Elites, Policies and State Reconfiguration: Transforming the French Welfare Regime (International Series on Public Policy) 3031415817, 9783031415814

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INTERNATIONAL SERIES ON PUBLIC POLICY

Elites, Policies and State Reconfiguration Transforming the French Welfare Regime

William Genieys Mohammad-Saïd Darviche

International Series on Public Policy Series Editors

B. Guy Peters Department of Political Science University of Pittsburgh Pittsburgh, PA, USA Philippe Zittoun Research Professor of Political Science LET-ENTPE, University of Lyon Lyon, France

The International Series on Public Policy - the official series of International Public Policy Association, which organizes the International Conference on Public Policy  - identifies major contributions to the field of public policy, dealing with analytical and substantive policy and governance issues across a variety of academic disciplines. A comparative and interdisciplinary venture, it examines questions of policy process and analysis, policymaking and implementation, policy instruments, policy change & reforms, politics and policy, encompassing a range of approaches, theoretical, methodological, and/or empirical. Relevant across the various fields of political science, sociology, anthropology, geography, history, and economics, this cutting edge series welcomes contributions from academics from across disciplines and career stages, and constitutes a unique resource for public policy scholars and those teaching public policy worldwide. All books in the series are subject to Palgrave’s rigorous peer review process: https://www.palgrave.com/gb/demystifying-peer-review/792492.

William Genieys Mohammad-Saïd Darviche

Elites, Policies and State Reconfiguration Transforming the French Welfare Regime

William Genieys Centre for European Studies and Comparative Politics Sciences Po Paris, France

Mohammad-Saïd Darviche CEPEL (UMR 5112) University of Montpellier Montpellier, France

ISSN 2524-7301     ISSN 2524-731X (electronic) International Series on Public Policy ISBN 978-3-031-41581-4    ISBN 978-3-031-41582-1 (eBook) https://doi.org/10.1007/978-3-031-41582-1 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: © Thomas Dutour / Alamy Stock Photo This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

For Larry Brown,

Foreword

In contrast to most other European health systems, the French welfare state, and its system of universal health insurance (UHI), is far more centralized in its overall management. In France, American nostrums of unleashing market forces under the banner of “consumer-directed health care,” and selective contracting by private health insurers, have gained little traction. France does not allow a choice among health-insurance plans for the basic package of services; virtually everyone covered has a right to the same health care benefits. Yet in other respects, the organization and financing of health care in France resembles that of the United States—more so than Canadian and German UHI. To begin with, France has allowed, even nurtured, a complementary private health insurance industry that accounts for roughly 13% of health care expenditures. This closely parallels the private health insurance industry that provides Medigap coverage for beneficiaries in the traditional Medicare Program. In addition, with respect to hospitals, France relies on a public-private mix—two-­ thirds of acute beds are public; the other third are private, of which more than half are proprietary, the largest commercial hospital sector in Europe. Finally, as in the United States, although there is a shift toward more health centers and alternative modes of payment, ambulatory care remains dominated by private fee-for-service practices. Given these similarities, this book on the recent evolution of French UHI, known in France as la Sécurité Sociale, should be of interest to

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Americans and all those who share an interest in how the pursuit of universal coverage can be combined with efforts to contain the rise of health care costs. The origins of French health insurance can be traced to the emergence of local mutual aid societies in the nineteenth and early twentieth centuries, but the institutional structure established following World War II was influenced by the Bismarckian model and based on the ideas of the Conseil de Résistance and an influential report by Pierre Laroque. The fundamental value of “solidarity” is common to all social insurance systems and still appears weak in the United States, but its other ideological roots favoring some degree of decentralization and enormous pluralism resemble deeply held American values. In 1945, French Social Security was a system of social insurance organized around occupational groups with notable differences in beneficiaries’ contributions and health insurance benefits. This led Jean Pierre Dumont, in his history of French Social Security, to compare the system to an unfinished cathedral with altars, steeples, and cloisters, each one providing distinctive benefits for different occupational groups. Its other distinguishing feature was the important role of employers and trade unions in the overall management of the largest fund for salaried workers. The system was designed to be managed by representatives of employers, employees (the unions), and the state. This was known as a French version of social democracy—le paritarisme—and its capacity to manage the health system was often compared to complexities of a mènage à trois with the state trying to balance the views of employer and employee representatives. As in the United States, health insurance and health policy, more generally, in France have been strongly beholden to organized interest groups— physicians, hospitals, private complementary health insurers, hospital workers, and pharmaceutical lobbies. Genieys and Darviche do not dispel this fact. But they zoom in with an unprecedented and original analysis of how an elite group of high-level civil servants with a shared vision of far-­ reaching reform for the French welfare regime succeeded in implementing a centralized health care cost containment policy while simultaneously extending health insurance coverage to all legal residents in France. Based on sociological portraits of high-level civil servants involved mostly in health insurance reform—what they call the custodians of state policies— they present strong evidence, based on careful interviews, that over the

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course of four decades (1981–2020), these policy elites effectively transformed the historically polarized conflict among trade unions, employers, and the state. In the end, they shed light on the long and fascinating process through which French welfare elites moved the health insurance system away from the Bismarckian model toward a more bipartisan, state-controlled, and centralized model of UHI. Emeritus Professor of Health Policy and Management at N.Y.U. New York, NY, USA

Victor G. Rodwin

Acknowledgments

Our book is based on three empirical studies carried out over a period of 20 years on the role of upper level social insurance officials (1981–2020). We have studied the role of these elites in the reforms that have transformed the French welfare regime—what the French call la sécurité sociale, established since the end of World War II. Using about a hundred interviews and biographical data, we emphasize the voice of those who, “out of sight,” worked over the course of several decades to transform the French welfare regime. We would like to thank the people who, despite their busy schedules, agreed to be interviewed several times, every few years, to explain to us the “black box” of the social security government. In this respect, we commemorate Anne-Marie Brocas, director of the High Council for Health Insurance Policy Planning (HCAAM) and, according to her peers, the “grande dame of social insurance” who recently passed away. We would also like to thank the French National Research Agency (Agence nationale de la recherche, ANR) and the Mission recherche (MiRe) at the Directorate of Research, Studies, Evaluations and Statistics (Direction de recherche, des études, des évaluations et des statistiques, DREES) of the Ministry of Health which funded three research programs on elites in the social insurance sector: (i) the Franco-German program (2018–2022) ANR-DFG ProAcTA (ANR-17-FRAL-0008-01/DGF BA 1912/3-1); and (ii) the two programs supported by the MiRe (1997–1999 et 2005–2008), Patrick Hassenteufel [PI] (see Table 1.1). We are grateful for the technical help provided by Damien Potier and Ludovic Sposito. xi

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ACKNOWLEDGMENTS

We thank our colleagues for their advice: Nils Bandelow, Anne-Laure Beaussier, Cyril Benoît, Henri Bergeron, Matthias Brunn, Patrick Castel, Johanna Hornung, Patrick Le Galès, Ulrike Lepont, Bruno Palier, and Jean-Claude Thoenig. Warm thanks to our road partner, Patrick Hassenteufel. Special thanks to Larry Brown for his patient review of our book and Victor Rodwin for his kindness in prefacing it.

Contents

1 Introduction  1 Bibliography   7 2 Unelected  Governmental Elites and State Reconfiguration  9 Connecting Unelected Governmental Elites to State Reconfiguration  10 Bringing “Strong States” and “Weak States” Back in  11 Revisiting Historical Institutionalism by Considering the Role of Elites  12 Studies on Elites and State Reconfiguration: A Critical Assessment  14 The Golden Age of the Planning Elites  14 Renewal of Studies on French State Elites  16 The Decline of Comparative Studies on State Elites  17 Unelected Governmental Elites and the Role of Custodian of State Policies  21 Bibliography  25 Part I The Advent of the Welfare Elites  31 3 The  Rise and Fall of Old-Fashioned Elites 35 The Influence of Corporatism in the 1945 Social Security Model  37 The “Golden Age” of Workers’ Unions Governance  39 The Conservatism of “Old-Fashioned” Elites  42 xiii

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Contents

The Criticism of Social Security Governance  44 Bibliography  47 4 Initiating  “Sustainable Social Welfare”: Jean Marmot 49 The Origin of “Sustainable Social Welfare” Program  50 The First Magistrate of the Cour des Comptes at the Head of the DSS  51 Shaping the New Programmatic Orientation  54 1981: The Difficult Implementation of the Social Accounts Policy  55 Strengthening Parliamentary Control  58 The Hidden Architect of the 1996 Constitutional Reform  60 Bibliography  61 5 Welfare  Elites as Custodians of State Policies 63 From the Cour des Comptes to the Head of the DSS  64 Rolande Ruellan: A Long-Term Career Path Inside the DSS  66 Raoul Briet: Leading the Magistrates from the Cour des Comptes  71 Gilles Johanet: An Atypical Welfare Elite  76 Other Magistrates at the Cour des Comptes Committed to the Reform  79 Bibliography  81 6 Reinforcements  to the Developing Role of Custodian 83 Jean Choussat: Ally from the Ministry of Finance  83 Jean-François Chadelat: The First Actuary of Social Accounts  86 What Can We Learn from the First Generation of Welfare Elites?  88 Bibliography  91 Part II The Institutionalization of Welfare Elites  93 7 Implementing  “Sustainable Social Welfare” Program 97 From Universal Health Coverage to Universal Health Protection  97 2004: The New Governance of Health Insurance Funds 101 2008: The Unpredictable Defeat of the Elites of the Ministry of Finance 105 Bibliography 110

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8 Shaping the Iron Triangle of Governance111 Dominique Libault: Strongman of the Directorate of the Social Security 113 Anne-Marie Brocas: A “Great Lady of the Sécu” 117 Pierre-Louis Bras: The End of Politicization 119 Didier Tabuteau: A Dissonant Voice 123 Bibliography 126 9 Consolidating  the Custodianship of State Policies127 Thomas Fatôme: A “Virtuoso” of Expenditure Control Policy 128 Mathilde Lignot-Leloup and Nicolas Revel: Interchangeable Career Paths 131 Franck Von Lennep: A Statistical Engineer to Strengthen the Custodianship 133 Career Paths Continuity of Welfare Elites 135 Bibliography 138 10 The  Resilience of Welfare Elites to Crises139 The Sarkozy Presidency and the Financial Crisis of 2008 140 The Paradox of the Socialist Presidency of Hollande 145 The Macron Presidency and the Covid-19 Pandemic Challenge 150 Bibliography 156 11 A  Comparative and Theoretical Assessment on the Elite Approach157 Evidence from the Transformation of the French Welfare Regime  158 An Elite Approach to the Policy Process in Democracies 159 The Custodianship of State Policies 161 Bibliography 164  Appendix (Tables A.1, A.2, and A.3; Figs. A.1, A.2, A.3, and A.4)167 Bibliography179 Index191

About the Authors

William Genieys  is a CNRS Research Professor of Politics and Sociology at the Center for European Studies and Comparative Politics at Sciences Po. He has published with Marc Smyrl, Elites, Ideas and the Evolution of Public Policy (Palgrave Macmillan, 2008). His A Government of Insiders. The People Who Made the Affordable Care Act Possible will be published by The John Hopkins University Press in March 2024. Mohammad-Saïd Darviche  is Associate Professor of Political Science at the University of Montpellier and a researcher at the CEPEL (UMR 5112). He has published (with William Genieys & Brent Epperson) “New Policy Elites and the Affordable Care Act: The Making of Long-term Insiders,” The Journal of Policy History, 34 (1), 2020: 1–24; (with William Genieys & Patrick Hassenteufel), “L’institutionnalisation de l’élite du Welfare au cœur de l’État. Les nouveaux gardiens des politiques d’assurance maladie,” Revue Française de Science Politique, 72 (5), 2022: 1–21.

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List of Figures

Fig. 8.1

Career paths within the Iron Triangle of social security governance113 Fig. A.1 Share of each branch in the expenses of the general social security system (2020). Source: Directorate of social security, Social security key figures 2020, 2021, p. 12. (https://www. securitesociale.fr/files/live/sites/SSFR/files/medias/ DSS/2021/CHIFFRES%20CLES%202020%20ED2021.pdf)174 Fig. A.2 Revenues of the general social security system: health insurance branch (2020). Source: Directorate of social security, Social security key figures 2020, 2021, p. 9. (https://www. securitesociale.fr/files/live/sites/SSFR/files/medias/ DSS/2021/CHIFFRES%20CLES%202020%20ED2021.pdf)175 Fig. A.3 Structure of the French social security revenues (all branches). Source: Social Security Policies Evaluation Report (REPSS) attached to the Social Security Financing Bill (PLFSS) 2022, p. 34. (https://www.securite-sociale.fr/files/live/sites/SSFR/files/ medias/PLFSS/2022/PLFSS-2022-REPSS-Financement.pdf)176 Fig. A.4 Evolution of the aggregate deficit of the compulsory basic social security schemes and the Old Age Solidarity Fund (2008–2021, in billions of euros). Source: Report of the Cours de comptes on the application of Social Security Budget Acts (October 2022, p. 34). (https://www.ccomptes.fr/system/files/2023-03/ 20221004-rapport-securite-sociale-2022.pdf)177

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List of Tables

Table 1.1 Table 1.2 Table 2.1 Table 2.2 Table 2.3 Table 3.1 Table A.1 Table A.2 Table A.3

The three research programs on welfare elites 4 Generations of welfare elites, reforms, and programmatic issues 6 Characteristics of the Grands corps18 Elites types and social security governance (1945–2020) 23 Social background and career path of the old and new elites (1945–2020)24 Main unions involved in social security governance since 1945 41 Brief history and reform of the French social security system 167 Health reimbursement in France since 1945 169 Glossary “memo” of the French social security model 170

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CHAPTER 1

Introduction

Contrary to the dominant view that neoliberal ideology has put an end to the French strong state (Brookes 2021), the latter has shown itself to be resilient by reconfiguring itself, particularly in the area of protection against social risks, where it was traditionally the weakest (Nord 2010). This book proposes an elite approach to the transformation of the French welfare regime.1 Indeed, since the beginning of the 1980s, a new generation of state elites has transformed the sécurité sociale (social security)2 model established at the end of World War II (Genieys 2010; Genieys and Hassenteufel 2015). Their program—which we will call “Sustainable Social Welfare”3—aimed to strengthen the state control over its 1  According to Gøsta Esping-Anderson “to talk of a ‘regime’ is to denote the fact that in the relation between state and economy a complex of legal and organizational features are systematically interwoven” (Esping-Andersen 1990: 2). 2  In France, social security, in its most general sense, is synonymous with social protection. In its strict sense, the one we are interested in here, it refers to the institutions that organize protection against social risks in five areas: health, work accidents, old age, family and, since 2020, the autonomy of the elderly and disabled. 3  This designation was inspired by a former head of the Directorate of Social Security, who insisted that “our policy is to make social security sustainable. […] It’s not just public finance performance that counts. […] we pay attention to the acceptability of reforms by the society. And our logic of action is based on the long term. We want and we carry out structural reforms over the long term, even if it means sacrificing financial results in the short term,” interview with social insurance high civil servant (MiRe 2, 2007).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_1

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governance and development. Our objective is to link the issue of the change in the elites’ structure to that of the reconfiguration of the state. Specialists on French health and social policy agree that the 1996 constitutional reform broke with the old governance model by increasing the role of the state (Palier 2002). The high point of this shift, the so-called Juppé Plan enacted on November 15 1995 (Bouget 1998), included an amendment to the French constitution that makes parliamentary approval of annual budgets mandatory for the social security. The Social Security Financing Act (LFSS) of July 22 1996 also called for the extension of French national health insurance to the remaining 2% of the population that was still uncovered. This objective was implemented under the socialist government of Lionel Jospin, with the universal health coverage act of July 27, 1999 (Couverture maladie universelle, CMU). These two reforms laid the foundation for the realization of “Sustainable Social Welfare” program. This Social Security Financing Act reinforced the legislative role, but it should not blind us to the reality of the power wielded by high civil servants and the difficulty of challenge democratic control. Patrick Hassenteufel and Bruno Palier (2005: 15) argued that this institutional reform “reinforces the power of the government—in the sense of the ministers of the moment—and of the civil service since funding authority remains in the regulatory rather than the legislative sphere, and the parliament has only minimal technical expertise at its disposal in this field and is heavily dependent on civil service for information.” For some actors in the policy domain, indeed, it might seem that this reform brought a series of mutually contradictory changes: increase in the power of parliament, in the prerogative of ministers, and reinforced oversight and management role for bureaucratic agencies, and the emergence of outside experts. A comparative overview carried out by specialists in health and social policy (Merrien et al. 2005: 353) comes to this conclusion with respect to France. They emphasize that direct tax revenue has replaced a portion of the financing from salary withholding and employer contributions. The share of social contributions in social security revenues has decreased from 82% in 1981 to 56% in 2020 (see Appendix, Fig. A.3). This trend is particularly marked for the health insurance branch, which is the most expensive (see Appendix, Fig. A.1). Today two-thirds of its revenues are made up of taxes (see Appendix, Fig. A.2). The continuous increase in state financing, particularly in the costly health sector where taxes now exceed social security contributions, has created a context that favors a growing

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role for new state elites in the governance of social security. At the same time, the system of social insurance has shifted partially to a logic of central state provision of health insurance coverage with the resulting targeting of some assistance to the neediest individuals. This shift has been supported by certain academic researchers (Ewald, Rosanvallon, Kessler, Bourguignon), as well as by state elites and the French employers’ union (MEDEF). We argue that the transformation of the welfare regime can be understood with respect to the change in the structure of elites and the reconfiguration of the state (Chap. 2). Revisiting Mosca’s “Ruling class” (1939), that is, the minority in charge of governmental activities, our approach to the elites focuses on the issue of a government of “insiders” with strategic capabilities (Keller 1963) in the policy domains that Machiavelli called the arte dello stato. In other words, elites who not only have technical expertise, but also an in-depth understanding of stakeholders and politics. In previous works, we have examined the correlation between two key issues in the sociology of elites: what “makes” the elites (who are they?) with what the elites “do” (How do they act?). In the Programmatic Elites Framework, these governmental elites are (i) unelected individuals, (ii) politically appointed at the apex of the state apparatus (iii) where they develop their career path over the long term by circulating vertically (occupational advancement) and horizontally (between governmental institutions),4 (iv) working collectively out of sight, and (v) influencing decisively policy decision-making process.5 In this framework, we analyze the correlation between the change in the social background6 and career

4  We borrow the concept of “circulation of elites” from the sociology of Vilfredo Pareto (1967) giving it a different meaning. For him, horizontal circulation takes place within the “governmental elite,” while vertical circulation refers to the integration of certain elements of the mass into the elite (Genieys 2011, chapter 2). 5  If these individuals who combine the status of unelected officials at the top of the state with that of “insider” because of the length of their career path in a policy domain are, for the most part, high civil servants in France, they may have different statuses and career paths in other countries (political appointees and Congress staffers for the US case; see Genieys 2024). 6  In the US tradition (Mills, Domhoff, Kahn) the term social background connotes elites going to private schools, having a lot of money, and playing golf at a fancy country club. For us, the term has three main elements: (i) attitudes/aptitudes/orientation (in this case toward activism and reform); (ii) education (where schooled, what studied); and (iii) the socialization that derives from institutional settings.

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Table 1.1  The three research programs on welfare elites Mire I (1997–99): Patrick Hassenteufel (dir.), Myriam Bachir Virginie Bussat, William Genieys, Claude Martin, Marina Serré, « L’émergence d’une “élite du welfare”? Sociologie des sommets de l’État en interaction », 1999 (hereafter MiRe 1). Around 50 interviews were conducted.   Period: 1980–1997; study population: cabinets members, director of administrative units   Biographical data on 133 persons (cabinets members, dir. of administrative units); interviews: 40 Mire II (2005–2007): Patrick Hassenteufel (dir.), William Genieys, Javier Moreno, Marc Smyrl, Anne-Laure Beaussier, Louise Hervier, « Les nouveaux acteurs de la gouvernance de la protection maladie en Europe (Allemagne, Angleterre, Espagne, France) », 2008 (hereafter MiRe 2). Around 20 interviews were conducted.   Period: 1997–2007; study population: cabinets members, director of administrative units   Interviews: 12 (cabinets members, director of administrative units) PRogrammatic Actors in Times of Austerity -ANR-DFG PRoAcTA (ANR-17-­ FRAL-0008-01/DGF BA 1912/3-1). This research program co-directed by William Genieys and Nils Bandelow, conducted between 2018 and 2020, focused on conflicts between the welfare elites and the advocates of fiscal austerity in a crisis context (2007–2018) in France, Germany, England, and the United States.   Period: 2007–2020; study population: cabinets members, director of administrative units   Biographical data on 52 persons; around 20 interviews conducted.

paths of these insiders with the formulation of programmatic orientations7 (see Chap. 2). This book is based on three empirical surveys conducted 10 years apart (MiRe 1 & 2, ProAcTA, see Table 1.1) on high civil servants at the apex of the social security government between 1980 and 2020. We have thus identified a homogeneous group of high civil servants (elites groups) who promoted and implemented a strategy of collective action structured around a shared vision of the far-reaching reform8 of social insurance system (programmatic orientiation). We present the changes in their 7  We define the “programmatic orientation” as a shared vision of public policy in an area of government intervention that (i) is based on the diagnosis of existing policy failures; (ii) on the formulation of problems to be solved; (iii) on arguments and solutions; and (iv) on implementation procedures and instruments. 8  A “far-reaching reform” introduces a considerable widening of the scope of social insurance system as well as integrating procedures and practices from the pre-existing system (Genieys 2024).

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structure through sociological portraits.9 By correlating the career paths and the carrying of policy programs, this tool seeks to overcome the opposition between structure and agency. The aim is to carry out a kind of thick description (Geertz 1973) by identifying the link between their actions and the meaning they have attributed to them with their social background and career paths. This analysis of career paths is similar to Cathérine Grémion’s approach concerning the influence of decision-makers’ career paths on decision-making (Brunier et al. 2019: 134–35). By tracing, over half a century, the evolution of the social background and career paths of these insiders—whom we call the “welfare elites” (Genieys 2010; Genieys and Hassenteufel 2015; Hassenteufel and Genieys 2021; Darviche et  al. 2022)—in relation to political struggles over the redefinition of the 1945 social security model, we will also show how the strong French state has been reconfigured within this policy domain. In their struggle for what they see as a “responsible” extension of state power through the formulation of policies (i) widening the “scope” and (ii) increasing the “strength” of state intervention (Fukuyama 2004), these elites developed the role of “custodian of state policies” (Genieys 2010, 2024). This role has been asserted in the context of the competition that the welfare elites have engaged in since the 1980s with other elite groups— notably “old-fashioned” elites10—internal and external to the governance of social insurance. Their success was achieved in two historical sequences, each centered on a generation of the welfare elites (see Tables 2.2 and 2.3). The first generation (see Part I) led the struggle with the “Sustainable Social Welfare” program against the members of the Conseil d’État at the Directorate of Social Security (Direction de la sécurité sociale, hereafter DSS) and the workers’ union leaders who defended the 1945 legacy (see Table 1.2). The struggle ended successfully with the constitutional reform of 1996 creating the Social Security Budget Act (LFSS). The second

9  The sociological portrait is a non-deterministic analytical tool. To realize sociological portraits, we will mobilize the sociobiographical data and the contents of the 100 or so interviews accumulated in our three academic studies (MiRe 1, MiRe 2 & ProAcTA, see Table 1.1). 10  We prefer the use of the term “old-fashioned” elites to traditional elites. The old-fashion dimension allows to better point the attachment of a group of elites with the defense of a policy orientation.

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Table 1.2  Generations of welfare elites, reforms, and programmatic issues Welfare elites

Main reforms

1st generation Finance law on December (1981–1999) 18, 1990: General social (See Part I) insurance contribution (CSG) Constitutional reform of 22 July 1996: Social Security Budget Act (LFSS)

Law of 27 July 1999: Universal Health Coverage Act (CMU) 2nd generation (2000–2020) (See Part II)

Law of August 13, 2004: Douste-Blazy Reform

Social security budget acts of 2016 and 2020: Universal Health Protection (PUMa)

Programmatic issues The CSG levied on all types of personal incomes, and it funds approximately 30% of expenditure on health care Break with the old governance model by increasing the role of the state. The new parliamentary competence helps the government to control the social policy agenda, notably on cost-containment issues Every person residing lawfully in France, irrespective of his or her employment status or contribution record is insured for the health risk Creation of UNCAM, High Authority on Health (HAS), attending physicians [médecins traitants],a and health insurance card (Carte vitale) The new social protection model is based on the principle of universal protection. People are covered simply because they live in France

In France, the “médecins traitants” is the gatekeeper between the patient and the medical community (specialist, hospitals, etc.) a

Sources: MiRe 1 (1996–1997), MiRe 2 (2006–2007) & ProActa (2018–2020) (see Table 1.1)

generation empowered itself by circulating within the Iron Triangle11 constituted by the main social security governance institutions (see Part II). Within the French state, the welfare elites have indeed come up against the doctrine of budgetary rigor. And for good reason: in 2020 the Social Security budget (470 billion euros in benefits) is larger than that of the state (350 billion euros). Social Security consumes 25% of the national wealth—the Gross Domestic Product (GDP) amounting to about 2000 11  We use the notion of the Iron Triangle in a different sense from American political science (Adams 1982). For the latter, the Iron Triangle refers to the formulation of policy by congressional committees, the executive branch bureaucracy and interest groups. For us, it characterizes the circulation of welfare elites between the “pillars” of social security governance in France (Directorate of Social Security, National Union of Health Insurance Funds [UNCAM], high authorities and high councils).

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billion euros.12 The “big spender” image of the Ministry of Social Affairs was the subject of an internal struggle with the elites of the Ministry of Finance.13 The second generation then developed alternative public policies by combining the extension of national health insurance coverage with their own version of budgetary constraints. Far from being limited to a defensive mode of action (“rescuing Social Security!”), the two generations of the welfare elites succeeded in elaborating their program in several steps (see Table 1.2): the implementation of the Social Security Budget Act (LFSS) following the constitutional reform of February 22, 1996; the extension of health insurance to achieve the proclaimed goal of its founders in 1945: Universal Health Coverage (CMU 1999) transformed in 2016 into Universal Health Protection (Protection Universelle Maladie, PUMa); the creation of the National Union of Health Insurance Funds (Union nationale des caisses d’assurance maladie, UNCAM 2004); and, in 2021, the creation of a fifth branch of coverage to assure autonomy (old age and disability). The Covid-19 pandemic, despite the media fever surrounding the weaknesses of the health system, did not call into question their commitment to “Sustainable Social Welfare” program. On the contrary, in July 2020, the general consultation with key health care system stakeholders—the “Ségur de la santé”— allowed the elites to commit sizable new resources to the public hospitals. The in-depth transformation of the welfare regime was led by elites who considered that any reform would be meaningless without the sustainability of its financing. Against all odds, their commitment contributed to the reconfiguration of the strong French state.

Bibliography Adams, Gordon, The Politics of Defense Contracting. The Iron Triangle, New Brunswick, Transaction Publishers, 1982. Bouget, Denis, “The Juppé Plan and the Future of The French Social Welfare System”, Journal of European Social Policy, 8 (2) 1998: 155–172. Brookes, Kevin, Why Neo-liberalism Failed in France. Political Sociology of the Spread of Neo-Liberal Ideas in France (1974–2012), Switzerland, Springer International Publishing, 2021. 12  To have a comparative vision of the budget of the social security in comparison with the budget of the French State, see https://www.securite-sociale.fr/la-secu-cest-quoi/chiffres-­ cles#:~:text=470%20milliards%20d’euros%20de,2%20000%20milliards%20d’euros. 13  To understand the devotion and organizational culture of the Directorate of the Budget at the Ministry of Finance in the fight against spending public money (Choussat 1990: 55–64).

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Brunier, Sylvain, Patrick Castel, Marie-Emmanuelle Chessel, « Catherine Grémion: comment j’ai écrit Profession: Décideurs », Entreprises et histoire, n°97, 2019: 130–35. Choussat, Jean, « Le budgétaire et le dépensier. Défense et illustration de la Direction du budget », Pouvoirs, n° 53, avril 1990: 55–64. Darviche, Mohammad-Saïd, William Genieys, Patrick Hassenteufel, « L’institutionnalisation de l’élite du Welfare au cœur de l’État. Les nouveaux gardiens des politiques d’assurance maladie », Revue Française de Science Politique, vol. 72, n°5, 2022, pp. 1–21. Esping-Andersen, Gøsta. The Three Worlds of Welfare Capitalism. Cambridge, UK.: Polity Press, 1990. Fukuyama, Francis, State Building. Governance and World Order in Twenty-First Century, Ithaca, Cornell University Press, 2004. Geertz, Clifford, The Interpretation of Cultures, New York (NY), Basic Books, 1973. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Genieys, William, Sociologie politique des élites, Paris, A. Colin, 2011. Genieys, William, A Government of Insiders. The People Who Made the Affordable Care Act Possible, Baltimore (M.A.), The John Hopkins University Press, 2024. Genieys, William, Patrick Hassenteufel, “The Shaping of the New State Elites. Healthcare Policymaking in France Since 1981”, Comparative Politics, 47 (3), 2015: 280–295. Hassenteufel, Patrick, William Genieys, “The Programmatic Action Framework: An Empirical Assessment”, European Policy Analysis, vol. 7 (1), 2021: 28–47. Keller, Suzanne, Beyond the Ruling Class. Strategic Elites in Modern Society, New York (NY), Random House, 1963. Merrien, François-Xavier, R.  Parchet, A.  Kernen, L’État social. Une perspective internationale, Paris, Armand Colin, 2005. Mosca, Gaetano, The Ruling Class, New York (NY), McGraw-Hill, 1939. Nord, Philip, The French New Deal, Princeton (NJ), Princeton University Press, 2010. Palier, Bruno, Gouverner la Sécurité sociale. Les réformes du système français de protection sociale depuis 1945, Paris, PUF, 2002. Palier, Bruno, “Ambiguous Agreement, Cumulative Change: French Social policy in the 1990s”, in Wolfgang Streeck, Kathleen Thelen (eds.), Continuity and Discontinuity in Institutional Analysis, Oxford (U.K.), Oxford University Press, 2005: 127–144. Pareto, Vilfredfo, Traité de sociologie générale, Geneva, Droz, 1967 (1st French ed., 1917–1919 2 vol.)

CHAPTER 2

Unelected Governmental Elites and State Reconfiguration

For Heinrich Best and John Higley, political elites are “individuals and small, relatively cohesive, and stable groups with disproportionate power to affect national and supranational political outcomes on a continuing basis” (Best and Highley 2018: 3). By focusing on unelected governmental elites, we will develop a little-explored area of sociology applied to political elites. Taking this perspective into account, we consider their strategic capabilities (Keller 1963) to influence policy programs and state reconfiguration. The issue of unelected governmental elites has been neglected by American and French political studies (Genieys 2005; Volpe 2021). Researchers examining the relationship between policies and the reconfiguration of democratic states have also underestimated the role of elites (King and Le Galès 2017; Orren and Skowronek 2017). In this chapter, we will present an elite-centered approach to policies and state reconfiguration. This approach is in line with the neo-elitist current (Field and Higley 1980; Higley and Burton 2006), which has demonstrated the effects of struggle between elites on the transformation of political regimes. Its perspective is inspired by Robert Dahl’s work (1961) on the consequences of competition between elites in democratic decision-making. Still, both political sociology and political science have underestimated the role of unelected elites who govern “out of sight.” © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_2

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In the early 2000s, a group of French researchers (MiRe 1 [1999], MiRe 2 [2008], see Table 1.1) developed a “programmatic approach” combining the sociology of elites and public policy analysis (Genieys and Smyrl 2008a, b; Genieys 2010; Hassenteufel et  al. 2010; Genieys and Hassenteufel 2015). Joined later by German researchers (ProAcTA 2021, see Table 1.1), they have developed the Programmatic Action Framework (Hassenteufel and Genieys 2021; Hornung and Bandelow 2018; Bandelow et al. 2021; Hornung 2022). Concomitantly, the study of health insurance reforms and the formation of a government of insiders in the United States1 has led Genieys and Darviche to further develop their approach to the unelected governmental elites issue (Genieys 2024; Genieys et al. 2022). The comparison of the US and French cases has led to pointing out the relationship between types of elites and types of state (Genieys and Joana 2017; Darviche and Genieys 2018). In order to underscore our elite approach, we have developed the Programmatic Elites Framework (Genieys 2024). The innovative dimension of this approach nests on two postulates: (i) a plurality of unelected governmental elite groups competing for the formulation of programmatic orientations; (ii) the effects of changes in the social backgrounds and career paths of elites on these programmatic visions. This perspective allows us to see the correlation between the change in elites’ structure, policies, and state reconfiguration. Our objective is to revisit Schattschneider’s famous observation that “new policies create new policies” (Brown 1983).

Connecting Unelected Governmental Elites to State Reconfiguration Our approach opens, de son côté, a way to relate the unelected governmental elites issue to that the state reconfiguration. The French and American cases have identified elites playing the role of custodians of state policies in the social insurance reform process (Genieys 2010, 2024). The elites endorsing this role are characterized by their long-term career path in their policy domain, leading most of the time to the institutionalization of 1  The OPERA program (“Operationalizing Programmatic Elite Research in America [1988–2010]”), which lasted from 2008 to 2012, focused on the transformation of the social background and career path of US unelected governmental elites in the health insurance and defense sectors from 1988 to 2010. William Genieys as principal investigator (Sciences Po, CNRS) benefited from funding from the ANR (OPERA: ANR-08-BLAN-0032).

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a government of insiders (Genieys 2024). The comparison between the French and US cases prompts us to reintroduce the distinction between strong and weak states (Nettl 1968; Birnbaum 1977, 2018; King and Lieberman 2009). Bringing “Strong States” and “Weak States” Back in Comparative historical sociology has opposed the French “strong state” to that of the US “weak state” (Badie and Birnbaum 1983; Birnbaum 1988, 2001; Krasner 1978; Skocpol 1985; Skocpol and Finegold 1982; Skocpol and Ikenberry 1983). Pierre Birnbaum (1977, 1984) has established a dynamic correlation between the type of state (strong or weak) and the type of elites. In the debate with Marxists on the question of the autonomy of the state in relation to organized interests (especially economic ones), Birnbaum associated the French strong state with the central role of the administrative elites in a centralized political society (Birnbaum 1977). The author specified that in this “empirical study of the political-­ administrative power elite in contemporary France, our ambition would be to pose […] the problem of the functional autonomy of the state, which is often treated in a purely abstract manner” (ibid.: 12). The case of the United States has been considered as the weak state model characterized by the lack of career state elites (Birnbaum 1984). Certainly, authors have identified the emergence, not lasting, of small groups of state elites in certain policy areas (Krasner 1978; Skocpol and Finegold 1982). The autonomy then acquired forms an “island of state strength in a sea of weakness” (Skocpol and Finegold 1982: 271). Moreover, the “decentralized federalism” (Skocpol and Amenta 1986: 149), and the “fragmented political institutions and […] the continuing ambivalence of most citizens about the proper—or possible—role of concentrated governmental authority in national life” (Skocpol 1992: 581) enacted opposition to centralized government policies. This idea of the weakness of the American state has been reconsidered from the “strong policies” issue (Novak 2008; King and Lieberman 2009). These authors have pointed out the paradox of the “weak American state” developing strong policies, particularly in the race policy domain (Lieberman 2002; King 2005). For these authors, the multiplication of public policies at the federal government level is an indicator of its strength. More recently, Orren and Skowronek (2017) have qualified this view. They have associated the emergence of a policy state in the twentieth century with the development of liberal ideas during the progressive era. The

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hegemony of these ideas never translated into the lasting institutionalization of a “strong” state. Since the 1980s, the revival of conservatism, with its project of populist America, has contributed significantly to the polarization of political life (ibid., p. 173). The progressivism of the policy state found itself “locked in the democratic party” (ibid., p. 196). Finally, these authors show that the “strength” of the policy state is, on the one hand, dependent on the partisan game and, on the other hand, different depending on the policy domains (Jacobs et al. 2019). Recent works mobilizing a new elitist approach have shown that the capacity of the policy state to intervene is correlated to the formation of unelected governmental elites— the “long-term insiders”—who assume the role of custodians of state policies during certain historical sequences (Genieys 2024; Brown and Genieys forthcoming). Unlike the French strong state, the US policy state cannot rely on the institutionalization of its elite. Our comparative sociology of unelected governmental elites reconsiders the opposition weak state vs. strong state. In the case of France, our work on the formation of a “welfare elite” has already shown that social insurance high civil servants have asserted their autonomy despite changes in the presidential majority (Genieys and Hassenteufel 2015; Darviche et al. 2022). It is from this perspective that the participation of elites in the reconfiguration of the strong state has been studied, particularly in the health and defense sectors (Genieys 2010). In France, high civil servants have strengthened their career paths within the state. On the other hand, in the United States, the weak autonomy of the policy state forces “long-­ term insiders” to build their career path by circulating, according to the changes in the political majority, between the government administration, Congress, and the private sector. It is for this reason that, despite the variations affecting the institutionalization process of its elites, the French state, unlike the American state, can still be considered strong (Birnbaum 1984, 2018). Revisiting Historical Institutionalism by Considering the Role of Elites With this elite approach, we also intend to contribute to the debate on historical institutionalism. In this perspective, the distinction elaborated by James Mahoney between two approaches to path dependency is very useful (2000). The first emphasizes the “self-reinforcing sequences” that contribute to the reproduction of the initial conditions of a historical

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sequence. The second orientation cites “reactive sequences” that can at least partially challenge the initial historical sequence and create the conditions for the production of a new sequence. Without calling into question the importance of the initial conditions of an institutional arrangement, reasoning in terms of “reactive sequences” makes it possible to imagine a more accidental subsequent evolution. The “exceptionalist” approaches of historical sociology (American, French, German exceptions, etc.) tend to make exclusive use of the “self-reinforcing sequences,” thus privileging the logic of “reproduction” over that of “bifurcation” (Krasner 1984, 1988). Questioning the reproductive dimension of institutions opens up at least two (non-exclusive) possibilities: (i) focusing on the configurations of actors invested in pre-existing institutional logics whose orientation they can influence to the point of diverting them from the rationale that presided over their birth (Thelen 2003; Bergeron and Castel 2015); (ii) reintroducing the “event” in historical trajectories (Sewell 2005). Applying this approach of historical institutionalism to the U.S. cases, we have identified unelected governmental elites with a comparable function in the design and implementation of reforms. Nevertheless, this function develops in different national contexts (Heclo 1987: 12–13). On both sides of the Atlantic, these elites have different statuses (senior civil servants in France and political appointees/congress staffers in the United States) and varying scope of action. The French state has administrative elites with an “autonomous” social status (Suleiman 1974, 1978) and a wider field of action. In this context, they embody the authority of the state and structurally assume the role of custodian of state policies covering all areas of social insurance (health, retirement, and more). In contrast, in the United States, elites circulate between the public and private sectors (Genieys et al. 2022; Genieys 2024) and because of the fragmentation of the federal administration (Skocpol 1985; Steinmo 2010) their action has been focused on the field of health insurance. Thus, in the US policy state, the development of the custodian role has adapted to the weakness of the federal government, which remains more sectoralized and reluctant to have senior officials govern policy. In France, the study of the change in the governance of social security shows that it is necessary to shift the analytical framework from path dependency (see Parts I and II). Indeed, since its creation in 1946, Social Security was one of the sectors where the government of policies remotely supervised a governance assumed by the social partners (Palier 2004; Nord 2010). The increase in the intervention capacity of welfare elites

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studied in this book allows us to understand the reconfiguration of the strong state. Social security has become a major societal issue with a permanent budget that is larger than that of the state. This is why, since the 1980s, a new generation of high civil servants has invested its governing bodies to reform it (see Part I). Thus, although weakened by globalization, European integration and decentralization (King and Le Galès 2017), the strong French state has reconfigured itself around a sector in which it was traditionally in the background. Our elite approach seeks to explain how the phoenix-like strong state (Darviche and Genieys 2018) has risen from the ashes around “Sustainable Social Welfare” program.

Studies on Elites and State Reconfiguration: A Critical Assessment Comparative historical sociology had pointed out the important role of state elites (Mann 1986; Linz and Stepan 1996) and even of “custodians of the state” (Daalder 1995) in the development of authoritarian political regimes in Western Europe. In addition, many researchers analyzing economic modernization policies after World War II identified the crucial role of planning elites and strategic elites (Keller 1963; Shonfield 1965; Thoenes 1966; Heclo 1974), even though, their action went unnoticed by the public opinion as the neo-elitist current specifies (Field and Higley 1980). On this point, the case of France, where the state elites have a particular prestige, is an exception (Suleiman 1978). Subsequently, with the oil shocks of the 1970s and the development of neo-liberal policies in both the United States and Europe, there has led to a lack of interest in analyzing the role of these elites in state reconfiguration. First, we will make a critical assessment of these different research streams. Then, we will show how our perspective revitalizes the theoretical and empirical framework of these approaches and reactivates interest in elites issue. The Golden Age of the Planning Elites The post-WWII period is the historical moment in which state elites demonstrated their political loyalty to liberal democracy in exchange for taking over welfare policies (Genieys and Joana 2017). The period corresponds to the golden age of planning elites in Western democracies. In his important book, The Elite in the Welfare State, Dutch sociologist Piet Thoenes

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(1966) defines the welfare state as a unique type of government because of the monopolistic role played by state elites in planning and policy-­ making. Thoenes attributes this change to “an elite of scientifically trained officials, in government departments, in semi-official departments, serving with big firms, with trade unions and with professional organizations. Many clashes of interest keep them divided, but the task of scientific oversight of the national economy is a unifying one, and it gives them a common stamp” (1966: 129). It also specifies their decisive role: “the functionaries’ elite is that official section of the community which claims, by virtue of its special skill, to have the task of understanding, bringing about and safeguarding the requirements which shall determine the structure and function of the nation’s controlled society” (ibid.: 183). These planning elites redefined the relationship between the economy and the structure of society through an industrial policy (nationalizations, planning) pursuing full employment (Shonfield 1965; Hall 1986). They were thus at the interface of the government of nationalized industries and administrative bodies, although planning styles varied between European countries (Thoenes 1966: 198). In some countries, they helped to shape new social protection systems, such as the National Health Service in Great Britain and the Social Security in France (Skocpol and Hacker 1997; Palier 2002). In the United States, the phenomenon occurred later, in the 1960s, under the Kennedy and Johnson administrations, and was limited to certain sectors, such as urban policies, social policies and national defense (Shonfield 1965). In practice, these elites came mostly from the administration, with strong generalist and legal expertise (Heclo 1974; Suleiman 1978; Putnam 1977). Their ability to implement new policies was facilitated by the transfer of the center of gravity of power from Parliament to the Ministries (Dogan 1975; Birnbaum 1977). Some authors criticized the development of a technocratic power that could undermine representative democracy (Meynaud 1964; Galbraith 1967). Meynaud observes that in France, after having penetrated most sectors of state activity, technocrats were gradually imposing their power over political staff and civil society (1964). In the United States, the debate opposed those who contented that “planning” lead to the formation of a polyarchic control system (Dahl and Lindblom 1953) to those who denounced the rise of an entrepreneurial technocracy (Galbraith 1967). Policy analysts have examined the role of state elites in the modernization of the economy in selected Western European countries. Hugh Heclo

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has analyzed how, in Sweden and the United Kingdom, they shaped the contours of social policy and then legitimized this political learning among elites (1974). Using the examples of the United Kingdom and France, Peter Hall confirmed that these elites have transformed planning policies into real instruments of government outside the traditional game of interest groups (Hall 1986). Yet, paradoxically enough, the central role of planning elites in the establishment of post-war welfare systems has remained largely invisible to public opinion (Field and Higley 1980). Indeed, in most Western democracies, the various governments have given the illusion that the democratic consensus obtained political elites, and not by states elites (ibid. 1980: 13–17). Renewal of Studies on French State Elites In France, the long dominance of Marxism in the social sciences slowed the development of the sociology of elites and of state autonomy (Birnbaum 2015, 2018). Paradoxically, at the international level of comparative politics, France is known as the home of the “strong state” (Badie and Birnbaum 1983). It is in the context of the French case that the “state elites” (Suleiman 1974, 1978) and the strong presence of high civil servants in the state power structure have been studied in depth (Birnbaum et al. 1978). Ezra Suleiman showed the correlation between elite training by the state and career path ascent within the state (Suleiman 1978: 40). This correlation, consolidated since the creation of the National School of Administration (École nationale d’administration, ENA) in 1945, led to the formation of an elite with a “sense of the state” (Suleiman 1978). Pierre Bourdieu (1989) stigmatized this logic with the expression “state nobility,” since the logic of reproduction specific to the preparatory classes and the Grandes écoles favors the formation of a closed groups like castes and noble lineages. Beyond the question of the social background of French administrative elites, the pioneering work of Ezra Suleiman (1974, 1978) highlighted the relationship between the Grandes écoles (training) and membership in a Grands corps (high ranked administrative bodies, see Table 2.1) (Suleiman 1978: 40). In the French system, administrative bodies are informally classified by order of prestige. Membership in a Grands corps is the privilege of the highest-ranked members of the ENA graduating class (Genieys 2010: 78). As Suleiman pointed out, “these corps are institutions that carry out functions on behalf of the state. At the same time, they are institutions, or

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clubs, that group together an elite that is united by a common educational background, common career horizons, and common corporate interest…to enter the Inspection des finances, the Cour des comptes, or the Conseil d’État, it is necessary to graduate within the top 20 percent of one’s class at ENA” (Suleiman 1978: 29).2 For Suleiman, one of their hallmarks is “non-specialization” leading to “organizational dexterity.” It is precisely this “non-specialization,” that, as we will demonstrate, has been overtaken by events, to be replaced by an increasingly strong sectoral specialization of elites. As we will see, this change cannot be attributed either to the recruitment or to the training of elite individuals, neither of which has changed substantially since the 1970s. Not the curriculum of the Grandes écoles but rather the career path of their graduates has been transformed. Directly related to this phenomenon is the changing role of the Grands corps and their associated schools.3 Passage through the latter and, to a lesser extent, membership in the former remains a central feature of the French high civil service. The role of the Grands corps as the pre-eminent collective actors of French policy-making is called into question by our analysis which explores a logic of action that is the opposite to theirs. While these Grands corps were characterized by institutionalization without specific policy purpose, the elites whose action we explore are defined by their policy purpose but largely lack institutionalization. The former, as Suleiman (1978) noted, pursue “politics of [institutional] survival,” while the latter pursue a policy success. In a recent essay, Pierre Birnbaum (2018) observed that despite the introduction of private management methods, the French state elites were able to adapt to the change in policies. The Decline of Comparative Studies on State Elites In a comparative analysis of Western democracies, Mattéi Dogan highlighted several structural factors (administrative centralization, ministerial instability, the increasing weight of ministerial staffs, etc.) confirming the power of “modern Mandarins” in political life (1975). From then on, 2  French research on the Grands corps and the ENA confirmed the specific role of these institutions in the making of French state elites (Thoenig 1973 [1987]; Kessler 1986; Eymeri 2001). Since its creation on 9 October 1945, out of 6938 énarques, 80% have remained in the service of the state throughout their career path (Rouban 2015: 7). 3  Membership in the Grands corps, ranked in order of traditional prestige, is the privilege of the highest-ranked members of an ENA graduating class (Genieys 2010: 78).

