DOCTORS AND DEFICITS: REGULATING THE MEDICAL PROFESSION IN FRANCE

AuthorPAUL J. GODT
Published date01 June 1985
Date01 June 1985
DOIhttp://doi.org/10.1111/j.1467-9299.1985.tb00897.x
DOCTORS
AND
DEFICITS: REGULATING THE
MEDICAL PROFESSION IN FRANCE
PAUL,
J.
GODT
This paper
seeks
to analyze the political factors involved
in
health care delivery in a modern
industrial welfare state and to illustrate
bw
the transformation of the French state has
affected the policymaking environment surrounding this particular issue. Cultural tradi-
tions rooted
in
the nineteenth century seriously circumscribed the role of the state in de-
the conditions
of
medical practice. Nonetheless, pressures emerging since
1945
for the
provision
of
a wide array
of
social services have drawn the state into ever closer regulation
of the health sector. The economic constraints
of
the ast decade resulted in state-imposed
cost-containment policies which accentuated the trenr! toward politicization of health care.
In
consequence, and despite the rear-guard defensive tactics of the medical profession,
the French state has succeeded
in
firmly establishmg its primacy in this major area of public
policy.
Health care in France as an object of policy analysis involves a number of disparate
but intricately intertwined elements: the role of the modern welfare state seeking
to manage
a
complex economy
and
assure the provision of social services, the
ambiguous nature of French authority relations, the evolving political party
configurations, the vicissitudes of professional power, the mystique of the doctor-
patient relationship, and the technological progress of medical science. Like the
fragments of some vast social kaleidoscope, these features have fitted together
in
a
variety of patterns over time, with only one constant: the growing involvement
of the state
in
health care policymaking.
THE RESTRAINTS
OF
LIBERALISM, THE
IMPULSE
OF
SOCIALISM
A
state role in social policy evolved slowly and reluctantly, largely because of
the dual cultural legacy of the 19th century. On the one hand, the liberal,
individualist values, combined with slow industrialization which retarded demand
for public action, made the state an unwilling accomplice in the development of
Paul Godt is Associate Professor
of
Political Science at the American College
in
Paris.
An
earlier draft
of
this paper was presented before the Conference Group on French Politics and
Society, at the annual meeting
of
the American Political Science Association, September 1984.
The
author wishes to acknowledge the perceptive insights shared by Victor Rodwin during the research,
and the helpful comments by Deborah Stone on the earlier draft.
Public Administration Vol. 63 Summer 1985 (151-169)
0
1985
Royal Institute of Public Administration
ISSN
0033-3298 $3.00
152
PAUL
J.
GODT
a socially inequitable distribution of health care; on the other hand, in the name
of solidarity, the state was promoting the proliferation of public and private systems
of protection for certain designated groups in society (Ashford
1985;
Launois
1984).
The delicate balance between the conflicting values
of
liberalism and national
solidarity was disturbed by the return of Alsace-Lorraine to France after World
War
I.
Unable for evident political reasons to discontinue the advantageous
Bismarckian system of compulsory workers’ insurance, the government was obliged
to adopt it for the rest of France, thus involving the state for the first time in the
definition of systematic coverage of health risks.
The proposals in the
1920s
to create collective contracts between physicians‘
associations and sickness funds sparked adamant resistance and organized pressure
from the profession. Doctors had long harboured ambivalent attitudes toward the
state, at once seeking public health campaigns and protection of corporatist
privilege, and yet fearing state intervention in the practice of their
arts.
Responding
to the challenge, they organized in a national trade union, the
Confkdkrution des
Syndicats
Mkdicuux
Franc&
(CSMF).
In
its first national congress in
1927,
the
CSMF
approved a medical charter in which the doctors cast the defence of their corporate
interests in terms of general principles to which they still ascribe transcendmg social
values: the right of the patient and the doctor to choose one another freely and
agree on a fee; the responsibility of the patient to pay the doctor directly for his
services; the doctor’s freedom of diagnosis and prescription; and the guarantee
of professional confidentiality.
These principles constitute what the French call
la
mkdecine libkrale
and form
the dominant ideology of the medical profession.
As
a statement of professional
concern, these principles are not only self-serving: in the physicians‘ view they
also assure responsible, high quality medical care for the patient. By associating
the medical profession’s interests in preserving its autonomy with the patient’s
interest in preserving his health, the principles of
mkdecine libkrale
established a
solid rampart against state interference.
The health legislation that eventually emerged in
1930
perpetuated the doctors’
freedom to set and collect fees, but introduced the first breach in the doctor-patient
relationship with collective financing: the sickness
funds
as third-party payers would
seek to reduce their members‘ out-of-pocket expenses, as these limited access to
health care. Whenever they raised the reimbursement schedules, however, the
doctors increased their fees correspondingly. Since only
14%
of the population
(the lowest-paid workers) was covered, there was no great pressure for the state
to interfere, and the doctors had demonstrated their influence and capacity to ward
off incursions into their professional autonomy.
In
the progressive political context of the Liberation, the ground-breaking Social
Security Ordinance of
1945
defined a new scheme of comprehensive coverage of
health and old-age insurance and family assistance, made compulsory for salaried
employees. The social security system, however, was designed to be insulated from
state control: contributors (employers and employees) would both finance and
operate it. Authority to manage the
funds
fell to private-law social
security
boards,
a striking anomaly in France’s legendary centralized administration. The board

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT