruments that tend to migrate, with substantial adaptations depending on national configurations, throughout the countries of the OECD.  In national healthcare systems, the work of integration comes indisputably from the state, which either proceeds in a highly centralized way, relying on performance-based steering mechanisms (Great Britain), or in a more decentralized manner (Scandinavia). In national health insurance systems (Germany), the insurance offices take on the primary roles, borrowing once again from the managerial repertoire. In France, the process of integration reveals both the original fragmentation of the healthcare sector and, above all, the fundamental ambivalence of the “legacy of 1945”: achieving the goals of Beveridge with the methods of Bismarck.  In fact, the development of the ARS was an issue of historical clarification… and one which remained incomplete, not just because of institutional power relations at the national level but also because of the “liberal” identity of organized medicine in France. 
58ARH: Agence régionale de l’hospitalisation – Regional hospital agency
59ARS: Agence régionale de santé – Regional health agency
60CNAMts: Caisse nationale d’assurance maladie des travailleurs salaries – National health insurance fund for employees
61CNP: Conseil national de pilotage (ARS network) – National steering council
62DDASS: Direction départementale des affaires sanitaires et sociales – Departmental directorate of health and social affairs
63DRASS: Direction régionale des affaires sanitaires et sociales – Regional directorate of health and social affairs
64DGS: Direction générale de la santé – Directorate general of health
65DHOS: Direction de l’hospitalisation et de l’organisation des soins (now the DGOS) – Directorate of hospitalization and healthcare organization
66DSS: Direction de la sécurité sociale – Directorate of social security
67HPST law: Loi Hôpital, Patient, Santé, Territoires (2009) – Hospital, patient, health, territories law (2009)
68ONDAM: Objectif national des dépenses d’Assurance-maladie – National objectives for health insurance spending
69T2A: Tarification à l’activité – Pricing by activity
70UNCAM: Union nationale des caisses nationales d’assurance maladie – National union of health insurance funding bodies
71UNOCAM: Union nationale des organismes complémentaires d’assurance maladie – National union of complementary health insurance organizations
Michael Moran, Governing the Healthcare State. A Comparative Study of the United Kingdom, the United States and Germany (Manchester: Manchester University Press, 1999).
Paul Pierson, Dismantling the Welfare State? Reagan, Thatcher and the Politics of Retrenchment (Cambridge: Cambridge University Press, 1994).
Paul Pierson (ed.), The New Politics of The Welfare State (New York: Oxford University Press, 2001); James Mahoney, Kathleen Thelen (eds), Explaining Institutional Change. Ambiguity, Agency and Power (New York: Cambridge University Press, 2010); Jacob S. Hacker, “Privatizing risk without privatizing the welfare state: the hidden politics of social policy retrenchment in the United States”, American Political Science Review, 98(2), 1998, 243-60; Bruno Palier, Gouverner la Sécurité sociale (Paris: PUF, 2005).
In particular, Robert G. Evans, “Incomplete vertical integration in the healthcare industry: pseudomarkets and pseudopolicies”, American Academy of Political and Social Science, 468, 1983, 60-87; more recently, William Richard Scott et al., Institutional Change and Healthcare Organizations. From Professional Dominance to Managed Care (Chicago: The University of Chicago Press, 2000); Martin Kitchener and Linda Gask, “NPM merger mania”, Public Management Review, 5(1), 2003, 19-44; Martin Kitchener, “Mobilizing the logic of managerialism in professional fields: the case of academic health centre mergers”, Organization Studies, 23(3), 2002, 321-420.
William Richard Scott, et al., Institutional Change, 343-4, citing Mary Ruggie, Realignments in the Welfare State: Health Policy in the United States, Britain and Canada (New York: Columbia University Press, 1996).
Robert G. Evans, “Incomplete vertical integration”.
See also James K. Galbraith, who recommends maintaining a certain distance from pro-market rhetoric in his book The Predator State. How Conservatives Abandoned the Free Market and Why Liberals Should Too (New York: The Free Press, 2008).
For an overview of the work of Robert G. Evans, see Morris L. Barrer et al., An Undisciplined Economist. Robert G. Evans on Health Economics, Healthcare Policy, and Population Health (Montreal: McGill-Queen’s University Press, 2016). See also Henry Mintzberg and Shotom Glouberman, “Managing the care of health and the cure of disease – Part II: Integration”, Healthcare Management Review, 26(1), Winter 2001, 72-86.