This independent Cours des comptes assists the parliament and the government (article 47–2 of the constitution) particularly in the area of public policy evaluation. The court judges the public accounts. It audits the state and its operators, social security organizations, public companies, organizations receiving donations as well as medical and social establishments and services (ESMS) and private clinics. Each year, the Cours des comptes certifies the accounts of the state (Finance Act) and of the general social security system (Social Security budgetary act/ LFSS)

The highest administrative court in France. It is the judge of cassation of the decisions of the administrative courts of appeal, and also has jurisdiction to hear, in the first and last instance, certain disputes such as appeals on the ground of abuse of authority against decrees. It also plays the role of advisor to the government. Pursuant to Article 39 of the constitution, it gives its opinion on draft laws before they are passed by the Council of Ministers. It also hears draft ordinances, as provided for in Article 38 of the Constitution, as well as the most important draft decrees referred to as “council of state decrees”

Cours des Comptes

Conseil d’État

Missions and field of intervention

Table 2.1  Characteristics of the Grands corps

It is composed of career magistrates, high civil servants, customarily trained at the ENA (high ranking). Its 230 members are divided between the Litigation Division, responsible for judging disputes between citizens and the administration, and the Advisory Divisions, which examine draft laws and regulations. Like all other members of the Grands corps are often appointed by the government (minister) as director of a central administration. The Directorate of Social Security and the social security policies were, for a long time considered, “by tradition” as the territory of elites of the Conseil d’Etat

It is composed of career magistrates, high civil servants, trained in general at the ENA (high ranking). Its auditors can monitor all policy areas. In the area of economic policy and social security, they may be in conflict with members of the Inspection Générale des Finances. On social security, they have been in conflict with the Magistrates of the Conseil d’Etat (see below Part I). Like all other members of the Grands corps are often appointed by the government (minister) as directors of a central administration

Members

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Sources: Authors’

Inspection Generale des Finances (IGF)

The IGFs missions are: to verify, control, ensure the technical, administrative, financial and accounting audit a priori and a posteriori on the whole of the National Public Administration; to study all questions, to carry out all missions related to public finance, public accounting, public investment programs, public procurement, the assets of the state and of the local authorities as well as those related to budgetary and financial discipline. The IGF also acts as an advisor to the Minister of the Economy and Finance. Unlike external audit bodies such as the Cour des comptes, the IGF is not independent of the executive

Recruitment is mainly done at the exit of ENA (four or five recruitments per year). The inspectorate has the reputation of providing a formidable career boost. Most of the members of the corps pursue a career in the public service, in central government administrations (notably in the General Directorate of the Treasury). More than 130 out of 333 inspectors have worked in a ministerial office or held a political mandate (Rouban 2002). In our study the IGFs, considered the elites of the Ministry of Finance, were in conflict with the new welfare elites (Cour des comptes and Inspection générale des affaires Sociales/see Chaps. 4, 5, and 7)

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research focused on the empowerment of technocratic elites by the acquisition of technical know-how about governing policy (Putnam 1976, 1977; Birnbaum 1977; Aberbach et al. 1981). By studying the beliefs and behaviors of technocrats in Germany, Italy, and the United Kingdom, Robert Putnam showed that mastery of this know-how generates a “technical identity” and a group spirit that allows technocrats, during struggles with “politicians,” to often impose their vision of public programs (Putnam 1977: 407). At the turn of the 1970s, with the crisis of Keynesian policies, the state elites were even designated by a fraction of the political class converted to neo-liberal ideology as responsible for the economic crisis and the bureaucratization of Western societies (Dezalay and Garth 2002; Suleiman 2003). Other political elites from the left in certain European democracies where the welfare regime has a long history, developed a populist discourse pointing to state elites as responsible for the social crisis (Blyth 2001, 2013; Hassenteufel 1991; Palier 2002). Faced with this double criticism from the radical left and the conservative right, technocratic elites were forced to renew the foundations of their legitimacy. In France, from the 1970s onward, technocrats slowly converted their “state interventionism” into a pragmatic neo-liberalism (Prasad 2005). According to Jobert and Théret, under the socialist presidency of François Mitterrand, a fraction of the state elites that occupied strategic positions in the powerful financial ministries transformed themselves into “state economists” to impose a policy of budgetary rigor while pursuing the internationalization of the French economy (1994: 80). For some, this paradigm shift in fiscal policy has erased Keynesian rhetoric in favor of neo-liberal discourse (Siné 2006), for others, it has invited Keynesian technocrats to integrate the rationalization of fiscal choices into their actions (Bénamouzig 2005). The choice of budgetary policies is becoming a key issue in the redefinition of the power of state elites, where the advocates of austerity and the supporters of “re-regulation” are pitted against each other (Bezes and Siné 2011; Blyth 2013). The works analyzing the “victory” of neo-liberal policies over the various types of Keynesian states have in common a tendency to relegate state elites to the cemetery of history. While these elites have seemingly abandoned Keynesianism, they have done so in order to better define its perimeter, notably by targeting a limited number of strategic sectors such as health insurance or national defense (Brookes 2021). Work on the emergence of new regulatory instruments for public action support this view

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(Lascoumes and Le Galès 2004). From this perspective, the reconfiguration of the state in Europe has been asynchronous and differentiated in domestic and foreign policies (King and Le Galès 2017). We will show that if budgetary control is a new struggle at the heart of democratic states (Schäfer and Streeck 2013), it also constitutes a context in which the power of unelected governmental elites is asserted, skillfully playing on the distinction between decision-­taking and policy decision-making (Giddens 1972: 366).

Unelected Governmental Elites and the Role of Custodian of State Policies Our elite approach centers on a government of “insiders” within certain policy domains (Genieys 2010, 2024). These insiders are unelected governmental elites at the apex of the state apparatus who, collectively and decisively, influence policy decision-making process and state reconfiguration. In the Programmatic Elites Framework, their identification is based on the observation of (i) their social background and career path inside the state apparatus; (ii) the policy domain in which they operate over the long term; and (iii) the programmatic orientation they promote. It provides, on the one hand, an analysis of influential unelected governmental elites (social background/career path), and, on the other hand, an analysis of the competition between programmatic orientations. Last but not least, it illuminates the link between the dynamics (a) of elites’ circulation (their strengthening or weakening over time) and (b) programmatic orientations (continuity or discontinuity). The main output that defines the success of these elites is the institutionalization of their power in a policy domain. In our empirical inquiries on the welfare policy domain in France and the US, we have, with this method, focused on “the rise and fall of elites” (Pareto 1991). In these two cases, a new generation of elites has distinguished itself from the old by playing the role of “custodians of state policies.” Philip Selznick had defined “custodians of policy” as individuals protecting certain “social values” in order to assert leadership, group identity and autonomy within an organization (Selznick 1957: 120–121). We have revisited his definition. In our conception, the role of “custodian” refers to elites fighting for what they consider a “responsible” extension of stateness (Genieys 2010, 2024). This role is both shaped by ethics of ultimate ends and ethics of responsibility (Weber 2004): (a) the development of policies strengthening the regulatory capacity of the public authority

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(ethics of ultimate ends); (b) the will to formulate effective “sustainable” policies considering political, budgetary, etc. constraints (ethics of responsibility). This ethic of responsibility is the result of a long career path inside the state apparatus and a specialization in a particular policy domain. In the French case, two initial research programs (MiRe 1 & MiRe 2, see Table 1.1) the emergence of welfare elites over the long term. These elites were composed of individuals sharing: (i) an institutional reform program following the goal of strengthening the role of the state in the social insurance domain; (ii) a collective strategy to gain political autonomy vis-à-vis “old-fashioned” elites (especially social partners and doctors). These findings were consistent with the hypothesis that competition among sectoral elites provides a creative dynamic for reform (Genieys and Smyrl 2008a, b). Affirming the state’s centrality in social security policies was a shared strategy when dealing with employers and workers’ unions, whose capacity to “govern” the policy was weakened. Replicated recently, our empirical inquiry confirms the political victory of the elites in implementing “Sustainable Social Welfare” program (see Part II). Our investigation on the US case focused on the last two attempts at major health care reforms (Clinton and Obama) since the 1990s (Genieys et al. 2022; Genieys 2024). Longitudinal analysis of elites’ career paths in the health insurance domain between the Clinton and Obama administrations confirms the forging of a group of “long-term insiders” who had long careers, experience in the legislative and executive branches of government (and circulation between them), and “socialization” by the failure of the Clinton Plan. They first won strategic positions in the two branches of power, defended their bi-partisan and consensual programmatic orientation, and then led negotiations “behind closed doors.” During the Obama administration, they had sufficient political resources to shape the reform. As insiders, they have indeed played a key role in building political consensus around a major reform program, the Affordable Care Act (2010). In this book we revisit our study of the French case. By drawing on the hundreds of interviews and biographical data of social insurance elites (Mire 1, Mire 2 and ProAcTA research, see Table 1.1), we will paint their sociological portraits and investigate the correlation between social background/career path and changes in the policy agenda. Illustrated by the transformation of the French welfare regime, our elite approach establishes precisely what differentiates them from their rivals and how they have driven programmatic orientations affecting the reconfiguration of the state (Tables 2.2 and 2.3).

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23

Table 2.2  Elites types and social security governance (1945–2020) Elites types

General sociological traits

Programmatic orientation

Old-­ fashioned social security elites 1945–1980

The social partners elites: Funds president selected by trade and employers’ unions The state elites: magistrates of the Conseil d’Etat (Grands corps) who leaded the DSS: Pierre Laroque and his heirs

Welfare elites 1981–2020

First generation (1981–1999) composed of magistrates of the Cour des comptes (Grands corps): Jean Marmot and his heirs Second generation (2000–2020) was IGAS (General Inspectorate of Social Affairs) or civil administrator or statistical engineer The elites of Ministry of Finance are generally Inspecteurs généraux de finances (Grands corps) Career path in the Directorate of the Budget of the Ministry of Finance

Bismarckian-flavored welfare regime: institutional fragmentation, employment-related entitlement, earnings-related benefits focused on the male breadwinner, contribution-based financing, an autonomous medical profession with a doctor– patient dyad subject to limited interference by third-party payers (liberal medicine), and social partners (employers and employees) with a management role in health insurance funds at local and national levels (statutory health insurance (SHI) scheme in 1945) Social security governance based on the partnership between social security funds and the state: social security funds managed by the social partners; regulatory role of the state “Sustainable Social Welfare” program: strengthening the role of the state on the governance, the control of expenditures and lay the foundations for national health coverage. Program implemented by the Constitutional reform (Social Security Budget Act 1996) and additional reforms (CMU, 1999; Douste Blazy reform 2004; PUMA, 2016) Social security governance model based on the interaction of the DSS and the UNCAM (led after 2004 by a high civil servant)

Elites of Ministry of Finances

Sources: Authors’

Fiscal austerity and strict control of social spending. Comprehensive macroeconomic approach to fiscal and budgetary policy “Guardians” of budget orthodoxy, they struggle against the “big spender” ministries as of the Ministry of Social Affairs

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W. GENIEYS AND M.-S. DARVICHE

Table 2.3  Social background and career path of the old and new elites (1945–2020) “Old-fashioned” elites (1945–80)

Welfare elites First generation: 1981–1999

Welfare elites Second generation: 2000–2020

Social background

Training

ENA

ENA

ENA/ENSAE

Home administrative body

Conseil d’État (Grands corps)

Cours des comptes (Grands corps)

General Inspectorate of Social Affairs (IGAS)/ civil administrator/ statistical engineer

Career path

Type of executive position occupied

Director of the Directorate of Social Security (DSS)

Director of the Directorate of Social Security (DSS) or fund director (CNAMTS, CNAF, etc.) Directorate of Social Security (DSS), Ministerial Cabinet & Grands corps

Sub-director and director of the Directorate of Social Security (DSS) or fund director (CNAMTS, CNAF, etc.)

Circulation Directorate of inside the state Social Security (DSS), Ministerial Cabinet and Grands corps Exit form Political advisors career in ministerial cabinets and/or return to the Conseil d’État Custodian role Defense of weak state interventionism: corporatism (ethics of ultimate ends) Programmatic orientation

Bismarckian model and employment-­ based social insurance framework

Mainly in Grands corps or IGAS, exceptionally other sector of the state or private sector Defense of strong (ethics of ultimate ends) and sustainable (ethics of responsibility) state interventionism “Sustainable Social Welfare” program: universalization of social insurance and state control of governance

Iron Triangle (DSS, UNCAM & High Authorities) and Ministerial Cabinet

Inside the state (more seldom nonprofit health-social sector) as head of new “high authorities” created since the 2000s Defense of strong (ethics of ultimate ends) and sustainable (ethics of responsibility) state interventionism “Sustainable Social Welfare” program: universalization of social insurance and state regulation

Sources: MiRe 1 (1996–1997), MiRe 2 (2006–2007) and ProActa (2018–2020).

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25

Bibliography Aberbach, Joel D., Robert D. Putnam, Bert A. Rockman, eds., Bureaucrats and Politicians in Western Democracies, Cambridge (Ma.), Harvard University Press, 1981. Badie, Bertrand, Pierre Birnbaum, The Sociology of the State. Chicago (Ill.), Chicago University Press, 1983. Bandelow, Nils, Johanna Hornung, Marc Smyrl, “Theoretical Foundations of the Programmatic Action Framework (PAF)”, European Policy Analysis, 7 (1), 2021: 14–27. Bénamouzig, Daniel, La santé au miroir de l’économie. Une histoire de l’économie de la santé en France. Paris, PUF, 2005. Bergeron, Henri, Patrick Castel, « Les habits neufs du néo-institutionnalisme ? La redécouverte de l’ordre mésologique et de l’agency », L’Année Sociologique, 3, 2015: 23–62. Best, Heinrich, John Highley, “Introduction”, in Heinrich Best, John Higley (eds), The Palgrave Handbook of Political Elites, London, Palgrave Macmillan, 2018: 1–6. Bezes, Philippe, Alexandre Siné, (eds.), Gouverner (par) les finances publiques, Paris, Presses de Sciences po, 2011. Birnbaum, Pierre, Les sommets de l’État. Essai sur l’Élite du pouvoir en France, Paris, Seuil, 1977. Birnbaum, Pierre, « Type d’élite et nature de l’État: l’exemple américain », Pouvoirs, n° 29, 1984: 12–128. Birnbaum, Pierre, States and Collective Action: the European Experience, Cambridge (Ma), Cambridge University Press, 1988. Birnbaum, Pierre, The Idea of France. New York (NY), Hill & Wang, 2001. Birnbaum, Pierre, Les désarrois d’un fou de l’État. Entretien avec Jean Baumgarten et Yves Déloye, Paris, Albin Michel, 2015. Birnbaum, Pierre, Où va l’État ? Essai sur les nouvelles élites du pouvoir. Paris, Seuil, 2018. Birnbaum, Pierre, Charles Barucq, Michel Bellaiche & Alain Marié, La classe dirigeante française, Paris, Presses Universitaires de France, 1978. Blyth, Mark, « The Transformation of the Swedish Model. Economic Ideas, Distributional Conflict, and Institutional Change », World Politics, 54 (1), 2001: 1–26. Blyth, Mark, Austerity. The History of a Dangerous Ideas, Oxford, U.K.: Oxford University Press, 2013. Bourdieu, Pierre, La noblesse d’État. Grandes écoles et esprits de corps, Paris, Editions de Minuit, 1989. Brookes, Kevin, Why Neo-liberalism Failed in France. Political Sociology of the Spread of Neo-Liberal Ideas in France (1974–2012), Switzerland, Springer International Publishing, 2021.

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Putnam, Robert D., “Elite Transformation in Industrial Advanced Societies. An Empirical Assessment of the Theory of Technocracy”, Comparative Political Studies, 10 (3)1977: 383–411. Rouban, Luc, « L’inspection générale des Finances 1958–2000: quarante ans de pantouflage », Cahiers du Cevipof, vol. 31, juin 2002: 2–76 Rouban, Luc, L’ENA ou 70 ans de paradoxe. Paris, Sciences Po-CEVIPOF, Septembre 2015. Schäfer, Armin, Wolfgang Streeck (eds), Politics in the Age of Austerity, Cambridge U.K, Polity Press, 2013. Shonfield, Andrew, Modern Capitalism. The Changing Balance of Public and Private Power, Oxford (UK), Oxford University Press, 1965. Sewell, William H. Jr., “Three Temporalities. Towards an Eventful Sociology”, in Logics of History. Social Theory and Social Transformation, Chicago, The University of Chicago Press, 2005: 81–123. Selznick, Philip, Leadership in Organization. A Sociological Interpretation, Oakland (CA), University of California Press, 1957. Siné, Alexandre, L’ordre budgétaire: l’économie politique des dépenses de l’État, Paris, Economica, 2006. Skocpol, Theda, ed., Bringing the State Back in?, Cambridge (MA), Cambridge University Press, 1985. Skocpol, Theda, Keneth Finegold, « State and Economic Intervention in the Early New Deal », Political Science Quarterly, 97 (2) 1982: 255–278. Skocpol, Theda, John Ikenberry, “The Formation of the American Welfare State in Historical and Comparative Perspective”, Comparative Social Research, 6, 1983: 87–148. Skocpol, Theda, Edwin Amenta, “States and Social Policies”, Annual Review of Sociology, 12, 1986: 131–157. Skocpol, Theda, “State Formation and Social Policy in the United States”, The American Behavioral Scientist, 35 (4–5), 1992: 559–584. Skocpol, Theda, Jacob Hacker, “The New Politics of Health Policy”, Journal of Health Politics, Policy and Law, 22 (2), 1997: 315–338. Steinmo, Sven, The Evolution of Modern States. Sweden, Japan and the United States, Cambridge MA., Cambridge University Press, 2010. Suleiman, Ezra N., Politics, Power and Bureaucracy in France: The Administrative Elite, Princeton (NJ), Princeton University Press, 1974. Suleiman, Ezra N., Elites in French Society: The Politics of Survival, Princeton (NJ), Princeton University Press, 1978 Suleiman, Ezra N., Dismantling the Democratic States, Princeton (NJ), Princeton University Press, 2003. Thelen, Kathleen, « How Institutions Evolve. Insights from Comparative Historical Analysis », in James Mahoney & Dietrich Rueschemeyer [eds], Comparative Historical Analysis in the Social Sciences, Cambridge, Cambridge University Press, 2003: 208–240.

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PART I

The Advent of the Welfare Elites

Abstract  In France, the social contract established in the aftermath of World War II was based on the legislative decrees of October 1945 creating the French system of the social security. Inspired by the German Bismarckian model, its management was handed over to the trade unions, which promoted a policy of expanding social rights. After two decades corresponding to a “golden age,” its original model of government was gradually called into question. The continuous increase in the state’s contribution to the financing of social security has favored the intervention of welfare elites that shaped the 1996 constitutional reform establishing the Social Security Budget Act. In France, the welfare regime established in the aftermath of World War II was based on the legislative decrees of October 1945 influenced by the Bismarckian model (Palier 2002, 2004, 2005). The legislative decrees establishing the general social insurance system (“régime général de la Sécurité sociale”, hereafter called the general fund) were the work of Pierre Laroque and few elites in the Conseil d’État (Valat 2001). After two decades corresponding to a golden age, the original model of government was called into question due to a structural increase in social spending, which rose from 19.2% in 1970 to 27.4% in 1981 (Tasso 1991: 168). Massive unemployment caused by the successive oil shocks of 1973 and 1979 led to the creation of the first Social Security Financing Plan by the conservative government of Raymond Barre on 22 September 1976 (Palier 2002: 176). The issue of the structural deficit was a key point of

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conflict among social partners, divided state elites, and advocates of privatization until the early 2000s. In this complex situation, the question of finding new ways of regulating expenditure and governing the social security system occupied an increasingly important place on the political agenda of successive governments (Barbet and Briet 1988; Brookes 2021). The continuous increase of the state’s contribution to the financing of social security, especially in the costly sector of health insurance, favored the intervention of new types of unelected governmental elites with career paths in this policy domain. Since 1980, arising welfare elites inside the state have promoted a far-­ reaching reform program of the French social security. Its first generation was composed of magistrates of the Cour des comptes.1 In this first part, we will analyze their characteristics. Our objective is to correlate the change in the governance of the social security model with the change in the structure of the elites to show how the advance of the new governance model on the political agenda is concomitant with the rise to the top of power of a group of senior officials characterized by a different social background and career path inside the governance of social security (Table 2.3). This new generation of elites waged its first battle against the “old-­ fashioned” elites governing the social security system that emerged from World War II: namely, the magistrates of the Conseil d’État and the union leaders (Table 1.2). The objective of this new generation was twofold. To ensure the future financing of the social security and at the same time to implement universal coverage in France (Rodwin 2003). To this end, they support a major social security reform by giving greater regulatory power to the state (Hassenteufel 2009; Genieys and Hassenteufel 2023) while achieving national health coverage (Nay et al. 2016). After two decades of struggle, exacerbated by the important political change of 1981, the first generation of the welfare elites secured powerful roles inside the Directorate of Social Security (Direction de la sécurité

1  We carried out a sociographical study of these members of the Cour des comptes in previous academic publications (Genieys 2010). In this book, we will deepen the analysis of these elites with a selection of sociological portraits. The objective is to bring out the distinctiveness of their career path by relating it to the political struggles waged for the reform of the social security.

  The Advent of the Welfare Elites 

33

sociale, hereafter DSS),2 a key institution of the Ministry of Health and Social Affairs. Under the socialist presidency of François Mitterrand (1981–1995), the outcome of their fight inside and outside the state against their opponents was uncertain. Their consecration came in 1995, when, against many expectations, President Jacques Chirac, after an election campaign marked by the world to reduce the “social divide” (fracture sociale), decided to put their reform program on the political agenda. The constitutional reform of February 22, 1996, laid the foundations for “Sustainable Social Welfare” program with the Social Security Budget Act (LFSS). The concomitant change in elites’ structure and programmatic orientation led to the reconfiguration of the French strong state.

Bibliography Barbet, André, Raoul Briet, « Financement et régulation du système de protection sociale », Revue française d’économie, 3(1), 1988: 51–80. Brookes, Kevin, Why Neo-liberalism Failed in France. Political Sociology of the Spread of Neo-Liberal Ideas in France (1974–2012), Switzerland, Springer International Publishing, 2021. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Genieys, William, Patrick Hassenteufel, “Health Policy in France”, in Martin Powell, Daniel Béland, Tuba Agartan, (eds.) Handbook on Health Policy Research, Oxford, UK, Oxford University Press, (forthcoming, 2023). Hassenteufel, Patrick, « Le rôle de l’État dans la régulation de l’assurance maladie », in Gérard de Pouvourville, Pierre-Louis Bras, Didier Tabuteau (eds.), Traité d’économie et gestion de la santé, Paris, Presse de Sciences Po, 2009: 369–377. Nay, Olivier, Sophie Béjan, Daniel Bénamouzig, Henri Bergeron, Patrick Castel, Bruno Ventelou, « Achieving the Universal Coverage in France: Policy Reform at the Challenge of Inequalities”, The Lancet published May 01 2016, https://www.thelancet.com/journals/lancet/article/PIIS0140-­6736(16) 00580-­8/fulltext Palier, Bruno, Gouverner la Sécurité sociale. Les réformes du système français de protection sociale depuis 1945, Paris, PUF, 2002. Palier, Bruno, “French Welfare Reform in Comparative Perspective”, Revue française de sociologie, 45 (5), 2004: 93–120. 2  The DSS is a key administrative unit in the social security government, responsible for the preparation of the law (social security Code), the monitoring of the Social Security Budget Act since the 1996 reform, and the overseeing of the implementation of public policies in the sector (see Appendix, Table A.3).

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Palier, Bruno, “Ambiguous Agreement, Cumulative Change: French Social policy in the 1990s”, in Wolfgang Streeck, Kathleen Thelen (eds.), Continuity and Discontinuity in Institutional Analysis, Oxford (U.K.), Oxford University Press, 2005: 127–144. Rodwin, Victor, “The Health Care System Under French National Insurance: Lesson for Health Reform in the United States”, American Journal of Public Health, 93 (1), 2003: 31–37. Tasso, Gérard, « Financement de la protection sociale et évolution de la part salariale: une comparaison de trois économies européennes à l’épreuve des chocs pétroliers des années soixante-dix », Informations économiques, 35 1991: 167–204. Valat, Bruno, Histoire de la Sécurité sociale (1945–1967). L’État, l’institution et la santé. Paris, Economica, 2001.

CHAPTER 3

The Rise and Fall of Old-Fashioned Elites

With the end of World War II, the Constitution of the Fourth Republic profoundly transformed the French welfare regime. Inspired by the Conseiller d’État Pierre Laroque, so called “founding father,” the legislative decrees of 4 October 1945 set the basis of the social security system and its health coverage organization (Merrien 1990; Palier 2010). Imposed in the name of a broad political compromise, this system differed significantly from its British equivalent, the National Health Service (N.H.S.), which was heavily state-funded, since it was financed by taxes and not by social contributions (cotisations sociales) as in France (Esping-­ Andersen 1990). The system was governed jointly by the unions (workers and employers) and the Ministry of Social Affairs via high civil servants from the Conseil d’État. Considered as the logical outcome of the wage society, the social protection system created in 1945 was an exception in French institutional history (Catrice-Lorey 1982; Palier 2002). Paradoxically, in France, the country of the strong state, the political influence of the high civil servants seems, for reasons reflecting the relationship between the political forces at the time of the “Liberation” (after de WWII), to have been less decisive than it was in the United Kingdom or Sweden during the same period (Heclo 1974). Indeed, the French state, although very interventionist in major areas of economic and social life (nationalization of industrial groups and banks, planning, training of elites

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_3

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[ENA, etc.], etc.), remained more restrained in the government of the social protection system (Suleiman 1974, 1978; Kuisel 1981; Jobert 1981; Ambler 1991). The social security system of 1945 took up ideas put forward in the 1920s and 1930s based on the management by private organizations of the professional type (Nord 2010). Bruno Palier (2002) describes this organization as a fragmented system because it “is divided into a number of different programs (branches). The régime général, which covers the dependent workers of the private sector in trade and industry (60% of the working population), comprises four branches: health care, old age, family and financing. In order to complement its benefits, numerous complementary private collective insurances have developed, such as the complementary pension funds for the salaried workers of the private sectors, which became compulsory in 1972, and mutuelles, complementary health insurance funds” (Palier 2010: 76). Through a gallery of sociological portraits of the welfare elites, we will show how and why a small group of high civil servants imagined the contours of a universal protection model in the early 1990s. Unlike the traditional state elites of social security governance, the overwhelming majority of whom came from the Conseil d’État, the welfare elites were from another Grands corps: the Cour de comptes. These new generation shared an economic preoccupation (the control of the famous “Social security hole” [trou de la Sécu]), a political solution, steering by the state and establishment of a national health insurance coverage. During the 1970s and 1980s, the agenda was ignored by the elites traditionally in charge of the various branches of Social Security. On the one hand, the workers’ unions and the employers’ union (le patronat) clashed over the redistribution of social benefits (health coverage, retirement, and family). On the other hand, within the administration, the elites of the Conseil d’État, heirs of Laroque, provided legal support for the extension of social rights. In this context, the elites in the Ministry of Finance were concerned about the growing deficit in the funds and demanded strict control of social spending. At the turn of the 1980s, unable to meet this challenge given their legal rather than accounting skills, the magistrates of the Conseil d’État were replaced by those from the Cour des comptes for the governance of policies (see above Tables 2.2 and 2.3). The Directorate of Social Security (Direction de la sécurité sociale, hereafter DSS) established by decree on 13 November 1970 (see Appendix, Table A.3), the

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focal point of the Ministry of Health and Social Affairs, because of its role in formulating and implementing welfare policies, was the site of the transfer of power.

The Influence of Corporatism in the 1945 Social Security Model France, an example of state centralism according to Tocqueville, “naturally” welcomed post-war interventionist policies in most sectors of social and economic activity (Kuisel 1981; Nord 2010). The “administrative super elites”, so called the “grands commis de l’État”, accompanied by young elites freshly graduated from the École Nationale d’Administration (hereafter ENA) founded in 1946, took control of economic and industrial planning policies (Suleiman 1978). But most of these young elites were not interested in Social Security matters. Originally, the Social Security Plan 1945 aimed to create a universal and centralized social protection system inspired by the Beveridgian (British) model, but in the political context of the Liberation, the proposals of the National Council of the Resistance favored management by the workers’ unions (Palier 2002). In a political compromise, especially with the Communist Party and the Catholic right, the German corporatist model prevailed. The legislative decrees of 1945, written by Pierre Laroque and Alexandre Parodi, argued for the creation of a single Social Insurance fund (Caisse nationale unique de Sécurité sociale) (Valat 2001; Dutton 2005), but the mobilization of Catholic political forces advocating for family policy led to the creation, alongside the Social Insurance fund, of a Family allocation fund (Caisse d’allocation familiale). These same legislative decrees established the principle of delegation of the management of funds to unions (Merrien 1990). The two branches of the social security, health coverage and family, operated under private law but were endowed with prerogatives of public authority. Why did the French high civil servants, bathed in a culture of public law, leave this autonomy of management of social insurance policies to the unions? The first reason was contextual and political. General De Gaulle was constrained by a balance of power favorable to the Communist Party (the leading political force in the 1945 Constituent Assembly), which relied on a powerful workers’ union: the Confédération Générale du Travail (hereafter CGT). Another explanation lies in the lack of interest

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among members of the Grands corps—especially the Inspection générale des finances and the Cour des comptes—to pursue their career paths in the social policy domain (see Tables 1.2 and 2.2). Indeed, apart from Pierre Laroque and Alexandre Parodi, members of the Conseil d’État, there were few members of the Grands corps during this period who had made notable careers there. The French program of economic modernization during the post-war period offered young high civil servants much more interesting career prospects in other sectors of state intervention (Kuisel 1973: 54, 1981). This low level of interest in the social insurance domain on the part of the Grands corps continued until the 1980s. From an institutional point of view, the Social Security Service (Service de Sécurité sociale), an administration then attached to the Ministry of Labour, and its high civil servants saw their action limited to the translation of the result of political negotiations of laws between government and social partners. Its workforce, composed of 7415 individuals in 1946, was reduced by more than 65% in the following decade (2576  in 1956).1 Finally, the pantouflage (movement between the public and the private sector) practiced by members of the Grands corps was limited in social affairs unlike in other sectors of the state (Suleiman 1978: 226–230). Career paths’ were limited to back and forth between the social chamber of the Conseil d’État and a few positions in the Ministry’s technical directorates (see Tables 2.2 and 2.3). The social security budget was then managed directly within the funds by the social partners under the supervision of the Directorate of the Budget of the Ministry of Economy and Finance. Moreover, the health administration, through its Directorate of hospitals which was dominated by the public hospital directors’ corps and its Directorate general for health (Direction générale de la Santé, hereafter DGS) under the influence of the “mandarins of medicine” (Weisz 1988)—the medical elites—left few leadership positions for the Grands corps. To understand the emergence of the first generation of welfare elites, it is necessary to show how their sociological characteristics were different from those of the members of the Conseil d’État. Pierre Laroque was a typical figure of the latter (Nord 2010: 183–190). Graduated from the École libre des sciences politiques a private public-policy school (Sciences Po currently), young member of the Conseil d’État, he was, before the World 1  Les cahiers du comité d’histoire, n° 15–16: “L’organisation des services centraux du ministère du Travail, 1945–2012,” vol. 1: “1945–1989,” décembre 2012: 16.

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War II, chief of staff at the cabinet at the Ministry of Labour (1931). In this capacity, he learned to negotiate with representatives of private social insurance companies and health care professionals’ unions. The model he imagined aimed to unify social security funds and family benefits into a single system, with management shared between workers and employers. With this management, Pierre Laroque wanted to make the social security an institution that would support the general policy of economic planning. The project failed with the converging political strategies of the sector’s interest groups and the fragmentation of political forces in parliament. Moreover, despite the break with the Vichy regime, Catholics were able to promote a strong and independent familialist policy (Valat 2001). In this context, in 1945, the Ministry of Public Health was renamed the Ministry of Population and the perimeter of intervention of the state elites was limited. They did, however, recovered the post of Director of social security (DSS), an administrative unit, which has since been occupied by a high civil servant from a Grands corps. Pierre Laroque, conseiller d’État, exercised this function from 1945 to 1950. Until the late 1970s, this function was almost exclusively reserved for members of the Conseil d’État. Pierre Laroque was then replaced in 1951 by another member of the Conseil d’État, Jacques Doublet (Valat 2001: 177–178), who headed the DSS from 1951 to 1960, had already enjoyed a long career as a high civil servant under the Third Republic and Vichy, and was an ardent defender of family policy (Nord 2010: 190–93). During this period, the management of the funds was checked by both the ministry of Labour (ex ante) and the ministry of Finances (ex post). Pierre Laroque opposed this power sharing during his term as Director of Sécurité sociale. The power granted to the Directorate of the Budget of the Ministry of Finance gradually became the source of a structural conflict over the management of public accounts of social affairs. The conflict appeared to be a quarrel of egos between members of two major Grands corps of the state but the gradual increase in the deficit of certain branches of the social security, intensified the clashes between the members of the Conseil d’État and those of the Inspection Générale des Finances.

The “Golden Age” of Workers’ Unions Governance But, before going further in the explanation, it is important to return on the period of the Trente glorieuses (1945–1975) (Fourastié 1979) to understand the origins of this internal conflict between the “big spenders”

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from the Ministry of Health and Social Affairs and the advocates of budgetary rigor from the Ministry of Finance. In inventing the social security model, the members of the Conseil d’État had to limit the state’s control over the social accounts. The original rule was simple: the accounts were indexed on the balance between social contributions (tax on workers and employers) and social benefits (redistribution). In the opinion of Pierre Laroque himself, as long as this balance was respected, there was no need to fear that the government would intervene. During the Trente glorieuses (Fourastié 1979), French society was experiencing full employment with a growth rate of around 6% per year, so this type of government of social insurance could be considered sustainable. For the social partners, it was a golden age of “social democracy” (démocratie sociale) (Valat and Laroque 2015). The regime was characterized by the participation of workers’ representatives in the management of the social protection system and aimed to guarantee for social and political integration of the workers within the society and the collaboration between workers and employers—hence social peace (Palier 2010: 76). Initially dominated by the Confédération Générale du Travail (CGT), the governance of social insurance was subsequently shared with other unions—the Confédération Française des Travailleurs Chrétiens (CFTC), Force Ouvrière (FO) and the Confédération Française Démocratique du Travail (CFDT) (Table  3.1). Any attempt to expand state power was denounced by the social partners as a risk of undermining “acquired rights” (acquis sociaux). In 1952, the Pinay government was overthrown because of a proposal to nationalize the collection of social contributions. To Laroque’s regret, political conflicts between the union forces involved took the stage. The CGT, affiliated to the Communist Party, and the CFTC, a union close to employers and Christian democracy, established a balance of power in the management of social protection. On one side, a fund dedicated to social security managed by the CGT and, on the other hand, a fund for family allowances in the hands of the CFTC. Moreover, the elections for the leadership of the funds in a context of internal division within the CGT—between those close to the Communist Party and those of socialist sensibility (who founded the CGT-Force ouvrière [FO] in 1948)—reinforced the divisions. These conflicts between workers’ unions impoverished social dialogue, a key goal for the founding fathers of the social security.

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Table 3.1  Main unions involved in social security governance since 1945 Workers’ unions

Year of foundation

Aims and goals

CGT (Conféderation Générale du Travail) Created in

1895

CFTC (Confédération Française des Travailleurs Chrétiens)

1919

FO (Force Ouvrière) Founded in

1948

CFDT (Confédération Française Démocratique du Travail)

1964

CGT is affiliated to the Communist Party The CGT, which had a political majority at the creation of the social security system, remained in a leading position in the governance of the social security system until the Jeanneney Decrees of 1967 The CFTC is a Christian union; it was created to oppose the CGT. In 1964, it experienced a split with the creation of the CFDT. The CFTC is a reformist union FO is the result of a split from the CGT in 1947 after World War II FO is the third largest union in France in professional elections The CCFDT is a reformist union close to the socialist party Since 2017, it is the largest union in the private sector

Sources: Authors’

From 1950 to 1967, there was a gradual but continuous extension of health insurance to initially excluded populations and the consolidation of “special” schemes (régimes spéciaux) for the employees of public companies (SNCF [National Railroad Company], EDF [National Electricity Company of France], RAPT [Autonomous Parisian Transport Company]). The general social insurance system was extended to students (1950), farmers (1961), self-employed workers in commerce and industry and the liberal professions (1966). In 1958, employers’ and workers’ unions agreed on the creation of a national unemployment insurance program. In 1961, a fund for complementary private but non-profit pensions (retraites complémentaires), the Association of Supplementary Pension Schemes (Association des régimes de retraite complémentaire des salariés/ARRCO), was created (Chadelat 2008). At the same time, between 1961 and 1966, social contributions increased from 32.75% to 34.5% of gross salary. At that time, the question of funding had not yet become a major concern. But a report of 12 November 1951, issued by the Superior Council

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of the Social Security, raises the issue of financial imbalance (Pavard 1967; Palier 2002: 138). The sustainability of the pay-as-you-go pension (retraite par repartition) system was already on the table. The same was true for health insurance, where the reliability of accounting projections remained low (changes in salaries, fluctuations in expenditure and revenue, etc.). In fact, the structural imbalance in the social security accounts was masked by an accounting game that projected a temporary financial balance. In reality, social security was experiencing cyclical balancing problems comparable to those of the state budget, but without the regulatory instruments of the Directorate of the Treasury (Direction du trésor). At the end of 1966, the employers’ social contributions had to be increased by ¾ of a point and the state advanced 1950 million francs to make up the deficit of the Social Insurance fund, even though no provision was made in the General Finance Act. Intervention was said to be justified only by the tradition of the state “mopping up” the deficit of the social security system. In addition, the creation of the Common Market in 1957, opening the way to competition between European countries, forced governments to commit to controlling public spending. In the social security sector, this mission was entrusted to social partners, but political strategies were increasingly divergent, with the unions emphasizing the extension of social benefits (acquis sociaux) against employers who refused a regular increase in their financial contribution. On the health side, moreover, the medical professions fiercely opposed any constraint on their reimbursement. Faced with these disputes the reform of the management of health insurance funds became urgent. These changes in the economic context have challenged the Bismarckian model of 1945 (Palier 2002). Fragmented into multiple special schemes, the system was moving away from the ideal of centralization and unification desired by Pierre Laroque. Meanwhile, the hold of the workers’ unions and the expansion of social rights have made it difficult to control the system.

The Conservatism of “Old-Fashioned” Elites The rising costs of the social protection system raised a series of political questions that were tackled in January 1966 by Georges Pompidou, the Prime Minister, and his Minister of Social Affairs, Jean-Marcel Jeanneney. The political context resulting from the legislative elections of March 1967 was not favorable to the Gaullist Party, which won only by a narrow

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margin. Faced with the left and a public opinion resistant to any reform likely to undermine social benefits, the government initiated a procedure of legislative decrees (Ordonnance n°67–706 of August 21, 1967) to shorten diffuse opposition in Parliament. The move triggered a general strike on May 17, 1967, and the filing of a non-confidence motion in the National Assembly which failed on May 18. The reform was then stigmatized by the left as being the work of a condescending technocracy. Nor did it satisfy the unions, who saw their power diminished to the benefit of employers who feared an increase in their financial contribution. Pierre Laroque, then president of the social section of the Conseil d’État, did not miss the opportunity, when the legislative decrees came before his jurisdiction, to underline the break with the model of 1945. Indeed, in addition to co-management (paritarisme), the legislative decrees also addressed the financing of social benefits. This problem had already been addressed by numerous reports such as those of the Bordaz Commission (April 1966), the Canivet Commission (March 1967) and the Freidel Commission (spring 1967), all of which called for a deep reform of the financial management of funds. The intent was an administrative reorganization that dismantled the single National Insurance fund and created a National Health Insurance fund (CNAMTS), a National old-age insurance fund (Caisse nationale d’assurance vieillesse, CNAV) and a National family allocation fund (Caisse nationale d’allocations familiales, CNAF)2 (Chadelat 2008). To this trio was added a Central Agency for Social Security Bodies (Agence centrale des organismes de sécurité sociale, hereafter ACOSS),3 managed by the social partners, for the collection of funds for the Union for the Recovery of Social Security Contributions and Family Allowances (Union de recouvrement des contributions de Sécurité sociale et d’allocations familiales, URSSAF). Finally, the governance of the fund system was reorganized at the regional level which favored the power of the unions. These regional funds would be able to propose an increase in social contributions and co-­ payment in health insurance (ticket modérateur) thus breaking with the centralizing spirit of 1945. Once again, the “nationalization” of social  For an overview of the social security funds see Appendix, Table A.3.  The ACOSS is the national financial management agency for the “general fund” of the social security. As such, it serves as a general clearing house for the funds, collected from salary withholding and employer contributions, and paid out for services by the various local and regional funds (Genieys 2010: 80). 2 3

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security was avoided. The power of the funds was increased to the detriment of the state because their boards were in charge of the financial balance of the system. In the general social insurance system, the National Health Insurance Fund (Caisse nationale d’assurance maladie des travailleurs salariés, CNAMTS) became the umbrella organization for the Regional Health Insurance funds (Caisses régionales d’assurance maladie, CRAM). The fund system was strengthened by the reform and, at the same time, the worker’s union Force Ouvrière (FO) emerged from the professional elections to take the presidency of the CNAMTS. This context of weak power of the state elites in the management of the social security meant that the ministry directorates of the social affairs domain did not attract candidates for thriving careers as high civil servants. Christian Prieur was an exception. Énarque and administrateur civil 4 at the Ministry of Finance, he participated, as technical advisor to the Ministry of Social Affairs under Jeanneney, in the drafting of the legislation in 6 weeks (1967), a record time considering the importance of the issues at stake, notably the reorganization of power within the National Health Insurance Fund (CNAMTS). Prieur would become the first director of this fund for a decade (1968–79), foreshadowing the career path that would later be taken by the welfare elites (see the following chapters). At the same time, at the top of the administration, the members of the Conseil d’État in position at the Directorate of Social Security (DSS) remained focused on strengthening the legal architecture of the system as laid in 1956 in the Social Security Code. But they remained silent in the face of the financial problems that became central at the end of the Trente glorieuses.

