The Changing Interest Group Role of French Physicians: from the Defense of Professional Liberties to Territorial Entrepreneurship

In France the organized medical profession is not only as strong veto-group like in several Western countries, but also a professional group that has shaped some key principles of the health insurance system. The long-term relation between the Government and the medical profession in France is characterized by a historical conflict on the degree of integration of physicians in the social insurance system, which was established at the end of the 1920’s (Hassenteufel 1996). The Confederation of French Medical Unions (CSMF) was created in 1928 in order to unite the profession under the principles of “liberal medicine” (“médecine libérale”), an expression aimed to express their opposition to a Bismarckian health insurance system and that brought together freedom of physician’s choice for patients, freedom of prescription for physicians, fee-for-service payment, and direct payment by the patient to the physician for the service provided. In the 1930 health insurance act, these principles as well as the physicians’ freedom to fix the amount of medical fees were guaranteed, and after the Second World War the principle of freedom of settlement was added. Despite the creation of the Social Security System in 1945, the French medical profession was successful in maintaining these principles in the health insurance system until now. The aim of this paper is twofold. The first one is to analyse the weakening of these principles in relation to two interrelated processes: . the development, since the end of the 20th century, of cost containment policies challenging them, especially the freedom of fixing medical fees, freedom of prescription and freedom of settlement. It has led to several mobilization of physicians against the State on these issues (and it is again currently the case). . the increasing organizational fragmentation of the French medical profession in relation to internal conflicts on the defence of these freedoms against the Government, which led to the creation of new organizations. The second aim is to shed the light on the shift of the French healthcare policy orientation from the priority given to healthcare cost containment to the territorial reorganization of healthcare provision, since the beginning of the 21st century, in relation with the agenda setting of the issue of the lack of primary care provision in an increasing number of local areas (framed as the “medical deserts” problem). This new policy orientation, which can be characterized as a territorialization trend, is related to the affirmation of new professional organizations, led by physicians promoting new primary care organizations (especially multi-professional team-based organizations-MSP). They are acting as “territorial entrepreneurs” (Hassenteufel and al., 2020) and are deeply involved in the new territorial institutions aiming to coordinate primary care: the territorial professional health communities (CPTS) created by the 2016 Health Modernization Act, which I currently analyze in a collective research project (Benamouzig, Boisson, Hassenteufel, Schweyer, forthcoming).