An approach to these issues in terms of “integration” was first proposed by Daniel Benamouzig and Frédéric Pierru in “Le professionnel et le ‘système’: l’intégration institutionnelle du monde medical”, in Philippe Bezes et al., “New Public Management et professions dans l’État: au-delà des oppositions, quelles recompositions?” Sociologie du travail, 3, 2011, 293-348.
Pierre François, Sociologie des marchés (Paris: PUF, 2008), 108-9. [Translation note: Where no English language version is given, quotations from the original French work have been made by the translator of this article.]
François Cusin and Daniel Benamouzig, Économie et sociologie (Paris: PUF, 2004), 247ff.
Philippe Lefebvre, L’invention de la grande entreprise. Travail, hiérarchie, marché. France, fin du 18e siècle-début du 19e (Paris: PUF, 2003).
Specifically, what is being referred to here is the most autonomous – and dominant – area of medicine, clinical medicine, as opposed to the two other areas, social medicine and the so-called auxiliary sciences. Patrice Pinell, “Champ médical et processus de specialisation”, Actes de la recherche en sciences sociales, 156-7, March 2005, 4-36.
Tom Christensen and Per Lægreid, “The whole-of-government approach to public sector reform”, Public Administration Review, 67(6), 2007, 1057-64. See the introduction to this special issue.
Ezra Suleiman, Le démantèlement de l’État démocratique en Europe (Paris: Seuil, 2003).
Theda Skocpol, “Bringing the state back in: strategies of analysis in current research”, in Peter B. Evans et al. (eds), Bringing the State Back In (Cambridge: Cambridge University Press, 1985), 3-43; Daniel P. Carpenter, The Forging of Bureaucratic Autonomy. Reputations, Networks and Policy Innovation in Executive Agencies (1862-1928) (Princeton: Princeton University Press, 2001).
R.G. Evans, “Incomplete vertical integration”.
Patrick Hassenteufel et al., L’émergence d’une élite du Welfare? Sociologie des sommets de l’État en interaction. Le cas des politiques de protection maladie et en matière de prestations familiales (1981-1997), Report for the MIRE, July 1999.
Bruno Valat, Histoire de la Sécurité sociale (1945-1967). L’État, l’institution, la santé (Paris: Economica, 2001).
Patrick Hassenteufel, Les médecins face à l’État. Une comparaison européenne (Paris: Presses de Sciences Po, 1997). The recent conflict between the socialist government and the main unions of private doctors concerning the third-party payment system demonstrates the strength of this historical identity.
Aquilino Morelle, La défaite de la santé publique (Paris: Flammarion, 1998).
Pierre Grémion, Le pouvoir périphérique. Bureaucrates et notables dans le système politique français (Paris: Seuil, 1976).
François Engel, Dominique Tonneau, and Jean-Claude Moisdon, “Contrainte affichée ou contrainte réelle? Analyse de la regulation du système hospitalier public français”, Sciences sociales et santé, 8(2), 1990, 11-32.
Bernard Marrot, L’administration de la santé en France (Paris: L’Harmattan, 1995), 182.
Alain Letourmy, “Les réformes économiques de la régulation des dépenses de santé: le gaspillage négocié”, Revue française d’administration publique, 76, 1995, 561-74.
This point has been comprehensively documented in Hassenteufel et al., L’émergence d’une élite du Welfare? From the end of the 1980s, senior officials from the grands corps became involved in an undervalued sector and developed a common sense of reform on which later reforms would draw.
Marc-Olivier Déplaude, “Une fiction d’institution: les ‘besoins de santé de la population’”, in Claude Gilbert and Emmanuel Henry (eds), Comment se construisent les problèmes publics (Paris: La Découverte, 2009), 255-72; Frédéric Pierru, “Planifier la santé: une illusion technocratique?”, Les tribunes de la santé, 37, 2012, 83-94.
Raymond Soubie, Santé 2010. Santé, maladie, technologies. Des données pour le futur (Paris: Commissariat général du Plan, 1993); Pierre-Louis Bras and Didier Tabuteau, “‘Santé 2010’: un rapport de référence pour les politiques de santé”, Les tribunes de la santé, 25, 2009, 79-93.
François-Xavier Schweyer, “La régulation régionale du système hospitalier: pilotage par l’État ou territorialisation?”, Politiques et management public, 16(3), 1998, 43-68.
