Guaranteeing Access to Healthcare in Turbulent Times – A Comparison of the German and French Welfare States' Health Access Policies

Access to healthcare is a human right (Article 12 of the International Covenant on Economic, Social and Cultural Rights, 1966). Guaranteeing this is a responsibility of the state. In the context of rapid global change in social, economic and political conditions, this responsibility has become a challenge even for affluent welfare states with highly developed health systems. This applies in particular to states in which healthcare for the population is organised on the basis of a health insurance system. In health insurance systems such as those in Germany and France, access to healthcare for the majority of the population has traditionally been determined by access to compulsory health insurance for employees. However, (full) membership of a statutory health insurance scheme meanwhile represents an insurmountable hurdle for a growing number of people in Germany and France. In an environment of economic and social (migration) globalisation, simultaneous political re-nationalisation, Europeanisation, growing social inequality, capitalist economic systems in transition, and cross-border natural (COVID 19 pandemic) and man-made (wars, crises) threats access to compulsory health insurance remains closed for different groups of people. As a result, these welfare states have come under considerable reform pressure in the past two decades. They have been faced with the task of creating alternative access to healthcare or of adapting the conditions for access in such a way that people who cannot be integrated into a health insurance scheme via a classic employment relationship can also make use of their human right to access healthcare. This contribution is interested in the influence of the institutional constellation of health insurance on access to healthcare. It examines the extent to which health policy in selected affluent welfare states – specifically Germany and France – is able to steer institutional health system development in favour of unrestricted access to healthcare and to implement according reforms. The following observation forms the starting point: While Germany has so far struggled with reforms to ensure universal access ( e.g. statutory regulation of general health insurance in 2009), France has made progress in ensuring universal access to unrestricted healthcare, particularly for vulnerable groups in recent years (e.g. introduction of the Aide médical de l'État/AME in 2000 and of the universal health coverage PUMA in 2016). The contribution comparatively examines which political factors (governing parties, distribution of power between and influence of interest groups, policy ideas, political institutions, etc.) influence the (in)ability to implement reform policies as a prerequisite for access to healthcare. Qualitative research methods are used for this purpose. In a combined longitudinal-cross-sectional comparison of both countries, systematically selected policy documents, laws and secondary literature are evaluated for the period from around 2000. The article uses the case comparison to show how political factors can influence access to health and healthcare in affluent welfare states with mature healthcare systems. Beyond the empirical example, the article shows the potential of policy analysis for the political-scientific acquisition of knowledge about health, health care and access to health.