The Criticism of Social Security Governance In the late 1960s, the issue of balancing social accounts became a concern, but primarily outside the social security where scientific expertise in economic and budgetary policy remained marginal, and controversies were confined to the tedious commentary of social law jurisprudence. It was within the Centre de recherche et de documentation sur la consommation, 4  In his pioneering work on the French administrative elites, Ezra Suleiman distinguishes between the different administrative bodies that make them up. He opposes the Grands corps (see Chap. 2) to the other less prestigious corps. Of these latter, the corps of the administrateurs civils is the largest in number (Suleiman 1974, chapter 3).

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the CREDOC, that a more economics centered vision of health issues emerged (Bénamouzig 2005). The CREDOC was a non-profit association composed of statistical researchers from the Institut national d’études démographiques (demography studies) and the Institut national de la statistique et des études économiques (statistical studies), high civil servants from the Commissariat général au Plan (General Commissioner to the Plan), and others from the social partners. Although important in the production of a more dynamic approach to public accounting, the CREDOC remained outside the administration of the Social Security (Bénamouzig 2005). The economic approach remained alien to the “old-­ fashioned” culture of the sectoral elites. On the other hand, economic ideas found a very favorable reception within the young Forecasting directorate of the Ministry of Finance (1965) in charge of the implementation of the “rationalization of budgetary choices” (RCB) policy.5 The development of the use of statistics and new calculation methods resulted in the making of a new elite profile: that of the “statistical engineers” (trained by the Grandes Écoles as Polytechnique, Mines, Ponts et chaussées, ENSAE, etc.). At that time, governors of social security knew how to build effective legal norms but did not know how to keep the accounts well. Counting was the strength not of the Conseil d’État but rather that of the Inspecteurs généraux des finances, whose careers generally took place within the Directorate of the Budget. Beyond a war of prestige between these two Grands corps border lines emerged around good management of public money (see Tables 1.2 and 2.2). The elites of the Ministry of Finance had a clear policy position: improving the management of social security affairs was the responsibility of their administration and the social partners. But their role was limited to providing a warning in case of need. At that time the financing of social security by taxes was almost non-existent, no one in the Ministry of Finance thought of taking over a sector whose deficit looked chronic. A high civil servant reminds us that “as curious as it may seem, it [was] its deficit that protect[ed] social security from the grip of the state” (Chadelat 2008: 134). At the end of the Trente glorieuses, the “old-fashioned” elites (i.e., the union leaders and the Conseil d’État members) still did not produce reliable fiscal accounts and even less develop an “actuarial” vision of the evolution of expanse. These elites lacked cultural and professional resources 5  This new approach to public policy was directly inspired by one developed in the United States known as the Planning Programming Budgeting System (PPBS) (Bénamouzig 2005).

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to implement such a vision. For their part, the unions wanted broader social benefits. The employers, whose contribution constantly increased, refused despite their technical capacities to contribute to improving the management of social accounts. The conditions of the rupture with the social security model of 1945 appeared more or less clearly at the turn of the 1990s (Palier 2002, 2005). The May ’68 movement was a collective refusal to question the social benefits that the trade unions strongly supported. In the face of this large-­ scale political mobilization, the state strengthened its control over social security, even though at that time the option of a comprehensive reform was not being considered. Thus, during the 1970s and 1980s, the balance of power, in terms of numbers, between the elites of the Ministry of Social Affairs and those of the Ministry of Finance favored the latter. A reorganization of the administrative directorates in charge of social security within the Ministry of Social Affairs was then envisaged. After first joining the Ministry of Labour under the name Directorate of Health Coverage and Social Insurance Funds (Direction de l’assurance maladie et des caisses de sécurité sociale) (1966), the Directorate of Social Security (DSS) next joined, at the end of 1970, a Ministry of “Public Health and Social Security” developing alongside the health, hospital and social action directorates (see Appendix, Table A.3). The seemingly minor attachment of the DSS to the new ministry is central to explaining the emergence of the first generation of welfare elites (see Tables 2.2 and 2.3). Indeed, it is in the battle for control of this strategic administrative directorate that they emerged as custodians of state policies. The conquest of the DSS, which has long been in the hands of the elites of the Conseil d’État, was a prerequisite for “Sustainable Social Welfare” program. For some authors, the 1980s saw the end of an era of “pragmatic state interventionism” implemented at the end of World War II, notably the progressive adoption by French state elites of “pragmatic neo-­liberalism” (Prasad 2005). In accordance with Kevin Brookes (2021) on the failure of neo-liberalism in France, we argue instead that the far-­reaching reform of the social security model corresponds to a reconfiguration of the strong state via a “pragmatic state regulationism”. Our elite approach grasps the hidden face of this process. We have pointed out (i) the change in the elites’ social background and career path with the taking of power by the high civil servants of the Cour des comptes to the detriment of those of the Conseil d’État and (ii) we have established its correlation with the formulation of “Sustainable Social Welfare” program committing the transformation of the French welfare regime.

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Bibliography Ambler, John S. (ed.), The French Welfare State. Surviving Social and Ideological Change, New York, New York University Press, 1991: 32–57. Bénamouzig, Daniel, La santé au miroir de l’économie. Une histoire de l’économie de la santé en France. Paris, PUF, 2005. Brookes, Kevin, Why Neo-liberalism Failed in France. Political Sociology of the Spread of Neo-Liberal Ideas in France (1974–2012), Switzerland, Springer International Publishing, 2021. Chadelat, Jean-François, « Pour une histoire de recouvrement. Entretien réalisé par Bruno Valat », Revue d’histoire de la protection sociale, n°1, 2008:121–135. Catrice-Lorey, Antoinette, Dynamisme interne de la Sécurité sociale, Paris, Economica, 1982. Dutton, Paul V., Origins of the French Welfare State. The Struggle for Social reform in France 1914–1947. Cambridge (UK), Cambridge University Press, 2005. Esping-Andersen, Gøsta. The Three Worlds of Welfare Capitalism. Cambridge, UK.: Polity Press, 1990. Fourastié, Jean, Les trente glorieuse ou la révolution invisible de 1945 à 1975, Paris, Fayard, 1979. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Heclo, Hugh, Modern Social Politics in Britain and Sweden, New Haven (CT), Yale University Press, 1974. Jobert, Bruno, Le social en plan, Paris, Les éditions ouvrières, 1981. Kuisel, Richard, “Technocrats and Public Economic Policy: From the Third to the Fourth Republic”, The Journal of European Economic History, 2 (1), 1973: 53–99. Kuisel, Richard, Capitalism and the State in Modern France: Renovation and Economic Management in the Twentieth Century, New York (NY), Cambridge University Press, 1981. Merrien, François-Xavier, « État providence: l’empreinte de origines », Revue française des affaires sociales, n°3 (July–September) 1990: 43–56. Nord, Philip, The French New Deal, Princeton (NJ), Princeton University Press, 2010. Palier, Bruno, Gouverner la Sécurité sociale. Les réformes du système français de protection sociale depuis 1945, Paris, PUF, 2002. Palier, Bruno, “Ambiguous Agreement, Cumulative Change: French Social policy in the 1990s”, in Wolfgang Streeck, Kathleen Thelen (eds.), Continuity and Discontinuity in Institutional Analysis, Oxford (U.K.), Oxford University Press, 2005: 127–144. Palier, Bruno (ed.), A Long Goodbye to Bismarck. The Politics of Welfare Reform in Continental Europe. Amsterdam, Amsterdam University Press, 2010.

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Pavard, Francis, « L’équilibre financier de la Sécurité sociale », Revue économique, 18 (2), 1967: 205–228. Prasad, Monica, “Why Is France So French? Culture, Institutions, and Neoliberalism, 1974–1981”, American Journal of Sociology, 111 (2), 2005: 357–407. Suleiman, Ezra N., Politics, Power and Bureaucracy in France: The Administrative Elite, Princeton (NJ), Princeton University Press, 1974. Suleiman, Ezra N., Elites in French Society: The Politics of Survival, Princeton (NJ), Princeton University Press, 1978. Valat, Bruno, Histoire de la Sécurité sociale (1945–1967). L’État, l’institution et la santé. Paris, Economica, 2001. Valat, Bruno, Michel Laroque, « La démocratie sociale dans la gestion de la Sécrutié sociale de 1945 à 1994 », Vie sociale, 10, 2015: 89–107. Weisz, George, « La transformation de l’Élite médicale en France », Actes de la Recherches en Sciences Sociales, 74, 1988: 33–46.

CHAPTER 4

Initiating “Sustainable Social Welfare”: Jean Marmot

In the 1980s, mass unemployment and its counterpart, the deficit of social accounts, signaled the obsolescence of a social security system governed by social partners. The political class and the trade unions were well aware of the problem but avoided addressing it because of the high political cost. The French asked President Pompidou to “give money” (Pompidou des sous!). The latter, like his successors, Valérie Giscard d’Estaing and François Mitterrand, refrained from any attempt to reform the social security model of 1945. During this period, a handful of high civil servants, the welfare elites, challenged by the uncertainties weighing on the future of the social security model reevaluated its foundations. Their diagnosis was clear: the system was financially unsustainable and unfair to French citizens. Under endemic unemployment, financing by payroll taxes (charges sociales) and companies had no future, especially if social coverage extended to the whole population was deemed necessity. The intervention of the state and financing by general taxes were henceforth inevitable. In this situation, the first generation of these elites imagined a “Sustainable Social Welfare” program organized around the development of a national social insurance system and governance capable of controlling expenses. The analysis of Jean Marmot’s portrait, the first magistrate of the Cour des comptes to head the Directorate of Social Security (DSS), illustrates changes in elites’ career paths.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_4

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The Origin of “Sustainable Social Welfare” Program Our work on the career paths of social insurance high civil servants has highlighted the emergence, from the 1980s onward, of a new “French social welfare” (Genieys 2010) whose first generation was composed mainly of magistrates from the Cour des comptes. The arrival of the latter meant a gradual replacement in Social Security government positions of the “old-fashioned” elites. Over time, the welfare elites confronted, in turn, and sometimes concomitantly, (i) the Directorate of Social Security from the Conseil d’État, heirs to Pierre Laroque; (ii) the social partners, anchored in their position of manager of the health insurance and pension funds; (iii) the Ministry of Finance; and finally, (iv) the parliamentarians and politicians reluctant to entertain any idea of reform. The story of how the first generation of these elites gained power begins with Marmot, a high-level magsitrate at the Cour des comptes (Genieys 2010: 103–104). Unknown to the public, he was unanimously considered by his peers as “administrative super elite” (grand commis de l’État). Marmot’s career path initiates the struggle for power led by members of the Cour des comptes, against the members of the Conseil d’État. Marmot stood at the origin of the change in the social background of the DSS high civil servants. Indeed, after his appointment in 1980 by the Raymond Barre government, no less than five magistrates of the Cour des comptes succeeded each other at the head of the DSS between 1980 and 2000 (Hervier 2008). More than much a classic struggle between two prestigious Grands corps seeking to maintain or extend their authority over a sector of state activity, this battle has resulted in a shift to “Sustainable Social Welfare” program. In this new perspective, Marmot’s approach was to pursue a financially responsible but proactive policy-making. It should be kept in mind that a career in social affairs for a magistrate of the Cour des comptes then made no sense. A key player in the Jeanneney Ministerial cabinet during the drafting of the legislative decrees of 1967 recalls the mocking remarks to which he was subjected: “My career has made me an expert on a subject (social security) that at first made everyone around me cry. People would say to me, ‘it’s a hole,’ poor guy, what are you going to do in there?”1 For young énarques2 wishing to succeed in a brilliant  Interview with social insurance high civil servant (MiRe 1, 1997).  “Énarque” is the name given in France to people trained at the National school of administration (ENA). 1 2

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career as a public servant or to use the “revolving doors” to the private sector (in French, pantouflage), the administration of social affairs was perceived as governed by “‘old maids’ in a charity way, like Médecins du Monde, or political activists. [You couldn’t] find managers.” So, why would high civil servants from a Grands corps come to social affairs when at that time careers in the prestigious administrations or in national public establishments were holding out their arms? Moreover the elites of the Ministry of Finance carefully ensured that financial incentives (bonuses) were not possible for the welfare elites. As Marmot points out, “the Ministry of Finance has ensured for years that good people are not attracted to the Ministry of Social Affairs. [How?] by strictly enforcing public service compensation regulations [no bonuses] ... which it does not apply to itself.”3

The First Magistrate of the Cour des Comptes at the Head of the DSS Born in Morocco and raised in a modest environment imbued with the cult of the Lyautean era,4 Marmot claimed to be close to Marshal Lyautey. This filiation resulted in an extraordinary sense of service to the state. In 2004, after Marmot’s death, Philippe Seguin, former Minister of Social Affairs and President of the Cour des comptes, underlined this resemblance during his tribute speech. Marmot’s commitment was the opposite of a ready-made career. Like his mentor, inspired by the Shakespearean maxim “the joy of the soul is in the action,” he left the beaten track and his “protective cocoon of the beautiful regal institution [the Cour des comptes] to discover the joys of the new world” (Fonteneau 2008a: 55). One of his loyal collaborators summed up Marmot’s committed idealism in this way: “the professional career of a high civil servant outside the social security: boredom.” (ibid: 56). Like Lyautey with the Kingdom of  Interview with social insurance high civil servant (MiRe 1, 1997).  Hubert Lyautey was a French military officer during the colonial wars and the first resident general of the French protectorate in Morocco in 1912. Lyautey relied on the institutions of traditional Morocco: administration of the Sultan (Makhzen), administration of the Habous, assemblies of notables and tribes. He developed the corps of officers of Indigenous Affairs, heirs to the Arab offices of Algeria, who had civil and intelligence tasks. https://fr. wikipedia.org/wiki/Hubert_Lyautey#:~:text=Hubert%20Lyautey%2C%20n%C3%A9%20 le%2017%20novembre%201854%20%C3%A0,d%27honneur%20des%20trois%20 f%C3%A9d%C3%A9rations%20des%20Scouts%20de%20France 3 4

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Morocco, his mission was to make social security a “protectorate” within the state. To do so, it was necessary to imagine a new organization and a new government rid of the “enemies” from outside—the social partners— and from inside—the members of the Conseil d’État—who failed to face the economic crisis. Bachelor of Law, graduate of the Institut d’études politiques de Paris (called today Sciences Po), Marmot followed the curriculum of the École nationale d’administation (“Saint Just” promotion) before joining, in June 1963, the social chamber of the Cour des comptes. He specified in an interview that his training at Sciences Po and École nationale d’administration (ENA) on social security was, with the exception of Pierre Laroque’s seminar courses, boring and not very educational. But, he continued, several énarques of “[his] generation were interested in these issues.”5 He excluded by personal conviction of a political appointment in a Ministerial cabinet (“I have never belonged to any Ministerial cabinet,” he insisted) which was a royal road to a career in banks and public companies. Choosing instead the Social Security he exercised “subordinate functions” at the beginning of his career between 1963 and 1968, sometimes as a reporter for the Conseil supérieur de la Sécurité sociale and as a technical advisor at the Délégation générale de la promotion sociale (an administrative unit), which “quickly gave the illusion that I had competence in this area.”6 After a post (obligatory for the high civil servant at the beginning of his career) of 4 years at the Presidency of the Audit Chamber of the Supreme Court of the Malagasy Republic (1968–72), Marmot returned to the Cour des comptes as general counsel in charge of “social issues in general, and Social Security in particular.” He commented on this experience as follows: “I have done a number of activities in the social field that made me believe I was competent in the sector … [then adding] that the Public Prosecutor of the Cour des comptes do not know much, if anything at all, about social security. He then thought that he had a very good specialist in me!” At this point in his career, his status as General Counsel to the Cour de comptes, a “highly coveted position and usually the antechamber to a future presidency” offered him the opportunity “to apply for a top management position in the central administration or to be offered an important position in the private sector” (Fonteneau 2008a: 192). Without hesitation, Marmot opted for the position of Director of the DSS 5 6

 Interview with social insurance high civil servant (MiRe 1, 1997).  Ibid.

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(1980–83): “Because anyone who thinks for a moment knows that a career in this sector is like joining a religious order. There is no career in this field. One can hope for what I have become, i.e. director of the Directorate of Social security or director of National health insurance funds, and then finish one’s career as president of the social section of the Cour des comptes [what happened] or to the Conseil d’État. These are lousy careers compared to what you do in any bank or public company.”7 His explanation of his appointment to the Directorate of Social Security, as well as the testimonies reproduced in “his Tributes” (Fonteneau 2008a, b), are very instructive on the state of crisis of the top social administration in the 1970s. At the beginning of the 1980s, when the Giscard d’Estaing presidency was coming to an end and social security deficits were steadily increasing, Marmot’s appointment occasioned a political conflict. Within the government itself, two ministers were opposed on the choice of the future director.8 Jacques Barrot, Minister of Health and Social Security, and Jean Farge, his deputy director (Secrétaire d’État) from the Inspection Générale des Finances, opposed Marmot. Farge, committed to the fight against the Social Security deficit, pleaded for the position to be given to an inspecteur des finances (Grands corps), while the minister defended, in the name of tradition, the appointment of a member of the Conseil d’État. According to Marmot, “the two ministers did not want to give in, the debate [got bogged down] and we [could] not choose between these two Grand corps. Then the Prime Minister, Raymond Barre, [indicated that] it is necessary to finish, it is necessary to take somebody of the Cour des comptes [other Grand corps]… He [called] the attorney general who [was] convinced that [I was] a good social security specialist, which was not true, in short, and that’s how I [became] director of Social Security.9” During one of his first meetings with his minister, Jacques Barrot, Marmot was surprised by how little importance he attributed to social security: “You know, Marmot, I have the impression that by taking care of social security, I am taking care of the past and by taking care of employment, I am taking care of the future.”10 In fact, whatever the minister then may have thought, the two issues were two sides of the same problem, the  Interview with social insurance high civil servant (MiRe 1, 1997).  Ezra Suleiman, in his study of the administrative super elites, pointed out that the allocation of central government positions since 1945 has been distributed among the various major bodies (1974: 239–281). 9  Interview with social insurance high civil servant (MiRe 1, 1997). 10  Ibid. 7 8

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resolution of which required the overhaul of the Social Security. This is why Marmot said that by taking leave of absence from the Cour des comptes to accept this appointment, he made “the most important decision [of his career]. I realized that [it is] one of the major projects of French society, perhaps not the most important, but a major project.”11 His political appointment as director of the DSS paved the way to a new career path for the magistrates of the Cour des comptes breaking with the governance of the social security that had fallen since 1945 to a magistrate of the Conseil d’État. This change in elites’ structure (social background and career path) correlated in turn with the making of a new policy orientation.

Shaping the New Programmatic Orientation Marmot’s time at the Directorate of Social Security was brief. He was appointed in February 1981 and the political changeover in May did not favor his retention because, although he had not been a member of any ministerial cabinet, he was nevertheless classified as right-wing. He left office in 1983, but his short time in office was marked by a strong commitment affirming the role of the state and the need to introduce parliamentary control of the social security. His short period at the head of the DSS disclosed the lack of legitimacy of the Ministry of Health and Social Affairs and the lack of visibility of its administrative directorates. Moreover, the managers in charge of the funds lacked technical savoir-faire to curb the growing deficit in the social accounts and to compete on equal terms with the social partners in charge of managing the funds. Although the deficits were relentlessly increasing in the economic crisis, there was still no reliable and standard accounting of the revenues and expenses of the different branches of social security. Marmot analyzed the situation this way: “I sought to make the social security accounts clearer, because before … it was an enigma surrounded by mystery, handled by a small number of high civil servants in the Ministry of Finance.”12 The creation by decree on 22 March 1979 of a Social Security Accounts Commission (Commission de comptes de la Sécurité sociale, CCSS), a ministerial advisory body placed under the authority of the Minister of Social Affairs, was a political response to these expectations. The commission was composed of two representatives (French Députés at the Assemblée  Ibid.  Ibid.

11 12

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Nationale), two senators, magistrates representing the Cour des comptes and social partners, was coordinated by a permanent secretary general appointed by the First President of the Cour des comptes. Marmot, who was secretary general, viewed this commission as the first step toward a proper Finance Act for the social security. The real issue was that Parliament should be able to exercise control, a point on which Marmot was at odds with the elites in the Ministry of Finance, who wanted a ministerial, not a parliamentary, commission for fear that their power in this area would be diminished (Marmot 1995). It was therefore not surprising “that we had to wait 34 years after the creation of social security ... to finally have a body where the accounts of social security were presented, if not voted” (Fonteneau 2008b: 29). Thus, “with the Social Security Accounts Commission, progressively clearer accounts have been put on the table...” (ibid.). He added that “[his] role was not to make accounts [like the high civil servants of the Directorate of the Budget], is was to comment on these accounts and to show their limitations and the need to improve them” (ibid.). Last but not least, for Marmot, social insurance policies could not be reduced to a macro-economic view and the budgetary issue alone. It was therefore necessary to formulate public policies that combined fiscal policy and social insurance issues. In doing so, Marmot laid the groundwork for the role of custodians of state policies: financial constraints expanding social insurance within.

1981: The Difficult Implementation of the Social Accounts Policy A few months after his appointment, Marmot had to face the accession of François Mitterrand to the French Presidency. The Socialist Party was back to government after an absence of more than 23 years. The expectations awaiting the implementation of the “Common Program” (Programme Commun) elaborated by left wing unions were immense. At the top of the social security government, the “old-fashioned” elites (members of the Conseil d’État and the trade unions) were supported by the new socialist government. The continuation of the previous government’s policy (i.e., control of account) was out of the question. The spirit of 1945 was blowing again. The new Minister of National Solidarity, the socialist Nicole Questiaux, a member of the Conseil d’État told the media

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“that she would not be the Minister of Social Accounts.” Marmot then understood that his program to reform the social security accounts was no longer a priority on the political agenda, that his future at the head of the DSS was in question. Marmot had to cohabit with a left-wing government whose ideology opposed the policy of budgetary rigor. Moreover, the DSS was surrounded within the Ministry by directorates of administrative units identified as “big spenders” such as the Directorate of Hospitals. Facing a battle that he knew he would lose in advance because the overall political balance of power was so unfavorable to him, Marmot chose to strengthen the technical capacity of the DSS by recruiting young technocrats with expertise in public accounting. Convinced “of the disproportion between the economic, financial and social importance of the social transfers piloted by his administrative unit directorate and the logistical means (personnel) assigned by the state to this piloting, [Marmot put] all the weight of his authority to seek and obtain the reinforcement of technical profiles with high added value” (Fonteneau 2008a: 101). The tactic was simple: open up his administration to people who could not only “account” but also prove their importance to the minister. In those hostile times, transforming the organizational culture of his administration was the only way forward. This was why he recruited Jean-François Chadelat, a doctor of mathematics and an actuary, who was in charge of financial matters within the Ministry of Social Affairs (see Chap. 6). This policy of recruiting high civil servants with new know-how would become a major strategy for the successors of Marmot at the head of the DSS. The objective was clear: to establish a new balance of power with the elites of the Ministry of Finance. In the political arena, tensions with the new socialist government quickly led to the suspension of the Social Security Accounts Commission. However, faced with the rapid deterioration of the finances of the social security system, Marmot and his collaborators confronted the ministers concerned, warning them of the dangerous drift of the accounts, which even pointed to a possible future bankruptcy of the system. But this diagnosis was not shared by the Minister of Social Affairs and National Solidarity, Georgina Dufoix (1984–86), who pronounced, in 1985, before Parliament, this sybiline phrase during her presentation of the Commission’s work: “the accounts I am presenting to you today are not mine.”13 Because of this difficult political context Marmot did not manage, during his short  Interview with social insurance high civil servant (MiRe 1, 1997).

13

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time at the DSS, to lay the foundations for the desired structural reform, although working with Jean de Kervasdoué, director of the Hospital Directorate, to promote the reform of the global hospital budget to the Minister Pierre Bérégovoy, who succeeded Nicole Questiaux in 1982 (−1984). It is likely that Marmot shared with Bérégovoy a similar interest in a thighter budgetary policy, but the political context of the time was not conducive to overcoming the left-right political cleavage. Thus, political pressure and the practice of the French “spoils system,”14 dominant at the time, led him to hand in his letter of resignation in July 1983, he returned to the Cour des comptes. His loyal collaborator, Jean-­ François Chadelat, immediately followed suit and joined the Directorate of the Budget “to make financial forecasts for social security” (Fonteneau 2008b: 33). But if these men left office, their ideas remained. Marmot’s retreat to the Cour des comptes was brief (1983–84) as he obtained an appointment to the French Atomic Energy Commission (Commissariat à l’énergie atomique, CEA), first as a management consultant, then, after 6 months, as Secretary General (1984–91). Even so, Marmot remained viscerally attached to the social security. During his appointment at the CEA, Marmot remained closely involved in the issues around “Sustainable Social Welfare” program. Chadelat, then in charge of the social security accounts at the Ministry of Finance, said that he visited him frequently to keep him informed of the evolution of the accounts. “Every time, he [feels] revived... [because] he [is] afflicted, alas like too many people, with the Social Security virus” (Fonteneau 2008b: 35–36). This “virus” became the vocation of the first generation of welfare elites: reform of social security and its governance.

14  Appointment of high civil servants politically loyal to the political party in power. In France the spoils system is distinct because it takes place in a “closed circuit” (circuit fermé). As a rule, it is high civil servants trained at ENA who succeed one another in the top positions (Quermone 1991).

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Strengthening Parliamentary Control With the return of the right-wing to government and the ensuing coexistence (cohabitation)15 of Mitterrand and Chirac (1986–88), Marmot, while keeping his post of Secretary General of the CEA, went back to the social security affairs to relaunch the battle for reform as Secretary General of the Social Security Accounts Commission (16 January 1987–96). From April to November 1987, he also held the key position of rapporteur for the “Estates General on Social Security” (États Généraux de la Sécurité sociale). In this role, “he directed all the operations: interministerial meetings, recruitment of rapporteurs, preparation of the work of the ‘Wise Men’, hearing of all the stakeholders, organization of the debate throughout France, at the departmental (administrative constituency) and national levels and, finally, drafting the general report submitted to the government” (Fonteneau 2008a: 188). When the first “General Estates on Social Security,” launched by the Minister of Social Affairs Philippe Seguin, was presented around the theme of the famous “social security hole” (metaphor for the deep financial deficit), Marmot’s reflections were much broader. They concerned both the viability of its mode of governance, which was considered to be inseparable from the policy of controlling expenditure, and the issue of increased financing through taxation, leading de facto to greater control by the state and the Parliament. One of his collaborators at the time maintains that “his appointment as rapporteur at the General Estates allowed Marmot to considerably increase his competence on the issues of Social Security, to extend his information network and his influence with the government and public opinion. It also allowed him to build up a kind of doctrine and to strengthen his authority both at the Social Security Accounts Commission and at the Cour des comptes” (Fonteneau 2008a: 132). If the principles of “Sustainable Social Welfare” program had been put forward but the struggles to achieve remained. The first struggle was to make the Social Security Accounts Commission (CCSS) a transparent and autonomous institution vis-à-vis the executive 15  Political cohabitation refers to the situation of coexistence of a head of state (Presidency) and a head of government (Prime Minister) belonging to a parliamentary majority that is politically opposed to him. There were three periods of political cohabitation during the Fifth Republic: the first (1986–1998) concerned President F.  Mitterrand (Socialist) and Prime Minister J. Chirac (conservative); the second (1993–1995), President F. Mitterrand (Socialist) and Prime Minister E. Balladur (conservative); the third (1997–2002), President J. Chirac (conservative) and Prime Minister L. Jospin (Socialist).

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branch. The Decree of June 23, 1987 (no. 87–441) removed the Minister’s power to amend the Secretary General’s reports, which now went directly to Parliament and were published intact in the Documentation française. In addition, the number of parliamentarians in the Commission was increased from two to four. Under Marmot’s leadership, the Social Security Accounts Commission became a site for debate reporting on the situation of the Social Security accounts at two plenary meetings in June and fall each year. Moreover, under his mandate, in 1994, the Commission was given legal recognition in the Social Security Code (art. L114–1). In short, there emerged a legal corpus governing the information of citizens on social accounts and a progressive call to parliamentarians to take charge of the forecasting of social accounts for which the Cour des comptes did not have the competence. Marmot also took advantage of the forum offered by his position to assert the need to provide the Ministry of Social Affairs with a specific staff responsible for managing budgetary issues: “the social budget [was] more than the state budget [its financial mass is more than 60% higher], but only a handful of competent men [had] taken an interest in it, whereas the Rue de Rivoli (Ministry of Finance) [had] its ‘black square’ of inspecteurs généraux des finances to manage its own” (Fonteneau 2008a: 142). It was a call for the recruitment of high civil servants capable of thinking about social health insurance policies and expenditure control policies at the same time; in other words capable of fulfilling the role of custodian of state policies. It was, moreover, a way to protect against the approval of the Ministry of Finance, always quick to seize issues relating to the state budget. Marmot strategically surrounded himself with people such as Dominique Libault, then a young administrateur civil and technical adviser to the cabinet of the Minister of Social Affairs and Employment (1987), who would make a career within the Directorate of Social Security, rising to director (see Chap. 7). Their common objective was to move “from cash-based accounting [that of the Directorate of the Budget] to accrual-based accounting” for the management of the social budget (Fonteneau 2008b: 37). The latter, also known as “commitment” accounting, enforced accounting standards on policy makers (social partners). With this type of accounting, the lag between receipt and payment could not be used to make it appear that expenditure was being reduced. For the formulation of this policy instrument, Marmot was recognized by his peers as the inventor of the “social security accounting plan.” Its objective was to present the truth of social accounts to French citizens. These major changes in only little

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remained at the time, set the stage for the new authority given to Parliament on the issue of social accounts, which won their ultimate embodiment, following the political struggle over the Juppé Plan in 1995, in the constitutional reform of 1996 and the Social Security Budget Act (Bouget 1998).

The Hidden Architect of the 1996 Constitutional Reform Marmot insisted on the need to distinguish between health care and health insurance when it comes to “controlling expenses”: “I am resolutely opposed to the concept of controlling health care expenses because I believe that to pose the problem in this way is to pose the problem in an insoluble manner….”16 With these words, he essentially endorsed the theory of Nobel Prize-­ winning economist Kenneth Arrow on the pervasive uncertainy of the health care market (Arrow 1963). Health has no price. More specifically: “I do not recognize the legitimacy of a state [in controlling health care spending], regardless of its leaders or its philosophy. The state does not claim to control the expenditure of Beaujolais (French wine), I do not see what qualifies it to control health expenditure. It must control health insurance expenditures....”17 To apply these principles Marmot played a hidden and determining role in the elaboration of the Juppé Plan of 1995 (Fonteneau 2008a: 149). Although still at the CEA (he did not leave until November 1996, a few months after the constitutional reform), he served as a shadow advisor to two of his colleagues at the Cour des comptes, Antoine Durrleman, social affairs advisor of Prime minister Alain Juppé (1995–97) and Raoul Briet, director of National Health Insurance funds (1994–96) and director of the DSS (1996–2000). Marmot’s ideas were shared and advanced by the first generation of welfare elites from the Cour des comptes who succeeded him, first, at the head of the Directorate of Social Security (DSS) and second, in the ministerial cabinets, to wage the battle for major reform of social security (see Chap. 4). Just before his death in July 2004, although he was very ill, Marmot threw his weight as President of the Social Chamber of the Cour des comptes to ensure that the 2004 Law, introduced by the Minister of Health Philippe Douste-Blazy, further strengthened the political autonomy of the Social Security Accounts Commission. With this law, the power  Interview with social insurance high civil servant (MiRe 1, 1997).  Ibid.

16 17

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of appointment of the commission’s Secretary General was transferred from the Minister to the First President of the Cour des comptes. Finally, still in his capacity as President of the Chamber, he wrote a landmark report on the regulation of the pharmaceutical industry (Nouguez and Benoît 2017). The general conclusion was clear: “it was therefore clearly up to the state to steer health insurance policies.” With Marmot, the custodianship of state policies took on its full meaning, namely a fight for reform of the governance of social security against the “old-fashioned” elites in an evolving political context. Playing on changes in the parliamentary political majority he paved the way for the transformation of the welfare regime. His portrait confirms the change in the elites’ social background (from the Conseil d’État to the Cour des Comptes) and highlights the originality of a career path dedicated to the governance of social security and to the formulation of “Sustainable Social Welfare” program. This new programmatic orientation paves the way to the reconfiguration of the strong state.

Bibliography Arrow, Kenneth J., “Uncertainty and the Welfare Economics of Medical Care”, The American Economic Review, 53 (5), 1963: 941–973. Bouget, Denis, “The Juppé Plan and the Future of The French Social Welfare System”, Journal of European Social Policy, 8 (2) 1998: 155–172. Fonteneau, Robert, A la mémoire de Jean Marmot, Paris, Comité d’histoire de la Sécruité sociale, 2008a. Fonteneau, Robert, A la mémoire de Jean Marmot. Fascicule complémentaires, Paris, Comité d’histoire de la Sécruité sociale, 2008b. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Hervier, Louise, « Le rôle des organisme de contrôle en matière d’évaluation 1949–2007: l’exemple de la Cour des comptes », Informations Sociales, n°150, 2008: 44–55. Marmot, Jean, « La commission des comptes de la Sécurité sociale », Droit social, n°5, mai 1995: 516–519. Nouguez, Étienne, Cyril Benoît, “Governing (through) Prices: the State and Pharmaceutical pricing in France”, Revue Française de Sociologie, 58 (3), 2017: 399–424. Quermone, Jean-Louis, L’appareil administratif de l’Etat, Paris, Le Seuil, 1991. Suleiman, Ezra N., Politics, Power and Bureaucracy in France: The Administrative Elite, Princeton (NJ), Princeton University Press, 1974.

CHAPTER 5

Welfare Elites as Custodians of State Policies

The sociological portraits drawn in this chapter aim at analyzing the social background/career paths and the mode of action of the first generation of new elites promoting the far-reaching reform of the Social Security (Genieys 2010: chapter 4). They were high civil servants, from the Cour des comptes, who progressively took power at the head of the Directorate of Social Security (DSS) and the National Health Insurance fund (CNAMTS). From both the left and the right, they shared a common vision for the social security reform in a strongly divided political setting (see Tables 2.2 and 2.3). The era was marked by a series of changes in political majorities, leading to periods of “cohabitation,” which favored the practice of “French spoils system” (i.e., political appointment) and a revolving door pattern within the directorate of administrative units. Meanwhile the revival of neo-liberal perspectives in public policy weakened state interventionism (Jobert 1994). The power of high civil servants declined, with the notable exception of those in the Ministry of Finance responsible for budgetary rigor. As a result of the mobilization of welfare elites as custodians of state policies, social security not only retained its iconic image within French society but also became a site of strong state interventionism.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_5

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From the Cour des Comptes to the Head of the DSS Sociological portraits of Rollande Ruellan and her successor, Raoul Briet, at the Directorate of Social Security, of Gilles Johanet at the Directorate of the National Health Insurance fund (CNAMTS) among others confirm the key role of the magistrates of the Cour des comptes (Genieys 2010: 104–108). These elites fought on multiple fronts: tax financing of health insurance, its democratic control, reinforcement of the role of the state administration in controlling expenses, and the development of universal coverage. Other magistrates of the Cour des comptes expand this gallery of portraits by confirming the major sociological characteristics identified by our previous studies. These include Dominique Coudreau (director of the National Health Insurance fund from 1979 to 1989), Michel Lagrave (director of the Directorate of Social Security from 1987 to 1994), Gérard Rameix (director of the National Health Insurance fund from 1993 to 1997), even Claire Bazy-Malaurie (director of the Directorate of Hospitals from 1995 to 1998). This last interviewee specified that alongside Raoul Briet and Gilles Johanet, “[they were so called] the band of ‘auditors’ in the 5th chamber of the Cour des comptes before it opened up to responsibilities other than Social security.”1 The years 1980–1997 gave rise to complex political dynamics between the left-wing President of the Republic, François Mitterrand, and right-­ wing governments, led first by Jacques Chirac (1986–88), then by Edouard Balladur (1993–95). Each change of political majority had a revolving door effect on the directors of central administration, particularly observable in the case of the DSS. According to one interviewee who lived through it, “there hasn’t been a director of the DSS [who has stayed in place] for more than a year and a half, two years since 1974. [It’s] a very politically exposed position. Jean Marmot stayed for two years, he was ousted by the left. His successor, François Mercereau, who came from the Bérégovoy cabinet, was thrown out by Seguin in 1987!”2 Michel Lagrave managed to survive a change of majority (1987–1994), but his successors Rollande Ruellan (1994–96) and Raoul Briet (1996–2000) saw their terms as director cut short.

1 2

 Interview with social insurance high civil servant (MiRe 1, 1997).  Interview with social insurance high civil servant (MiRe 1, 1997).

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After the departure of Marmot from the DSS, a young énarque, Inspecteur général des affaires sociales (hereafter IGAS),3 François Mercereau, political advisor to the Socialist Minister of Social Affairs Pierre Bérégovoy, headed the DSS until the cohabitation government of Jacques Chirac (1983–87). With a distinct political profile, he was close to the “working group of experts” composed of Jean-Michel Bélorgey, Jean-­ Louis Bianco, Jean de Kervasdoué, Gilles Johanet, and Marie-Laurence Pitois-Pujade, who drafted the “public health” section of the socialist party’s Common Program. Although not from the Cour des comptes, he nonetheless shared their reformist perspective. In an interview, François Mercereau pointed out that he and his advisors did not agree with Minister Nicole Questiaux’s clumsy statement that “[she] will not be the minister of social accounts.”4 The need for a policy of budgetary rigor was already on the minds of the high civil servants. They were reinforced by Pierre Bérégovoy who, once a minister, reinforced the policy by putting the balance of social accounts at the center of the government’s concerns. His successor at the head of the DSS said that Mercereau “coming from the Bérégovoy cabinet was very young when he was appointed, 37 years old ... he is a remarkable intellectual who has worked to make the DSS more technical and competent.”5 The recruitment of a highly qualified leaders had become a major issue, as demonstrated Marmot’s efforts for the first generation of welfare elites (Table 2.3). But the Ministry of Social Affairs was unable to recruit “actuaries [because] they were too expensive.”6 Economists and statisticians from the Institut national de la statistique et des études économiques (INSEE) were a rare commodity. In an interview, Mercereau praised the magistrates of the Cour des comptes, such as Gilles Johanet or even Bertrand Fragonard, who had developed innovative instruments for controlling health insurance expenditure in the ministerial directorate of administrative units or funds. He also insisted that the ideas developed during his time as head of the DSS were later taken up by the right-wing governments in the “Estates General on Social Security” (Seguin/Marmot) and in drafting the Juppé Plan (1995–96). 3  The Inspection Générale des Affaires Sociales (IGAS) is an inspection corps dedicated to social affairs. https://www.igas.gouv.fr/spip.php?article737 4  Interview with social insurance high civil servant (MiRe 1, 1997). 5  Interview with social insurance high civil servant (MiRe 1, 1997). 6  Ibid.

