Learning from variations in institutions and politics: the case of social health insurance in France and Japan

Despite their similar theoretical model, social health insurance schemes are based on different societal relationships, administrative structures, and political institutions. The aim of this comparative study is to deepen our understanding of how different institutional settings affect the politics of health care reforms and impact the policy outcome of those politics. The paper first isolates the most strategic institutional differences and similarities between the two countries, including: arrangement of health insurance schemes, involved actors, interests and lobbies, types of state intervention, regulations on additional charges by physicians, public-local combination in provision and finance, central-local relationship, and division or coordination between hospital and ambulatory sectors. The Japanese health insurance system links employment- and community-based insurance schemes, each of which have distinct principles for eligibility, financial sources and political actors, whilst demands for universalism and possible mutual co-operation between these existing institutions have now penetrated policy debates. The French system, on the other hand, characterized as one of "liberal universalism", consists of three occupation-based schemes, completed by residence-based schemes for people without sufficient income, most but not all of whom are unemployed. Although both systems are essentially unique, because of their historical development, they both maintain the principle of compulsory contributions by employers and beneficiaries, free choice of providers by the patients, and universal access to medical care. The second part of the paper analyses the policy debates in each country, together with the policy outcomes in terms of care reforms, with a particular focus on reforms on financing and on cost containment. The third and conclusive part interprets the comparative results, with special attention given to the ways social and political factors push, or not, towards unification in these institutionally divided SHI systems