Annick Valette, “Fallait-il une nouvelle organisation pour changer les modes de régulation? L’expérience des agences régionales de l’hospitalisation”, Revue française des affaires sociales, 4, 2001, 69-75.
Frédéric Pierru, “Budgétiser l’assurance maladie. Heurs et malheurs d’un instrument de maîtrise des dépenses publiques: l’enveloppe globale (1976-2010)”, in Philippe Bezes and Alexandre Siné (eds), Gouverner (par) les finances publiques (Paris: Presses de Sciences Po, 2011), 395-449. Since the Juppé plan drew abundantly on the repertoire of reform developed by the welfare elite gravitating around the DSS, it is hardly surprising that the latter bolstered the position of the former.
We were told about these attempts at informal coordination between DDASS and DRASS several times during our inquiry, highlighting the time-consuming and random aspect of the integrating mechanisms of the time.
John W. Kingdon, Agenda, Alternatives and Public Policies (New York: HarperCollins, 1995).
Philippe Bezes, “Morphologie de la RGPP: une mise en perspective historique et comparative”, Revue française d’administration publique, 136, 2010, 775-802 (791-2).
Philippe Ritter, Rapport sur la creation des agences régionales de santé, January 2008. Online
Interviews with the primary technical advisor in charge of the ARS in the Bachelot cabinet and some members of the ARS group project in the Ministry.
Yves Bur, Rapport d’information en conclusion des travaux de la mission sur les agences régionales de santé, Commission des Affaires sociales de l’Assemblée nationale, 697, 6 February 2008.
Such as the “Hôpital 2007” plan and the pricing of hospital services, and the reform of health insurance in 2004.
As frequently emphasized during the interviews, it is rare to benefit from political involvement of this sort in this type of institutional reform. The minister’s involvement is clearly to be connected with the politicization of the RGPP, which was supposed to embody the political will of the new president of the Republic and his willingness as a leader to break with the past.
For the characteristics of this group project, in which the consultants were numerically superior to the senior officials, see Frédéric Pierru, “Le mandarin, le gestionnaire et le consultant. Le tournant néolibéral de la politique hospitalière”, Actes de la recherche en sciences sociales, 193, 2012, 32-51 (41ff).
Alain Lopez, Réguler la santé. Objectifs, méthodes et outils pour une stratégie globale des politiques de santé (Rennes: Presses de l’EHESP, 2013); Pierre-Louis Bras, “La création des agences régionales de santé: notre système de santé sera-t-il encore mieux gouverné?”, Droit social, 11, 2009, 1126-35.
Marina Serré, “Un tournant néolibéral de la santé? Les réformes de la protection maladie en France ou l’acclimatation d’un référentiel de marché”, PhD thesis in political science, under the supervision of Michel Offerlé, Paris, Université Paris I-Panthéon Sorbonne, 2001.
Frédéric Pierru, Hippocrate malade de ses réformes (Bellecombe-en-Bauges: Éditions du Croquant, 2007).
On the evolution of this rather opaque institution, see the former senior executive of the Assurance-maladie network, Rémy Fromentin, L’imbroglio sanitaire français (Paris: Éditions de Santé, 2003).
Patrick Hassenteufel et al., Les nouveaux acteurs de la gouvernance de la protection maladie en Europe (Allemagne, Angleterre, Espagne, France), Report for the MIRE, March 2008.
“Thus it is indeed an overall engineering of risk management that health insurance has developed during the 2000s” (Pierre-Yves Bocquet, Michel Peltier, Mission sur la gestion du risque, IGAS, December 2010, 17).
For analyses of the consequences of this method of management on the exercise of social rights, see Pascal Martin, “Les métamorphoses de l’État social: la réforme managériale de l’assurance-maladie et le nouveau gouvernement des pauvres”, PhD thesis in sociology, under the supervision of Patrice Pinell, Paris, EHESS, 2012.
For more details, see Frédéric Pierru, “Planifier la santé”.
See Benjamin Lemoine, L’ordre de la dette. Enquête sur l’infortune de l’État et la prospérité du marché (Paris: La Découverte, 2016), and his contribution to this special issue. On this general movement of de-democratizing/ technologizing public action in the framework of the advent of “state consolidation”, see the important book by Wolfgang Streeck, Du temps acheté. La crise sans cesse ajournée du capitalisme démocratique (Paris: Gallimard, 2014), chapter 3.