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Rolande Ruellan: A Long-Term Career Path Inside the DSS The sociological portrait of Ruellan underlines another feature of the welfare elites’ career paths (Genieys 2010: 107). Only after having directed the DSS from 1994 to 1996 was she appointed magistrate at the Cour des comptes. In 2007, she became President of the 6th Chamber (Social Security, health, medico-social sector). Her appointment said to be justified by “more than 23 years” of service in different sub-directorates and directorates of the DSS, but also within the National Old Age Pension Fund (Caisse nationale d’assurance vieillesse des travailleurs salariés, hereafter CNAVTS). In addition to her long career in the health and social sector, she shared with Marmot a deep devotion to the social security issues. Ruellan confirmed that “in the 1970s, this ministry [was] of little interest to énarques ... but there [was] a certain ageing of the management (deputy director and office manager) and, consequently, opportunities for rapid careers because there were many retirements accompanied by an increase in workload.”7 She noted that this career option was beginning to be attractive to some of the other young énarques in her class: “fourteen chose social affairs, [among them] five [...] assigned to the DSS ... We [wanted] to show that [it was] interesting and that we’re not going there because of the ENA exit ranking ... And I have never regretted it.”8 She went on to build a long and brilliant career “while [even] at the time we did not have in mind the prospect of careers of this type.”9 Ruellan was, for more than two decades, playing a key role in the transformation of the social security model. In 1974, she joined the Directorate of Social Security as administrateur civil. Very quickly, this young énarque was put in charge of the Sub-Directorate for Old Age Insurance (1975), then became office manager and technical advisor to the director of DSS (1976) and, finally, office manager for international conventions (1977). After moving to the Cour des comptes (1979–81), she then returned to her position as technical advisor to Marmot, director of the DSS (1981–83), was thereafter promoted to deputy director of old age insurance and family benefits, then to head of department assistant to the director (1984–90). Later, she served as Director of the National Old Age Pension Fund  Interview with social insurance high civil servant (MiRe 1, 1997).  Ibid. 9  Ibid. 7 8

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(CNAV, 1990–94), which opened the door to appointment as Director of the DSS. This brilliant career reflected an unwavering commitment to the social security governance reform program despite a difficult political and economic context. The deficits were growing while the means to curb them remained weak. According to Ruellan, when she was deputy director of the DSS, with an absence of human resources “the workload has not stopped increasing.”10 When Pierre Bérégovoy arrived at the ministry, “we ‘tightened the bolts’ everywhere and the DSS has become a directorate for financing and controlling health insurance expenditures.”11 Bérégovoy she recalled was “this man surrounded [by] a fantastic team in terms of intellectual quality, with whom we did a lot of things.”12 Of course, in this period of great uncertainty, policy could change from one minister to another, as was the case during the ministry of Georgina Dufoix. In this regard, another high civilian servant of the DSS observed that “[Georgina Dufoix is] a very sympathetic woman, endowed with an ability to improvise on everything ... [but] when she had to defend our budget in Parliament, she said anything beside....”13 Ruellan criticized the role of ministerial cabinets whose members act as a barrier between the minister and his administration (Suleiman 1972). Thus, many ministers never saw their central administration directors: “they have young people around them [the cabinet members] who transform the briefs memo transmitted by the services into short ‘notes’ in their own way, with the technical advisors pre-machining the work.”14 This practice could dissonage the proper investigation of issues on the administrative side. From this point of view, she mentioned the exception of the practice of Simone Veil’s cabinet. The latter, Minister of Social Affairs, Health and Urban Affairs in the Balladur government from 1993 to 1995, frequently organized meetings with her directors of administration. “In a rare occurrence,” Veil asked that the “notes” written by her cabinet also be sent to the directors. With this practice, the administration and the Ministry shared the same policy vision. Her long career within DSS allowed her to affirm that “in fine it is [the DSS] that decides if the issue [is] very important  Ibid.  Ibid. 12  Ibid. 13  Interview with social insurance high civil servant (MiRe 1, 1997). 14  Interview with social insurance high civil servant (MiRe 1, 1997). 10 11

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or not […] It happened to me to travel to meetings at Matignon on files such as the accounts of the Social Security, important reforms, the preparation of legislative decrees.”15 This period saw the strengthening of the power of DSS over all social insurance policies. With Ruellan at its head, the administration strengthened its regulatory capacity and asserted its leadership in the control of health insurance accounts. This evolution was accompanied by a change of the sociological profile of the elites in positions at DSS. Ruellan spelled out the characteristics of the young new comers who would form the second generation of elites: “people with a very technical profile, not frankly social and ideological [like the previous generation], members of the Inspection générale des affaires sociales (IGAS), and not of the Cour des comptes.”16 In addition, on the initiative of Simone Veil, énarques coming from the corps of administrateurs civils who had spent their entire career “in-house” could now be appointed to the position of director of a central administration within the ministry. This innovation broke with the tradition of the French strong state, where only the high civil servants from the Grands corps had been previously appointed to this management position (Suleiman 1974). In fact, the appointment of Ruellan at the top of the DSS was a first for members of the corps of administrateurs civils. “Internal” promotion was gradually becoming the rule for these elites’ careers (see Chap. 8). Ruellan cited the example of a young énarque and administrateur civil, Anne-­ Marie Brocas, who, a few years after her, took a similar career path within the DSS and who shared the same vision of administrative management, as calling “for people who lead a crazy life of working 15 hours a day.”17 Ruellan also remembered having encouraged Brocas to take a position as a young high civil servant at the Forecasting directorate (direction de la Prévision) of the Ministry of Finance. This is the time when the welfare elites were shaping their expertise in cost-containment issues through the Ministry of Finance in order to “strengthen the health insurance expenditure control unit of the DSS.”18 Obtaining, in 1994, from the Minister Simone Veil, “the creation of a new sub-directorate” dedicated to social insurance expenditure control was a step toward the institutionalization of these new elites. The increase in the  Ibid.  Interview with social insurance high civil servant (MiRe 1, 1997). 17  Ibid. 18  Ibid. 15 16

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number of positions at the DSS allowed for the promotion of “meritorious” young high civil servants. The case of Dominique Libault, énarque and member of the corps of administrateurs civils, who briefly worked as a technical advisor for health insurance in Simone Veil’s cabinet, is representative of the development of these new career paths. After his cabinet appointment, Libault was recruited by Ruellan “to become a very young deputy director at the DSS.”19 It was under his command that the DSS acquired the capacity for “internal reproduction” of its young executives (see Chap. 7), who would later form the second generation. Interviewed after leaving DSS, Ruellan explained the effects of career paths in the learning process of social insurance policy issues. She revisited her personal experience by using the word “we,” adding “I say ‘we’ as if I were still there, 23 years, it stuck with me ... [my collaborators] were my children, they were my family, whom I loved, teamwork and social work.”20 On the evolution of this Directorate, she added that “at the beginning of the 1990s, it was said about the relationship between the Directorate of Social Security and other directorates of the Ministry that a health insurance policy on the one hand and a health policy on the other made no sense. Health insurance is not an end in itself, it must be put at the service of a health policy. We must therefore work together to define goals and put resources at the service of these goals.”21 To do so, she created a “club of [department] directors meeting outside the presence of cabinet members”22 to develop a more collaborative approach to health insurance policy. These organizational practices would influence the formulation of the future Juppé Plan. With the Social Security Budget Act (LFSS), the DSS became the pillar of social security government. Under the authority of the Parliament, welfare elites would have control over the formulation and implementation of policies. Following the accession to the presidency of Jacques Chirac and the settling of political scores within the conservative right, the “extraordinary story of the Juppé Plan” would continue without Ruellan. The preparatory work that she had initiated during 6 months was continuing with “a small group composed only of people from this house (DSS), associating neither the ministers, nor the cabinets, nor the directorates of the Ministry.”23  Ibid.  Interview with social insurance high civil servant (MiRe 2, 2007). 21  Ibid. 22  Ibid. 23  Interview with social insurance high civil servant (MiRe 1, 1997). 19 20

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There were several members of the elites in this small group, such as Marmot, Briet, and others to whom we will return later. In spite of her exit imposed by the new political majority, Ruellan “largely approves the reform project, the content of which owes much to the proposals made by the DSS.”24 Indeed, within the group “ideas circulate, they come from the directorate and people move from directorates to back-offices [cabinets] and back again. People who have worked in the administration find themselves preparing the electoral campaigns of this or that political party. A reform is always the product of a technical preparation and a political impetus.”25 This captures the political strength of these elites: individuals were interchangeable because they shared the same vision for action. The best evidence of this is the approach to the long-term control of universal health insurance expenditure, which was taken up in extenso by the 1996 reform and was led by its deputy director “Anne-Marie Brocas and [the] working group involving people from the DSS, the Plan and the Directorate of the Budget, who [will] work hand in hand to build a project.”26 Its main recommendations were taken up by the Juppé Plan. The conjunction of expenditure control and the quest for universal insurance confirmed the coherence of “Sustainable Social Welfare” program. In a second interview on her career path, Ruellan emphasized the transition from the old-fashioned elites to the first generation of welfare elites: “the DSS [was] no longer solely a legal directorate dominated by members of the Conseil d’État, the heirs of Pierre Larroque. In the 1980s, a new generation of young énarques from the Cour des comptes, from the IGAS or as administrateur civil [chose], against the grain, [to] make a career of it.”27 The challenge of controlling health insurance expenditures favored those who possessed this savoir faire and the development of an accounting and management approach enabled them to obtain top executive positions inside administrative directorate. But the elites’ enduring and loyal commitment as custodians of state policies was based on a broader calling: their sense of writing a new page in the history of social security.

 Interview with social insurance high civil servant (MiRe 2, 2007).  Ibid. 26  Interview with social insurance high civil servant (MiRe 1, 1998). 27  Interview with social insurance high civil servant (MiRe 2, 2007). 24 25

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Raoul Briet: Leading the Magistrates from the Cour des Comptes The sociological portrait of Briet, Ruellan’s successor at the DSS (1996–2000), sheds new light on the career paths of the first generation. Graduated in the first rankings (“dans la botte”) of the ENA, he could choose between the three Grands corps (Genieys 2010: 109–110) and went to the Cour des comptes to start his career. The financing and regulation of Social Security would be the key issues around which he built his career (Barbet and Briet 1988). As with Marmot, his mentor, this choice was rooted in a personal vocation: “I had always been interested in social issues in my education. At the Cour des comptes, I chose the social chamber. I think that those who are interested in social issues […]. One cannot make this profession, have the responsibilities that I had [he was Director of Social Security at the time of the interview], without having, as they say in this ministry, an interest for social issues and, at the same time, a sense of public service. Throughout my schooling, I never imagined that I would end my career in the bank. For me, it was not opportunity that made me come here and work in this sector. It was deeply a way to be useful collectively and to do what I felt was in line with my interests.”28 He continued: “When I was at ENA, I did a three-month internship at the National Employment Agency for the knowledge of the interior and took a seminar on the reform of hospital financing. When I [left] the ENA, I could choose the Inspection Générale des Finances, but I was not interested in ending up in banking or industry. I chose the Cour des comptes because I knew that I would make my career in the social sector. Whereas if I had been in the classic mold [of the time], I would have opted for the Inspection Générale des Finances, but I would have been unhappy there by finding myself in a bank like Société Générale or BNP. That’s how it was determined. So, when you fall into it, you don’t really know why or how. But it’s an old story, a kind of vocation.”29 He confirmed, in turn, the low interest the sector held for high civil servants of the Grands corps; social affairs were then “not a very attractive sector in the universe of the civil service.” Social security was becoming a key sector for the career paths of young énarques. First, the emergence of an autonomous monetary power (Europe  Interview with social insurance high civil servant (MiRe 1, 1997).  Ibid.

28 29

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and the markets) at the end of the 1970s challenged the interventionism of the strong French state. Second, the issues of to concern to French public opinion were predominantly social and fell under national responsibility. Last but not least, the increase in power of the DSS, following the Social Security Budget Act, (the interview took place in 1997) widened the career path options. Indeed, DSS managed a larger budget than that of the state. For Briet, “distributing income and jobs and managing solidarity mechanisms in an internationalized economy was the primary responsibility of the state and an increasingly strong expectation on the part of French citizens.”30 This context empowered welfare elites to position themselves above partisan cleavages. For Briet, social issues elicited a community of people attached to distinct principles and favorable to the reform of the social security: “shared values were stronger than political divisions. Moreover, the Juppé Plan did not appear to be a partisan choice. I knew ministers, such as Claude Évin [a socialist politician], who followed the same logic.”31 For Briet, “there was a circle [of high civil servants] who shared these principles and values. These were people who had chosen to serve the state and to do so in the social sector for reasons that had to do with their personal affinity and the question of saying in the state where can I be most useful?”32 He cited the example of Bertrand Fragonard, another magistrate of the Cour des comptes (see portrait below), “an elder” who was asked to take the director’s role of the National Health Insurance Fund (CNAMTS) to improve the policy of control of the accounts (Genieys 2010: 102–104). Briet nevertheless emphasized that he was considered the “social budgeter” during his time at the DSS. He justifies this approach by indicating that it was necessary to sustain this societal asset: “if I spent my time looking for savings, looking for a rebalancing, it was not because I considered the system to be bad, it was because if we did not do it, the system would disappear.”33 The development of “Sustainable Social Welfare” program around this rescue agenda was contested by some fringe of politicians and by certain social scientists who saw it as a simple extension of neo-liberalism and its austerity “diktat” (Grimaldi et al. 2011). Briet’s perspective was an invitation to look “beyond the pointless debates on accounting control or managed care (medicalized control), which are semantic and rhetorical debates, they  Ibid.  Ibid. 32  Ibid. 33  Ibid. 30 31

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are not serious debates. If the invisible hand of managed care were enough to control spending, no one would have been at the bedside of health insurance for years.”34 No market without the state. Briet explained how these first generation of welfare elites, through their collective foresight, imagined the new governance program for social security. He highlighted his role—while he was at the Commissariat Général au Plan to deal with social affairs (1992–94)—in launching, in 1993, of Soubie Commission, Santé 2010.35 To produce a future scenario for health insurance in the appendix to the report, he collaborated with a dozen experts, including Anne-Marie Brocas—at the time deputy director of the cabinet of the socialist minister Bruno Durieux (Edith Cresson’s government)—who later became his deputy at the DSS (1997–2000). Thus, the main characteristics of the new welfare regime were sketched by welfare elites during the decade preceding the 1996 reform. Claiming to have co-written the final report with health economist Gérard De Pouvourville, Briet explained that he tried to “invent a French-style model for regulating the health system that was more efficient and respects historical principles.”36 He noted, in retrospect, that he “had something to do” with the fact that four major elements of the Santé 2010 report—universal health insurance, financing by a new tax in the form of a generalized social insurance contribution (CSG), the vote by Parliament in the Social Security Budget Act (LFSS), and regionalized management of the health insurance system—were contained in the Juppé Plan. These elements are logically correlated. “If we wanted to control spending effectively, Parliament had to assume this responsibility; for Parliament to be legitimate in doing so, we needed a tax, the Contribution Sociale Généralisée [CSG]37 It was then logical to move the rules of access to health insurance towards a universal system; finally, since the guiding principles were set at the top [of the state], a more decentralized mode of organization had to be introduced and the

 Ibid.  Soubie, Raymond (ed.), Santé 2010. Rapport du groupe « Prospective du système de santé ». Paris, La Documentation Française, 1993. https://bdsp-ehesp.inist.fr/vibad/index.php? action=getRecordDetail&idt=76591 36  Interview with social insurance high civil servant (MiRe 1, 1997). 37  The Contribution Sociale Généralisée, called CSG, is a new tax created in 1990 to finance the social insurance system. The CSG is levied on all types of personal incomes and it funds approximately 30% of expenditure on health care (Hassenteufel and Palier 2007: 590). 34 35

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National Health Insurance fund (CNAMTS) had to be given a more limited role in managing expenditures.”38 Returning to the members of this “small world” working to make the program a reality, Briet observed that in the decade preceding the reform, they occupied all the key positions within the administration and found themselves in the ministerial cabinets involved in the Juppé Plan, which led to the constitutional reform of 22 February 1996 and the legislative decrees of 22 July 1996. This first generation of welfare elites was composed of “the ‘unavoidable’ of the sector” between whom “osmosis is quite natural” despite the differences of partisan sensibility. Partisanship aside, Briet explained that his appointment as head of the DSS in January 1996 in place of Rollande Ruellan reflected the search for a strong cohesion between ministerial cabinets and the administration: “you couldn’t work with the directorates on the one hand and the cabinets on the other, when you had three months to draft the legislative decrees. There was a kind of hit squad that was set up. It [had to] be possible to work in the most efficient and compact way possible between the directorate of the administration, the cabinet of the Ministry of Social Affairs and that of the Prime Minister’s. […] Clearly, it was the collective work between these three parties that [resulted] in legislative decrees of 1996. So it was here, inside the DSS, and not outside that they [were] written. All this because there was a natural osmosis, we were all in the same boat.”39 The challenge for the designers of “Sustainable Social Welfare” program was great. Building from three lines of the Prime Minister’s speech of November 15, 2015 to legislative decrees of several hundred pages, and all in less than 3 months by integrating administration and cabinets, and arbitrations of Minister and Prime Minister. The Minister had set up three “workgroups” for the reform, each with a manager from the welfare elites: “the first with Jean Marmot, on the institutional aspect; the second with Christian Prieur, magistrate of the Cour des comptes and former director of the National Health Insurance Fund, on medical control [maîtrise médicalisée] of health care expenses and the third, which was my responsibility, on the reform aspects of financing.”40 The DSS—where Briet was then assisted by Anne-Marie Brocas—“was responsible for the writing of the medical control of health care expenses legislative decrees” enjoyed considerable leeway  Interview with social insurance high civil servant (MiRe 1, 1997).  Interview with social insurance high civil servant (MiRe 1, 1997). 40  Ibid. 38 39

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in guiding the content of the new program. In addition to technical design, this directorate sought political validation of the content of legislative decrees by using its contacts with the directorate of the National Health Insurance fund (headed by Fragonard, another member of the first generation) and also by communicating with the unions. A hellish weekly work rhythm ended with busy Saturdays and Sundays, including the minister and his cabinet chief of staff. The schedule included “working and consultation meetings during the week on preliminary projects between February and March 1996 within the DSS under the leadership of Marmot and Prieur with the social partners (FO, CFDT, CSMF…). First, we developed the projects in five pages. The next time we [presented] more precise orientations. Then we [moved] to a more political phase with written texts. In the weekend meetings on Avenue de Ségur, Marmot and Prieur [reported] on what [was] acceptable to the social partners and the minister [decided]. […] Between the workshop managers, the minister’s office and the DSS, there [were] about ten people.”41 The bill thus developed went directly from the offices to the minister, who took care, throughout the incubation period, to inform the social affairs committees of the two legislative assemblies so that elected representatives would not feel “out of touch” with what was being written and would understand that “the directors of the administration [listen] to what the elected representatives [tell them].”42 The Juppé plan led to the revision of the Constitution and the promulgation of several legislative decrees. Parliament has been given new prerogatives to exercise democratic control over social security. In recounting the course of this reform, which turned the governance of social insurance upside down, Briet explained that by assuming the functions once occupied by his mentor Marmot, he and other welfare elites built “stone by stone the institutions that today structure the landscape to the point that it is hard to imagine that we could have done without them for 50 years” (Fonteneau 2008: 24). The political implementation of the reform opened up new conflict: on the one hand, the “old-fashioned” elites of the sector tried to slow its implementation; on the other hand, political forces caught in a new period of cohabitation between the socialist government of Prime minister Lionel Jospin and right wing President Jacques Chirac divide about the timetable for implementation of the reform.

 Ibid.  Ibid.

41 42

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Gilles Johanet: An Atypical Welfare Elite The sociological portrait of Johanet sheds light on how certain welfare elites confronted political power. He too was a magistrate at the Cour de comptes and had actively engaged in “Sustainable Social Welfare” reform program (Genieys 2010: 105–106). A maverick, for some, a major intellectual figure in the social field, for others, he was described by his peers as a great connoisseur of the “affairs of Social Security” (Libault and Damon 2017). Though close to the socialist party, he did not hesitate to assert his ideas even if it means offending the prevailing political powers in place (including the socialists). One of our interviewees described him as “quite atypical in the sector, [with] a messianic conception of his role.”43 Loyal to his original Grands corps, Johanet ended his career as the prestigious Attorney General to the Cour de comptes (2012–19). The Court remained “his home.”44 He regularly returned to the Court, after several stints in ministerial cabinets and at the Directorate of the Funds, to climb the ranks: Auditor, Referendary Advisor, Secretary General of the Court (1997–98), and Master Advisor… So, aside from the chamber presidency, Johanet met all the criteria for a brilliant career path inside the social insurance sector. But his Garden of Eden remained “Sustainable Social Welfare” program to which he devoted two books. These caused a stir in the “social affairs community” at the time of their publication (Johanet 1995, 1998). His critique was clear: the continuing crisis of health insurance since 1945 was the result of “buffoonery” and “deception” because “the truth is that the system is vitiated in its very essence and that none of its aspects is viable” (Johanet 1998: 7–8). Johanet added: “We must tell the French that the two assumptions on which the health care system has been based since 1946 are pure idiocy: the system has been managed—and glossed over—on the assumption that quality could be achieved without constraint and that the resources to be devoted to health were unlimited. Today, we are just beginning to recognize that the resource is necessarily limited. Constraint, on the other hand, remains taboo” (Johanet 1998: 9). Johanet dispensed with the familiar technocratic language but shared the same credo as did Marmot and Briet: “we must reform the Sécu,” again and again. Unafraid to confront conservatism to innovate as a member of the Socialist Party’s “group of experts” on social security, he participated in the cabinet of Georgina Dufoix, then  Interview with social insurance high civil servant (MiRe 1, 1998).  Interview with social insurance high civil servant (MiRe 1, 1997).

43 44

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Secretary of State for the Family (1981), and then in 1983, in the cabinet of Prime Minister Pierre Mauroy, as advisor for social affairs (Genieys 2010: 106). His Diploma of Advanced Studies in Statistics obtained at the Institut national des études démographiques (INED) equipped him to understand what was at stake for the future social insurance system in the evolution of the population. But it was during his first tenure in the directorate of the National Health Insurance Fund (CNAMTS) from 1989 to 93, that he faced the issue of the deficit of the health insurance system. As early as 1990, Johanet developed the notion of managed care (medical control) of health insurance expenditures because “the control of care has no value if it is purely financial, disconnected from the patient’s approach and from the practice of the care provider.”45 To strengthen theses connections, he had been involved in the promotion of several policy instruments, for example Opposable Medical References (Références médicales opposables/ RMO) whose aim was to avoid abusive prescriptions by private sector physicians. Johanet also participated in the launch of the “Carnet de Santé” (health record) and the “Médecin referent”46 to make patients more accountable (Hassenteufel and Palier 2005). The objective was to control health care spending by involving patients and health care professionals (Rodwin and Le Pen 2004). For the welfare elites, this way of formulating policies is based on the articulation of financial and social issues. This argument would be adopted by the second generation who, after 1996, were responsible for implementing the reform. They have also used it as an argument in their struggle within the state against the elites of the Ministry of Finance. With the return of the wright wing government in 1993, Johanet returned as magistrate of the Cour des comptes while keeping in touch with his favorite sector. Close to Briet and his spiritual father at the Cour, Bertrand Fragonard (see below), he was informally consulted on the Juppé Plan, but was critical of the legislative decrees of 1996. While he saw the assertion of the role of the state as inevitable, he deplored the lack of courage of political decision-makers who declined to effective control of health  Bulletin de l’Ordre des Médecins, janvier 1999: 16.  A “médecin référant” (referring physician) is a general practitioner who has signed a contract with the health insurance fund. Generally speaking, he undertakes to contribute to the control of health care costs, in particular by respecting several criteria such as the application of conventional tariffs, the procedure for waiving the advance payment of expenses or the respect of a specific quality charter. 45 46

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insurance expenditures. Did not the social security cost 100 billion francs too much per year? Countering the short-termism of the “old-fashioned” elites Johannet sought to “develop a systemic and global approach to the problem, because what was missing in the sector was [...] an intellectual command of the subject”47 that would overcome the gap between the sector’s technocrats, “tinkering with policy tools” on a “piecemeal basis,” and “elected politicians who did not understand the ins and outs of this type of policy.”48 His solution: a strategic plan to contain the structural deficit of the health insurance system over the long term, which was adopted by the social partners and the board of directors of the National Health Insurance fund. He stated that he “prepared this plan internally at the National Health Insurance Fund (CNAMTS), with left-wing ‘feathers’, the core of which was a systemic approach to controlling health care spending,”49 and added that “I didn’t hide the fact that this Plan was an apotheosis for me because I developed a systemic approach.”50 The Johanet Plan was thus born. The cabinet of the Minister Martine Aubry viewed the Johannet Plan differently: “[Johanet] was proposing a surreal strategic plan for us in which there was talk of making 60 billion in savings, including 30 billion in the hospital, while the Minister was trying to make savings of hundreds of millions in the hospital so that the system, which was built on a logic of spending, did not break down. And then, on one ‘page’, they told you that 30 billion can be saved, which was also reported in the national press.”51 In the autumn of 1999, the Johanet Plan led to a bitter political conflict between its bearer and the socialist minister Aubry. The conflict was often presented a war of egos between two strong personalities, deriving from deep enmity, intensified in this instance (Frémaux 1999).52 Some welfare elites explain it by “the particular psychological profile [of Gilles Johanet], as well as his penchant for provocation.”53

 Interview with social insurance high civil servant (MiRe 1, 1997 & MiRe 2, 2007).  Ibid. 49  Ibid. 50  Ibid. 51  Interview with social insurance high civil servant (MiRe 1, 1998 et MiRe 2, 2006). 52  https://www.alternatives-economiques.fr/assurance-maladie-chi-va-piano-vasano/00020749 53  Interview with social insurance high civil servant (MiRe 1, 1998 et MiRe 2, 2006). 47 48

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Johanet “galvanized the executives of the National Health Insurance Fund by giving them a sense of pride around the speech ‘here we go to fight, we are the best,’”54 but this battle cost him his position as director of the CNAMTS. It also revealed the difficulty of promoting a new vision of collective solidarity premised on the control of expenditure. At the turn of the millennium, a third political cohabitation and preparation for the 2002 presidential elections again encouraged political short-termism.

Other Magistrates at the Cour des Comptes Committed to the Reform The gallery of sociological portraits also includes Bertrand Fragonard, Claire Bazy-Malaurie and Gérard Rameix. All members of the Cour de comptes, they all held important positions in the governance of social insurance (Genieys 2010: 104). Fragonard, direct descendant of the rococo painter, successor of Marmot to the presidency of the social chamber of the Cour de comptes, served in the cabinet of Simone Veil (1975–79) and then, after a time at the National Family Allowance Fund (Caisse nationnale des affaires familiales, CNAF) he was appointed, in 1986–87, at the interdepartmental delegation dedicated to the creation of the Minimum insertion income (Revenu minimum d’insertion, RMI).55 After working on family policy in the Juppé Plan, he directed the National Health Insurance fund (CNAMTS) from 1997 to 1998. During his mandate, he launched the famous Carte Vitale 56 and advanced the future Objectives and Management Agreement (Conventions d’Organisations et de Gestion, COG),57 with health professionals. Subsequently, while assuming the presidency of the Social Chamber of the Court, he also became president of the High  Interview with social insurance high civil servant (MiRe 2, 2007).  Created in 1988, the RMI is intended to guarantee a minimum level of resources and facilitate the integration or reintegration of people with low incomes. The RMI is paid to anyone who meets the following conditions: residing in France, at least 25 years old (except in special cases: pregnant women, etc.), having resources below the amount of the RMI and signing an integration contract. 56  The Carte vitale is the health insurance card first issued in 1998. 57  The COG is a policy instrument based on a target and management agreement between doctors’ organizations and health insurance funds (Hassenteufel 2007: 585). 54 55

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council for health insurance policy planning (HCAAM) from 2003 to 2009, where, with Briet he developed the “health care shield” (bouclier sanitaire)58 (2007). In the late 1990s, this close friend of Simone Veil considered Johanet, who was nevertheless a leftist, “a bit like [his] spiritual son.”59 In his book—Vive la protection sociale!—he enrolled the long battle that led to “Sustainable Social Welfare” program, and appealed to “our collective responsibility [to] become aware that stricter control of spending is necessary and should no longer be postponed” (Fragonard 2012: 298). Similarly, he pointed to the correlation between the ability of welfare elites to control health insurance expenditures and the possibility of extending the scope of Social Security to cover emerging societal risks such as dependency and ecology. It should be noted that his acknowledgments as an author were addressed to one of the second generation of elites, Franck Von Lennep, who helped him during the writing of his book. Von Lennep became in June 2020, head of the DSS. Claire Bazy-Malaurie, after participating in the campaigns for reform, was appointed president of a chamber of the Cour des comptes (2006) before becoming a member of the Conseil constitutionnel (2010–2022). She recalled that it was as a young magistrate that she got to know the social sector and, more particularly, that of the hospital before she rose to Directorate of Hospitals (1995–98). Within the Cour des comptes—“where she was in good company with Gilles Johanet, Raoul Briet [and] where they formed the group of auditors of the 5th chamber”—60 she learned to exercise control over social security policies. She also mentions Marmot and Michel Lagrave, whom she considers to be of “great value” and “excellent connoisseurs of the system who allowed her to penetrate its mysteries.”61 It was therefore the magistrates of this Grands corps who, since the end of the 1970s, chose and designed the constitutional reform of 1996. Our elite approach highlighted, with this series of portraits, the sociological change in the social background and career paths of the welfare elites that adopted the role of custodians of state policies in the social  The health shield is a system for capping all out-of-pocket expenses, that is the costs that remain payable by consumers of medical goods and services after the intervention of the social security system. 59  Interview with social insurance high civil servant (MiRe 1, 1997). 60  Interview with social insurance high civil servant (MiRe 2, 2006). 61  Ibid. 58

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security sector. Most of them came from the Cour des comptes. They developed their career paths by circulating at the top of power (DSS, CNAMTS, and ministerial cabinets). They were strongly connected to each other, and their frequent return to the Cour des comptes reinforced the community spirit of this first generation by formulating a new programmatic orientation (see Table 2.2). They agreed on the need for profound reform of the governance of social security. Finally, they had a common vision of the need to move toward a system of universal coverage increasingly financed by taxes and controlled by Parliament. This program is the basis for the transformation of the French welfare regime.

Bibliography Barbet, André, Raoul Briet, « Financement et régulation du système de protection sociale », Revue française d’économie, 3(1), 1988: 51–80. Fonteneau, Robert, A la mémoire de Jean Marmot. Fascicule complémentaires, Paris, Comité d’histoire de la Sécruité sociale, 2008. Fragonard, Bertrand, Vive la protection sociale!, Paris, Odile Jacob, 2012. Frémaux, Philippe, « Assurance Maladie: chi va piano va sano », Alternatives Économiques, n°173, le 01/09/1999. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Grimaldi, André, Didier Tabuteau, François Bourdillon, Frédéric Pierru, Olivier Lyon-Caen, Manifeste pour une santé égalitaire et solidaire, Paris, Odile Jacob, 2011. Hassenteufel, Patrick, « L’État mis a nu par les politiques publiques », in B. Badie, Y. Déloye, (dir), Le temps de l’État. Mélanges en l’Honneur de Pierre Birnbaum, Paris, Fayard, 2007: 311–329. Hassenteufel, Patrick, Bruno Palier, “Trompe-l’œil in the Governance of Health Insurance. French-German Contrasts”, Revue française d’administration publique, 113, 2005: 13–27. Hassenteufel, Patrick, Bruno Palier, “Toward a Neo-Bismarkian Health Care States? Comparing Health Insurance Reforms in Bismarkian Welfare States”, Social Policy & Administration, 41 (6), 2007: 574–596. Jobert, Bruno, (ed.), Le tournant néo-libéral en Europe, Paris, L’Harmattan, 1994. Johanet, Gilles, Santé: dépenser sans compter, des pensées sans conter, Paris, Santé de France, 1995. Johanet, Gilles, Sécurité sociale: l’échec et le défi, Paris, Seuil, 1998. Libault, Dominique, Julien Damon, (entretien) « Grand témoin: Gilles Johanet, procureur général près de la cours des comptes », Regards, 2017: 11–26.

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Rodwin, Victor, Claude Le Pen, “Health Care Reform in France. The Birth of State-Led Managed Care”, New England Journal of Medicine, 351 (22), 2004: 2259–62. Suleiman, Ezra N., « Sur les limites de la mentalité Bureaucratique: conflits de rôles entre cabinets ministériels et directeurs », Sociologie du travail, 14 (4) 1972: 388–409. Suleiman, Ezra N., Politics, Power and Bureaucracy in France: The Administrative Elite, Princeton (NJ), Princeton University Press, 1974.

CHAPTER 6

Reinforcements to the Developing Role of Custodian

High civil servants, with social backgrounds and career paths different from those of the welfare elites, also reinforced the “Sustainable Social Welfare” program by assuming the role of custodian of state policies. They were recruited from the top positions in the sector for their expertise in public finance and their ability to technically implement expenditure control. Among them, in particular, to help design the tools necessary for a new accounting plan: Jean Choussat, inspecteur général des finances, and Jean-François Chadelat, PhD in statistics and actuary. The first generation of elites had thus integrated individuals with different sociological profiles to refine its policy knowledge and develop its program.

Jean Choussat: Ally from the Ministry of Finance What was the role of this high civil servant, who was Director of the Budget at the Ministry of Finance from 1981 to 1985, alongside the welfare elites? The first one can be found in Choussat’s personal links with Marmot, his “very close” friend, and Bertrand Fragonard, his brother-in-­ law. A second factor was his proximity to the socialist party and his interest in social issues. But most important, Choussat was a visionary aware of the budgetary impasse of the Social security. Interviewed shortly after his death in 1998, Marmot described him as “a very close friend, a very dear

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_6

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friend [...] a great servant of the state, who played a decisive role in the conduct of social policy during that period and who shared some of [his] views.” 1 Marmot praised Choussat’s role in Social Security in these terms before Choussat’s arrival at the Directorate of Health and Hospitals in 1981: “... from 1965 to 1980, you had a guy, a civil servant of my generation, who was in charge of these subjects at the directorate of Budget and who had a coherent and structured vision. Social affairs suck, it was not a problem [because] in the Ministry of Finance, there was a reference point. With him gone, there was nothing at all, the boat starts rocking as if it were drunk. [So, on the one hand, we had] a Ministry of Finance that no longer has any ambition in this area and, on the other hand, a Ministry of Social Affairs that was not adapted to the needs, neither quantitatively, nor structurally, nor qualitatively.”2 This is why he invited Choussat, then director of the Assitance Publique-Hôpitaux de Paris, to join him in the committee of “wise men” organizing the “Estates General on Social Security” of 1987. In 2001, Marmot paid a ringing tribute to him on the theme of “The function of the state in the face of change” (Fonteneau 2008a: 212–13). He recalled how Choussat was a precursor in changing the role of the financial and social administrations at the end of the twentieth century with the objective of extending the budgetary power of Parliament to the Social Security. With his multi-faceted experience as a manager, Choussat worked at the Directorate of Health and Hospitals (1980–81), at the Directorate of Budget (1981–1986), and at the head of the Assistance Publique-Hôpitaux of Paris (1986–89), to bring the administration closer to the public so that they become more aware of the cost of public action. His approach to government reform was clear: “the problem was not to curb spending in the name of some religion of balanced budgets. It was fundamental for the government to keep its hands free in the conduct of its policy... because there was no budgetary sustainability without prior control of spending” (ibid.: 214). Rejection of a dogmatic approach to the budget but a stronger control of public spending was the credo that he shared with the welfare elites. In an article published in the review Pouvoirs, Choussat (1990) clarified his policy vision and the role of the elites of the Ministry of Finance. 1 2

 Interview with social insurance high civil servant (MiRe 1, 1998).  Ibid.

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Rigorous in the criticism of the latter, he also advised the welfare elites to avoid falling into a war between the “financial” ministry (i.e., the Ministry of Finance) and the “spending ministries” (the others). For Choussat, former acted in the name of a “moral crusade,” the fight against spending public money. Since the turn to austerity by François Mitterrand’s socialist presidency in 1983, when Choussat was head of the Directorate of Budget, this new budgetary pastoral had come under fire from political opponents and the public. Seen from the angle of austerity, the “financial deficit of social security” made the Ministry of Social Affairs look like the paragon of “spending ministries,” the one that was brought under austere fiscal rules at all costs. The history of the “Sustainable Social Welfare” program also shows how the social insurance elites implemented reforms and developed tools to rid the sector of its big spenders’ reputation. Thanks to his career path in the health sector, Choussat knew, better than anyone, that unlike the “fortress” of the Ministry of Finance, which keeps the “public” at bay, the Ministry of Social Affairs felt the pressure of organized interests. Health care workers’ unions, pharmaceutical lobbies, private clinics, and doctors all had “good reasons” to oppose budget cuts, and it was not uncommon for the disgruntled to demonstrate under the ministry’s windows. This frontal exposure to the aggressiveness of these interest groups has made Social Security reform politically complex. Their fight therefore demanded tools of war. Choussat, one of the few people to wear the twin hats of budget and health, outlined these tools in two programmatic texts written shortly before his death in 1998. The first one imagined “The hospital in 2025” around four principles: “a collective financing ensuring the equality of all citizens confronting disease; a broad autonomy of management of the establishments that allowed the research on effectiveness; integration of hospital organizations in the global health system and a continuing evaluation of results” (Choussat 1995). The second text reaffirmed, on its first page, the essential challenge of controlling health insurance expenditure: “For ages in France, as in all other developed countries, controlling health expenditure [have] been an obligatory feature of all governmental programs... The almost universal concerns to stabilize, or even reduce, the rate of compulsory levies naturally [led] to questions about the justification and future of social protection systems” (Choussat 1997).

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Jean-François Chadelat: The First Actuary of Social Accounts Classified politically as a high right-wing civil servant, Chadelat was very close to Marmot and Choussat (Fonteneau 2008a, b; Charpentier 2018), he joined them in most of the battles for the constitutional reform of the social security system in 1996. His academic formation 3 gave him a different profile from his two great friends. He assisted Marmot in setting up a reliable analytical accounting system for social accounts, then participated in the Social Security Accounts Commission (CCSS) when it was created by the right-wing Raymond Barre government in 1979. Following Marmot to the Directorate of Social Security, Chadelat was credited with defining a mathematical formula for implementing “demographic compensation,” a redistribution mechanism based on national solidarity between the various branches of social security (family, illness, work accident, and retirement). This technical innovation gave the first generation of welfare elites a formidable instrument in public accounting as they raised balance in the financing of the various branches of social security. His long career focused on social protection issues, particularly health insurance and pensions. From the early 1970s until the Juppé reform and even after, Chadelat stood on the front lines of almost all the battles waged to control the accounts. Having chosen to join the DSS at an early stage in 1971, as an actuary working for the deputy director of old-age insurance and social benefits, he participated until 1974 in reforming the system. Spotted for his qualities, he became head of the actuarial section, then head of the Economic and Statistical Studies Division (Division des études économiques et statisques, DEES), a position he held until he left in 1983 following Marmot’s dismissal. During their collaboration, the Directorate of Social Security saw its staff increase continuously, to include, in 1983, 22 technicians, including 5 actuaries. With them, Chadelat took charge of the vast and increasingly important field of financial studies of legislative texts concerning Social Security policies. As the accounts deteriorated in the economic crisis, he had a key role in drawing up financing plans to contain the deficit. In this, he was in one mind with Marmot: “Jean Marmot was a great servant of the state. I always had a strong admiration for him, and I believe that he 3  A graduate of the French Institute of Actuaries, he held a postgraduate degree in applied mathematics and a diploma in l’Institut de statistique des universités of Paris.

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was willing to honor me with his friendship” (Fonteneau 2008b: 29). Instead of the legal approach of the “old-fashioned” elites of the Conseil d’État, they promoted a more economic and actuarial vision of the sector’s policies, which is why, for several decades, they developed tools to make the social accounts intelligible to the public. The creation of the Social Security Accounts Commission (CCSS) in 1979 was the first victory that allowed to public to see the forecasts of social security accounts carried out by the Directorate for Research, Studies, Evaluation and Statistics (DRESS). Marmot, head of the DSS, could rely on the work of this Commission on these accounts to develop a policy of expenditure control. With the arrival in power of the socialist government, this policy was put in brackets. The same day that Marmot was replaced at the DSS, Chadelat resigned to join Choussat at the Directorate of Budget (1983–87), with the mission of managing the social security accounts; this exit among the elites of the Ministry of Finance owed much to the political tensions that characterize an era of strong partisan bipolarization. And so, during the first governmental cohabitation between a right-wing Prime Minister (Chirac) and a left-wing President (Mitterand) (1986–88), Chadelat joined the cabinet of the right-wing Philippe Seguin, his political mentor who had become Minister of Social Affairs, as an advisor for Social Security. Once again, he collaborated closely with Marmot in the preparation of the Estates General on Social Security of 1987. He was, moreover, in charge of finding a new secretary general for the Social Security Accounts Commission (CCSS), relaunched by Seguin. Chadelat suggested Marmot: “I did not have to make an intense effort of imagination to find the name of the suitable person. Jean Marmot was obviously the right name. His competence, his sense of the state and of the public interest, his charisma would have been enough to retain him. But I knew, perhaps better than anyone, that by asking him to become General Secretary of the Social Security Accounts Commission, I could not have given him greater pleasure. I realized this when I went to see him and offered him the job. He understood perfectly well why I was doing this, and I think he was always grateful to me” (Fonteneau 2008b: 35). Following his mission in the ministerial cabinet, Chadelat would serve, from 1987 to 1990, as director of the Central Agency for Social Security (ACOSS) bodies. With this cross-cutting position between health insurance, retirement, and family, he worked to ensure that the financial balance of each branch of Social Security is ensured by those in charge of its

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management. Although he worked in the private sector (AXA insurance group) between 1990 and 1993, he returned to public service when the Right regained power in 1993. From January 1994 to May 1997, he was director of the Old Age Solidarity Fund (Fonds de solidarité vieillesse) created by the 1993 pension reform. In this new role, Chadelat pushed for the adoption of a crucial measure in the Law of July 25, 1994, that recognized the ACOSS as national fund of the Social Security and Family Allowance Contribution Collection Offices (Union de recouvrement des cotisations de sécurité sociale et d’allocations familliales, URSSAF) (Chadelat 2008). A status that gave the ACOSS budgetary supervision, that is, the implementation of the budget for the whole nation. He also defended a measure obliging the state to ensure full financial compensation for all total or partial exemptions from social contributions (Chadelat 2005), arguing that the famous exemptions (exonérations) of payroll taxes sought by the government should be borne by the state budget, not that of the Social Security. This tactic, which was beneficial for the Social security accounts, constrained governments who were inclined to use exemptions to promote employment, it also rebuffed the Ministry of Finance, which had the habit of charging the health and social sector for certain expenses that properly come under the state budget. During the preparation of the 1995 Juppé Plan, Chadelat helped to produce brief memos on the content of the reform for Marmot and Briet, both advisors to the Prime Minister. In particular, he pushed for the creation of a new tool for controlling social accounts, the Objectives and Management Agreement (COG), introduced by the reform of April 24, 1996. These agreements both strengthened the rights of employees and increased the DSS’ power over the funds. The new partnership confirmed the increased power of the welfare elites. For his numerous achievements, Chadelat was appointed to the IGAS in 1997.

What Can We Learn from the First Generation of Welfare Elites? What does an analysis of the sociological portraits tell us about the formation of the first generation of welfare elites? First, high civil servants with a new social background and career paths had engaged the social security reform when the system went financial crisis amid a period of strong

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right-left divide. But in spite of these challenges (changes of political majority, cohabitation, etc.), this generation, developing the role of custodians of state policies, succeeded in pushing the “Sustainable Social Welfare” program onto the government agenda (see Tables 2.2 and 2.3). The énarques/magistrates at the Conseil d’État were replaced in power by the énarques/magistrates at the Cour des comptes. An interviewee in the 1990s evokes the names of Marmot, Fragonard, Briet, and Johanet to demonstrate that “the Cour des comptes [considered] that the social sector [was] one of its favorite areas. A kind of implicit tradition, unwritten of course, of the French high civil service, we [had] territories there... When you look at the thirty appointments that [counted] in this sector [director or department head positions], whether in the ministerial cabinets, in the central administrations or in the national funds, you [had] of course Inspectors General of Social Affairs, but in the end, less IGAS than Cour des comptes.”4 From the 1980s to the 1990s, it was often the President of the Social Division of the Cour des comptes who candidates for the Director of the DSS to the Minister. This was the case for example with “Jean Marmot [then President of the Social Chamber], for the appointment of Fragonard at the directorate of the National Health Insurance fund in 1996.”5 Another insider recalled about the constitutional reform of 1996: “I know that someone like Jean-François Chadelat gave notes to Antoine Durlemann, magistrate at the Cour des comptes and social advisor to Alain Juppé at Matignon (1995–97). We know that [there] was a small team composed of Marmot, Briet, but these people are people, I was going to say, of the family who were fed at the ‘house’ [i.e., Cour des comptes]. All this is a bit of a ‘DSS family’, which does not exclude political divergences and possibly personal enmities, but it is a bit of a melting pot of high civil servants in social protection which necessarily passes through the DSS.”6 But this insider argued that these appointments were not a matter of “entre soi.” Marmot, Fragonard, Johanet, and Briet were “quite remarkable” candidates for the directorate of an administrative unit. The first generation found itself at the head of the DSS because they brought a new technical know-how and a coherent vision of reform of the governance of social security. As we will see below, this ministerial directorate would become, from the 2000s, an obligatory passage in the careers of the second generation  Interview with social insurance high civil servant (MiRe 1, 1998).  Ibid. 6  Interview with social insurance high civil servant (MiRe 1, 1997). 4 5

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of welfare elites (Table 2.3). The DSS was the place to be if one wanted to become a social or health insurance advisor in a minister’s cabinet, or a director of funds, or even a member of a “high authority” (hautes autorités) and agency in the sector. Moreover, in accordance with Simone Veil’s wishes, the DSS would train its own executives internally, gradually marginalizing the members of the earlier generation from the Cour des comptes. The rise of Dominique Libault (administrateur civil and member, for a time, of Veil’s cabinet) to the head of DSS, from 2000 to 2012, is proof of this pattern (see Chap. 7). During this era, the DSS systematically placed its young office managers in the key position of social advisor in the ministerial cabinets, enabling the DSS to benefit from precious links at the heart of the Ministry to make his voice heard on the sector’s policies. And, at the end of their governmental mission, this second generation, enriched by their experience in the Ministerial cabinet, would extend their career paths either by returning to the DSS or by becoming the head of a fund. These career paths within the sector help explain the strategic retreat of the magistrates of the Cour des comptes and their replacement by a new generation. The conquest of the heights of power by the welfare elites helps to understand the origins of the “Sustainable Social Welfare” program that began in the mid-1990s. The election of a conservative President, Jacques Chirac, offered a window of opportunity to put on the political agenda the question of the future governance of social security (Palier 2010). In the political context of the time, when strong partisan bipolarization prevailed, the “crisis” of the French welfare regime was mainly attributed to the neo-liberal revolution (Jobert and Théret 1994). It is true that certain private interest groups, headed by the CEO of the insurance firm AXA, Claude Bébéar (2012), then advocated a competitive system based on the US model of HMOs (Brown 1983; Launois et al. 1985), but this project never made it onto the government agenda (Damon 2016: 8–9; Brookes 2021). Our elite approach tells a different story: that of the reconfiguration of the strong French state in the social security sector around the DSS. The second generation of welfare elites would proceed to strengthen its power and marginalize its rivals in the governance of social security. It was no longer a question of “saving the social security” (sauver la Sécurité sociale), as was the case for the first generation, but of centering it on a different

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logic (Fragonard 2012). Their twofold aim fits their identity as custodians of state policies built around a programmatic orientation: control with a stronger regulatory hand the expenditures of a budget (i.e., of social security) and develop and extend social insurance policies.

Bibliography Brookes, Kevin, Why Neo-liberalism Failed in France. Political Sociology of the Spread of Neo-Liberal Ideas in France (1974–2012), Switzerland, Springer International Publishing, 2021. Brown, Lawrence, Politics and Health Care Organization: HMOs as Federal Policy, Washington, DC: The Brookings Institution, 1983. Chadelat, Jean-François, « Les enjeux du financement de la santé », Revue française d’administration publique, n°113, 2005: 65–73. Chadelat, Jean-François, « Pour une histoire de recouvrement. Entretien réalisé par Bruno Valat », Revue d’histoire de la protection sociale, n°1, 2008:121–135. Charpentier, François, « In memoriam: Jean-François Chadelat, homme de passion et de conviction », Revue d’histoire de la protection sociale, n°11, 2018: 9–11. Choussat, Jean, « Le budgétaire et le dépensier. Défense et illustration de la Direction du budget », Pouvoirs, n° 53, avril 1990: 55–64. Choussat, Jean, « L’hôpital en 2025 », Droit Social, n° 9–10, 1995: 792–796. Choussat, Jean, « Rapport d’ensemble sur la démographie médicale », Paris, La documentation française, 1997. Damon, Julien, « Restrospective et prospective de la protection sociale », in Michel Borgetto, Anne-Sophie Ginon, Frédéric Guiomard (eds.), Quelle(s) protection(s) sociale(s) demain?, Paris, Dalloz, 2016: 1–15. Fonteneau, Robert, A la mémoire de Jean Marmot, Paris, Comité d’histoire de la Sécruité sociale, 2008a. Fonteneau, Robert, A la mémoire de Jean Marmot. Fascicule complémentaires, Paris, Comité d’histoire de la Sécruité sociale, 2008b. Fragonard, Bertrand, Vive la protection sociale!, Paris, Odile Jacob, 2012. Jobert, Bruno, Théret Bruno, « France : consécration républicaine du néo-libéralisme », in Bruno Jobert, (dir.), Le tournant néo-libéral en Europe, Paris, L’Harmattan, 1994: 21–86. Launois, Robert, Béatrice Majoni-d’Intignano, Jean-Claude Stephan, Victor Rodwin, « Les réseaux de soins coordonnés (R.S.C.): Proposition pour une profonde réforme du système de santé », Revue Française des Affaires Sociales, n°1 1985: 37–61. Palier, Bruno (ed.), A Long Goodbye to Bismarck. The Politics of Welfare Reform in Continental Europe. Amsterdam, Amsterdam University Press, 2010.

PART II

The Institutionalization of Welfare Elites

Abstract  Advancing the “Sustainable Social Welfare” program required a double political confrontation: (i) outside the state, against the “old-­ fashioned” elites, the 2004 reform created the National Union of Health Insurance Funds to reinforce the role of the central government; (ii) within the state, against the elites of the Ministry of Finance with the creation of a Ministry of Public Accounts in 2007. This reform obliged the welfare elites to struggle with the elites of the Ministry of Finance in the field of budgetary rigor. Faced with this double confrontation, they combined the role of custodian of state policies with the implementation of their program. The process of institutionalization of welfare elites around the new welfare regime has resulted in the reconfiguration of the strong state. The transformation of the French welfare regime adopted by the constitutional reform of February 22, 1996, met political resistance. The march toward “Sustainable Social Welfare” program was never set in motion, but this institutional change went unnoticed by the public. The nostalgia for the enchanted past of the 1945 model had forgotten its dependence on Marshall Plan subsidies, colonial policy, and exceptional economic expansion in a favorable demographic context (Fourastié 1979). The weak growth of the last five decades, which had generated mass unemployment, had put it out of reach (Pisani-Ferry 2000). All the same, successive governments had not been able to explain or capitalize on “Sustainable Social Welfare” program. One explanation is electoral short

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termism. Haunted by the fear of social movements, governments prefer to the reform out of sight, introducing institutional change in a stealthy manner. This tactic risks exposing high civil servants to popular hostility, as the development of anti-elitism at the turn of the 1990s attests (Julliard 1997). Political leaders of the far right and the radical left have not hesitated to point fingers at the technocrats who are distorting the old social security model, which, alas, special regimes and weak governance made inequitable and inefficient (Merrien et al. 2005). After the Social Security Budget Act (LFSS) went into effect in 1996 through the passage of laws between 2016 and 2019 that established the Universal Health Protection (Protection Universelle Maladie, dite PUMa), the second generation of welfare elites worked to strengthen state institutions and make their program effective. Containing spending in order to expand redistribution was the mission for which political struggles would be fought. This work proceeded in an unfavorable economic context, due, in part, to the financial crisis of 2008. In addition, the launch by President Sarkozy of the “General Review of Public Policies” (Révision générale des politiques publiques) in 2007, with the objectives of reforming the state (Bezes 2010; Gibert and Thoenig 2022: 53), complicated the work of the welfare elites. The political parties in government, moreover, have been clumsy in promoting the new social security model. The right has been uncomfortable with the universalization of health coverage, and the left has been less than skillful with the issue of expenditure control. And for good reason, everyone passed the buck, citing the European budgetary pact (Article 3 of the Treaty limiting the deficit to 3% of GDP). When President Hollande continued his predecessor’s efforts to control spending to reduce a public deficit worsened by the 2008 crisis,1 he attracted criticism from his left, which saw “Sustainable Social Welfare” program imperiled by the austerity policy. Our elite approach, by correlating the change in social backgrounds and career paths of the elites with their programmatic orientation, shows how they dealt with this new context since they first took power in the governance of funds (Douste-Blazy Reform 2004) (see Tables 1.2, 2.2, and 2.3). Confronted after the financial crisis of 2008 with an attempt by the Ministry of Finance to take control of the social security budget, the second generation of welfare elites, coming from the corps of General  The social security deficit rose between 2008 and 2010 from −9.4 to −28 billion euros. See Guillaume Guichard, “Les déficits de la Sécu seront moins élévés que prévu en 2013”, Le Figaro published on 25:09/2013, updated on 26/09/2013 at 14:45. 1

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Inspectors of Socials Affairs (Inspecteurs généraux des affaires sociales, IGAS) or Administrateur civils, built their career paths inside an Iron Triangle of social security governance. In this context, they developed the role of custodians of state policies (Genieys 2010, 2023). Advancing “Sustainable Social Welfare” program required a double political confrontation: (i) outside the state, against the “old-fashioned” elites—the social partners and portions of the political class who thought to thwart the reform process and return to the mythical model of 1945 (see Tables 1.2, 2.2, and 2.3)—the 2004 reform created the National Union of Health Insurance Funds (UNCAM) to reinforce the role of the central government (Rodwin and Le Pen 2004); (ii) within the state, against the elites of the Ministry of Finance with the creation of a Ministry of Public Accounts in 2007. This reform obliged the welfare elites to struggle with the elites of the Ministry of Finance in the field of budgetary rigor. Faced with this double confrontation, they combined the role of custodian of state policies with the implementation of their program. The process of institutionalization of welfare elites around the new welfare regime has resulted in the reconfiguration of the strong state.

Bibliography Bezes, Philippe, “The Morphology of General Review of Public Policies: A Historical and Comparative Overview”, Revue française d’administration publique, 136 (4) 2010: 775–802. Fourastié, Jean, Les trente glorieuse ou la révolution invisible de 1945 à 1975, Paris, Fayard, 1979. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Gibert, Patrick, Jean-Claude Thoenig, Assessing Public Management Reforms, London, Palgrave-Macmillan, 2022. Julliard, Jacques, La fautes aux élites, Paris, Gaillimard, 1997. Merrien, François-Xavier, R.  Parchet, A.  Kernen, L’État social. Une perspective internationale, Paris, Armand Colin, 2005. Pisani-Ferry, Jean, Plein emploi (Rapport), Paris, La Documentation française, 2000. Rodwin, Victor, Claude Le Pen, “Health Care Reform in France. The Birth of State-Led Managed Care”, New England Journal of Medicine, 351 (22), 2004: 2259–62.

CHAPTER 7

Implementing “Sustainable Social Welfare” Program

Following the Juppé reform, the Directorate of Social Security (DSS) developed the conditions for implementation of the Social Security Budget Act. The battles for power therefore took place in two arenas. The first saw welfare elites and social partners in conflict over the management of national health insurance funds (Palier 2005, 2010; Hassenteufel 2007), because implementation of health expenditure control required stronger involvement of the state. The second, less visible, conflict occurred within the state, between the Ministry of Social Affairs and the Ministry of Finance, on the question of how austerity should be practiced (Darviche et al. 2022). These confrontations took place alongside the universalization of the social protection system. It is by confronting these battles in parallel with the policy of “generalizing the benefits of social protection” that we can grasp the essence of the “Sustainable Social Welfare” program.

From Universal Health Coverage to Universal Health Protection The implementation of the Social Security Budget Act (LFSS) in 1996 changed the course of the institutional history of social security. From that moment on, the DSS had privileged access to a “legislative weapon,” namely, the legislative decree (loi organique) that was discussed in the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_7

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plenary session of the National Assembly and the Senate by the parliamentarians on the proposal of the government. The Social Security Budget Act gave an unprecedented opportunity in French history for reformers. An example was the advent of the Universal Health Coverage (CMU)1 in 1999, and its extension to the Universal Health Protection (Protection universelle maladie), hereafter PUMa, in 2016 (see appendix, Table A.3). As early as 1977, Chadelat emphasized the need to generalize access to the health insurance coverage system. The 1978 Law promoted by Minister Simone Veil opened a breach in the 1945 model by dissociating the benefit of health insurance coverage from the obligation to practice a profession (Chadelat 2012). All that was required was to reside in France, a measure that announced the abandonment of the Bismarkian model. The Universal Health Coverage (CMU) simply enshrined this change in the welfare regime by extending equal health coverage to all persons residing consistently in the country. In 1999, during the cohabitation between President Chirac and the Jospin government, Martine Aubry, head of the large Ministry of Labour and Social Affairs, pushed for the adoption of Universal Health Coverage (CMU) (Act of July 27, 1999, effective January 1, 2000). This reform widened the access to the health system to some 6 million people at an estimated cost of 9 billion francs. Chadelat, then working in the Inspection générale des affaires sociales (IGAS) and Director of the Universal Health Coverage (CMU), on September 8, 2009, at a symposium for the 10th anniversary of the Universal Health Coverage (CMU), linked the Universal Health Coverage (CMU) with the establishment a the new welfare state (Chadelat 2012). While highlighting it changing nature, Chadelat insisted that the Universal Health Coverage (CMU) was the result of a long evolution. The Rocard government had earlier extended health coverage to the Revenu minimum d’insertion, RMI (Loi du 15 décembre 1988). A series of departures from the principle that bound the Social Security system to professional activity raised the question of moving to an insurance principle linked to residence. As early as 1993, under the leadership of Lagrave and Ruellan, the DSS launched an inquiry into the establishment of universal health 1  The Universal Health Coverage (CMU) decreed that every person residing lawfully in France, irrespective of his or her employment status or contribution record was insured for health risks (Hassenteufel and Palier 2007: 591). The CMU provided the poorest with free access to health care and free complementary health insurance for those who could not pay for complementary health care (CMU Complémentaire, hereafter CMU-C [Palier 2010: 84]).

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insurance, after which the project of Universal Health Insurance (AMU, Assurance maladie universelle) took firm shape. As written by Anne-Marie Brocas (see this chapter below), it entered the Juppé Plan introduced to the National Assembly on 15 November 1995. This innovative scheme simplified the system by linking people who were not covered to a compulsory scheme and by harmonizing the social benefits between the different régimes. The Universal Health Insurance (AMU) had to provide the same social benefits to everyone as long as the residency requirement was met. As Alain Bacquet, member of the Conseil d’État, who examined its legal viability in a report submitted to the Prime Minister in March 1996, put it, “AMU is the new form of guarantee given to every person, in the name of the principle of national solidarity” (Chadelat 2012: 104). The social movement of 1995, opposed to the pension and health insurance aspects of the Juppé plan put an end to the AMU project. Although supported by the CFDT, the Fédération nationale de la mutualité française and the National Health Insurance fund (CNAMTS), it was strongly criticized by the CGT, FO and the trade unions of liberal doctors. In addition, the self-employed were opposed to the harmonization of social benefits for fear of increasing their financial contribution. The dissolution of the National Assembly in 1997 temporarily buried the project. But after the 1997 legislative elections, Lionel Jospin, the leader of the Socialist Party, who had become Prime Minister, kept Briet at the Directorate of Social Security “because of his competences to implement the policy of supply and expenditure control,”2 the Universal Health Insurance (AMU) project was relaunched under another name: Universal Health Coverage (CMU). With the left-wing government, the focus broadened to providing the poorest people with access to complementary protection. The Universal Health Coverage act (CMU) included three major changes in access to health insurance: (i) basic insurance for all residents; (ii) complementary coverage for the most disadvantaged, with free care via a waiver of advance payment; (iii) state medical aid for people who did not meet the criteria for legal residence. After 10 years, Chadelat’s 2012 assessment of the implementation of the Universal Health Coverage (CMU) was positive. The policy ensured that coverage of the population residing on French territory was complete. At the end of 2011, 2.2 million people benefited from it, and 4.4  Interview with social insurance high civil servant (MiRe 1, 1998).

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million people had access to the Universal Complementary Health Coverage (CMU-C mutuelle complémentaire). Opposition from professionals in the sector, including physicians, dentists, and insurers who felt their interests were threatened, had gradually declined. Even the question of its cost emphasized by its opponents, no longer seems to be a problem. The growth of the average cost of care covered by the Universal Health Coverage (CMU) remained, in fact, below the National Health Spending Objectives (Objectif national des dépenses d’assurance maladie, ONDAM) since its inception. However, a number of difficulties have arisen. First, the CMU did not replace the pre-existing systems. It only worked if none of the other coverage logics were possible. Being employed remained the rule for accessing the system. Moreover, the complementary universal health insurance (CMU-C) was rejected by a minority of physicians, in particular in the sector II specialists (free fees). Moreover, a part of the population in a very precarious situation remained outside its scope. The second generation of welfare elites wondered how to overcome these problems. First of all, since 2002, French cross-border workers working in Switzerland had been able to benefit from the Universal Health Coverage (CMU). A medical agreement (“convention médicale”) signed on January 7, 2005 took into account the excess fees of certain “specialists” into the existing system. In 2006, a Médecins du monde report revealed that 37% of city doctors refused to take patients receiving state medical assistance.3 The Hôpital, Patients, Santé et Territoires Act (July 21, 2009) proposed by the right-wing Health Minister Roselyne Bachelot prohibited discrimination against Universal Health Coverage (CMU) patients. Finally, under the socialist presidency of François Hollande and the ministry of Marisol Touraine, the Universal Health Protection Act (PUMA) came into effect on January 1, 2016. Although it was little noticed in the dramatic context of the terrorist attacks of November 2015, this law affirmed the new social protection model based on the principle of universal protection. From then on, people were covered simply because they lived in France. It also ended the status of “beneficiary,” as spouses had to join the Social Security system individually, thus avoiding rupture of rights in case of divorce. The Universal Health Protection Act (PUMa) has been criticized by these opponents as a set of scattered technical 3  Le Monde, October 16, 2006. https://www.lemonde.fr/societe/article/2006/10/16/ un-generaliste-sur-trois-refuse-les-soins-aux-plus-demunis_824233_3224.html

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measures. But for the social insurance policy elites who consider them as a whole, these measures of universalization of social protection fundamentally changed the meaning of the social security model.

2004: The New Governance of Health Insurance Funds Challenging the governance of health insurance funds was one of the two major battles fought by welfare elites after the 1996 reform (Darviche et  al. 2022). The new organization of powers resulting from the Social Security Budget Act (LFSS) established a close institutional partnership between the DSS and the various funds (health insurance, family, old age, ACOSS, Mutelles Sociales Agricoles, and the régimes spéciaux). The goal was to ensure that stakeholders comply with the National Health Spending Objective (ONDAM). While the DSS now played the role of policymaker, the funds, still chaired by elected officials from the social partners, had to ensure the management and redistribution of social benefits. After the reform, the Objectives and Management Agreements (COG) united the two parties, who pointedly set a four-year target for expenditure control. This contractual mechanism was supplemented by an evaluation carried out on behalf of the state by the General Inspectorate of Social Affairs (IGAS). With this new policy instrument, the state aimed to ensure proper management of the considerable sums at stake in the context of financial deficit. According to DSS Director Dominique Libault (2011, 2015), this new instrument introduced a previously missing culture and process of policy evaluation, and thus constituted a major tool for the modernization of Social Security organizations. By combining the National Health Spending Objectives (ONDAM) with the COG, the welfare elites forged an effective policy instrument to prove to the Ministry of Finance their ability to control social accounts. Until the 2004 reform, the funds did not respect the ONDAM (fixed at 4%, it could reach 7%). The welfare elites took the opportunity to criticize the social partners for declining to use the policy tools in their hands to regulate spending. The latter retorted that this was the role of the state. According to one interviewee, it then became imperative “to create an operator with real [...] fundamental responsibility for the management and control of expenditure and, to do this, it was necessary to give it the tools to do

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so.”4 Reinforcing the organizational aspect was the shift from financing the system through social contributions to financing it through taxation. This affirmation of the principle of the Social Security Budget Act (LFSS) was in turn reinforced in the 2000s with the implementation of the Universal Health Coverage (CMU), also financed by taxes. It is in this context of innovation in governance that the “Douste-Blazy” reform was initiated in 2004 (Hassenteufel and Palier 2005: 592). The reform process began in November 2003, the internal proposals of the administration were ready between January and February 2004. A first series of interdepartmental meetings produced plans for a new governance model centered on the National Union of Health Insurance funds (UNCAM). The first volume of a confidential report (at the time still not archived) of January 2004, entitled “Health insurance reform” (Réforme de l’assurance maladie) shows that the architecture of the reform was formulated by the social insurance elites well before Philippe Douste-Blazy was appointed minister (31 March 2004). Political negotiations took place with the social partners because the state proposed to limit their power. The first challenge was to get the employers’ union, the MEDEF, which retired from fund management in 2000, back to the negotiating table. Among the workers’ unions, only Forces ouvrières (FO) opposed a reform that contributed, in its opinion, to both “the privatization and the nationalization of Social Security” (sic).5 Still, according to the same sources, “that’s why it has ‘fought’ in Parliament.”6 The DSS and the cabinet of Minister Douste-Blazy were then confronted with the submission of 8500 legislative amendments: “it cost us a lot of time, it was hell.”7 In the end, the Douste-Blazy Act, which passed on August 13, 2004 (Hassenteufel 2007), confirmed the principles introduced in the 1996 constitutional reform of health insurance: a compulsory, universal, and solidarity-based system that made the state the guarantor of effective access to care throughout the country. Some measures in Title I of the law specified the objectives of controlling health care spending by making all stakeholders accountable (design of the “co-payment” in health insurance

 Interview with social insurance high civil servant (MiRe 2, 2007).  Interview with social insurance high civil servant (MiRe 2, 2006). 6  Ibid. 7  Interview with social insurance high civil servant (MiRe 2, 2007). 4 5

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[ticket modérateur], “traiting physician”8 [médecin traitant], etc.). But it was Title II that put in place the new governance of the health care system with the creation of the UNCAM and the High Authority for Health (Haute autorité de santé, HAS). The UNCAM, combining all the health insurance funds (CNAMTS, MSA, etc.), now had authority over the expenditure control policy (reimbursement rates, social benefits, etc.), was newly headed by a director appointed by the government for 5 years and difficult to dismiss (a two-thirds vote of the board of directors is required). The welfare elites would take control of the UNCAM. Parliamentary opposition focused heavily on this issue. Thus, the Socialists, represented by the deputy Jean-Marie Le Guen, denounced the new director general of the UNCAM as an omnipotent “pro-consul” acting on behalf of the state. The Communists, meanwhile, deplored the end of social democracy; governance in their eyes, should only reflect the results of elections in social insurance funds. The 1945 model still had its defenders in Parliament. The effects of the creation of the UNCAM, and especially the increase of the power of the second generation of elites, were summarized by the former director of the Health Chair of Sciences Po, a few years after the reform, as follows: “Is it the state that is strengthening its powers with a ‘health prefect’ as the left said in 2004, or on the contrary, is it a ‘health insurance technocracy’ that is taking power, outside of social partners, a sort of Third power, which binds the social partners, whereas before it was the President of the National Health Insurance Fund [an elected official] the real decision-maker? He had veto power, or even more. From 2004 onwards, a third actor emerged, a technocracy specific to health insurance and distinct from the state technocracy.”9 The appointment as head of UNCAM of Frédéric Van Roekeghem, a polytechnician, former director of the Fonds de solidarité vieillesse and of the Central Agency for Social Security bodies (ACOSS), and a former member of right-wing ministerial cabinets, was a clear sign of change. As soon he took office, he began his first address to the Board of Directors of the National Health Insurance Fund by declaring: “reform, reform, reform... we must succeed in reforming or we will lose the legislative 8  The traiting physician is the referring physician for a social security recipient, in charge of his or her medical follow-up. He is the first health professional to whom a patient turns if he has any doubts about his health. He/she ensures the usual and preventive care of his/her patients. 9  Interview with social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019).

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elections.”10 This indicated his view of the predominantly left-wing social partners. A knowledgeable observer recounted his arrival at the headquarters of the UNCAM. At the outset, he “made the point that he [did] not wish to occupy the same floor as the President of the funds,”11 then moved with his cabinets to occupy the sixth and top floor in place of the President of the funds. Then, when arrived with a large number of young ex-­ members of ministerial cabinets, including Thomas Fatôme, future director of the DSS and the UNCAM, the political strategy was clearly displayed and the affirmation of the director’s independence was made official. He made it clear “that he did not need [the trade unions].” Surrounded by young members of the second generation, he proceeded to govern in cooperation with the DSS. The policy of controlling health care spending, framed by the ONDAM and shaped by the COG, finally became a reality. Its effectiveness was quickly demonstrated by the (almost permanent) compliance with the National Health Spending Objectives (2%) after 2005. The success of the reform was welcomed by the DSS. Dominique Libault, then director of the DSS, stated that the new contract embodied by the COG constituted “a revolution in the relationship between the state and the public social security service around the search for objectives/results facilitating a posteriori the evaluation of their performance” (2015: 72). Indeed, “social security was a pioneer in the use of this approach to analyzing the performance of public policies, which then spread to other areas of state activity” (ibid: 73). Thanks to this success, the welfare elites were now equipped with policy instruments that would allow them to hold their own with the elites of the Ministry of Finance. Last but of major importance in confirming the institutionalization of the second generation, the UNCAM would become a strategic site for the development of their career paths at the top of the health insurance sector. The DSS and UNCAM together formed the institutional pillars on which the spirit of the reform was maintained, while the number of managerial positions increased significantly. The career path of Thomas Fatôme is in this respect emblematic because after his passage through the cabinet of the director of the UNCAM, he successively became head of the DSS (2012–17) before being appointed in 2020 director of the UNCAM. In the following chapters, we will see how the consolidation of circulation at the top of the sector has made the  Interview with social insurance high civil servant (ProAcTA, 2019).  Ibid.

10 11

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policy elites largely interchangeable. Although they have served in ministerial cabinets on both right and left, their political identities were invisible in the appointments, because they shared the same objective: to implement the “Sustainable Social Welfare” program. The new pattern broke with previous periods of strong bipartisan politicization, when the rule was to leave administrative management after a change of political majority (see Part I above). By the early 2000s, the welfare elites were recognized as custodians of state policies in their sector of intervention, who were capable of giving meaning to a new welfare state. But, they earned this status by challenging the legitimacy of the elites of the Ministry of Finance in their own area of expertise during and after the 2008 financial crisis (Darviche et al. 2022).

2008: The Unpredictable Defeat of the Elites of the Ministry of Finance In 2007 and 2008, the second generation elites faced the challenge of implementing the new Ministry of Public Accounts12 amid effects of the 2008 financial crisis on the social security deficit (which rose between 2008 and 2010 from −9.4 to −28 billion euros). The creation of this ministry was seen by some of the high civil servants of the Ministry of Finance as an opportunity to extend their policy of budgetary rigor to social security policies by essentially integrating the Social Security Budget Act (LFSS) into that of the state. Such an outcome would have drastically reduced the welfare elites’ power, they vigorously struggled for their “survival” and that of the “Sustainable Social Welfare” program. To understand this conflict, it is important to recall the arguments mobilized by both sides. High civil servants in Finance saw the placement of the DSS under the Ministry of Public Accounts as an opportunity to bring the social security budget (at least its “revenue” part) within their authority. This, in turn, presupposed the removal of the Social Security Budget Act, which the defenders of the Ministry of Finance’s austerity policy justified by the need to avoid countless budgetary tricks by the administrative directorates of the Ministry of Health and the health insurance funds to circumvent the National Health Spending Objectives (ONDAM). For the elites of the Ministry of Finance, both these parties tried to “pass on” their debts to 12  To which the DSS is since then also attached, in addition to the Ministry of Health and the Ministry of Labor.

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the other in order to balance their annual budget, which they considered to be a considerable waste of time and efficiency. To put it plainly, the welfare elites were accused of doing their job badly. The elites of the Ministry of Finance argued too that the existence of two finance laws in France (one for the state and one for the Social security) put it at odds with the budgetary rules of the European Union. The European Commission considers the budget of the social security as part of the state’s global budget. Some high civil servants of the Ministry of Finance declared their preference for a “nationalization [bringing under the state control] of the social security”13 which amounted to reducing the governmental authority of the welfare elites. The argument was logical though: “How can parliamentarians, when they vote on the Finance Act, arbitrate between spending on National Education and Defense, when they cannot arbitrate between spending on Education and Health or between spending on Defense and Health?”14 In fact, compulsory levies (various taxes) form a coherent whole for the elites of the Ministry of Finance. Bringing the DSS under the umbrella of the new Ministry of Public Accounts was a political opportunity to merge the two finance laws (state and Social Security). Finally, the elites of the Ministry of Finance denounced the “reckless passion for the Sécu (social security) issues” of the welfare elites.15 A senior budget official said flatly that “the problem with the Sécu is that it considers itself a species, a world apart. In fact, the people of the Sécu are all people who love the Sécu.”16 Whereas “within the state, it’s more varied. There are the budget people who say no (to spending), and the ministries who say yes (also to spending), then nobody agrees, but in the end there are inter-ministerial arbitrations.”17 With the LFSS, “at the Sécu, even the people who have to say no [those at the DSS] are all people who love the Sécu. So we are in a logic of backyard preservation. And as soon as there is money in the Sécu, it must be recycled in the Sécu. Is this money theirs? In any case, they consider it as such.”18 The conflicts between the Ministry of Finance and the Ministry of Social Affairs are long-term. Thomas Fatôme director of the DSS indicated that before the attachment of the DSS to the Ministry of Pulic Accounts, conflicts were frequent between the two ministers, especially at the time of financial  Interview with high civil servant of the Ministry of Finance (ProAcTA, 2019).  Interview with high civil servant of the Ministry of Finance (ProAcTA, 2019). 15  Ibid. 16  Ibid. 17  Ibid. 18  Ibid. 13 14

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negotiations. But the plan to repeal the Social Security Budget Act (LFSS) pushed by some within the Directorate of the Budget was defeated by the rhetoric and arguments mounted by the welfare elites. At the start of Nicolas Sarkozy’s presidency (2007–09), the first struggle waged by the latter concerned the reimbursement of payroll tax exemptions on overtime and low wages. This economic stimulus affected the budgetary resources of the Social Security system, even though employment policy did not fall within its field of intervention. The second generation elites in DSS were not opposed to efforts to control spending for purposes other than improving social protection, and once attached to the Ministry of Public Accounts, they obtained the reimbursement of payroll tax exemptions. Indeed, the Minister of public account, Éric Woerth, wanted to quickly repay all the debts of the state to Social Security, an obligation he sought to enshrine in law. The elites of the Ministry of Finance have clashed with the welfare elites over the austerity issue. In this conflict taking place between the two ministries, their tactics consisted, first, in denigrating the enemy and, second, in galvanizing the troops. The social insurance elites emphasized the lack of deep knowledge of the elites of the Ministry of Finance in matters of social security. This confirmed their identity as custodian of state policies in the social security domain, which turned on their unique capacity to design solidarity policies (health insurance, family, and pensions) that were not based solely on budgetary rigor, but rather gave primacy to the protection and coverage of citizens, with a logic of (financial) sustainability intervening at a later stage as a policy adjustment. It was the opposite of the Ministry of Finance’s approach, in which the search for budgetary rigor took precedence over other policy issues. When accused of replicating the autocratic doxa of the Ministry of Finance (Pierru 2011), the second generation elites claimed to develop a different type of efficiency in public policy. Their ability to sustain this dual policy perspective was emphasized collectively by welfare elites, who saw this “art” as a key advantage in inter-­ ministerial policy arbitrations with the Directorate of the Budget. One who participated in many settlements during this period confirmed: “From the Ministry of Finance, there is no [alternative policy], just a mix of budgetary rigour.”19 While “The strength of DSS is that it is not only budgetary. It is not only a sort of Directorate of the Budget bis […] on the social insurance side. It is a directorate that carries out social insurance policies […] and who run a public service.”20 Two visions of the use of the budget constraint therefore  Interview with social insurance high civil servant (ProAcTA, 2019).  Ibid.

19 20

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clashed at the top of the state. In this confrontation, the welfare elites turned the attachment to the Ministry of Public Accounts to their advantage. To understand how this happened, we must take into account, first, the change in the career paths of the second generation within the Iron Triangle of the social security governance, which allowed them to develop an innovative conception of strategies to control spending, and, second, their adroit management of budget arbitrations, which were no longer played out between ministries competing for public money, but between two directorates of the same Ministry (DSS versus Directorate of the Budget). The ranks of welfare elites had, in the course of the 2000s, become qualitatively and quantitatively more important (see this chapter below). During Dominique Libault’s term as Director, the DSS conducted a recruitment campaign targeting engineering graduates from the National School of Statistics and Economic Administration (École nationale de la statistique et de l’administration économique, ENSAE). These young engineers were “recruited on contract21 because the DSS was not a research and statistics directorate as the Directorate for Research, Studies, Evaluation and Statistics (DRESS) and from which these profiles of high civil servants [i.e. statistical engineers] are traditionally attached.”22 It was no longer a question of sporadically recruiting one or two actuaries as had been the case before 1996 with the first generation elites, but of playing on equal terms with the Ministry of Finance. The Sub-Directorate of Studies and Financial Forecasts of the DSS had become a sanctuary for elites with an actuary profile (see Table 2.3), and the evolution of their career paths within the top positions of the DSS was extremely fast. The appointment of Franck Von Lennep, a statistical engineer, as Director of the DSS on June 1, 2020, was a tangible proof of this trend. This type of leadership meant that disregard of the National Health Spending Objectives was over, and indeed, in 2012, France stayed within the voted 2% ceiling. Faced with these results, the elites of the Ministry of Finance gradually revised their vision of the Ministry of Social Affairs as a spending ministry. They acknowledged, that “the social ones’ don’t [do anything more] with public money... and don’t [spend] too much.”23 Moreover, the arrival of the Ministry of Public Accounts required a cross-cutting approach to budgetary issues, which soon led to the pacification of relations between the welfare elites and those of the Ministry of 21  In France, state statistical engineers can only be appointed as career civil servants in interministerial directorates dedicated to statistical studies. 22  Interview with social insurance high civil servant (ProAcTA, 2018). 23  Interview with high civil servant of the Ministry of Finance (ProAcTA, 2019).

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Finance. The new institutional mechanisms gave the DSS a strategic advantage in the negotiations within the Ministry, as the second generation elites exploited their dual professional know how on social insurance and fiscal policies. When other directorates of the Ministry of Social Affairs and Health proposed expensive reform projects to the DSS, they sometimes said “no, it’s too expensive, it won’t pass for the Ministry of Finance.”24 Meanwhile on the same policy issue, the Budgetary directorate, “said ‘yes, it’s the cheapest, it’s useful.’”25 This double game allowed to “find points of equilibrium,” and consequently to turn the political settlements to their advantage much of the time. One observer articulated a Machiavellian hypothesis, according to which the DSS “finds itself with two supervisory ministers and in fact the DSS can play a certain margin of maneuver.”26 This strategy of reversing budgetary rhetoric largely explains the failure of the project to merge the Finance Act with that of the Social Security Budget Act (LFSS) envisaged by the elites of the Ministry of Finance. The welfare elites had an unbeatable argument when they warned that abolition of the LFSS would transform the Ministry of Health and Social Affairs back into a “spending ministry,” thus compromising hard-won financial balances, by making a sector that consumes one-third of GDP (180 billion euros) less financially responsible. They also argued that since 1996 “the DSS has been in charge of the LFSS. It is the heart of the reactor of the relations between the government and the parliament.”27 As an illustration of this, a member of the second generation claimed to have “dealt” directly with the Minister of Health, Roselyne Bachelot, on this political issue, when her chief of staff (chef de cabinet) echoed the wishes of the Ministry of Finance. He claimed to have won his case as the minister told him that she was not going to “go along with what her chief of staff proposed to [her].”28 The austerity policy of the Ministry of Finance—“I’ll lower the reimbursement rate and that’s that”—was no longer acceptable. The welfare elites proposed another approach by policy instruments, allowing for expenditure management that took explicit account of the distinctive issues of social security. This mobilization of their policy skills later enabled them to propose an extension of the scope of intervention of the social security system to new social risks such as “old age and disability.”  Interview with social insurance high civil servant (ProAcTA, 2019).  Ibid. 26  Ibid. 27  Interview with social insurance high civil servant (ProAcTA, 2019). 28  Ibid. 24 25

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Our approach explains the correlation between the implementation of the “Sustainable Social Welfare” program and changes in career paths of elites. It pointed out how they consolidated their role as custodians of state policies. These converging processes reinforced the reconfiguration of the state in the social security domain.

Bibliography Chadelat, Jean-François, « La couverture maladie universelle », Revue d’histoire de la protection sociale, n° 5, 2012: 101–113. Darviche, Mohammad-Saïd, William Genieys, Patrick Hassenteufel, « L’institutionnalisation de l’élite du Welfare au cœur de l’État. Les nouveaux gardiens des politiques d’assurance maladie », Revue Française de Science Politique, vol. 72, n°5, 2022, pp. 1–21. Hassenteufel, Patrick, « L’État mis a nu par les politiques publiques », in B. Badie, Y. Déloye, (dir), Le temps de l’État. Mélanges en l’Honneur de Pierre Birnbaum, Paris, Fayard, 2007: 311–329. Hassenteufel, Patrick, Bruno Palier, “Trompe-l’oeil in the Governance of Health Insurance. French-German Contrasts”, Revue française d’administration publique, 113, 2005: 13–27. Hassenteufel, Patrick, Bruno Palier, “Toward a Neo-Bismarkian Health Care States? Comparing Health Insurance Reforms in Bismarkian Welfare States”, Social Policy & Administration, 41 (6), 2007: 574–596. Libault, Dominique, « La transformation du pilotage de la Sécurité sociale : une expérience pour l’ensemble de l’action publique », Informations sociales, n°189, 2015: 72–79. Libault, Dominique, Sandrine Dauphin, « Le sens du service public comme moteur de la performance », Informations Sociales, n°167, 2011: 52–57. Palier, Bruno, “Ambiguous Agreement, Cumulative Change: French Social policy in the 1990s”, in Wolfgang Streeck, Kathleen Thelen (eds.), Continuity and Discontinuity in Institutional Analysis, Oxford (U.K.), Oxford University Press, 2005: 127–144. Palier, Bruno (ed.), A Long Goodbye to Bismarck. The Politics of Welfare Reform in Continental Europe. Amsterdam, Amsterdam University Press, 2010. Pierru, Frédéric, « Budgétiser l’assurance maladie. Heurs et malheurs d’un instrument de maîtrise des dépenses publiques: l’enveloppe gobale (1976–2010) », in Philippe Bezès, Alexandre Siné, Gouverner (par) les finances publiques, Paris, Presses de Sciences Po, 2011: 393–449.

CHAPTER 8

Shaping the Iron Triangle of Governance

The decade following the constitutional reform of 1996 has been marked by a change in the social background and career path of welfare elites. In this chapter, we sketch a series of sociological portraits correlating the development of policy orientation and the change in elites’ structure, the second generation of which worked to complete “Sustainable Social Welfare” program. Their portraits will be compared with those of the previous generation for elements of continuity and discontinuity in their social backgrounds/career paths. Unlike the first generation, those of the second generation do not come from a Grands corps. The majority are young énarques trained and promoted within the DSS, passing through the General Inspectorate of Social Affairs (IGAS) or serving as administrateurs civils during their career path, before reaching leadership positions. With a strong relational proximity to the first generation (they were office managers and/or cabinet members under their authority), they acquired their policy learning in past struggles with the “old-fashioned” elites (see Table 2.3). At the beginning of the 2000s, the DSS was changing to become the cornerstone of an Iron Triangle. The other two corners were composed, first, by the UNCAM and, second, by the set of “high authorities” (hautes autorités) and “high councils” (hauts conseils) of the social security sector

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_8

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created in the 2000s.1 It is by circulating vertically (occupational advancement) and horizontally (between institutions) within this Iron Triangle that the career paths of the second generation of welfare elites were shaped. Young énarques began their careers in a sub-directorate of the DSS, then spent a short time in a ministerial cabinet, and continued their careers in the cabinet of the UNCAM. They then worked with the social partners in the implementation of expenditure control. This policy learning opened the door for them to return to a leadership position in one of the sub-­ directorates of the DSS or in another directorate of the Ministry of Health and Social Affairs. The high authorities and councils constitute, for their part, prolonging the career path of the first generation in a role of “sage,” producing reports on current and future social security issues. Appointed to head these institutions for “service rendered,” those who held leadership positions assumed a proactive role. Their strong moral authority defined them as the guarantors of the future of “Sustainable Social Welfare” program and strengthened the state control over social security policies in accordance with the spirit and letter of the 1996 constitutional reform (Fig. 8.1). In this chapter, we focus on elites whose social backgrounds/career paths foreshadow the change between the two generations. These are the avant garde of the second generation who occupied top positions in the social security governance between 2000 and 2010 before joining the high authorities and high councils. After reviewing the careers of Dominique Libault, the second internally trained director of the DSS (2002–2012), and Anne-Marie Brocas, for a long time its deputy director, we will continue with a sociological portrait of Pierre-Louis Bras, a politicized social insurance policy elite. We end with a contrasting portrait of Didier Tabuteau.

1  From the 2000s onwards, a large number of “independent administrative authorities” such as high councils or high authorities were created in the social welfare sector: in 2000, the Pension Advisory Council (Conseil d’orientation des retraites, COR); in 2003, the High Council for Health Insurance Policy Planning (Haut conseil pour l’avenir de l’assurance maladie, HCAAM); in 2004, the High Authority for Health (Haute autorité de santé, HAS); in 2009, the High Council for the Family (Haut conseil de la famille, HCF); in 2012, the High Council for the Financing of Social Protection (Haut conseil pour le financement de la protection sociale, HCFiPS).

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Fig. 8.1  Career paths within the Iron Triangle of social security governance

Dominique Libault: Strongman of the Directorate of the Social Security In 2019, Libault, former director of the DSS (2002–2012), and current chairman of the High Council for the Financing of Social Protection (Haut conseil pour le financement de la sécurité sociale, HCFiPS), submitted a report on the policy for the elderly to Prime Minister Édouard Philippe.2 Not surprisingly, the report, which contained 175 proposals for a new policy on old age and disability in France,3 concluded that it was necessary to create a new branch of social security dedicated to this issue 2  Dominique Libault, Concertation. Grand âge et autonomie, Paris, Ministère des solidarites et de la santé, mars 2019. 3  https://solidarites-sante.gouv.fr/archives/consultation-place-des-personnes-agees/ concertation-grand-age-et-autonomie/article/rapport-de-la-concertation-grandage-et-autonomie

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(see Chap. 9). For the elites of the Ministry of Finance, this report was further evidence of the unreasonable love “of these people [welfare elites] for social security.”4 One even described Libault as “just about the most conservative thing in the world of social security, and that’s saying something,”5 an acerbic that reveals latent conflicts on the very definition of the public interest. Libault’s sociological portrait clarifies the change in the social backgrounds and career paths and divergent conception of public action between the two generations. In his 30-year career path within the DSS, he held all command positions up to that of Director, a path himself described as “extraordinary.”6 Before him, these management positions were the preserve of the Grands corps, the Conseil d’État and then the Cour des comptes. After him, this practice of power belonged to the past, as an appointment to the management of the DSS shifted to the elites circulating within the Iron Triangle of the social security governance. Upon graduating from ENA, Libault joined the DSS as a member of the corps of the administrateurs civils. He then moved directly to Simone Veil’s cabinet, between July 1993 and June 1995, as a technical advisor. Encouraged by the Veil’s policy favoring internal career promotion, the young Libault re-entered the DSS in 1995 and climbed all the management positions, namely: Deputy Director of Access to Health Care (June to November 1995), Deputy Director in charge of the financing and management of Social Security (December 1995 to June 2000), Deputy Director (July 2000 to October 2002), then Director under the Raffarin government. His appointment, under consideration during the socialist government of Jospin, was, for the time, highly symbolic because politically unexpected.7 A left-wing government proposed to appoint a center-­ right member of the welfare elites as director. Libault’s career path heralded the decline of antagonism in the affairs of the social security, which until then had been strongly divided politically. His nomination consecrated the “handover” in positions of power to the benefit of the second generation: those of the “children” of the DSS (Ruellan was an earlier exception) (see Chap. 4). A keen observer asserted that “a ministerial administrative directorate is really strong when it can select and train  Interview with a high civil servant of the Ministry of Finance (ProAcTA, 2019).  Ibid. 6  Interview with a social insurance high civil servant (ProAcTA, 2019). 7  Interview with a social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019). 4 5

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its own leaders. Today [in 2006], we can say that it reproduces them, as is the case with the current director Dominique Libault.”8 His predecessor as head of this directorate, close to the socialist party, underscored the novelty of this appointment made under the ministry of Martine Aubry: Libault, “was my second in command [deputy director]... we knew that he [had] come through the Veil cabinets, but his qualities and his skills on the issues of the sector. He [was] extremely competent. He [was] therefore indispensable for this appointment”.9 He added that Briet, DSS' former director and architect of the 1996 reform, “[gave] an important place to statisticians and evaluation, relegating jurists to second place.”10 And in conclusion, “we [were] [...] politically divided, but we [functioned] as a professional community”.11 As this vignette shows, during the Libault era, professional identity took precedence over partisan politicization in DSS leadership appointments. Despite changes in the government majority, Libault remained in office until 2012. Strongly protective of the autonomy acquired since 1996  in the execution of the budget act and respectful of the National Health Spending Objectives (ONDAM), he committed the forces of “his” directorate to the preparation of the Douste-Blazy Plan “in confidentiality while taking into account what the actors of the sector [think] in order to make proposals acceptable [both] by the social body and the political body”.12 The objective of the reform was “to clarify the relationship between the state and the national health insurance funds to facilitate consensus on policy issues”,13 specifically by reorganizing the governance between the state and the social partners in order to make the expenditure control policy more efficient. The proposed solution would subordinate the Presidential power over the funds to a new directorate, the UNCAM, which would facilitate the development and implementation of the ONDAM. The new organization would create a directorate with a cabinet in which welfare elites could expand the scope of their career paths. At the same time, Libault led another long and decisive struggle to empower the second generation within the state by making the DSS an institution that offered highly appealing career paths. He claimed to have  Interview with a social insurance high civil servant (MiRe 2, 2006).  Interview with a social insurance high civil servant (MiRe 2, 2006 ProAcTA, 2019). 10  Ibid. 11  Ibid. 12  Interview with a social insurance high civil servant (MiRe 2, 2007 ProAcTA, 2019). 13  Ibid. 8 9

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built staff within the DSS by developing a well-developed human resources policy, and by communicating with young énarques, especially those from the IGAS, in order to attract them to the sub-directorates of his administration. In the early 2000s, the image of the ministry was changing, but it was not yet perceived within the high civil service as a destination for a distinguished career within the state. On this point, Libault’s own career was his best asset, as it highlighted the potential for internal promotion within the Iron Triangle of the social security governance. The best recruits might be appointed to the ministerial cabinets as technical advisors or even as the director of the UNCAM, and then return to top positions inside the DSS. Moreover, aware of the long-standing conflict between the both generations of welfare elites and those of the Ministry of Finance, Libault trained his staff “to use the same language as the Finance high civil servants” by absorbing “a culture of rigor and control of social accounts”.14 The goal was twofold: to be able to successfully confront the Ministry of Finance during interministerial budget arbitrations and to go beyond their purely macroeconomic reasoning by developing an alternative approach to health insurance issues (Libault 2015). To do so, Libault implemented a recruitment policy for statistical engineers trained at ENSAE in order to strengthen the public accounting skills of its directorate.15 He explained that “[having] also instituted, and this is very important, an industry. I [went] looking for engineers. Because I see that on subjects [related to] cost control, organization, all that, [...] engineers can be good. And so I [went] looking for engineers [...] some of whom will really succeed and have a career and enjoy themselves.”16 As we have seen (Chaps. 7 and 9), this recruitment strategy was decisive in defeating the attempt to merge the finance laws, initiated by the Ministry of Finance, when the Ministry of Public Accounts was created in 2007. With a newly favorable balance of power in staffing members, the welfare elites asserted their ability to control both the largest state budget and the development of public policies specific to social security.