Albert Ogien, L’esprit gestionnaire. Une sociologie de l’air du temps (Paris: Éditions de l’EHESS, 1995).
Albert Ogien, Désacraliser le chiffre dans l’évaluation du secteur public (Paris: Éditions Quae, 2013), 56.
This expression comes from a senior official who is a member of this planning elite.
We should note in passing that the model of the strategic state does not avoid conceptual difficulties: it is somewhat complicated to distinguish the political (the definition of objectives) from implementation.
Cécile Courrèges, “Réforme de la gouvernance régionale: quel impact sur le pilotage national?”, Actualité et dossier en santé publique, 74, 2011, 31-4.
In their absence, the CNP is presided over by the general secretary of social ministries, and the general secretariat also acts as the secretariat of the CNP.
Directorate General of Healthcare Organization, Directorate General of Health, Directorate General of Social Security, Directorate of Research and Statistics, Directorate General of Social Cohesion, in addition to the head of the IGAS and the budget director.
See also the critical review of the CNP mechanism by two important actors in the ARS project group, “L’agence nationale de santé: le défi d’un pilotage unifié, refusant technocratie et centralisation”, Santé publique, 24(3), 2012, 229-40.
Frédéric Pierru and Christine Rolland, “La quadrature du cercle de la territorialisation des politiques de santé: la fusion de l’administration territoriale à l’épreuve de la concurrence des institutions et des rationalités de l’action publique”, in Thomas Alam and Marion Gurruchaga (eds), Collectivités, territoires et santé. Regards croisés sur les frontières de la santé (Paris: L’Harmattan/Grale, 2015), 45-73, and “Les ARS deux ans après: une autonomie de façade”, Santé publique, 4, 2013, 411-9.
Benoît Apollis, “La dualité fonctionnelle du directeur général de l’ARS”, Revue générale de droit médical, 46, March 2013, 317-8.
Paul J. DiMaggio and Walter W. Powell, “The iron cage revisited: institutional isomophism and collective rationality in organizational fields”, American Sociological Review, 48 (2), 1983, 147-60.
Patrice Duran, Penser l’action publique (Paris: LGDJ, 1999).
Duran, Penser l’action publique, 132.
Pierre-André Juven, Une santé qui compte (Paris: PUF, 2016).
Frédéric Pierru, “Les mandarins à l’assaut de l’usine à soins: bureaucratisation néolibérale de l’hôpital français et mobilisation de l’élite hospitalo-universitaire”, in Béatrice Hibou (ed.), La bureaucratisation néolibérale (Paris: La Découverte, 2013), 203-30.
Florent Champy, Nouvelle théorique sociologique des professions (Paris: PUF, 2011).
Nicolas Belorgey, L’hôpital sous pression. Enquête sur le nouveau management public (Paris: La Découverte, 2010); Fanny Thomas, “L’évolution des modes de légitimation de l’autorité clinique au sein du champ médical: les hiérarchies médicales hospitalo-universitaires dans le contexte de réforme des hôpitaux”, PhD thesis in sociology, under the supervision of Choukri Ben Ayed, Limoges, Université de Limoges, 2015.
A reference to the important book by Alfred Chandler, The Visible Hand: The Managerial Revolution in American Business (Cambridge, MA: Harvard University Press, 1977).
Pierre-Louis Bras and Didier Tabuteau, Les assurances maladie (Paris: PUF, 2012).
Jacob Hacker, The Divided Welfare State. The Battle over Public and Private Social Benefits in the United States (New York: Cambridge University Press, 2002).
Kimberly J. Morgan and Andrea L. Campbell, The Delegated Welfare State. Medicare, Markets and the Governance of Social Policy (New York: Oxford University Press, 2011). For a critical presentation of the contributions of this work, see Frédéric Pierru, “La ‘gouvernance déléguée’ ou la face cachée de l’État social américain”, Gouvernement et action publique, 3, 2012, 125-43.
Frédéric Pierru, Hippocrate malade de ses réformes.
Bruno Palier, Gouverner la Sécurité sociale.
The authors would like to express their thanks in particular to Philippe Bezes and Patrick Le Lidec for rereading the previous versions of this text, which allowed us to refine and explain much more clearly the concept of integration, as well as to the anonymous readers of the RFSP for their suggestions.