 Ibid.  In France, traditionally, statistical engineers can only be appointed to a career in administrative directorates specialized in the evaluation and production of statistics. This is not the case for the DSS within the Ministry of Health and Social Affairs. 16  Ibid. 14 15

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At the end of his long tenure as director of the DSS, Libault was appointed “au tout extérieur”17 in 2012 to the Conseil d’État. This appointment did not prevent him from continuing his career within the Iron Triangle that he had helped to build. After becoming vice-president of the newly created High Council for the Financing of Social Protection (HCFiPS), he assumed its chairmanship in 2018. He wrote a series of reports on the completion of “Sustainable Social Welfare” program, including one on “Old Age and Disability”. This report led to the creation of a 5th branch of Social Security, focused on dependency. Moreover, as Director of the National School of Social Security (École Nationale Supérieure de Sécurité Sociale), he trained future generations in service of “the sustainability of the French social security model”.18 At the end of an interview, Libault summarized his career path in these words: “I participated in the reforms establishing the universality of social protection (The General Social Insurance Contribution [CSG] and Universal Health Coverage [CMU]), in the reform strengthening the role of the state and in the search for financial sustainability through the execution of the Social Security Budget Act (LFSS). This is a French originality. I am the one who really wanted this”,19 added that “social security is Sisyphus... an eternal restart…”.20

Anne-Marie Brocas: A “Great Lady of the Sécu” Less publicly visible than Libault, whose deputy director she was in the DSS, Brocas shaped her career around issues of expenditure control policy and the development of universal coverage. Trained by Ruellan at the DSS (see Chap. 4), she played a key role, with Briet, in drafting the 1996 reform and drew an initiative for Universal Health Insurance (AMU). With the professional legitimacy she had acquired in policy formulation, she went, au tour extérieur, to the IGAS (2013) and then, from 2014 until her death in February 2020, she chaired the High Council for Health Insurance Policy Planning (HCAAM). 17  The “tour extérieur” is a practice of recruitment into the top administration outside the normal procedures. It thus allows the political power to directly appoint civil servants or place non-civil servants in certain positions of responsibility. 18  Interview with a social insurance high civil servant (ProAcTA, 2019). 19  Ibid. 20  Ibid.

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Member of the corps of administrateurs civils like Libault, she joined the DSS after graduating from ENA to work on pensions, then moved to the Forecasting Directorate of the Ministry of Finance (Bureau D 3: Social Transfers), where she acquired know-how about the issues of fiscal policy, then lacking in the welfare elites. This remarkable career path opened doors to the cabinet of the Minister of Health (socialist Bruno Durieux in the Rocard government), where she served, as technical advisor and then as deputy director (1990–92). This last role brought Brocas into the negotiation of policies with health professionals. Her objective was to “negotiate the financial constraint and be ready to offer compensation to the health professions on a barter basis. You do less volume of activity and, within the framework of an envelope, you will be granted increases in your unit remuneration”.21 From this experience, she learned that it was imperative to involve health professionals in policy formulation: “We could not set up systems that would be purely financial frameworks... we had to reach agreements that integrated the evolution of practices or professional practice and the organization of care. From that time, I have kept the conviction that we [are] obliged to deal with all this... The Ministry of Finance, she says, [does] not have an alternative method of regulation... It is content to say each time that the financial guarantee clauses are not sufficiently locked in. But that’s secondary to the overall design.”22 After her stint in a ministerial cabinet, Brocas returned to the DSS as deputy director. Regarding the Universal Health Insurance (AMU) project that she led, she explained that “it was a project that had been in progress for some time and that I had initiated on my own without anyone asking me to do so... I also [...] obtained the agreement of the elites of the Ministry of Finance on the very conception of the project. It is perhaps because the dossier appears to be technically very mature or very advanced that the politicians [were able] to say to themselves: we can make the announcement and integrate it into the Juppé Plan as a flagship proposal.”23 Leaving her position at the Directorate of Social Security in 2000, she was appointed secretary general of the Pension advisory council (COR) and then, in 2006, for 6 years, at the head of the Directorate for Research, Studies, Evaluation and Statistics (Direction de la recherche, des études, de l’évaluation et des statistiques, DREES). Participating in discussion forums organized as part  Interview with a social insurance high civil servant (MiRe 1, 1998 & ProAcTA, 2018).  Interview with a social insurance high civil servant (ProAcTA, 2018). 23  Ibid. 21 22

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of the “2010 Health Plan” on the challenges and prospects of social protection policies, she ensured that “Sustainable Social Welfare” program adapted as well as possible to constantly changing realities. As chair of the HCAAM, Brocas co-organized the Grande Conférence Santé (February 11, 2016) under the socialist government of Manuel Valls (Brunn and Genieys 2022). The ideas in the resulting report were mostly taken up in the law on the reorganization of the health care system, known as Ma santé 2022, promoted by Agnès Buzyn and adopted in July 2019 (see Chap. 9). The objective was to move away from the French model of medicine centered on the hospital and to reorganize access to medical care. Brocas’ report argued for correcting “the policy of controlling the evolution of health care spending which, although it has achieved all its objectives, has become too dominant in relation to other regulatory approaches such as medical or economic regulation,”24 and concluded that the shift to a “universal funding logic, and ultimately universal population coverage”25 now stood in contradiction with the Bismarkian model of social security inherited from 1945.

Pierre-Louis Bras: The End of Politicization Bras’ career path was marked by several stints in ministerial cabinets. In the still highly polarized context of the late 1990s, he defined himself as a “high civil servant in the cabinet”,26 a personal choice that destined his career in the high administration of the Social Security to be short-lived. His repeated appointments to socialist ministerial cabinets, from Claude Evin to Jérôme Cahuzac via Martine Aubry, led him to be “placardisé” (given the “silent treatment”) at the IGAS whenever the conservatives were in power. Nonetheless, he defended, through a sustained production of academic articles, and reports, the implementation of “Sustainable Social Welfare” program. Bras having graduated from HEC (École des Hautes études commerciales, a major French Business School) and from ENA in 1982 as an administrateur civil, joined the Caisse des dépôts et consignation (public bank). He specified that “at the time, social work was not appreciated and there was no question of me going to the IGAS. But, with the arrival of the left in power,  Ibid.  Ibid. 26  Interview with a social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019). 24 25

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I would have gone to any ministerial cabinet”,27 which he did in 1988, joining the cabinet of Claude Evin, the Socialist Minister of Health, as technical advisor for social security “which accelerated my career”. In this role, he became socialized with the issues of social protection policy. Following the political changeover in 1993, he left his career in the ministerial cabinets, returning in 1997 with the socialist government of Jospin: “with the new changeover, I [returned] to government first as an advisor in charge of social protection, then as deputy director in 2000, in the cabinet of Martine Aubry”28 alongside his close friend Didier Tabuteau (see the following sociological portrait). His service in the cabinet led to his appointment to the DSS from July 2000 to October 2002. The end of his mandate as director of the DSS followed the return of the conservatives to power. “Appointed director of the DSS by Martine Aubry, [I was] fired by the right-wing Minister Jean-François Mattéi after six months”.29 He explained that “high civil servants in the cabinet have careers that are indexed to a political color and therefore suffer what goes with it. The political tradition is that when a director of a central administration is unloaded [he is offered] these ‘elephant graveyards’ that are the IGAS or the Cour des comptes”.30 Going into the private sector was unthinkable to him at the time, so he accepted an appointment to the IGAS, which “allowed [him] to increase my expertise on policy issues. [and to publish] in journals such as Droit social and others”.31 During his 10 years in power—right-wing governments obliging—far from remaining inactive, he developed his knowledge of social security issues. He noted the development, during this period, of a “culture of rigor and control of social accounts”.32 He pointed out that “more and more énarques are making good careers there” and contented that he contributed to the change in career paths of the second generation elites, in particular, by pushing the appointment of Libault as head of the DSS. In retrospect, he added that: “[in 2006] the movement was even stronger because [it] is led by people who [were] trained there. Symbolically, it’s a strong trait that an administrative directorate is led by someone who was trained in-house and [did not] come  Interview with a social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019).  Ibid. 29  Interview with a social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019). 30  Ibid. 31  Ibid. 32  Ibid. 27 28

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from a large corps or an inspectorate. Libault, he started in the A1 office and now he is the director of the DSS”.33 As early as 2002, Bras knew that he would not return to a position as director of administration until the left regained power. With the election of the Socialist President François Hollande, the professional know-how acquired over the long term as well as his personal proximity to the Minister Jérôme Cahuzac, “an ex-member of the Evin cabinet (socialist minister of health 1988–1990)”, enabled him to become an advisor in charge of social accounts within the cabinet of the new Minister delegated to the Budget [2012–2013]. He observed that in this new era, there were now “policies of the Directorate of Social Security [but] less politicization in the appointments to its top position”,34 and illustrated his argument by citing his two successors at the head of the DSS: Libault and Thomas Fatôme. He noted too that the socialists, François Hollande and Marisol Touraine, kept Fatôme in office throughout their left-wing presidency, even though he had served in several cabinets under the right-wing Sarkozy presidency. Henceforth, the political staff would change with the elections, but the welfare elites would keep their posts. Because, according to Bras, the second generation had been trained by the first generation, depoliticization was coupled with a common culture in the interpretation of the stakes of social insurance policies. He again cited the example of Thomas Fatôme (see his sociological potrait in the next chapter), who passed through President Sakozy’s cabinet as a technical advisor, then the DSS, and again through the cabinet of the Prime Minister, Édouard Philippe, before arriving in 2020 at the Directorate of the UNCAM. “[He was] a ‘baby elite’ during your ‘work’ on ‘social welfare elite’ [1990-2000s]. He has become a ‘super’ elite today”.35 The DSS, the cornerstone of the Iron Triangle, shaped the career paths of the second-­ generation “because careers are even more specialized than before [...]. The new ones come from or go through IGAS. They meet people like Libault or myself [...]. Now there is a pool to draw from”.36 These “insiders” were, moreover, protected from “outsiders”, which is why “in the ministerial

 Ibid.  Ibid. 35  Our first academic articles on the making of a French “social welfare elite” were published between 2001 and 2015 (Genieys and Hassenteufel 2015; Genieys 2010). 36  Interview with a social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019). 33 34

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staffs, the political appointee positions on health are more and more occupied by individuals who have careers in social affairs”.37 The development of career paths of the welfare elites promoted continuity in policy formulation. In 2012, the socialist President Hollande, despite campaign announcements of massive investments in the hospital sector “asphyxiated by the Sarkozy administration,” was not able to change the direction of social insurance policies, especially for the public hospitals, because the public finances of the state weighed heavily on the National Health Spending Objectives (ONDAM). In this context, Thomas Fatôme, director of the DSS, mobilized his expertise in expenditure control policy to convert the socialist minister Marisol Touraine, despite the simultaneous opposition of private and public hospital doctors. Bras remarked that economic policy, especially the reduction of the public deficit, constrained the initial ambitions of the Socialist Presidency to devote more resources to care (Bras 2016). Paradoxically, French citizens “want at the same time a decrease of taxes and an increase of social benefits!”.38 These contrasting demands are strongly reflected in the electoral platforms of the governing parties and put pressure on the hopes of the welfare elites to contain the increase in taxes, payroll taxes, and spending while expanding social benefits. After a brief stint in the cabinet to “monitor” the activities of the DSS from within the Ministry of Public Accounts, Bras served as secretary general of the ministries in charge of social affairs (2013–14) before returning to the IGAS. Since 2015, like many other members of the second generation, he continued his career within the Iron Triangle in the high authorities of the sector, chairing the Pension Advisory Council (COR) and the orientation committee of the Technical Agency for Information on Hospitalization (Agence technique de l’information sur l’hospitalisation, ATIH). Finally, Bras joined the debate on the government’s exit from the prospective payment system (Tarification à l’activité, T2A) (Bras 2017). Invented by the second generation, this policy instrument, whose purpose was to ensure better control of hospital spending, has been strongly criticized since it came into force in 2003. Professionals in the sector and left-­ wing defenders of the public hospital system denounced its perverse effects on the health care system. In essence, T2A based on allocation of resources measures of the nature and volume of hospital activities, not on a global  Interview with a social insurance high civil servant (ProAcTA, 2019).  Ibid.

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authorization of funds in hospital budgets as had been the case before. Bras noted the rationale for the T2A, notably the incentive to increase the production of care, but admitted that it leads to less attention paid to patients, a threat to the quality of care that justified a limitation of the use of the T2A.

Didier Tabuteau: A Dissonant Voice Tabuteau, member of the Conseil d’État, has a profile resembling that of the heirs of Pierre Laroque who were pushed out of the governance of social security by the first generation, as the legal culture, which characterized the 1945 model, was replaced by a specialized culture confronting the challenges of social insurance policies. One close colleague stated that “although recognized by all as extremely brilliant in the field of social affairs, [he] did not have the expected career path for this reason [member of the Conseil d’État]”.39 Despite having occupied several important positions in the socialist ministerial cabinets, he pursued a career path that diverged from that of the welfare elites. Like his close friend Bras, Tabuteau’s interest in social security was strongly shaped by his political commitment to the left. Technical advisor in the cabinet of Claude Evin, he was then, from 1992 to 1993, chief of staff to Bernard Kouchner (then Minister of Health and Humanitarian Action). After the Left won the legislative elections of June 1997, he was appointed deputy director of the cabinet of Martine Aubry (Minister of Employment and Solidarity) and then, in 2001, director of the cabinet of Bernard Kouchner (Minister for Health). Between these intervals, Tabuteau directed the new Drug agency (Agence du médicament) from 1993 to 1997. His deep experience in ministerial cabinets enabled him to follow closely the progress of reform. For example, the continuous strengthening of the role of the state from the invention of the General Social insurance Contribution (CSG) through the “apotheosis” of the Social Security Budget Act (LFSS). On a dissonant note, he contended that “the Juppé Plan was made by people [whose] aim was to allow better control of social accounts”.40 In 1999, while cabinet director for the Socialist Minister Martine Aubry, Tabuteau was on the front line of the conflict over the Johanet  Interview with a social insurance high civil servant (ProAcTA, 2019).  Interview with a social insurance high civil servant (MiRe 2, 2006 & ProAcTA, 2019).

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Plan (see Chap. 4). Johanet, then director of the National Health Insurance Funds for Salaried Employees (CNAMTS), wanted the Minister to endorse his proposal for a policy of controlling health expenditure that projected 60 billion francs of new savings, including 30 billion francs in the public hospital sector. Tabuteau remembered that “we [saw] this strategic plan coming and we [found] it very badly timed”41 because politically impossible for a left-wing government preparing for the presidential elections of 2002. Tabuteau’s long path in the ministerial cabinets of health policy is told in his book Les contes de Ségur (2006), which explains why and how he distanced himself from the second generation. From his point of view, expenditure control policy wrongly took precedence over the logic of universalization of the system and the defense of a strong public hospital system. With the return of the conservatives to government, “necessity made virtue,” so Tabuteau assumed the role of critical expert. Having held the “Health” chair at Sciences Po from 2006 to 2019, he also served as chair of the Center for Public Policy Analysis in Health at the École des hautes études en sciences sociales and co-chair of the Institute “Law and Health” of the Université René Descartes Paris V. Since 2006, he has directed the academic journal Sève: les tribunes de la santé.42 His numerous publications denounced the effects of the “neo-liberal drift” on the French health system (Tabuteau 2010; Grimaldi et al. 2011). On the other hand, he also criticized “the reform [of 2004] [which was] a real break. With the governance component, they made a decoy. The creation of the National Union of Health Insurance funds (UNCAM) and the Regional Hospital Agencies (ARH) has passed... Today, [2006], it is a super technocrat who has all the powers [at UNCAM].”43 In Démocratie Sanitaire (2013), he denounced the governance of the social security system, which no longer honors social democracy. This vision, which opposes the reform agenda of the second generation, also drove his other battle for the exit from the “all prospective payment system (T2A).”  Interview with a social insurance high civil servant (MiRe 2, 2006).  Sève for “santé, enjeux, visions, équilibres” (health, issues, visions, balances). Launched in 2003, the Tribunes de la santé is a quarterly analysis and forecasting journal “to better understand the movements affecting the world of health and to try to anticipate its transformations”. It aims to develop a multidisciplinary and inclusive approach to health and health insurance, and includes analyses by economists, sociologists, lawyers, historians, and philosophers. 43  Interview with a social insurance high civil servant (MiRe 2, 2006). 41 42

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In a book of 2011, the Manifesto for an Egalitarian and United Health (Manifeste pour une santé égalitaire et solidaire), he and the medical professors Olivier Lyon-Caen and André Grimaldi questioned the T2A, and asked the left to abolish it if they came to power. After the election of François Hollande as President, Tabuteau tried to get this message across to Minister Touraine “whom he knew well”. Aware of the strong presence of welfare elites defending T2A in her staff, he had no illusions about changing the policy in the short term, because a return to global budget, even a partial one, clashed with the preferences of the second-generation elites who favor the use of T2A, a policy instrument (efficient for them) they find efficient and on which they have based control and limitation of expenses in the public hospital (see Chap. 10). Tabuteau’s disagreement with the welfare elites fades when it comes to the development of the national health insurance coverage system merging the national health insurance funds with the complementary health insurances (mutuelles). With Martin Hirsch, then Director General of the Assistance Publique-Hôpitaux de Paris (AP-HP), he proposed to end the partition of the system between the national health insurance funds and the complementary health insurances (“mutuelles”) is said to be unfair and inefficient.44 The second generation of course share this proposal because it supports their programmatic orientation.45 From July 2018 to January 2022, Tabuteau held the position of President of the Social Section of the Conseil d’État, formerly held by social security founder Pierre Laroque. In this role regularly formulated “opinions” (avis du Conseil d’État) on the future of social security. By January 2022, he has been Vice-Chairman of the Conseil d’État. The reform era since 1996 is rich in lessons on the change in the social background and career path of the second-generation elites. The magistrates of the Cour des comptes, members of the first generation, left their positions in the governance of social insurance, and were supplanted by high civil servants with a different social background. The members of the 44  Martin Hirsch, Didier Tabuteau, “Créons une assurance maladie universelle”, Le monde  – Débat: Tribunes, January 14, 2017. https://www.lemonde.fr/idees/article/2017/01/14/creons-une-assurance-maladie-universelle_5062590_3232.html 45  The HCAAM (2021) report submitted to the Minister of Health, Oliver Véran, highlights this possibility in order to simplify the number of operators in the management of health care reimbursements. HCAAM, Avis du HCAAM sur la régulation du système de santé, Paris, Ministère de la santé, April 21 2021. https://www.strategie.gouv.fr/sites/strategie.gouv.fr/files/atoms/files/avis_regulation_hcaam_avril_2021.pdf

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second generation come from the IGAS and administrateurs civils corps and a strategic opening of the recruitment policy targeting statistical engineers has been carried out. As far as career paths are concerned, there is an increase in their length within the DSS where advancement is achieved through vertical circulation (from office manager to deputy director, from deputy director to director). Beyond the DSS, these career paths are shaped inside an Iron Triangle of governance, of which the DSS is the cornerstone.

Bibliography Bras, Pierre-Louis, « Politique économique et politique de santé », Les Tribunes de la santé, n°53, 2016: 73–86. Bras, Pierre-Louis, « Sortir de la T2A par le haut: la mesure de la qualité des soins », Journal de la gestion et d’économie médicales, 35 (6) 2017: 245–263. Brunn, Matthias, William Genieys, “Entry into Healthcare Education: Half-Baked Reform Only Complicates the French System”, Medical Teacher (published on line 30/11/2022). https://doi.org/10.1080/0142159X.2022.2151885 Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Genieys, William, Patrick Hassenteufel, “The Shaping of the New State Elites. Healthcare Policymaking in France Since 1981”, Comparative Politics, 47 (3), 2015: 280–295. Grimaldi, André, Didier Tabuteau, François Bourdillon, Frédéric Pierru, Olivier Lyon-Caen, Manifeste pour une santé égalitaire et solidaire, Paris, Odile Jacob, 2011. Libault, Dominique, « La transformation du pilotage de la Sécurité sociale: une expérience pour l’ensemble de l’action publique », Informations sociales, n°189, 2015: 72–79. Tabuteau, Didier, Les contes de Ségur. Les coulisses de la politique de santé, 1988–2006, Paris, Ophrys, 2006. Tabuteau, Didier, Dis, c’était quoi la Sécu ? Lettre à la génération 2025, Paris, Éditions de l’Aube, 2010.

CHAPTER 9

Consolidating the Custodianship of State Policies

In order to pry the governance of social security from the grip of the social partners following the 2004 reform, the second generation of welfare elites reinforced their specialization in social security issues within the Iron Triangle of the social security governance. In 2007, with the creation of a Ministry of Public Accounts that includes DSS, they had to validate their distinct approach to state policies. To do so, they determined to show that “the strength of the DSS is that it is not only budgetary [...]. It is a directorate that carries out social policies [...] and that pilots a large public service”.1 Far from limiting their power, the new governance structure gave them a solid strategic position in the political settlement. The second-generation elites typically start out in management positions within the DSS (a sub-­ directorate) or the UNCAM (in the directorate cabinet since 2004). They tend to continue their career path with an appointment to ministerial cabinets in charge of social insurance financing. Most of them come from the IGAS or are administrateurs civils. The arrival of engineers, trained at the National School of Statistics and Administration (ENSAE), is another ­crucial novelty. In this chapter, the three successors of Libault at the DSS—Thomas Fatôme (2012–May 2017), Mathilde Lignot-Leloup  Interview with a social insurance high civil servant (ProAcTA, 2019).

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(2017–2020), and Frank Von Lennep (2020–...)—exemplify the pattern of these career paths. Their sociological portraits will be complemented by those of other young representatives of this second generation.

Thomas Fatôme: A “Virtuoso” of Expenditure Control Policy By circulating within the Iron Triangle, the second generation has considerably increased its professional know-how. One of its opponents, close to the social partners and attached to the 1945 model, complained: “from the moment when after [Libault], you put younger profiles, more techno, a little interchangeable, which is the case with Thomas Fatôme and Mathilde Lignot-­ Leloup... very brilliant people... I suspect them of not being followers of social protection [understood 1945 Laroque version]”.2 Fatôme’s career path is emblematic of the Iron triangle effect. Fatôme studied at HEC Business School before joining the IGAS after his graduation from ENA (2000). His 3 years at the IGAS enabled him to specialize in the management of organizations in charge of social insurance issues. He then began his service in the ministerial cabinets of various right-wing governments. Between 2003 and 2005, he was successively a technical advisor to Jean-François Mattei and Philippe Douste-Blazy (Ministers of Health and Social Affairs) and to Xavier Bertrand (Secretary of State for Health Insurance). Between 2008 and 2009, he was the chief of cabinet to Laurent Wauquiez (Secretary of State for Employment) and then cabinet deputy chief to Christine Lagarde (Minister of the Economy and Finance). Then, between November 2010 and February 2012, he succeeded Raymond Soubie as health and social advisor to President Sarkozy. Despite his appointment to several conservative ministerial cabinets and to President Nicolas Sarkozy’s team, he was retained as director of the DSS throughout Hollande’s socialist presidency. With the Macron presidency, Fatôme was appointed as cabinet deputy director for Prime Minister Édouard Philippe in charge of social issues (2017–2020), then, on July 29, 2020, left this position to be appointed director general of the UNCAM. He thus became the first member of the second-generation elites to have led two of the three pillars of the Iron Triangle of the social security governance. 2

 Interview with a social insurance high civil servant (ProAcTA, 2018).

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Fatôme is recognized by his peers as a high civil servant virtuoso because of his outstanding expertise in fiscal control policies. One of the first generations said that Fatôme “has this ability to invent measures that allow savings of 200 to 300 million in one year without it being noticeable,”3 which is to say he knew how to introduce policy instruments within the annual framework of the LFSS without generating strong opposition from health professionals or the public. Though identified as center-right, he owed many political appointments in cabinets to his mastery of both the social and budget dimensions of social insurance policies. A decade earlier, his political appointments in conservative cabinets would have been sent through revolving doors when the political majority changed to left. His exceptional career path inside the social security domain highlights the increased interchangeability of second-generation elites in top policy-­ making positions. In the wake of the 2004 reform, Fatôme set up the Objectives and Management Agreement (COG) within the cabinet of Fréderic Van Roekeghem, director of the UNCAM, and implemented it for 3 years. In an interview published on November 17, 2015, in the magazine Futuribles, he looked back at this “innovation [which] has become the hallmark of social security policies, which is regulation, i.e., all the tools (the LFSS, the ONDAM, the Objectives and Management Agreement, conventional actions, agreements on drugs [Nouguez and Benoît 2017]...) that allow the coordination of the decisions of the different actors in order to control the different volumes of the global expenditure” (Fatôme 2015). He insisted, moreover, that the 2004 reform “[broke] definitively with the concept of health insurance, [where] the role of funds [was] to reimburse care, and not necessarily to control expenditure... if we [wanted] to be more efficient, we [needed] an autonomous operator [the UNCAM], somewhat distant from the central administration [the DSS], which [was] given more means”.4 Drawing on experience at the Directorate of the UNCAM, he pointed out that the partnership with the DSS gradually put an end to voting the “surreal” ONDAM (meaning that targets were not met). Fatôme also explained the original role played by the UNCAM following its creation in 2004 by the Douste-Blazy reform. Previously, relations between the DSS (the administration), ministerial offices and health  Interview with a social insurance high civil servant (ProAcTA, 2019).  Interview with a social insurance high civil servant (MiRe 2, 2007) and interview with social insurance high civil servants (n2 persons, ProAcTA, 2019). 3 4

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insurance (the funds), and especially between the last two, were quite distant: “The DSS was just acting as a gatekeeper. In addition, cooperation between the Ministry and the health insurance services was very complicated. Now there are direct relationships, if only because people know each other. There are high civil servants from the ministries who are integrated at the directorate of the National Union of Health Insurance Funds. I think it works better that way.”5 And its hybrid status (social partners and high civil servants) gives the UNCAM the same insulation from both the state and the social partners. Before elections (especially presidential elections), its director can obtain the support of the MEDEF (Employers’ union) and the CFDT (center-left worker’s union) in order to curb governments that often open the floodgates of public spending for their loyal electoral clientele (doctors, hospital workers, etc.). Fatôme’s career path at the top of power shows the effects of the circulation of elites within the Iron Triangle of social security governance. After his appointment to the UNCAM, he went to the DSS, first as deputy director to Libault (2009–10), then as director (2012–2017). A member of the cabinet of the socialist minister Marisol Touraine explained why Fatôme was retained at the head of this directorate in 2012: “The minister kept him because he is a very consistent person. He is one of the people who have internalized since 2007–2008 that we had a problem with the implementation of the spirit of the 1996 reform. We need to get out of the imbalances that the 2008 financial crisis had accentuated”.6 Moreover, this was a special time. First, it was necessary to consolidate the program to transform the governance of Social Security implemented by Libault. Second, the DSS had come under the supervision of the Minister of Public Accounts, but no elites within the DSS had as much knowledge of expenditure control policies as Fatôme in confrontation with the elites of the Ministry of Finance on these issues. Fatôme took advantage of his directorate experience to ensure that the welfare elites, and only they, formulated “policies of solidarity that [were] not only financial. We can say that family policies, health insurance, retirement policies, [these are] policies that have objectives of protection, care, etc., but that must be done within a logic of sustainability. And to have this double vision, I think that it gives something quite relevant”.7 In other words, they  Interview with social insurance high civil servants (n2 persons, ProAcTA, 2019).  Interview with a social insurance high civil servant (ProAcTA, 2018). 7  Interview with social insurance high civil servants (n2 persons, ProAcTA, 2019). 5 6

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would act as custodians of state policies in their areas of responsibility. This strategy also made it possible to “make the Ministry of Finance realize that [these were] different modes of regulation, that pensions were managed in a certain way, that for health insurance, there was [a] National Health Spending Objective”.8 The elites in the Ministry of Finance could no longer argue “ah... the social ones, they do anything, they spend too much money!”.9 After 2007, the budgetary negotiations reflecting a balance of power between the Directorate of the Budget and the directorate of the “spending ministry,” where “we punch each other in the face as much as possible and then we arbitrate [between ministries]”10 had grown outdated. Now, “we have a directorate [the DSS] that internalizes the financial constraint and confronts it with itself, with its public policy objectives.”11 This new formulation of social insurance policy issues affected political as well as administrative elites. Marisol Touraine’s “[had] internalized the fact that she was carrying financial constraints,”12 so she kept Fatôme as head of the DSS because she knew that he could enforce the National Health Spending Objectives (ONDAM) better than anyone else. It is for these reasons that the project of the elites of the Ministry of Finance to use the Social Security Budget Act (LFSS) to merge the Directorate of the Budget with the DSS was postponed indefinitely. For Fatôme, this would have been a step backward, condemning the Ministry of Health and Social Affairs to become a spendthrift again, thus “disempowering a sector which, if we take it in the broad sense of the word, weighs one third of the French GDP”13 in a nation that had one of the highest public expenditure rates in the world.

Mathilde Lignot-Leloup and Nicolas Revel: Interchangeable Career Paths Two members of the second-generation elites, Nicolas Revel and Mathilde Lignot-Leloup, share a similar career path. Both were appointed several times in ministerial cabinets (of the left for the first, of the right for the second) to take charge of social insurance policies and social accounts.  Ibid.  Ibid. 10  Ibid. 11  Ibid. 12  Interview with a social insurance high civil servant (ProAcTA, 2019). 13  Interview with social insurance high civil servants (n2 persons, ProAcTA, 2019). 8 9

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Nicolas Revel was director of the National Union of Health Insurance Funds (UNCAM) from 2014 to 2020 before being appointed Cabinet Director of Prime Minister Jean Castex. He then succeeded Thomes Fatôme in the role of “hidden” Minister of Health to the Prime Minister.14 The career of Mathilde Lignot-Leloup, who succeeded Fatôme in 2017 as director of DSS, also illuminates career paths within the Iron Triangle. After all, it was to implement “Sustainable Social Welfare” program that the second-generation elites succeeded in marginalizing competing elites in other government institutions, starting with the pro-social partners, a heterogeneous coalition including a minority of the MEDEF (employers’ union), the FO and the CGT (workers’ unions), who wanted management to be returned to the unions. Second, a small cadre within the health and social administration advocated nationalization of social security (bringing it under the state control), either in the manner of the British National Health Services or in the Scandinavian fashion (financing exclusively by taxes). Another minority currently defended competition between the national health insurance funds (a French version of “managed competition”), somewhat on the American model supported by the liberal wing of the conservative party, Les républicains. Revel and Lignot-Loup did not share this enthusiasm. For them, “social security [had to] be efficient. For this, the state [had to] be the guarantor of principles and balances. To this end, it [had to] exercise its guardianship by negotiating contracts with organizations [the funds] that [were] responsible for implementing policy orientations”.15 For the second-generation elites, as our many interviews show, this strategy was the best way to successfully implement their program. In fact, this perspective is currently the subject of a “fairly broad consensus, left [and] right alike,”16 precepts which have been followed under the Macron presidency. Mathilde Lignot-Leloup’s career path, like that of Fatôme, reveals the roots of this consensus on social insurance policy issues. An énarque like Fatôme, she joined the IGAS and spent the first years of her career there from 2000 to 2004. As a first career move, she became Director of Strategy and Audit at the Central Agency for Social Security bodies (ACOSS) for 14  Julie Carat, Grégoire Biseau & François Béguin, “Nicolas Revel, un macroniste installé directeur du cabinet du Premier ministre”, Le Monde, July 4, 2020. https://www.lemonde. fr/politique/article/2020/07/04/nicolas-revel-un-macroniste-installe-directeur-du-­ cabinet-­du-premier-ministre_6045186_823448.html 15  Interview with a social insurance high civil servant (ProAcTA, 2019). 16  Ibid.

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2  years, in charge of the budgetary supervision of the national funds, which initiated her into social accounts control policies. Between 2007 and 2009, as the Ministry of Public Accounts began to exercise control over the DSS, she was appointed, as an advisor in charge of social accounts, to the cabinet of Minister Éric Woerth and then to that of Prime Minister François Fillon until the end of 2010. In 2011, Lignot-Leloup continued her career path, this time within the UNCAM, where for 6  years, she served as Director delegate for the management and organization of care. Finally, in June 2017, she succeeded Fatôme as head of the DSS, thus becoming the second woman, after Ruellan, to hold this position. In 2020, she left her position (to Franck Von Lennep) when she was appointed magistrate at the Cour des comptes. These sociological portraits point to three characteristics that differentiate the career paths of first-generation welfare elites from those of the second generation: (i) circulation within the Iron Triangle, (ii) depoliticization, and (iii) strong interchangeability. This new career path shows why social security has become a strong sector, with elites enjoying considerable autonomy and under a state with the capacity to formulate and implement strong public policies.

Franck Von Lennep: A Statistical Engineer to Strengthen the Custodianship The sociological portrait of Von Lennep, who became director of the DSS on June 12, 2020, shows a new face of the career path of the second generation, one resulting from the policy of recruiting ENSAE engineers initiated by Libault within the DSS (see Chap. 7). Once the Ministry of Public Accounts was created, this recruitment strategy decisively contributed to the inversion of the previous balance of power vis-à-vis the elites of the Ministry of Finance. As a member of the first-generation welfare elites points out, Von Lennep has “an unusual career path for a civil service contractor”.17 As a young graduate in statistical engineering, he worked within the Employees’ National Health Insurance Fund (CNAMTS) from 1998 to 2008, interspersed with a short stay at a private insurance company (Vauban Humanis). 17  Recruited in the sector by private contract. Marianne Bliman, “Franck Von Lennep Expert ès protection sociale à la DREES,” Les Échos, May 22, 2012. https://www.lesechos. fr/2012/05/franck-von-lennep-expert-es-protection-sociale-a-la-drees-1093635

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Von Lennep was in charge of the accounts, but as one observer put it “[if] he has a very good ability to analyze the figures [...] he is not a fan of statistical techniques for their own sake”.18 What interested him in economic and social data was above all what they say about reality, how they serve “to construct a thought in the long term”.19 After a first cabinet appointment as advisor to the right-wing Minister of Employment Laurent Wauquiez (2008–2009), he joined Bretrand Fragonard at the High Family Council as Secretary General (2009–2010). Fragonard saw in him “an intellectual machine that must be constantly fed [because] constantly in motion”.20 He then returned to the Ministerial cabinets under the right-wing presidency of Sarkozy. Under François Baroin, Minister of Budget and Public Accounts, Von Lennep participated in the drafting of two Social Security Budget Acts (LFSS) in 2010 and 2011, and then continued that work with Valérie Précresse, the Minister of Budget. When the Socialists took the Presidency with Hollande (2012), he was appointed to head the Directorate for Research, Studies, Evaluation and Statistics (DREES) in the field of health and solidarity, succeeding Brocas. In this position (2012–2017), he supervised the writing of several reports on the health of the French population. At the end of his mandate in 2017, he joined the cabinet of Prime Minister Edouard Philippe at Matignon alongside Fatôme to take charge of social security policies. The newspaper Libération commented on their appointment in these terms: “[Von Lennep] is the man of precision, a perfectionist”.21 The journalist adds, relying on anonymous sources: “This whole little world is a very tough team [with Fatôme], very brutal, very technically competent and very sharp... There is no equivalent at the Élysée (Presidency), in the administrations or the Ministries of Social Affairs! Nobody stands up to them”.22 With the onset of the Covid-19 pandemic, Von Lennep was appointed director of DSS at just 48 years of age. Although opponents criticized this appointment as a reflection of his personal proximity to Fatôme, there was no denying his quality as an expert statistician in social insurance.  Ibid.  Ibid. 20  Ibid. 21  Lilian Alemagna, « À Matignon. “Une équipe très brutale” venue de la droite », Libération, January 23, 2020. https://www.liberation.fr/france/2020/01/23/amatignon-une-equipe-tres-brutale-venue-de-la-droite_1774903/ 22  Ibid. 18 19

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Moreover, Von Lennep, as Director of the DREES, a collaborator with Marisol Touraine, socialist Minister of Health and Social Affairs, fully shared in the consensual approach to health insurance policies. One observer judged that “there is a strong consensus among the administrative elites of the center-left and center-right social sectors on the stakes of health insurance policies and the budgetary constraints”.23 The recruitment of engineers means that the policy elites can rely on individuals with the technical resources to perfect the consensual approach to expenditure control policies. Nor was Von Lennep’s career path unique. By embracing these new types of careers, the DSS and the UNCAM confirmed the elites’ ability to regenerate themselves.

Career Paths Continuity of Welfare Elites To understand the continuity of the second generation, it is important to extend the gallery of sociological portraits to the newcomers, to look at the career paths of young elites circulating inside the Iron Triangle without having yet occupied management positions. At the end of their policy apprenticeship as deputy director, technical advisor, or Bureau Chief, these young individuals constituted a rich pool of future candidates for top management positions at the DSS or the UNCAM. Sociological portraits of three engineers (Thomas Wanecq, Guillaume Couillard, and Jonathan Bosredon) and two énarques-IGAS (Jean-Philippe Vinquant and Agathe Denéchère) show how they shared the same vision of the custodians’ role: “the search for efficiency rather than savings” so that “we can continue to care for kids as well tomorrow as we do today”.24 Thomas Wanecq, a polytechnician with a specialization in ENSEA (1996) and an énarque (2003–2005) who joined the IGAS, embodies the dual profile of “budgeteer” and “policymaker.” In his own words, his “job” was to “fit the quilt into the suitcase” (faire entrer l’édredon dans la valise).25 His long career at the sub-directorate for the financing of the health care system within the DSS, first under Libault, then Fatôme (2010–2019), made him an advocate of the “[respect] of the National Health Spending Objectives” (2010–2019). A policy tool he invented in  Interview with a social insurance high civil servant (ProAcTA, 2019).   Solveig Godeluck, “Portrait: Thomas Wanecq, Monsieur W,” Les Échos, January 14, 2020. 25  Ibid. 23 24

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2014 to counter a “big pharma” strategy for the release of an innovative and “overpriced” hepatitis C treatment, the Solvadi, illustrates his role as custodian of state policies during his time at DSS. The cost of this drug, estimated at 1 billion euros annually for the health insurance fund, could simply “break the bank of the Sécu”.26 Wanecq responded by a system for reducing the reimbursement rate with a safeguard clause. This tool, called by its collaborators the ‘W’ rate, in fact “did not have to be activated. [Because] the signal [was] strong enough to avoid it.”27 Wanecq, a follower of game theory and the anticipations it induces, calls this “good regulation” of policies. His innovative management of the social accounts enabled him to move early to the top of the governance of social insurance. Indeed, at barely 43  years old, he was appointed by Fatôme, on January 5, 2019, to the directorate of the High Authority for Health (HAS). Other sociological portraits of polytechnic engineers confirm this new career path for second-generation elites. For example, Jonathan Bosredon, top administrator at INSEE, started his career as a statistician in the Ministry of Finance at the Tax directorate (2003 à 2006), then, in 2009, joined the DSS as assistant to the deputy director of social insurance financing. From 2013 to 2017, under the direction of Fatôme. In 2017, he served, as interim director of the DSS, before becoming again, for 2 years, deputy director this time under Mathilde Lignot-Leloup. From February to July 2020, he was a health advisor in the “task force social insurance policies” of Prime Minister Edouard Philippe’s cabinet, alongside Fatôme and Von Lennep. Finally, in September 2020, he was appointed as an external member of the Conseil d’État. Guillaume Couillard, a polytechnician and graduate of the École nationale des ponts et chaussées, is an engineer who presents a comparable sociological profile. Quickly head of office at the Ministry of Health and Social Affairs (2008–2009), he spent a year at the Ministry of Public Accounts overseeing the implementation of the General Review of Public Policies (2009–2010). For 3 years, he served as assistant to the deputy director of the financing of the health care system at the DSS (2010–2013), and was also appointed to the cabinet of Prime Minister Edouard Philippe as health advisor within the “task force” led by Fatôme. He left Matignon in September 2020 to take an appointment as Director of a public hospital group (Groupe Hospitalier Universitaire Paris-Psychiatrie et Neuroscience).  Ibid.  Ibid.

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The other type of sociological portrait of members of the second generation is that of énarques-IGAS graduates like Jean-Philippe Vinquant and Agathe Denéchère, who came from the left-wing, but developed brilliant careers within the Iron Triangle. Vinquant began his IGAS career as a social protection advisor in the ministerial cabinets and as deputy director of the financing of the health care system at the DSS. In 2002, he moved to the Central Agency for Social Security bodies (ACOSS) to take charge of the collection of social contributions. Back at the DSS, between 2005 and 2009, he worked under the direction of Libault. Drawing lessons from the implementation of the 2004 reform, he participated in the birth of the political consensus around the “principle of social solidarity [now] linked to that of efficiency in the management of social benefits”.28 Between 2009 and 2012, he was appointed General Secretary of the High Council for Health Insurance Policy Planning (HCAAM), where he grew close to Bertrand Fragonard, a member of the first-generation elites. With the arrival of the socialists in power (2012), Vinquant entered the Prime Minister’s cabinet as technical adviser for social protection, working for Jean-Marc Ayrault (2012–2014), and then for Manuel Vals (2014–2015). Upon leaving Matignon, he became Director General of Social Cohesion (DGCS) at the Ministry of Health and Social Affairs until 2019, when he returned to the IGAS. Agathe Denéchère’s career path is very similar. This énarque-IGAS began her career in 2008  in the other pillar of the Iron Triangle: the UNCAM, where, she served for 4 years as chief of staff of the cabinet of Frédéric Van Roeckeghem, the director (2008–2012). In this cabinet, composed of policy advisors from the right and the left, she found that discussions were balanced and consensual.29 At UNCAM, she worked to apply the National Health Spending Objectives and to implement the Objectives and Management Agreements in collaboration with the DSS. Denéchère continued her career for 2  years in the cabinet of the socialist minister Marisol Touraine (2012–2014), and was then appointed for 4 years in the DSS as deputy director of pensions and institutions of complementary social protection. In July 2018, she was named deputy director general in charge of general affairs at the National Agency for Food, Environmental and Occupational Health Safety (ANSES). Denéchère reflected that “the culture of social security is something that is  Interview with a social insurance high civil servant (MiRe 2, 2007).  Interview with a social insurance high civil servant (ProAcTA, 2019).

28 29

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very strongly shared and rests on two legs”.30 The first leg is a strong attachment to the extension of health coverage. The second rests on public policies that insist on the efficient use of public spending. It is by walking on these two legs that the “Sustainable Social Welfare” program has progressively become a reality. Our elite approach shows that the implementation of this programmatic orientation has been accompanied by a change in the elites’ social backgrounds. The arrival of statistical engineers has consolidated the know-how of social insurance policies. The analysis of career paths within the Iron Triangle has shown a generalization of the horizontal circulation of elites. This phenomenon explains the depoliticization of these insiders and their attachment to the role of custodians of state policies. Furthermore, their institutionalization, corollary of the transformation of the welfare regime, favored the reconfiguration of the French strong state.

Bibliography Fatôme, Thomas, « Tribunes: La Sécruité sociale en 2045 selon Thomas Fatôme », Futuribles, 17/11/2015, https://www.futuribles.com/fr/article/la-­securite-­ sociale-­en-­2045-­selon-­thomas-­fatome/ Nouguez, Étienne, Cyril Benoît, “Governing (through) Prices: the State and Pharmaceutical pricing in France”, Revue Française de Sociologie, 58 (3), 2017: 399–424.

 Ibid.

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CHAPTER 10

The Resilience of Welfare Elites to Crises

Having drawn a sociological portrait of the second generation of welfare elites, it is important to analyze their response to the global financial crisis of 2008 and the Covid-19 pandemic of 2020. These two historical events were crash tests for “Sustainable Social Welfare” program. The first rattled public finances and ricocheted the logic of the social insurance policies developed by the elites after the 1996 reform. The second, directly related to health, put the hospital system under pressure and much increased the health insurance deficit, endangering the elites’ programmatic ambition. Political science and historical institutionalism contend that crises can be critical junctures where seemingly stable institutional arrangements on paths or trajectories can be newly contested (Capoccia and Kelemen 2007). We postulate that critical junctures are also contexts in which unelected governmental elites play for their survival. What happened to the second generation when these two crises, 10 years apart, challenged their program? The quest for efficiency meant that the welfare elites had to avoid the loss of control of public health care spending. Just after the financial crisis, the social security deficit was 29.6 billion euros in 2010 and 10.2 billion euros in 2015 (see Appendix, Fig. A.4). In 2018, it stood at 1.4 billion euros before rebounding in 2019 to 1.7 billion euros. Then, with the pandemic in 2020, it surged 39.7 billion euros (see Appendix, Fig. A.4),

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_10

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with 21.6 billion euros expected in 2022.1 Faced with these critical junctures, the challenge was to consolidate their program. Facing the Covid-19 pandemic, they quickly drafted the health and health insurance parts of the state of emergency voted by the Parliament on March 24, 2020. This reform was amended thereafter many times, according to the evolution of the epidemic and the health measures likely to curb it (curfew, vaccination, and more). Moreover, a national consultation of health professionals led to the Ségur de la Santé, whose agreement was signed on 26 July 2021. Indeed, the policy results were significant. Nearly 28 billion euros were committed to improve the quality and efficiency of the health care system. Issues negotiated included an exit from prospective payment system (T2A), a higher priority for quality of care, re-evaluation of the salaries of public hospital staff, creation of 15,000 jobs, and more. In spite of this context, the welfare elites won the creation of a fifth branch of the social security system dedicated to the care of dependence arising from old age and disability. Finally, as the Covid-19 pandemic continues, some members of the second generation elites (re)launched their project of “Grande sécu” to abolish the complementary health coverages and move to a 100% coverage of health-related costs by health insurance funds.

The Sarkozy Presidency and the Financial Crisis of 2008 In 2007, one of the promises of candidate Nicolas Sarkozy was to include a “Golden Budget Rule” in the Constitution. Inspired by the European Union, it would put a ceiling on the use of deficits in public finances. With this in mind, his conservative government created the Ministry of Public Accounts, which recast the relations between the elites of the Ministry of Finance and the welfare elites (see Chap. 7). Have policy instruments such as the National Health Spending Objectives (ONDAM) and the Objectives and Management Agreements (COG), among others, effectively curved deficits during this period? Were other mechanisms developed to mitigate the effects of the crisis? As the welfare elites, like those of the Ministry of Finance, faced a sharp increase in the public deficit. Nor were the advocates of Keynesian recipes 1  Daniel Rosenweg, “Budget 2020 de la Sécu: tout ce qui change pour vous”, Le Parisien, September 30, 2019 at 11:31 am, updated September 30, 2019 at 6:44 pm.

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always in ascendancy within the top administration. An IGAS official confirms that “for a very short period between 2008 and 2009, people considered social protection spending as a shock absorber of the crisis, and so this did not translate immediately into restrictions. [...] But this Keynesian movement was quite brief. And from 2010 onwards, all European countries, notably because of European rules, began to have rather restrictive overall public finance policies. This translated into a much stronger emphasis on health spending because it determines health insurance spending, and into a more restrictive National Health Spending Objectives.”2 The increasing public deficit offered an opportunity to assert their role as custodians of state policies with expertise in expenditure control. As the government planned to curb the effects of the financial crisis, the Ministry of Finance preferred a global management of public spendings, whereas, the welfare elites advocated steering “from the ground up.” The latter insisted that the formulation of public policies must take into account the professionals in the sector (hospitals, general practitioners, pharmaceutical groups, and so on) and the expectations of citizens in terms of social and health coverage. With this in mind, Libault, director of the DSS, assisted by Fatôme from 2009, went back and forth between the cabinet of the Minister of the Economy and the “social pole” of the Presidency of the Republic (November 2010 to March 2012). At the time, the context was favorable for meeting the ONDAM target to get out of the imbalances established by the 2008 crisis (Libault and Dauphin, 2011; Libault, 2015)—a perfect opportunity for the second-generation elites to confront those of the Ministry of Finance on the terrain of expenditure control. One of the high civil servants at the Ministry of Public Accounts recalled that it was during the financial crisis that the “social pole” was established: a collection of social advisors from the ministerial cabinets and executives from the DSS, committed to defend the perimeter of health insurance in the financial bargaining with the Directorate of the Budget.3 Henceforth, the welfare elites opposed any interference in their management of the Social Security Budget Act (LFSS). Points of disagreement that used to be arbitrated in Matignon before the Prime Minister were now settled within the Ministry of Public Accounts. As often happens in crisis situations, the first reaction was to extend the working day at the DSS “until two or three o’clock in the morning quite often” in order to complete the draft of the  Interview with a social insurance high civil servant (ProAcTA, 2019).  Interview with a high civil servant of the Ministry of Finance (ProAcTA, 2019).

2 3

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LFSS and refine the ONDAM.4 A high civil servant at the service of the Ministry of Finance acknowledged that “it [was] nevertheless [they] who [had] the procedure for preparing and adopting the LFSS... The drafters within each office [of the sub-directorate of financing] [were] in charge of producing the text according to their competence.”5 Afterward, the draft followed the classic path: office manager, deputy director, and department director. The preparation of the LFSS of 2008 illustrated the custodial action in the face of the crisis. One participant recalls that the DSS first sent proposals to other Directorates of the Ministry. “From this raw material, they put together a file [the draft law] with a strategic dimension, a financial package and a set of measure sheets, about 300, to be arbitrated by the various competent ministerial cabinets.”6 The DSS occupied the front line in this time of crisis, and the welfare elites managed the process and developed the bill. A Ministry of Finance’s high civil servant acknowledged that “with the DSS, we [had] a great deal of convergence both on the substance of the reforms to be implemented and on the financial framework, at least on the expenditure side. On the other hand, we [had] strong differences with the other directorates of the Ministry of Health.”7 The DSS had the upper hand in this issue and had, indeed, a financial office that oversaw the other directorates of the Ministry of Health and Social Affairs (Directorate General of Health Care Supply [Direction générale de l’offre de soins, DGOS], Directorate General of Social Cohesion [Direction générale de la cohésion sociale, DGCS] and the Directorate General of Health [Direction générale de la santé, DGS]) (see Appendix, Table A.3). DSS often rejected proposals that it considered “too expensive” and unfit to pass “to the Directorate of the Budget,”8 while, top managers of these directorates often criticized the DSS for “being ‘too risk-averse’ and not taking enough risks,”9 particularly with proposed investments in hospitals. Officially, administrative departments of the Ministry of Health and Social Affairs reproached the DSS, complaining that “no decision [since 2008] [was] taken without the financial aspect in mind [to the point that] the fear of spending [paralyzed] public  Interview with a social insurance high civil servant (ProAcTA, 2019).  Interview with a high civil servant of the Ministry of Finance (ProAcTA, 2019). 6  Interview with a social insurance high civil servant (ProAcTA, 2019). 7  Interview with a Ministry of Science high civil servant (ProAcTA, 2019). 8  Interview with social insurance high civil servants (n2 persons, ProAcTA, 2019). 9  Ibid. 4 5

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action.”10 In the financial crisis of 2008, the ONDAM was imposed as a deus ex-machina for rebalancing not only health insurance expenditures but also, beyond that, the entire social security budget. Created by the Douste-Blazy reform (2004), the Health Insurance Spending Alert Committee (Comité d’alerte sur les dépenses d’assurance-­ maladie) demanded for the first time in May 2007, before the crisis, a plan of adjustment of the social security accounts. When the crisis arrived in 2008, the pressure on welfare elites was redoubled to ensure that the ONDAM was respected. This policy choice had been implemented by the DSS and the UNCAM for a decade. 316 billion euros in expenditures for all the social security schemes demanded more precise steering by these institutions; according to one observer, “no decision [was] taken without having its financial impact in mind.”11 The need was urgent because after the financial crisis, the social security deficit increased from 8.9 billion euros in 2008 to 29.6 in 2010, greatly destabilizing the overall balance of the accounts (see Appendix, Fig. A.4). Following the committee’s warning, a political choice was made to focus steering policies on the ONDAM—i.e., health insurance—and not on all branches of social security: “it was quite violent, it’s the kind of situation that no government wants to have to go through ... [it resulted in] an obligation for [the UNCAM] to formulate savings proposals, review the savings measures, implement the savings measures.”12 In 2008, in order to shrink the budget deficit, the second generation elites invented a series “of ‘medical deductibles’ on medicine boxes, and the one of 1 euro applied to each consultation carried out by a doctor.”13 A member of the UNCAM remembered that “it was from that moment on that we experienced a tightening of the monitoring and control of expenditures [...]. I remember, at the time, we [held] to a National Health Spending Objectives of 3%, [it was] hard but we [held] to it.” This, she added, was when “we made a lot of progress in analyzing health insurance spending.”14 Since 2006–2008, accurate databases such as those of the SNIIRAM (https://www.snds.gouv.fr/SNDS/ Composantes-­du-­SNDS) capturing all reimbursements for ambulatory care have been available.  Ibid.  Interview with a social insurance high civil servant (ProAcTA, 2019). 12  Ibid. 13  Ibid. 14  Interview with a social insurance high civil servant (ProAcTA, 2019). 10 11

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Welfare elites did not mobilize statistics and analyze medical data to make unilateral cuts in expenditures. Rather, they develop policy instruments by involving medical professionals in implementation, sharing the results of the data analysis with physicians. They are thus able to dialogue with physicians in the private sector about feedback on their professional practice that shows them “how your patients are followed.” In this context, the UNCAM created in June 2009, among other measures, the “Individual Practice Improvement Contract” (Contrat amélioration des pratiques individuelles) to encourage better prescribing by private doctors in order to reduce the cost of care. During this period, the effects on the fiscal recovery of health insurance and health accounts were substantial. In this setting, under the conservative presidency of Sarkozy, the Hospital, Patients, Health and Territory Act (Hôpital, Patients, Santé et Territoire, HPST) was approved on July 21, 2009. One of its key objectives, the transformation of Regional Hospital Agencies (Agences regionales de l’hospitalisation, ARH) into Regional Health Agencies (Agences régionales de santé, ARS), triggered a conflict between the DSS and the Minister of Health and social affairs, Roselyne Bachelot, on the autonomy of the new agency within the central administration. The initial version of the reform project sought to strengthen the role of the state at the regional level by making the directors of the ARS “health prefects” (préfets santé). This plan, defended by the director of the cabinet of Roselyne Bachelot, put the new prefects managers of the social insurance policies in the regional health insurance funds in competition with each other. Nor was the supervision at the national level of the future ARS explained. On behalf of the DDS, Libault intervened, bypassing Bachelot’s cabinet and addressing the minister directly to alert her to the dangers of this reorganization which risked destroying the power of the UNCAM, the regional funds, which had since the law of 2004 worked closely with the DSS to implement the policy of expenditure control. Libault also argued that “they [were] outside the state”15 (albeit well connected to the DSS via the Iron Triangle), that the UNCAM “had really transformed itself to think of original tools for controlling spending and regulation ... something that the state was incapable of doing.”16 Hoping to get the bill amended during the parliamentary debates, some health insurance fund executives “spent nights writing amendments that they then sold to the  Interview with a social insurance high civil servant (ProAcTA, 2019).  Ibid.

15 16

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parliamentarians. In this way, they managed to undo a certain number of measures.”17 This “rewriting” of a law in progress was possible both because welfare elites were among the social advisors to the Prime Minister and the General Secretariat of the Élysée Palace, and because, for once, they had also benefited from the support of the Ministry of Finance, who of course favored the fight against expenditures. The HPST Act, voted on July 21, 2009, incorporated the corrections sought by the UNCAM and the DSS. All in all, the financial crisis did not alter the power of the welfare elites and the implementation of “Sustainable Social Welfare” program. On the contrary, they acted as custodians of state policies “by combining a conception of solidarity policies with the financial constraint (the logic of sustainability), [they] had even made it possible to cushion the effects of the crisis on French citizens.”18 Indeed, the crisis strengthened their cohesion and determination to implement the program. In combination, the triggering of the Alert Committee, “a huge wake-up call that had [...] traumatized everyone,”19 the Ministry of Public Accounts’ control over the DSS, and the threat to the Social Security Budget Act by the elites of the Ministry of Finance strengthened the welfare elites’ resolve to meet the ONDAM.

The Paradox of the Socialist Presidency of Hollande François Hollande’s accession to the presidency of the Republic brought the return to the Matignon of a social-democratic prime minister, a fact not seen since 2002. The conservative policies of controlling health care expenditure were denounced by the left wing of the socialist party for having sacrificed the public hospital service. The new political majority had, during the electoral campaign, clearly announced its ambition to change this policy. Marisol Touraine, former spokesperson of the socialist party on health, had added to the agenda an assault on social inequalities in health, which was understood to mean establishing national (universal) health insurance coverage (Nay et al. 2016). For his part, the future President was closely linked to the world of health care, first, as the son of a doctor and second, because, as Secretary General of the Socialist Party, he knew  Interview with a social insurance high civil servant (ProAcTA, 2019).  Interview with a social insurance high civil servant (ProAcTA, 2019). 19  Ibid. 17 18

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the tight connection between his political party and the hospital civil service. The first speech of Touraine (the new Minister of Health and Social Affairs), delivered on May 22, 2012, proclaimed a profound evolution of access to care and to hospitals: a territorial reorganization of the supply of care, the fight against “medical deserts” (déserts médicaux),20 a reaffirmation of the central role of the public hospital service, which Minister emphasized that “been damaged in recent years by the uniform application of financial constraints.”21 The Minister concluded her speech by declaring: “A hospital in deficit is a hospital that no longer invests in the future and that will eventually lose its professionals and no longer be able to offer patients a quality public service!”22 The tone was set, but the reality of the policies developed by the minister and her administration diverged, particularly on the weakening of policies to control health expenditures. For a member of the Touraine cabinet, the explanation lay in the economic situation and the effects of the 2008 financial crisis on public finances. In 2012, the public deficit was 4.8% (exceeding the European Union target of 3%), public debt stood at 90.2%, and the unemployment rate was approaching 10%, where it remained throughout Holland’s term. The unemployment curve became an obsession for President Hollande, who had promised to try everything to reverse it. Paradoxically and against all odds, the social security, which posted a record deficit of 23.9 billion euros in 2010, saw it reduced first to 17.4 billion euros in 2011, and then to 13.3 billion in 2012. Indeed, in the Hollande quinquennium, it fell drastically from 9.7 billion euros in 2014 to 4.4 billion in 2017.23 The continuity in policy orientation between the Sarkozy and Hollande presidencies reflects the hidden role of the welfare elites who retained power at the DSS and at the direction of the UNCAM all the while. Under the change in the leadership directorate of Libault to that of Fatôme, they

20  A medical desert is a geographical area in which it is very difficult, if not impossible, to be treated by a health professional due to the absence of doctors nearby. This situation reflects a territorial inequality in access to care and can be dangerous for the health of local populations. 21  Interview with a social insurance high civil servant (ProAcTA, 2018). 22  Ibid. 23  https://solidarites-sante.gouv.fr/archives/archives-presse/archives-breves/article/ securite-sociale-fin-du-deficit-en-2017

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gambled under the Hollande administration both “their” social security model and their own survival in office. In addition to the highly restrictive socio-economic context, another insider from the ministerial cabinets pointed out that Touraine, who was very close to the Ministry of Finance Pierre Moscovici, “her mentor in the Socialist Party,”24 and part of the support network for the aborted candidacy of Dominique Strauss-Kahn, had quite naturally aligned herself with the economic policy line he was pursuing. In an analysis of health policies under the Hollande quinquennium (2012–2017) published in Les tribunes de la santé, Pierre-Louis Bras (2017) argued that economic policy had relegated health policy to the status of an adjustment variable. Moreover, the choice not to reduce reimbursements of medical acts for patients had obliged the socialist government to focus their expenditure control policy solely on hospitals and the price of drugs. The retention of Fatôme at the head of the DSS was in line with this logic, because, as the minister herself put it, health care spending “it was going to be tight.” From the moment, the socialist government began to repair the financial imbalances caused by the crisis of 2008: “people like Thomas Fatôme, were people who arrive with the idea that we [had to] be serious [about controlling spending]... why he stayed so long? it is his efficiency. He had results every year.”25 Both the private sector doctors and the hospitals opposed the minister’s policy. Although marginalized within the government and the socialist party, Touraine stood firm on this policy choice, stigmatized by her opponents as one of “austerity” (Grimaldi et al. 2011). An interviewee explained how the architecture and annual preparation of the LFSS facilitated the pursuit of expenditure control. The elites of the Ministry of Finance, he observed, are only involved in setting the overall annual budget. After that, the DSS is responsible for enforcing the general framework, which leads to battles with the spending directorates of the Ministry of Health and Social Affairs, such as the General Directorate General of Health Care Supply (Direction générale de l’offre de soins), a fierce protector of public hospitals. But with their hands on the budget and on the pen that writes the future laws, the DSS has the power to implement their policy goals. Finally, the strong presence of welfare elites in the cabinets (Nicolas Revel [Presidency of the Republic], Jean-Philippe Vinquant [Prime Minister], Agathe Denéchère [Minister of Health and Social affairs],  Interview with a social insurance high civil servant (ProAcTA, 2018).  Interview with a social insurance high civil servant (ProAcTA, 2019).

24 25

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Pierre-Louis Bras [Minister of Public Accounts]), the DSS, and the Directorate of the UNCAM promotes the continuity of policies. A social adviser in Marisol Touraine’s cabinet agreed that “[when] you have a strong enough consensus with the administration, the relationship is fluid, everyone feels at ease.”26 He opined that “the Ministry of Social Affairs is now the strongest machine after the Ministry of Finance, which is in decline.”27 Personal connections forged during their circulation and their collaboration within the Iron triangle of the social security governance facilitated consensus on the continuity of policies as political power shifted from the right to the left. Another interviewee recalled: “I was working with the cronies of the Ministry of Finance, the [health insurance advisors to the Minister of Public Accounts] who were colleagues I knew well. We worked very well together. I would say there hasn’t been a day that I haven’t had them on the phone. And, in some cases, we also divided files because we had a lot of things to do and we had other things to do than to fight, even if that happened a few times.”28 And so, despite the change in the government’s political majority, there was “not necessarily a break in institutional management. As far as social security was concerned, there was a fairly common backbone regardless of the governmental majorities. Afterwards, we saw differences that could be quite clear on the measures of de-reimbursement of care and drugs [more right-wing] or on the state medical aid [more left-wing]. But it was very different from what we had known in previous decades.”29 The differences between right and left were in fact much more apparent when it came to pension policy than to health insurance policy.30 All the same, divisive issues arose under the left-wing government, a prominent example being the prospective payment system (T2A) which, had allegedly damaged the public hospital system (Pierru 2020). T2A, which measured the activity of medical acts in a hospital in order to link its financing to a form of “profitability,” had said its detractors, caused a decline in the quality of care. According to Tabuteau, “T2A is not simply a technical tool for regulating expenses. It is first and foremost the symbol of a change in power.”31 It allows a high civil servant to exert control over what hospital doctors do. Tabuteau also specified that he is “not anti-T2A [but]  Ibid.  Ibid. 28  Interview with a social insurance high civil servant (ProAcTA, 2019). 29  Ibid. 30  Ibid. 31  Interview with a social insurance high civil servant (ProAcTA, 2019). 26 27

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rather in favor of its application in certain areas. But the way it has been presented and mobilized since 2007, it has become an instrument symbolizing the inversion of powers.”32 In the financial crisis of 2008, T2A was overused because argues Tabuteau, few high civil servants gained legitimacy from it. Their art of implementation allows them to secure both technocratic legitimacy and career paths at the apex of the governance of social insurance. The power of the second-generation welfare elites depends both on a specific career path and on mastery of complex policy instruments (see Chap. 8). Thus, faced with the mobilization of the authors of the “Manifesto for an egalitarian and united health” (Manifeste pour une santé égalitaire et solidaire, Grimaldi et al. 2011) sharply criticized the policy of budgetary rigor pursued under Hollande. The welfare elites countered by arguing that, in the post-crisis context, there was no sound alternative to continuing to control health insurance expenditure. Defending T2A, one argued that “the prospective payment system (T2A) is not a control tool imported from the Ministry of Finance. It is a regulatory tool invented by the elites of the sector [social insurance].”33 Moreover, “Grimaldi and Pierru believe that French high civil servants have been inoculated with a neo-liberal vaccine from birth, and that they spend their time trying to implant neo-­ liberalism in France.”34 He added, clearly annoyed: “So frankly, if you find a French civil servant from the Ministry of Social Affairs who has read Milton Friedman, give me his name!”35 These sharp anti-liberal critiques of Touraine’s reforms probably explain why they have been little noticed by public opinion. These were major reforms indeed. The law promulgated on January 26, 2016, generalized “third-party payment” (le tiers payant) exempting all insured persons from having to pay a portion of medical expenses in advance. No less “major” reform was establishing the Universal Health Coverage (CMU). Although critical, not without controversy, the Hollande Presidency took important steps to implement the “Sustainable Social Welfare” program.

 Ibid.  Interview with a social insurance high civil servant (ProAcTA, 2019). 34  Ibid. 35  Ibid. 32 33

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The Macron Presidency and the Covid-19 Pandemic Challenge In May 2017, the center-left candidate Emmanuel Macron, former policy advisor and then minister of Economy and Finance under Hollande, was elected President of the Republic. He appointed as Prime Minister, Édouard Philippe, a center-right figure long close to former Prime Minister Alain Juppé (1995–97) under President Chirac. The new political majority encompassed political sensitivities that cut across two generations of welfare elites. Moreover, the social security deficit of minus 4.8 billion euros in 2017 fell, in 2018, to the lowest level in several decades: “only” 1.4 billion euros (see Appendix, Fig. A.4).36 Capitalizing on this happy outcome, the second generation elites continued their circulation within the Iron Triangle and are consistently appointed to the key positions of the governance of social insurance policies (DSS, UNCAM, and Ministerial Cabinets of the Prime Minister and the Minister of Health and Social Affairs). Nicolas Revel, appointed by the socialist government in 2014 (see his sociological portrait in Chap. 8), of center-left sensibility and close to Macron, stayed at the directorate of the UNCAM. Fatôme left the cabinet of Prime Minister Philippe (Chap. 8), and was appointed Director of the UNCAM. Mathilde Lignot-Leloup took over as head of the DSS. At the same time, former managers such as Brocas (High Council for Health Insurance Policy Planning, HCAAM), Dominique Libault (High Council for the Financing of Social Protection, HCFiPS) and Bras (Pension Advisory Council, COR) continued their careers within the high authorities of the Iron Triangle. This alignment of the stars was therefore highly favorable to “Sustainable Social Welfare” program. In the Macron presidency, the policy of controlling health insurance expenditure, which was still very much in force, was accompanied by a reorganization of the health care system with the PUMa, Section 59 of the Social Security Budgetary Act of 2019 (see Appendix, Tables A.1 and A.3). The act aimed to improve “at the same time” the quality of care and relationships with patients, on one hand, and financial efficiency, on the other. This rebalancing was a reminder that “Sustainable Social Welfare” program has always relied on these “two legs.” This “ambidextrous” 36  PLFSS, Projet de Loi de Financement de la Sécurité sociale 2022, September 24, 2021, https://solidarites-sante.gouv.fr/IMG/pdf/dp-plfss-2022-24-09-2021.pdf

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approach gives the welfare elites a big advantage over their opponents. In that they can emphasize whatever “leg” is most suitable for the “game.” Thus, to respond to criticism during Hollande’s term, which was stigmatized for excessive financial control, policymakers made once again quality of the health care system a top priority. Under the Hollande Presidency, Prime Minister Manuel Valls had requested that Brocas (President of the HCAAM) and Professor of Medicine Lionel Collet (future health advisor to Agnès Buzyn) pilot a Great Health Conference (Grande conférence de la Santé) in February 2016 with the goal of generating ideas for combating inequalities in access to the health care system (Brunn and Genieys 2022). Many professionals from the medical world were engaged, including Olivier Véran, hospital doctor, socialist deputy of Isère, and future Minister of Health. The reflections focused on the reform of training and the future of the medical professions. Taking up this theme in the 2017 election campaign, President Macron denounced the “inefficient and unfair” selection method for young doctors. Once in power, he entrusted the new Minister of Health and Social Affairs, Agnès Buzyn, with the task of designing a new approach to physician training. The Law of July 16, 2019, responded to the inequality of access to care and training of doctors by abolishing the numerus clausus37 at the end of the first year of medicine (20% more doctors would be trained each year) and introducing a more socially inclusive mode of selection (Act n°2019–774). The reform also revised the “hospital map” (la carte hospitalière) to relieve congestion in the emergency room.38 Hospital activities were reorganized around three types of institutions. Among the 1000 hospitals spread over the French territory, between 500 and 600 of the smallest were to become “proximity hospitals” in charge of medical care, rehabilitation, and geriatrics. Other hospitals would specialize in surgery and maternity, and the third type would provide “ultra-specialized care” in centers with state-of-the-art equipment. The law also included measures to promote the development of digital technology (telemedicine, telecare, and so forth). The 2019 reform demonstrates, first, that their positions of 37  Since 1972, the numerus clausus has set the number of students who can enter the second year of medical, midwifery, dental, or pharmacy studies. The selection is made through a competitive examination at the end of the first year of health studies (Brunn and Genieys 2022). 38  Document issued on September 9, 2019, by the Ministry of Solidarity and Health: https://solidarites-sante.gouv.fr/IMG/pdf/_urgences_dp_septembre_2019.pdf

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power within the Iron triangle enabled the welfare elites to participate upstream in the reform deliberations by joining forces with health care professionals. Second, the search for system efficiency had become central to the redefinition of health expenditure control. This new policy architecture was challenged by the Covid-19 pandemic in early 2020. France suddenly faced the most important health and political crisis in its history, a crisis so grave that, on September 10, 2021, former Minister of Health and Social Affairs, Agnès Buzyn, was indicted by the Court of Justice of the Republic “for voluntary abstention from combating a disaster” and “for endangering the lives of others” by her management of the pandemic.39 By extension, it was also the lack of foresight of the administration she led from May 2017 to February 2020 that was targeted. In early 2019, a former health adviser to President Hollande blamed the welfare elites for having weakened the Ministry: “what worries me a lot as a citizen, is the extreme weakness of the Ministry of Health. It is better that there is no epidemic or major public health problem because, for the moment, the competences are no longer there. Which is a bit annoying.”40 The Covid-19 pandemic occurred a few months after these remarks. At the beginning of the pandemic, uncertainty and disputes about the need to wear masks, the severity of the epidemic, and the (in)effectiveness of hydrochloroquine were often taken as a failure of the health administration and of the state. The imbroglio surrounding the production and distribution of FFP2 masks, considered the most protective types, reinforced a sense of negligence in the management of the crisis. The report evaluating the management of the Covid-19 crisis and the anticipation of pandemic risks, entrusted to Professor Didier Pittet (25/05/2021), pointed out “a lack of anticipation that led to significant delays in decision-­ making.”41 Nevertheless, the same report recognized an improvement in

39  Le Monde avec AFP, “Covid-19: Agnès Buzyn mise en examen pour ‘mise en danger de la vie d’autrui’ pour sa gestion de l’épidémie”, Le Monde, September 10, 2021, at 21h29, https://www.lemonde.fr/police-justice/article/2021/09/10/covid-19-agnes-buzynmise-­en-examen-pour-mise-en-danger-de-la-vie-d-autrui_6094234_1653578.html 40  Interview with a social insurance high civil servant (ProAcTA, 2019). 41  Didier Pittet, Laurence Boone, Anne-Marie Moulin & Raoul Briet, Mission indépendante nationale sur l’évaluation de la gestion de la crise Covid-19 et sur l’anticipation des risques pandémiques, Rapport Public, Vie Publique au cœur du débat public, May 2021. https://www.vie-publique.fr/rapport/279851-gestion-crise-covid-et-anticipation-derisques-pandemiques-rapport-final

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management over the months and called for strengthening the public health domain in France. Debates about the lack of beds and staff in hospital intensive care units, policies on PCR antigenic tests, on vaccines, and on the implementation of curfews and/or confinement are outside the scope of our reflection. Elites from other directorates of the Ministry of Health (the Directorate General of Health [DGS], the Directorate General of Health Care Supply [DGOS], National Agency for Public Health France [Agence nationale Santé publique France]) as well as the Scientific Committee and the National Defense and Security Council played key decision-making roles (see Appendix, Table A.3). Although this temporarily relegated welfare elites to a secondary role, the DSS provided support for the drafting of texts establishing the state of health emergency of March 23, 2020, and also supported the implementation of President Macron’s political choice of “whatever it takes” (“quoi qu’il en coûte”); the state would cover the costs of supporting the economy and providing free health care. Various types of tests as well as vaccines remained free of charge and expenditure control was put on the save burner. Meanwhile, the profound impact of the pandemic on the hospital system quickly led to the organization of a national consultation of health professionals—Ségur de la Santé—whose objective was to improve working conditions (in particular by increasing salaries) and patient care in the hospital (by reopening beds). Launched by Prime Minister Philippe on May 25, 2020, the “Ségur agreements” were signed at Matignon by his successor, Jean Castex, on July 13, 2021.42 Although they were the result of interprofessional negotiations initiated by Nicole Notat (a CFDT trade union figure) with the DGOS (the directorate in charge of hospital policy), the law also reflected the work of the cabinet of Véran, Minister of Health and Social Affairs, and the “Social Task Force” created by the Prime Minister, which included Fatôme and Von Lennep. A quick glance at the main conclusions of the Ségur de la Santé might support that the crisis had profoundly altered the policy of controlling health insurance spending that the second generation of welfare elites had long pursued. Indeed, the hospital debt of 13 billion euros was absorbed 42  Statement by Mr. Jean Castex, Prime Minister, and Mr. Oliver Véran, Minister of Health and Solidarity, on the conclusion of the wage agreements signed in Paris on July 13, 2020, as part of the Ségur de la santé: https://www.vie-publique.fr/discours/275478-jeancastex-13072020-segur-de-la-sante

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by the state. An allocation of 8.1 billion euros was dedicated to hospital recruitment and the upgrading of jobs in health establishments and in institutions for the elderly and dependent people (EHPAD).43 A working paper by the conservative think tank Institut Montaigne, “Rebuilding the System No Matter What It Costs?” (Reconstruire le système quoi qu’il en coûte?), April 21, 2021, lamented that the financial effort proposed in the Ségur de la santé came at a time when the financial condition of the Social Security system, particularly its health branch, had deteriorated considerably.44 In 2020, the budget deficit balance reached −39.7 billion euros, a deterioration of 38 billion euros (see Appendix, Fig. A.4) in 1 year since 2019. The highest ever recorded in the history of the Social Security. Still, the historical financial commitment of the Ségur de la santé to future spending sought both to address the effects of the health crisis and a wish to correct perverse effects arising from expenditure control that had been reinforced since the financial crisis of 2008. During the last two decades, these policies weighed much more heavily on hospital medicine than on general medicine, but the Segur promises did not completely extinguish the discontent of health professionals. The Institut Montaigne proposed in particular that we “change the software” by rethinking the regulation of the health system. Contending the ONDAM was too rigid and short-termist,45 it proposed to replace it by health programming law set for a five-year period. For his part, Pierre-­ Louis Bras wrote a working paper for the pro-government think tank Terra Nova proposing another path.46 After highlighting connections between the hospital crisis, Covid and the limits of the ONDAM, he then pointed out how the pandemic revealed the non-respect of its implementation. The challenge was to break with a mode of “one-eyed regulation” that favors the policy of controlling expenditures to the detriment of the search for quality care. Nevertheless, even amid the game of “musical chairs” that followed the first wave of Covid-19 in the summer of 2020,  Les Echos, 19/10/2020.  Angèle Malâtre-Lansac, Laure Millet, Reconstruire le système de santé qui qu’il en coûte?, Paris, Institut Montaigne, April 27, 2021. https://www.institutmontaigne.org/blog/ reconstruire-le-systeme-de-sante-quoi-quil-en-coute 45  Ibid. 46  Pierre-Louis Bras, « Comment le Covid transforme le débat sur les dépenses de santé », Note Terra-Nova—The progressive think tank, March 25, 2021: https://tnova.fr/ economie-­social/protection-sociale-solidarites/comment-le-covid-transforme-le-debat-surles-depenses-de-sante/ 43 44

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the second-generation elites remained firmly in office within the Iron Triangle of health insurance policy governance. After the two Covid years (2020–21), the National Health Spending Objectives (ONDAM) would decline slightly (−0.6%)47 and the Social Security deficit of 39.7 billion euros in 2020 has been reduced to around 24.3 billion euros in 2021 (see Appendix, Fig. A.4). One can imagine that with the management of such a deficit, the effort linked to the Ségur de la Santé and the commitment of the current government around the improvement of the quality of care, the custodian role had to adapt the governance of the Social Security. One of the major strengths of the welfare elites is their ability to strike a balance between controlling health spending and improving the level of social protection. A balance that rejects dogmatic postures defending either fiscal orthodoxy or extravagant spending. Moreover, this “art” of governing social security could serve as a “model for public management” and for policy formulation in other sectors of the state.48 Because their approach to policy was recognized as “reliable” and trustworthy, the social security system was given, in the midst of the Covid crisis, a fifth branch designed to take care of “Old Age and Disability” Act (August 7, 2020). This innovation was defended in 2012 by Bertrand Fragonard in his book Vive la protection sociale! (2012) and, more recently, by Libault, in a report produced for the Ministry of Health and Social Affairs (Grand Âge, le temps d’agir, March 2019). The first budget for the frail elderly was passed as part of the LFSS of 2022, which committed 400 million of funding for home care workers, and the number of caregivers in EHPAD was expected to rise to 1.3 billion by 2025. Understandably, the parliamentary opposition questioned how these commitments will be funded, but the welfare elites were playing their role as custodians of state policies by developing this new branch of social security without losing sight of its sustainable financing. Our approach shows that the 2008 financial crisis and Covid-19 pandemic left the power of welfare elites and their custodian role, unaltered, indeed strengthened. Neither their career paths nor their agenda for the 47  HCFiPS, Pour des finances sociales soutenables, adaptées aux nouveaux défis, Synthèse Janvier 2022, https://www.strategie.gouv.fr/sites/strategie.gouv.fr/files/atoms/files/ hcfips_-_finances_sociales_synthese.pdf 48  See Special Issue 54, January 2019, of the journal Regards published by the École nationale supérieure de la Sécurité sociale dedicated to the theme “Social Security, another model for public management” (La Sécurité sociale, un autre modèle pour la gestion publique?).

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transformation of social security has changed. On the contrary, the logic of career paths inside the Iron Triangle of the governance of social security has reinforced and expanded the policy knowledge of the second generation. In this respect, it appears that the two crises have reinforced “Sustainable Social Welfare” program and the process of reconfiguration of the strong state.

Bibliography Bras, Pierre-Louis, « Sortir de la T2A par le haut: la mesure de la qualité des soins », Journal de la gestion et d’économie médicales, 35 (6) 2017: 245–263. Brunn, Matthias, William Genieys, “Entry into Healthcare Education: Half-Baked Reform Only Complicates the French System”, Medical Teacher (published on line 30/11/2022). https://doi.org/10.1080/0142159X.2022.2151885 Capoccia, Giovanni, Daniel Kelemen, « The Study of Critical Junctures. Theory, Narrative, and Counterfactuals in Historical Institutionalism », World Politics, 59 April 2007: 341–369. Fragonard, Bertrand, Vive la protection sociale!, Paris, Odile Jacob, 2012. Grimaldi, André, Didier Tabuteau, François Bourdillon, Frédéric Pierru, Olivier Lyon-Caen, Manifeste pour une santé égalitaire et solidaire, Paris, Odile Jacob, 2011. Libault, Dominique, Sandrine Dauphin, « Le sens du service public comme moteur de la performance », Informations Sociales, n°167, 2011: 52–57. Libault, Dominique, « La transformation du pilotage de la Sécurité sociale: une expérience pour l’ensemble de l’action publique », Informations sociales, n°189, 2015: 72–79. Nay, Olivier, Sophie Béjan, Daniel Bénamouzig, Henri Bergeron, Patrick Castel, Bruno Ventelou, « Achieving the Universal Coverage in France: Policy Reform at the Challenge of Inequalities”, The Lancet published May 01 2016, https://www.thelancet.com/journals/lancet/article/PIIS0140-­6736(16) 00580-­8/fulltext Pierru, Frédéric, « Entretien avec Brigitte Dormont: La tarification à l’activité (T2A) à la française », Revue française d’administration publique, n°174, 2020: 487–497.

CHAPTER 11

A Comparative and Theoretical Assessment on the Elite Approach

This book has developed an elite approach to policy and reconfiguration of the state in France. It has traced the work of welfare elites who, in a difficult economic and social context beginning in the mid-1970s, worked “out of sight” to design and implement “Sustainable Social Welfare” program. By gaining power in the upper echelons of the central state, they not only launched a policy of cost containment but also reformed its governance by enlarging the role of the state and breaking with the Bismarckian model of social insurance in favor of tax-financed universal coverage (Palier 2002, 2004). This transformation of the welfare regime provides further evidence for the failure of neo-liberal policies in France (Brookes 2021). Our approach to elites, politics, and the reconfiguration of states engages more general comparative remarks. Indeed, the comparative reflection begun a few years ago in a book co-edited with Marc Smyrl Elites, Ideas and the Evolution of Public Policy (2008) has produced unexpected results in contrasting fields of study such as France and the USA. These results highlight the importance of political science in correlating the analysis of the structure of unelected governmental elites with that of the policy decision process. They also show how the role played by these elites as custodians of state policies can be associated with the transformation of welfare regimes in different contexts. The study of the government of insiders shows that unelected governmental elites are key players in the exercise of power by elected officials in democratic states. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1_11

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Evidence from the Transformation of the French Welfare Regime Sociologist Piet Thoenes (1966) pointed out the role of state elites in the establishment of welfare regimes in Western democracies after World War II. Yet, as we have studied, France opted for a form of social security governance that contradicts its tradition of a strong state. During the Trente Glorieuse, the administrative elites, made up of members of the Conseil d’État, had little power in the governance of social security, which was essentially in the hands of the trade unions. This situation changed in the 1980s with the emergence of welfare elites. A first generation of these elites, made up of magistrates from the Cour de Comptes promoting a new programmatic orientation (“Sustainable Social Welfare”), challenged the elites of the Conseil d’État to head the Directorate of Social Security (DSS). The aim of this program was to strengthen the state’s authority over the welfare regime. A second generation reinforced their institutionalization in the governance of social security. The DSS was transformed into a cornerstone of the Iron Triangle of Social Security governance, composed of three pillars: (i) the DSS, (ii) the directorate of the National Union of Health Insurance funds (UNCAM), and (iii) the high authorities (Hautes autorités) in the health and social policy domain. The career path of this second generation was shaped by circulating vertically and horizontally within this Iron Triangle, where they built a common identity and honed their role as custodians of state policies through implementation of their program. The latter took shape after many battles, first with the “old-fashioned” elites of the social security and then with the elites of the Ministry of Finance. The steps involved in implementing their program are as follows: (i) the creation, in 1991, of a new tax, the Contribution Sociale Généralisée (CSG); (ii) the 1996 constitutional reform that included the Social Security Budget Act (LFSS); (iii) the establishment, in 2004, of new institution, the UNCAM, transforming the governance of funds (2004); and (iv) the universalization of health insurance (CMU in 2000 by the Jospin government, then the PUMa under the Hollande Presidency in 2016). To achieve these results, the welfare elites had to confront those of the Ministry of Finance, who, before the constitutional reform of 1996 and the LFSS, were accustomed to controlling the “spending ministries,” of which the Ministry of Health and Social Affairs was the perfect example. In order to shed this image and assert their influence and autonomy, the

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two generations adopted their own policy of expenditure control. Following the creation of a Ministry of Public Accounts (2007) to which the DSS was attached along with the Ministries of Health and Labour, and taking advantage of the crisis of 2008, the Ministry of Finance launched a counter-offensive. They urged an end to the LFSS on the pretext of obeying the European standards of the Finance Act, but against heavy odds, the welfare elites won their case because the effectiveness of their policy of expenditure control was widely recognized. The resulting reforms aimed to (i) increase public financing under parliamentary oversight and strengthen state regulation, (ii) gradually introduce universal national health insurance coverage, and (iii) widen the scope of social security intervention to include new social risks. Applied to the case of the transformation of the French welfare regime, our elite approach has disclosed the “hidden springs” of their political success. The sociological portraits, analyzing in detail career paths within the Iron triangle of the social security governance, have shown that controlling insurance expenditure lies at the very heart of the identity and role of these elites who act as custodians of state policies. To preserve and expand its influence in policy formulation, the second-generation elites recruited statistical engineers who make their careers in top positions in the Iron Triangle. First, the 2008 financial crisis and, second, the COVID-19 crisis have, against all expectations, reinforced their institutionalization and the implementation of “Sustainable Social Welfare” program. Amid the state of emergency, the Ségur de la Santé and vaccine policies progressively curbed the pandemic, leaving room for the welfare elites to continue to adapt. Remaining at the apex of the government, serving governments of both the right and the left, they expanded their program by creating a fifth branch (Cinquième branche): “Old Age and Disability.”

An Elite Approach to the Policy Process in Democracies In addition to its contribution to understanding the transformation of the welfare regime in France, this book points toward more general conclusions for the sociology of elites and the study of the policy process. With the programmatic elites framework, we have established a link between the transformation of the elites’ structure (social backgrounds and career

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paths) within the state apparatus and the programmatic policy orientations they bring to the decision-making agenda. This led us to revisit Lasswell’s (1936) classic questions: what “makes” elites (Who are they?) and what elites “do” (How do they act?). Our empirical studies on non-elected government elites and the transformation of the welfare state in France and the United States have tested these two questions. The analysis of the success of the Affordable Care Act (ACA) in the US supports the relevance of our elite approach to the policy process (Genieys et  al. 2022; Genieys 2024). A close look at the social background and career paths of political appointees and congressional staffers from the Clinton to the Obama administrations has enabled us to identify a group of elites with singular sociological characteristics: the long-­ term insiders. Comparing the results obtained in the US case with those presented in this book suggests that these elites have played a similar role in the reform of health insurance systems. In the USA, for example, we observed that the unelected governmental elites, with a different status than their French counterparts (high civil servants in France versus political appointees/congressional staffers in the United States), had the same policy-making know-how and arte dello stato, enabling them to pursue long career paths in the back-offices of power. With training in schools of public policy or public health, these elites have developed different types of career paths: either circulating vertically within the executive branch or Congress (“technocratic translator” and “policy bureaucrat”) or circulating horizontally between the two (“institutional migrant”). The career paths of long-term insiders with migrant institutional profiles reveal the formation of an Iron Triangle between the Department of Health and Human Services, the White House, and the Congress. The correlation between these career paths and the formulation of a far-reaching reform of the health insurance system revealed the hidden face of the ACA’s political success. We have shown that Heclo’s famous Government of Strangers was, in this case, supplanted by a Government of insiders (Genieys 2024). Our approach reassesses the theory and sociology of elites for the comparative analysis of political regimes and states (Linz and Stepan 1996; Genieys 2011). The study of the French and US cases has enabled us to revisit the contributions of Gaetano Mosca, Vilfredo Pareto, and Suzanne Keller:

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(i) By renovating the foundations of Mosca’s theory of the “ruling class” (a special class of persons forming the government) (Mosca 1939). For him, “a governmental machine is bound to be in existence, which machine will again ‘naturally’ be composed of a minority in charge of all activities of government” (Meisel 1962: 35). By focusing on the transformation of the structure of elites who are inside the government and shape policies, we have provided empirical evidence in support of his theory. (ii) By revisiting Pareto’s concept of circulation of elites (1967). For him, horizontal circulation relates to “l’élite gouvernementale,” while vertical circulation describes the relationship between elites and non-elites (Genieys 2011: chapter 2). By examining the social backgrounds and career paths of unelected governmental elites, we shed new light on how the horizontal and vertical circulation of insiders consolidates their power in the policy process. (iii) By adapting Suzanne Keller’s concept of « strategic elites » (1963), for example, elites who “differ from a ruling class in their manner of recruitment, internal organization, and degree of specialization” (ibid.: 58). By focusing on the strategic capabilities of elites in policymaking and l’arte dello stato, we have highlighted their role as custodians of state policies. Altogether, the empirical testing of these key concepts in the sociology of elites reveals an aspect considered marginal in understanding the process of reconfiguration of democratic states (King and Le Galès 2017).

The Custodianship of State Policies By linking the action of non-elected governmental elites and the programmatic orientations they promote to the process of reconfiguring democratic states, our approach to elites makes some contributions to the comparative sociology of the state. In sociological portraits, elites are described through their proactive role as guardians of state policies (Genieys 2010, 2024). Like the “carriers” (träger) of values and actions promoting the process of state and nation building identified by Juan Linz (1993), we have identified elite groups promoting state interventionism in the context of the transformation of the welfare regime. Comparing the British and Dutch cases at the end of World War II, Piet Thoenes (1966) associated the emergence of the welfare state with a new

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type of elite: the “plan-fulfilling elites” (or “the functionaries’ elite”). These elites had a special knowledge “in the machinery of government… and which claimed to have the exclusive role of safeguarding the interests of a larger whole” (Thoenes 1966: 188–89). Hugh Heclo’s study of modern social politics in Sweden and Britain confirmed the influence of new administrative elites on policymakers (1974). Taking the sociological analysis of unelected governmental elites a step further, we have shown how they have developed the role of custodian of state policies in both France and the U.S. This role is reflected in programmatic guidelines that reinforce the state’s capacity to intervene. To this end, we have revisited Selznick’s concept of “custodians of policy” (Selznick 1957). For him, the custodians of policy are individuals protecting certain social values in order to assert leadership, group identity, and autonomy within an organization (ibid.: 120–121). For us, the elites acting as custodians are close to what Bergeron and Castel call “entrepreneurs of change” (Bergeron and Castel 2015). Their custodial attitude is guided by a value system which, from their point of view, must be “responsible.” Their actions are characterized by (i) the ethics of ultimate ends promoting the extension of state interventionism and (ii) the ethics of responsibility shaping “sustainable” policies, taking into account political, budgetary, and other constraints. This perspective sheds new light on the issue of the dismantling of democratic states (Suleiman 2003). Studies on the transformation of bureaucratic power have generally associated the development of New Public Management with the retreat of the state. The NPM, by promoting the deprofessionalization and politicization of unselected governmental elites, is said to have affected the state’s ability to produce and implement public policies in the US and Europe (ibid.: 17). Recent research on administrative modernization in France contradicts this interpretation, pointing out how senior civil servants had turned this change to their advantage (Gibert and Thoenig 2022: 191–194). Our comparison of the French and the US cases shows that unelected governmental elites in certain areas of public policy have profiles that are both specialized and depoliticized. The study of health insurance reforms in France and the US points to the development of the custodian role by unelected governmental elites in different institutional configurations (Genieys 2024). To underline the specificity of the elites studied, the distinction between strong and weak states is relevant (Nettl 1968; Skocpol and Finegold 1982; Birnbaum 1984).

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In the configuration of the strong French state (Birnbaum 2001, 2018)—e.g., centralized with a large bureaucracy and endowed with a “state culture” (Nettl 1968)—it is groups of elites with high civil servant status who have endorsed the role of custodian of state policies. In the United States, these unelected elites have different statuses and career paths. In the field of health insurance, we have identified long-term insiders—mainly political appointees and members of the congressional committees hired under private legal contracts—who developed the role of custodian between the Clinton and Obama administrations by promoting a new reform project (Genieys et al. 2022; Genieys 2024). Moreover, unlike the French case, the development of the role of custodians in the USA remains more dependent on partisan polarization (Republicans versus Democrats). Orren and Skowronek (2017) have shown that during the twentieth century, the policy state’s capacity to intervene was strengthened during periods of Democratic political hegemony (“progressive era,” “great society”). The predominance of the Republican Party from the 1980s onward initiated retrenchment policies seeking to reduce the perimeter of state intervention (Pierson 1994; Orren and Skowronek 2017), which did not prevent defense sector policies from seeing the role of the state strengthen (Glenn and Teles 2009; Jacobs et al. 2019). This conservative counter-attack did not prevent the emergence of custodian elites around the reform of the Affordable Care Act (Genieys 2024). On the other hand, in both cases, certain groups of unelected governmental elites have asserted their custodianship around programmatic orientations considered financially sustainable. They are faced with the challenge of managing a constantly growing public budget. While in the US, federal public spending on health insurance remains lower than on defense, in France, the social security budget has overtaken that of the state. In the case of the weak US state, the Trump administration’s tax cut has temporarily curbed the development of the ACA. In France, despite globalization, new European wide powers, and so-called ascendancy of neo-liberal ideology, “custodial” elites have been able to reassert the authority of the strong state. This reassertion has entailed new modes of interventionism. The craftsmen of these reconfigurative modes are the welfare elites, who have placed social security and its policies at the heart of a redefinition of state authority and the public interest.

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Bibliography Bergeron, Henri, Patrick Castel, « Les habits neufs du néo-institutionnalisme ? La redécouverte de l’ordre mésologique et de l’agency », L’Année Sociologique, 3, 2015: 23–62. Birnbaum, Pierre, « Type d’élite et nature de l’État: l’exemple américain », Pouvoirs, n° 29, 1984: 12–128. Birnbaum, Pierre, The Idea of France. New York (NY), Hill & Wang, 2001. Birnbaum, Pierre, Où va l’État ? Essai sur les nouvelles élites du pouvoir. Paris, Seuil, 2018. Brookes, Kevin, Why Neo-liberalism Failed in France. Political Sociology of the Spread of Neo-Liberal Ideas in France (1974–2012), Switzerland, Springer International Publishing, 2021. Genieys, William, The New Custodians of the State. The Programmatic Elites in French Society, New Brunswick, NJ, Transactions Books, 2010. Genieys, William, Sociologie politique des élites, Paris, A. Colin, 2011. Genieys, William, A Government of Insiders. The People Who Made the Affordable Care Act Possible, Baltimore (M.A.), The John Hopkins University Press, 2024. Genieys, William, Mohammad-Saïd Darviche, Brent Epperson. (2022), “New Policy Elites and the Affordable Care Act: The Making of Long-term Insiders”, The Journal of Policy History, 34 (1): 1–24. Genieys, William, Marc Smyrl, Elites, Ideas and the Evolution of Public Policy, New York (NY), Palgrave Macmillan, 2008. Gibert, Patrick, Jean-Claude Thoenig, Assessing Public Management Reforms, London, Palgrave-Macmillan, 2022. Glenn, Brian J., Steven M.  Teles, Conservatism and American Political Development, Oxford, Oxford University Press, 2009. Heclo, Hugh, Modern Social Politics in Britain and Sweden, New Haven (CT), Yale University Press, 1974. Jacobs, Nicolas, Desmond King, Sidney M. Milkis, 2019, “Building a Conservative State: Partisan Polarization and the Redeployment of Administrative Power”, Perspectives on Politics, 17(2): 453–469. Keller, Suzanne, Beyond the Ruling Class. Strategic Elites in Modern Society, New York (NY), Random House, 1963. King, Desmond, Patrick Le Galès, Reconfiguring European States in Crisis, Oxford (UK), Oxford University Press, 2017. Lasswell, Harold D., Who Gets What, When, How, New  York (NY), McGraw-­ Hill, 1936. Linz, Juan J., “State Building and Nation Building”, European Review, 1(4) 1993: 355–369.

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Linz, Juan J., Alfred Stepan, Problems of Democratic Transition and Consolidation, Southern Europe, Southern America and Post Communist Europe, Baltimore (MD), John Hopkins University Press, 1996. Meisel, James H., The Myth of the Ruling Class: Gaetano Mosca and the Elite, Ann Arbor (MI), The University of Michigan Press, 1962. Mosca, Gaetano, The Ruling Class, New York (NY), McGraw-Hill, 1939. Nettl, John Peter, “The State as a Conceptual Variable”, World Politics, 20 (4), 1968: 559–592. Orren, Karen, Stephen Skowronek, The Policy State. An American Predicament, Cambridge (M.A.), Harvard University Press, 2017. Palier, Bruno, Gouverner la Sécurité sociale. Les réformes du système français de protection sociale depuis 1945, Paris, PUF, 2002. Palier, Bruno, “French Welfare Reform in Comparative Perspective”, Revue française de sociologie, 45 (5), 2004: 93–120. Pareto, Vilfredfo, Traité de sociologie générale, Geneva, Droz, 1967 (1st French ed., 1917–1919 2 vol.) Pierson, Paul, Dismantling the Welfare State? Reagan, Thatcher, and the Politics of Retrenchment, Cambridge (UK), Cambridge University Press, 1994. Selznick, Philip, Leadership in Organization. A Sociological Interpretation, Oakland (CA), University of California Press, 1957. Skocpol, Theda, Keneth Finegold, « State and Economic Intervention in the Early New Deal », Political Science Quarterly, 97 (2) 1982: 255–278. Suleiman, Ezra N., Dismantling the Democratic States, Princeton (NJ), Princeton University Press, 2003. Thoenes, Piet, The Elite in the Welfare State, London (UK), Faber & Faber, 1966.



Appendix (Tables A.1, A.2, and A.3; Figs. A.1, A.2, A.3, and A.4)

Table A.1  Brief history and reform of the French social security system Social security Legislative decrees October 4 and 19, 1945

Teaching hospitals (CHU) Legislative decrees December 30, 1958 Jeanneney legislative decrees on social security reorganization Legislative decree of August 21

The Bismarckian-flavored post-war system with its state control One fund for the general social security system, four domains of intervention: Health, work accident, retirement, and family. A multiplicity (more than a hundred) of special funds for specific professional situations (“executives,” civil servants, self-employed, farmers, students, etc.). Managed by Social partners (3/4 workers’ representatives and 1/4 employers’ representatives) “Ordonnances Debré,” Article 1: In the cities where there are medical schools, mixed medical and pharmaceutical schools, or national medical and pharmaceutical schools, the schools and the hospitals shall jointly organize all their services into care, teaching, and research centers, in accordance with the provisions of this ordinance. These centers shall be known as hospital and university centers (CHU) The previous governance organization of the system was modified with the dismantling of the single National Insurance Fund and the creation of the National Health Insurance Fund (CNAMTS), the National Old-Age Insurance Fund (Caisse nationale d’assurance vieillesse, CNAV), and the National Family Allocation Fund (Caisse nationale d’allocations familiales, CNAF). To this trio is added a Central Agency for Social Security bodies (Agence centrale des organismes de sécurité sociale, hereafter ACOSS) managed by the social partners, for the collection of funds for the Union for the Recovery of Social Security Contributions and Family Allowances (Union de recouvrement des contributions de Sécurité sociale et d’allocations familiales, URSSAF)

(continued)

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1

167

168 

APPENDIX (TABLES A.1, A.2, AND A.3; FIGS. A.1, A.2, A.3, AND A.4)

Table A.1  (continued) General social insurance contribution (CSG) Finance Act on December 18, 1990 Social Security Budget Act (LFSS) Constitutional reform of July 22, 1996 Universal Health Coverage Act (CMU) July 27, 1999

Douste-Blazy Reform August 13, 2004

Universal Healthcare Protection (PUMa) Social security budget Act of 2016 and 2022

The Contribution Sociale Généralisée, called CSG, is a new tax created in 1990 to finance the social insurance system. The CSG levied on all types of personal incomes and it funds approximately 30% of expenditure on health care (Hassenteufel and Palier 2007: 590)

The 1996 reform made a break with the old governance model by increasing the role of the state. The new parliamentary competence helps the government to control the social policy agenda, notably on cost-containment issues

The Universal Health Coverage (CMU) says that every person residing lawfully in France, irrespective of his or her employment status or contribution record, is insured for the health risk (Hassenteufel and Palier 2007: 591). The CMU provides the poorest with free access to health care and provides free complementary health insurance for those who cannot pay for complementary health care (CMU Complémentaire, hereafter CMU-C [Palier 2010: 84]) On the social security governance, the 2004 reform creating the National Union of Health Insurance Funds (UNCAM) and the regional hospitalization agencies (Agences régionales hospitalières, ARH) reinforces the role of the central government Created High Authority for Health (HAS); traiting physician [médecin traitant], and The Carte vitale is the health insurance card The new social protection model is based on the principle of universal protection. From now on, people are covered simply because they live in France. It also ends the status of “beneficiary,” as spouses must join the social security system individually. This avoids a rupture of rights in the case of divorce. The administrative procedures for accessing the Universal Health Coverage (CMU), which had to be completed every year or every 3 years depending on the person’s status, are also eliminated

Sources: Authors’. For the acronyms, see Table A.3

  APPENDIX (TABLES A.1, A.2, AND A.3; FIGS. A.1, A.2, A.3, AND A.4) 

169

Table A.2  Health reimbursement in France since 1945 The principle is stated in the Preamble of the 1946 Constitution: “[the nation] guarantees health protection to all, especially to children, mothers, and elderly workers.” In practice, the principle has been translated into: 1. A “basic compulsory health insurance” plan (Assurance maladie obligatoire de base) financed by compulsory contributions. It reimburses 100% of long-term illnesses. For other medical conditions, it is, in general, 70% of the reimbursement base (e.g. 25€ for a general practitioner) when the acts are performed within a care pathway (Parcours de santé)a (otherwise 30%). The rate of reimbursement for drugs depends on the severity of the condition, effectiveness, etc. (from 100% to 15%). In addition, some care is poorly reimbursed (optical, dental care, etc.) This scheme has been extended to people who do not benefit from the basic compulsory health insurance thanks to the Universal Health Coverage Act (Couverture maladie universelle CMU, 2000). The procedures for accessing it were eased by the Universal Health Protection Act (Protection universelle maladie, PUMa, 2016). This coverage is free or paid, depending on income level 2. Complementary health plans. To improve the rate of reimbursement, the insured can take out private insurance with complementary schemes (mutual insurance companies, insurance companies, and provident institutions). The level of improvement will depend on the type of contract taken out (Benoît and Coron 2019) The law of January 1, 2016, made it mandatory for private companies to subscribe to a “complementary health insurance” for the benefit of their employees. Financing is provided equally by the company and the employee A complementary universal health coverage (Couverture maladie universelle complémentaire, CMU-C) was introduced in 2000 at the same time as the CMU for people of modest means. The scheme was extended and simplified in 2019 with the complementary health insurance (Complémentaire santé solidaire) Sources: Authors’ The coordinated care pathway consists of entrusting the attending physician with the coordination of care for your medical follow-up. The care pathway allows a better reimbursement. To benefit from it, you have to choose and declare an attending physician a

170 

APPENDIX (TABLES A.1, A.2, AND A.3; FIGS. A.1, A.2, A.3, AND A.4)

Table A.3  Glossary “memo” of the French social security model Central Agency for Social Security bodies (Agence centrale des organismes de sécurité sociale ACOSS) Directorate of Social Security (Direction de la sécurité sociale, DSS) Previously: Directorate of Health coverage and social insurance funds

Employers’ Union (Mouvement des Entreprise de France, MEDEF) High Authority for Health (Haute Autorité de Santé, HAS) High Council for Health Insurance Policy Planning (Haut conseil pour l’avenir de l’assurance maladie, HCAAM)

High Council for the Financing of Social Protection (Haut conseil pour le financement de la protection sociale, HCFiPS)

The national financial management agency for the “general fund” of the Social Security. Managed by the social partners, it serves as a general clearing house for the funds collected from salary withholding and employer contributions, and paid out for services by the various local and regional funds (cash management for CNAMTS, CNAF, and CNAVTS) Designs social security policies and ensures their implementation. Its general mission is to ensure that social security benefits meet the needs of the population, while ensuring the financial balance of resources. To this end, it prepares the Social Security Budgetary Act (LFSS). The DSS develops and implements policies relating to: the regulation of the health insurance system and the coverage of care by the CMU; family benefits and coverage of the risks of illness, maternity, disability, death, old age, widowhood, and occupational accidents and diseases An employers’ organization founded in 1998, representing French companies. This employers’ union has a significant weight in the French social debate, despite a low representativeness (less than 8% of union members) An independent public authority of a scientific nature, it works alongside the public authorities, whose decisions it informs, with professionals to optimize their practices and organizations, and for the benefit of users, whose ability to make their own choices is strengthened Created for a period of 3 years, and was given four missions. It must “evaluate the health insurance system and its evolution”; “describe the financial situation and prospects of the health insurance schemes”; “ensure the cohesion of the health insurance system with regard to equal access to high-quality care.” It should also “make recommendations or proposals for reform, where appropriate, to meet the objectives of financial soundness and social cohesion” Responsible for taking stock of the social protection financing system and making proposals for its development. The Prime Minister, the minister in charge of social security, and the minister in charge of the economy may also refer any question to it

(continued)

  APPENDIX (TABLES A.1, A.2, AND A.3; FIGS. A.1, A.2, A.3, AND A.4) 

171

Table A.3  (continued) National Family Allowance Fund (Caisses nationale d’allocation familiale, CNAF) National Health Insurance Spending Objectives (Objectif National des Dépenses de Santé, ONDAM) National Old Age Pension Fund (Caisse nationale d’assurance vieillesse des travailleurs salariés, CNAV) National Health Insurance Fund (Caisse nationale d’assurance maladie des travailleurs salariés, CNAMTS) National Union of Health Insurance Funds (Union nationale des caisse d’assurance maladie, UNCAM) 2004 “Douste-Blazy” Law Objectives and Management Agreement (Convention d’Objectifs de Gestion, COG)

The Jeanneney legislative decree reorganized the general social security system with the financial separation of risks into three autonomous “branches” health, family, and old age (CNAMTS, CNAF, and CNAVTS). Each branch became responsible for its own resources and expenditures. CNAF had responsibility for the family fund (own resources and expenditures) The policy of controlling health care spending introduced in Social Security Budget Act (LFSS) and framed every year by the National Health Spending Objectives (ONDAM). It was shaped by the Objectives and Management Agreements (COG) defined jointly by the DSS and social partners The Jeanneney legislative decree reorganized the general social security system with the financial separation of risks into three autonomous “branches” health, family, and old age (CNAMTS, CNAF, and CNAVTS). Each branch became responsible for its own resources and expenditures. CNAVTS had responsibility for the Old Age pension fund (own resources and expenditures) The Jeanneney legislative decree reorganized the general social security system with the financial separation of risks into three autonomous “branches” health, family, and old age (CNAMTS, CNAF, and CNAVTS). Each branch became responsible for its own resources and expenditures. CNAMTS had responsibility for the national health insurance fund Title II of the 2004 Law puts in place the new governance of the health care system with the creation of the National Union of Health Insurance Funds (UNCAM). The UNCAM, bringing together all the health insurance funds (CNAMTS, MSA, etc.), now has authority over expenditure control policies (reimbursement rates, social benefits, etc.). The UNCAM is headed by a director appointed by the government for 5 years who is difficult to dismiss (a two-thirds vote of the board of directors is required) A policy instrument for controlling social accounts. It is based on a target and management agreement between doctor’s organizations and health insurance funds (Hassenteufel 2007: 585)

(continued)

172 

APPENDIX (TABLES A.1, A.2, AND A.3; FIGS. A.1, A.2, A.3, AND A.4)

Table A.3  (continued) Pension Advisory Council (Conseil d’Orientation des retraites, COR)

A high authority responsible for analyzing and monitoring the medium- and long-term prospects of the French pension system. On all pension issues (financial equilibrium, pension amounts, age and insurance duration, redistribution, etc.), the COR develops elements of a shared diagnosis and formulates proposals likely to enlighten the choices, if necessary, for pension policy Prospective Payment A prospective payment system, whose purpose is to ensure System better control of hospital spending. In essence, T2A is based on (Tarification à l’activité, measuring the nature and volume of hospital activities, and not T2A) on a global authorization of expenditures by allocation of a hospital budget as was the case before Regional Health Created by the 2009 law “Hôpital, patients, santé et territories” Agencies (hospital, patient, health and territory act). These new state (Agences Régionale de agencies bring together, in one entity, all public-sector actors Santé, ARS) that were responsible for organizing and financing health care at the regional level Regional Responsible for implementing, at the regional level, the hospital Hospitalization policy defined by the government, for analyzing and Agencies coordinating the activity of public and private health (Agences Régionale establishments, for concluding multi-year contracts of d’hospitalisation, ARH) objectives, and for determining their resources Regional Health Regional Branch of the National Health Insurance fund Insurance Funds (CNAMTS). Until the reform organized by the law on hospital (Caisses régionales reform and on patients, health, and territories (2009), there is d’assurance maladie, one in each region of metropolitan France CRAM) Social Insurance The Directorate General of Health (Direction générale de la Administrative Santé, hereafter DGS); the Directorate of Hospitals (now Directorate Units Direction Générale de l’offre de soins, DGOS); the Directorate (Directions General of Social Cohesion (Direction générale de la cohésion administratives du sociale, DGCS) and the Directorate of Social Security (DSS). secteur de l’assurance Directorate for Research, Studies, Evaluations and Statistics maladie Ministère de la (Direction de la recherche, des études, des évaluations et des santé et des affaires statistiques, DREES) sociales) (continued)

  APPENDIX (TABLES A.1, A.2, AND A.3; FIGS. A.1, A.2, A.3, AND A.4) 

173

Table A.3  (continued) Social Security Accounts Commission (Commission de comptes de la Sécurité sociale, CCSS)

Union for the Recovery of Social Security Contributions and Family Allowances (Union de recouvrement des contributions de Sécurité sociale et d’allocations familiales, URSSAF) Universal Health Insurance Project (Assurance maladie universelle, AMU) Sources: Authors’

A ministerial advisory body placed under the authority of the Minister of Social Affairs, which analyzed the social security accounts. It is composed of two representatives (Assemblée Nationale), two senators, magistrates representing the Cour des comptes and social partners and coordinated by a permanent secretary general appointed by the First President of the Cour des comptes. Its work serves as a reference for understanding the financial situation of social security, with presentation of both the results of the past year and the forecasts for the coming year In charge of collecting social security contributions—taxes from companies

It intended to reform the SHI 1945 system by linking people who are not covered to a compulsory scheme and to harmonize the social benefits between the different régimes. The Universal Health Insurance (AMU) planned to grant the same social benefits to everyone as long as the residency requirement is met

174 

Appendix (Tables A.1, A.2, and A.3; Figs. A.1, A.2, A.3, and A.4)

Family Branch 11%

Retirement branch 32%

Sickness branch 57%

Fig. A.1  Share of each branch in the expenses of the general social security system (2020). Source: Directorate of social security, Social security key figures 2020, 2021, p. 12. (https://www.securitesociale.fr/files/live/sites/SSFR/files/medias/ DSS/2021/CHIFFRES%20CLES%202020%20ED2021.pdf)

  Appendix (Tables A.1, A.2, and A.3; Figs. A.1, A.2, A.3, and A.4) 

Tranfers 0,8%

175

Other Revenues 3,3%

Social contributions 32,4%

Other Taxes 29,5%

CSG 32,7%

Contributions paid by the state 1,3%

Fig. A.2  Revenues of the general social security system: health insurance branch (2020). Source: Directorate of social security, Social security key figures 2020, 2021, p. 9. (https://www.securitesociale.fr/files/live/sites/SSFR/files/medias/ DSS/2021/CHIFFRES%20CLES%202020%20ED2021.pdf)

176 

6 10 1 1

Appendix (Tables A.1, A.2, and A.3; Figs. A.1, A.2, A.3, and A.4)

6 7 1 2

4 6 21 2

4 7 1 4 5

4 4 1 8

4 3 1 9

17

17

4 3 1

4 3 1

12

12

17

17

4 3 1 16

20

82

85

85

78 66

1981

1986 Social contributions

1991 CSG

1996 Other Taxes

65

64

63

2011

2016

2001

2006

Transfers

Public contributions

56

2020

Other revenues

Fig. A.3  Structure of the French social security revenues (all branches). Source: Social Security Policies Evaluation Report (REPSS) attached to the Social Security Financing Bill (PLFSS) 2022, p. 34. (https://www.securite-sociale.fr/files/live/ sites/SSFR/files/medias/PLFSS/2022/PLFSS-2022-REPSS-Financement.pdf)

  Appendix (Tables A.1, A.2, and A.3; Figs. A.1, A.2, A.3, and A.4) 

0

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018 -1.4

-5

2019

2020

177 2021

-1.7

-4.8

-8.9

-7

-10

-10.2 -12.8

-15 -16 -20 -25 -30

-19.2 -24.3

-22.6 -24.9 -29.6

-35 -40

-39.7

-45

Fig. A.4  Evolution of the aggregate deficit of the compulsory basic social security schemes and the Old Age Solidarity Fund (2008–2021, in billions of euros). Source: Report of the Cours de comptes on the application of Social Security Budget Acts (October 2022, p.  34). (https://www.ccomptes.fr/system/ files/2023-03/20221004-rapport-securite-sociale-2022.pdf)

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Index1

A Accounts public, 39, 45, 56, 86, 87, 107, 116 social security, 42, 55–57, 59, 87, 88, 143 Aubry, Martine, 78, 98, 115, 119, 120, 123 B Bachelot, Roselyne, 100, 109, 144 Balladur, Edouard, 64, 67 Barre, Raymond, 31, 50, 53, 86 Barrot, Jacques, 53 Bazy-Malaurie, Claire, 64, 79, 80 Beregovoy, Pierre, 57, 64, 65, 67 Bosredon, Jonathan, 135, 136 Bras, Pierre-Louis, 112, 119–123, 147, 148, 150, 154 Briet, Raoul, 32, 60, 64, 70–77, 80, 88, 89, 99, 115, 117, 152n41

Brocas, Anne-Marie, 68, 70, 73, 74, 99, 112, 117–119, 134, 150, 151 Buzyn, Agnès, 119, 151, 152, 152n39 C Cahuzac, Jérôme, 119, 121 Career path(s), 3–5, 3n5, 10, 10n1, 12, 16, 17, 17n2, 21, 22, 24, 32, 32n1, 38, 44, 46, 49, 50, 54, 61, 63, 66–72, 76, 80, 81, 83, 85, 88, 90, 94, 95, 104, 108, 110–115, 117–123, 125–133, 135–138, 149, 155, 156, 158–161, 163 Castex, Jean, 132, 153, 153n42 Central Agency for Social Security Bodies (Agence centrale des organismes de sécurité sociale, ACOSS), 43, 43n3, 87, 88, 101, 103, 132, 137

 Note: Page numbers followed by ‘n’ refer to notes.

1

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 W. Genieys, M.-S. Darviche, Elites, Policies and State Reconfiguration, International Series on Public Policy, https://doi.org/10.1007/978-3-031-41582-1

191

192 

INDEX

Chadelat, Jean-François, 41, 43, 45, 56, 57, 83, 86–89, 98, 99 Chirac, Jacques, 33, 58, 58n15, 64, 65, 69, 75, 87, 90, 98, 150 Choussat, Jean, 7n13, 83–87 Civil(s) administrator(s) (Administrateur(s) civil(s), 44, 44n4, 59, 66, 68–70, 90, 95, 111, 114, 118, 119, 126, 127 Cohabitation, 58, 58n15, 63, 65, 75, 79, 87, 89, 98 Confédération Française Démocratique du Travail (CFDT), 40, 75, 99, 130, 153 Confédération Française des Travailleurs Chrétiens (CFTC), 40 Conseil d’État, 5, 17, 31, 32, 35, 36, 38–40, 43–46, 50, 52–55, 61, 70, 87, 89, 99, 114, 117, 123, 125, 136, 158 Conservative, 20, 31, 58n15, 69, 90, 114, 119, 120, 124, 128, 129, 132, 140, 144, 145, 154, 163 Corporatism, 37–39 Couillard, Guillaume, 135, 136 Cour des comptes, 17, 32n1, 36, 38, 46, 49–55, 57–61, 63–66, 68, 70–75, 77, 79–81, 89, 90, 114, 120, 125, 133 Cresson, Edith, 73 Crisis Covid-19, 139, 152, 155, 159 financial, 88, 94, 105, 130, 139–146, 149, 154, 155, 159 Custodian(s) of policies, 21, 162 of state policies, viii, 5, 12, 13, 21–24, 46, 55, 59, 61, 63–81, 83, 89, 91, 95, 105, 107, 110, 127–138, 141, 145, 155, 157–159, 161–163

D Denéchère, Agathe, 135, 137, 147 Directorate of the Budget (Direction du budget, DB), 45, 55, 57, 59, 70, 84, 85, 87, 107, 108, 131, 141, 142 of General of Health (Direction générale de la santé, DGS), 38, 142, 153 of General of Health Care Supply (Direction générale de l’offre de soins, DGOS), 142, 147, 153 of General of Social Cohesion (Direction générale de la cohésion sociale, DGCS), 137, 142 of Hospitals (Direction des hôpitaux, DH), 38, 56, 64, 80 for Research, Studies, Evaluation and Statistics (Direction de la recherche, des études, de l’évaluation et des statistiques, DRESS), 87, 108, 118, 134 of Social Security (Direction de la sécurité sociale, DSS), 1n3, 5, 32, 33n2, 36, 39, 44, 46, 49–54, 56, 57, 59, 60, 63–75, 80, 81, 86–90, 97–99, 101, 102, 104–109, 105n12, 111–118, 116n15, 120–122, 126–137, 141–148, 150, 153, 158, 159 of the Treasury (Direction du trésor, DT), 42 Douste-Blazy, Philippe, 60, 102, 128 Douste-Blazy reform, 94, 102, 129, 143 Dufoix, Georgina, 56, 67, 76 Durieux, Bruno, 73, 118

 INDEX 

E Elites administrative, 11, 13, 16, 37, 44n4, 50, 131, 135, 158, 162 circulation, 3n4, 6n11, 21, 130, 138, 161 policy, ix, 9–24, 63–81, 101, 105, 122, 129, 157, 159–161 state, 1–3, 6, 9–24, 32, 36, 39, 44, 46, 63–81, 95, 157, 158 theory, 160 unelected governmental, 9–14, 21, 32, 139, 157, 160–163 welfare, ix, 4–7, 6n11, 12, 13, 22, 31–33, 36, 38, 44, 46, 49–51, 57, 60, 63–81, 83–86, 88–91, 93–95, 97, 100, 101, 103–109, 111, 112, 114–116, 118, 121–123, 125, 127, 130, 133, 135–159, 163 European Union, 106, 140, 146 Evin, Claude, 72, 119–121, 123 F Farge, Jean, 53 Fatôme, Thomas, 104, 106, 121, 122, 127–136, 141, 146, 147, 150, 153 Finance Act, 55, 106, 109, 159 Force ouvrière (FO), 40, 44, 75, 99, 102, 132 Fragonard, Bertrand, 65, 72, 75, 77, 79, 80, 83, 89, 91, 134, 137, 155 Fund National family allocation (Caisse nationale d’allocations familiales, CNAF), 43, 79 National Health Insurance (Caisse nationale d’assurance maladie des travailleurs salariés, CNAMTS), 43, 44, 53, 60, 63, 64, 72, 74, 75, 77–79, 81, 89,

193

97, 99, 103, 115, 124, 125, 132, 133 National old-age insurance (Caisse nationale d’assurance vieillesse, CNAV), 43, 67 Regional Health Insurance (Caisses régionales d’assurance maladie, CRAM), 44, 144 G General Inspectorate of finances (Inspection générale des finances, IGF), 38, 39, 53, 71 General Inspectorate of Social Affairs (Inspection générale des affaires sociales, IGAS), 65, 68, 70, 88, 89, 95, 98, 101, 111, 116, 117, 119–122, 126–128, 132, 135, 137, 141 General social insurance contribution (Contribution sociale généralisée, CSG), 73, 73n37, 117, 123, 158 Giscard d’Estaing, Valéry, 49, 53 Government agenda, 89, 90 central, 95 cohabitation, 58, 65, 87 conservative/right wing, 31, 58, 64, 65, 77, 120, 124, 128, 140 reform, 2, 84, 94 socialist/left wing, 2, 55, 56, 75, 87, 99, 114, 119, 120, 124, 147, 148, 150 H Health coverage, 35–37, 94, 125, 138, 140, 141, 145, 159 High Authority for (Haute autorité de la santé, HAS), 103, 112n1, 136

194 

INDEX

Health (cont.) insurance, vii–ix, 2, 3, 7, 10, 10n1, 13, 20, 22, 32, 36, 41–43, 50, 59–61, 64, 65, 67–70, 73, 76–78, 79n56, 80, 85–87, 90, 98–100, 98n1, 107, 116, 124n42, 125, 129–131, 135, 139–141, 143–145, 148, 150, 153, 155, 158–160, 162, 163, 175 insurance fund(s), 36, 42, 77n46, 79n57, 101–105, 125, 136, 140, 144 national—coverage, 32 policy(ies), viii, 69, 124, 147 spending, 139, 141, 147, 153, 155 Universal Complementary— Coverage (Couverture universelle maladie complémentaire, CMU-C), 98n1, 100 universal—coverage (Couverture universelle maladie, CMU), 2, 7, 97–102, 98n1, 117, 149, 158 Universal—Protection (Protection maladie universelle, PUMa), 7, 94, 97–101, 150, 158 Health care costs, viii, 77n46 expenditures, vii, 145 reimbursements, 125n45 system, 7, 76, 103, 119, 122, 135–137, 140, 150, 151 High civil servant(s), 1n3, 2, 3n5, 4, 12, 14, 16, 35–39, 44–46, 49–52, 51n3, 54–56, 57n14, 59, 63, 65, 68, 69, 71, 72, 83, 88, 89, 94, 105, 106, 108, 116, 119, 120, 124n43, 125, 129, 129n4, 130, 141, 142, 148, 149, 160, 163 service, 17, 89, 116

High Council for the Family (Haut conseil de la famille, HCF), 112n1 for the Financing of Social Protection (Haut conseil pour le financement de la protection sociale, HCFiPS), 112n1, 113, 117, 150 for Health Insurance Policy Planning (Haut conseil pour l’avenir de l’assurance maladie, HCAAM), 80, 112n1, 119, 125n45, 137, 150, 151 Historical institutionalism, 12–14, 139 Hollande, François, 94, 100, 121, 122, 125, 128, 134, 145–152, 158 I Independent administrative authorities, 112n1 Insiders government of, 3, 10, 11, 21, 157, 160 long term, 12, 22, 160, 163 Insurance health, vii–ix, 2, 3, 7, 10n1, 13, 20, 22, 32, 36, 41–43, 50, 59–61, 64, 65, 67–70, 73, 76–78, 77n46, 79n56, 79n57, 80, 85–87, 90, 98–105, 98n1, 107, 115, 116, 124n42, 125, 129–131, 136, 139–141, 143–145, 148–150, 153, 158–160, 163, 175 policy elites (see Elites) social, viii, 1n3, 3–5, 4n8, 10, 12, 13, 22, 31, 37–41, 44, 49, 50, 55, 68, 69, 75–77, 79, 85, 91, 101–103, 107, 109, 112, 121–123, 125, 127–129, 131,

 INDEX 

132, 134, 136, 138, 139, 144, 149, 150, 157 social insurance funds (see Social security) Iron Triangle, 6, 6n11, 95, 108, 111–128, 130, 132, 133, 135, 137, 138, 144, 150, 152, 155, 156, 158–160 J Jeanneney, Jean-Marcel, 42, 44, 50 Johanet, Gilles, 64, 65, 76–80, 89, 123 Jospin, Lionel, 2, 75, 98, 99, 114, 120, 158 Juppé, Alain, 60, 86, 89, 97, 150 Juppé plan, 2, 60, 65, 69, 70, 72–75, 77, 79, 88, 99, 118, 123 K Kervasdoué, Jean de, 57, 65 Keynesian policies, 20 recipes, 140 rhetoric, 20 states, 20 L Lagrave, Michel, 64, 80, 98 Laroque, Pierre, viii, 31, 35–40, 42, 43, 50, 52, 123, 125, 128 Left wing, 55, 56, 64, 78, 87, 99, 104, 114, 121, 122, 124, 145, 148 Libault, Dominique, 59, 69, 76, 90, 101, 104, 108, 112–118, 120, 121, 127, 128, 130, 133, 135, 137, 141, 144, 146, 150, 155 Lignot-Leloup, Mathilde, 127, 128, 131–133, 136, 150

195

M Macron, Emmanuel, 128, 132, 150–156 Marmot, Jean, 49–61, 64–66, 70, 71, 74–76, 79, 80, 83, 84, 86–89 Mauroy, Pierre, 77 Mercereau, François, 64, 65 Minimum Insertion Income (Revenu minimum d’insertion, RMI), 79, 79n55, 98 Ministerial cabinets, 52, 54, 60, 67, 74, 81, 87, 89, 90, 103, 104, 112, 116, 118–120, 123, 124, 127, 128, 131, 134, 137, 141, 142, 147, 150 Ministry of Finance, 7, 36, 39, 40, 44–46, 50, 51, 54–57, 59, 63, 68, 77, 83–85, 87, 88, 94, 95, 97, 101, 104, 105, 114, 116, 118, 130, 131, 133, 136, 140–142, 145, 147–149, 158, 159 of Health and Social Affairs, 33, 37, 40, 54, 109, 112, 116n15, 131, 136, 137, 142, 147, 155, 158 of Public Accounts, 95, 105–110, 116, 122, 127, 133, 136, 140, 141, 145, 159 Mitterrand, François, 20, 33, 49, 55, 58, 64, 85 Mouvement des entreprises de France (MEDEF), 3, 102, 130, 132 N National Health Spending Objectives (Objectif national des dépenses d’assurance maladie, ONDAM), 100, 101, 104, 105, 108, 115, 122, 129, 131, 135, 140–143, 145, 154, 155

196 

INDEX

National School of Administration (École nationale d’administration, ENA), 16, 17, 17n2, 17n3, 36, 37, 50n2, 52, 57n14, 66, 71, 114, 118, 119, 128 National School of Statistics and Economic Administration (École nationale de la statistique et de l’administration économique, ENSAE), 45, 108, 116, 127, 133 National Union of Health Insurance Funds (Union nationale des caisses d’assurance maladie, UNCAM), 6n11, 7, 95, 102–104, 111, 112, 115, 116, 121, 124, 127–130, 132, 133, 135, 137, 143–146, 148, 150, 158 Neo-liberal(ism), 1, 90 O Objectives and Management Agreement (Convention d’objectifs et de gestion, COG), 79, 79n57, 88, 101, 104, 129, 137, 140 P Path dependency, 12, 13 Pension Advisory Council (Conseil d’orientation des retraites, COR), 112n1, 118, 122, 150 Philippe, Édouard, 113, 121, 128, 134, 136, 150, 153 Planning elites, 14–16 policies, 16, 37 Policy(ies) budgetary, 20, 44, 57 economic, 122, 147 elites (see Elites)

family, 37, 39, 79, 130 fiscal, 20, 55, 109, 118 formulation, 117, 118, 122, 155, 159 health, viii, 69, 124, 147 health insurance, 59, 61, 69, 135, 148, 155 instrument, 59, 77, 79n57, 101, 104, 109, 122, 125, 129, 140, 144, 149 issues, 11, 69, 107, 109, 115, 120, 131, 132 social, 2, 15, 16, 38, 84, 127, 158 state, viii, 5, 10–13, 21–24, 46, 55, 59, 61, 63–81, 83, 89, 91, 95, 105, 107, 110, 127–138, 141, 145, 155, 157–159, 161–163 Pompidou, Georges, 42, 49 Prieur, Christian, 44, 74, 75 Program “Common Program”, Programme Commun, 55, 65 new governance, 73 policy, 5, 9 reform, 22, 32, 33, 67, 76 Sustainable Social Welfare, 1, 2, 5, 7, 14, 22, 33, 46, 49–61, 70, 72, 74, 76, 80, 83, 85, 89, 90, 93–95, 97–112, 117, 119, 132, 138, 139, 145, 149, 150, 156–159 Programmatic action framework (PAF), 10 ambition, 139 elites framework (PEF), 3, 10, 21, 159 orientation(s), 4, 4n7, 10, 21, 22, 33, 54–55, 61, 81, 91, 94, 125, 138, 158, 161, 163 text(s), 85 vision(s), 10

 INDEX 

Prospective payment system (Tarification à l’activité, T2A), 122–125, 140, 148, 149 Public health, 65, 139, 152, 153, 160 Public hospital, 7, 38, 122, 124, 125, 136, 140, 145–148 Public service, 51, 71, 88, 107, 127, 146 Q Questiaux, Nicole, 55, 57, 65 R Raffarin, Jean-Pierre, 114 Rameix, Gérard, 64, 79 Reform comprehensive, 46 constitutional, 2, 5, 7, 33, 60–61, 74, 80, 86, 89, 93, 102, 111, 112, 158 far-reaching, viii, 4, 4n8, 32, 46, 63, 160 health insurance, viii, 10, 102, 162 institutional, 2, 22 process, 10, 95, 102 program(s), 22, 32, 33, 67, 76 project(s), 70, 109, 144, 163 social security, 32, 63, 85, 88 structural, 1n3, 57 Regional Health Agencies (Agence régionale de santé, ARS), 144 Regional Hospitalization Agencies (Agence régionale d’hospitalisation, ARH), 124, 144 Revel, Nicolas, 131–133, 147, 150 Right wing, 54, 58, 64, 65, 75, 86, 87, 100, 103, 120, 121, 128, 134, 148 Rocard, Michel, 98, 118 Ruellan, Rollande, 64, 66–71, 74, 98, 114, 117, 133

197

S Sarkozy, Nicolas, 94, 107, 121, 122, 128, 134, 140–146 Sécurité sociale, 1, 39 Seguin, Philippe, 51, 58, 64, 65, 87 Social democracy, viii, 40, 103, 124 Socialist, 2, 20, 33, 40, 55, 56, 65, 72, 73, 75, 76, 78, 83, 85, 87, 100, 103, 114, 115, 118–123, 128, 130, 134, 135, 137, 145–151 Social partners, 13, 22, 32, 38, 40, 42, 43, 45, 49, 50, 52, 54, 55, 59, 75, 78, 95, 97, 101–104, 112, 115, 127, 128, 130 Social security accounts (see Accounts) Accounts Commission (Commission des comptes de la sécurité sociale, CCSS), 54–56, 58–60, 86, 87 Beveridgian model of, 37 Bismarkian model of, 119 branch(es), 36, 37, 39, 54, 86, 87, 113, 143, 155 Budget Act (Loi de financement de la sécurité sociale, LFSS), 2, 5, 7, 33, 33n2, 60, 69, 72, 73, 94, 97, 98, 101, 102, 105–107, 109, 117, 123, 129, 131, 134, 141, 142, 145, 147, 155, 158, 159 deficit, 53, 94n1, 105, 139, 143, 150, 155 fifth branch, 117, 140, 155 governance, 6, 6n11, 23, 36, 41, 44–46, 67, 95, 108, 112–114, 116, 127, 128, 130, 148, 158, 159 system, 32, 35, 36, 42, 49, 56, 80n58, 86, 98, 100, 107, 109, 124, 140, 154, 155, 167–168, 174, 175

198 

INDEX

Sociological portrait(s), viii, 5, 5n9, 22, 32n1, 36, 63, 64, 66, 71, 76, 79, 88, 111, 112, 114, 120, 121, 128, 133, 135–137, 139, 150, 159, 161 Soubie, Raymond, 128 State elite(s) (see Elites) French, 5–7, 12–14, 16–18, 35, 46, 72, 90, 163 policy(ies) (see Policy(ies)) reconfiguration, 9–24 strong, 1, 11–12, 14, 16, 33, 35, 46, 61, 63, 68, 95, 138, 156, 158, 163 weak, 11–12, 162 welfare, vii, 15, 98, 105, 160, 161 Sustainable Social Welfare, 1, 2, 5, 7, 14, 22, 33, 46, 49–61, 70, 72, 74, 76, 80, 83, 85, 89, 90, 93–95, 97–112, 117, 119, 132, 138, 139, 145, 149, 150, 156–159 T Tabuteau, Didier, 112, 120, 123–126, 148, 149 Technocratic, 15, 20, 76, 149, 160 Technocrat(s), 15, 20, 56, 78, 94, 124 Touraine, Marisol, 100, 121, 122, 125, 130, 131, 135, 137, 145–148

U Union for the Recovery of Social Security Contributions and Family Allowances (Union de recouvrement des contributions de Sécurité sociale et d’allocations familiales, URSSAF), 43, 88 Union(s) employers, 36, 102, 132 professionals, 39 trade, viii, ix, 15, 46, 49, 55, 99, 104, 153, 158 workers, 5, 22, 36, 37, 40–42, 85, 102, 132 V Valls, Manuel, 119, 151 Van Roeckeghem, Frédéric, 137 Veil, Simone, 67–69, 79, 80, 90, 98, 114, 115 Vinquant, Jean-Philippe, 135, 137, 147 Von Lennep, Franck, 80, 108, 128, 133–136, 153 W Wanecq, Thomas, 135, 136 Welfare elites first generation of, 38, 46, 57, 60, 65, 70, 73, 74, 86, 88–91 second generation of, 90, 94, 100, 127, 139, 153 Woerth, Éric, 107, 133