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Private Health
Insurance and
the European Union
Edited by
Cyril Benoît · Marion Del Sol
Philippe Martin
Private Health Insurance and the European Union
“This book offers a sharp and comprehensive overview of the ongoing creeping
privatization of healthcare and how it is shaped by the European Union through
the making of a European insurance market. The chapters investigate both the top
down and bottom up dynamics of marketization and are thus of interest not only
for students of healthcare but also of the Europeanisation of public policy more
broadly. In times of global pandemics where the healthcare sector is facing major
challenges, this book could not be more timely”.
—Amandine Crespy, Associate Professor of Politics Science,
Université Libre de Bruxelles, Belgium
“This comparative study of private health insurance in Europe shines a welcome

light on an intricate and poorly understood topic of great consequence. Private
insurance schemes vary widely, with distinctive roles and regulatory frameworks in
the member states and at the EU level. In some systems, their operation belies
egalitarian promises of the broader health system. Member state and European
reforms in the sector rightly awaken fears that private insurance will undermine
social systems. This comparative analysis demystifies the complex world of private
health insurance regulation while making clear the ways in which private insurance,
and even well-intentioned policy reforms, can create inequality and inefficiency in
health care”.
—Scott Greer, Professor of Management and Health Policy,
University of Michigan, USA
“Private Health Insurance and the European Union explores the complex dialogue
at European and national level between market and public health contrasting log-
ics. This interdisciplinary book, which is a unique collection of theoretical and
empirical research papers, shows that choices made about private health insurance
greatly influence the nature of the coverage. The book underlines the ambiguity of
the interactions between public and private stakeholders and at the same time
questions the role of the latter. Researchers, practitioners and students in the fields
of social protection, insurance, healthcare and EU-policy making will find invalu-
able information and elements of analysis in this research project”.
—Jean-Philippe Lhernould, Professor of Law, Université de Poitiers, France
Cyril Benoît • Marion Del Sol
Philippe Martin
Editors
Private Health
Insurance and the
European Union
Editors
Cyril Benoît Marion Del Sol
Centre for European Studies and Intitut de l’Ouest : Droit et Europe
Comparative Politics, Sciences Po Université de Rennes 1
(Paris), CNRS Rennes, France
Paris, France
Philippe Martin
Centre for Comparative Labour Law
and Social Security
Université de Bordeaux, CNRS
Pessac, France
ISBN 978-3-030-54354-9 ISBN 978-3-030-54355-6 (eBook)

https://doi.org/10.1007/978-3-030-54355-6
© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
Nature Switzerland AG 2021
Chapter 1 is licensed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/). For further details see licence
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Acknowledgements
Funding for this work was provided by the French National Research
Agency (Agence Nationale de la Recherche—ANR) as part of the MaRiSa
research project (Marché du Risque Santé), Grant No. ANR-17-CE26-
0018. For Chaps. 2 and 7, Coron received additional support from the
Erasmus + Programme of the European Union.
v
Contents
1 Introduction: The European Union, the Insurance

Industry and the Public-Private Mix in Healthcare 1
Cyril Benoît, Marion Del Sol, and Philippe Martin
Part I The Political Roots of EU Insurance Legislation 27
2 Insurance Directives and the Single Market: Towards a

Trivialisation of Private Health Insurance? 29
Gaël Coron and Marion Del Sol
3 Solvency II, the European Government of Insurance

Industry and Private Health Insurance 55
Cyril Benoît
Part II The Impact of the European Union Private Health

Insurance 83
4 The Uncertain and Differentiated Impact of EU Law on

National (Private) Health Insurance Regulations 85
Philippe Martin and Marion Del Sol
vii
viii Contents
5 An Increasing Homogenisation of Private Health

Insurers Under Solvency II?129
Philippe Abecassis and Nathalie Coutinet
Part III Shifting the Public-Private Mix in Healthcare?

Multifaceted Paths Towards Europeanization 161
6 Private Health Insurance in Belgium: Marketization

Crowded Out?163
Cyril Benoît and Marion Del Sol
7 Europeanized, Marketized but Still Governed by the

State? Private Health Insurance in France191
Gaël Coron, Thomas Houssoy, and Cyril Benoît
8 Ireland: The Ambiguous Role of the Health Insurance

Market219
Philippe Martin and Pascale Turquet
9 The Dutch Way: Experimenting with Competition

in the Healthcare System247
Pascale Turquet and Philippe Martin
10 In Between the Market and Public Health Insurance:

A Place for Occupational Welfare in Europe?281
Thomas Houssoy, Marion Del Sol, and Philippe Martin
List of Contributors
Philippe Abecassis CEPN (UMR CNRS 7234), Université Sorbonne

Paris Nord, Villetaneuse, France
Cyril Benoît Centre for European Studies and Comparative Politics,
Sciences Po (Paris), CNRS, Paris, France
Gaël Coron Arènes (UMR CNRS 6051), EHESP, Rennes, France
Nathalie Coutinet CEPN (UMR CNRS 7234), Université Sorbonne
Paris Nord, Villetaneuse, France
Thomas Houssoy Clersé (UMR CNRS 8019), Université de Lille,
Lille, France
Philippe Martin Centre for Comparative Labour Law and Social
Security, Université de Bordeaux, CNRS, Pessac, France
Marion Del Sol Intitut de l’Ouest : Droit et Europe, Université de
Rennes 1, Rennes, France
Pascale Turquet LiRIS, Université de Rennes 2, Rennes, France
ix
List of Figures
Fig. 4.1 Overview of the different functions of private health insurance

(PHI)86
Fig. 4.2 Organic scope of EU economic law 91
Fig. 4.3 The three legal spaces resulting from the EU competition law 96
Fig. 5.1 OOP payments evolution, 1991–2018 133
Fig. 5.2 Level and evolution of share of public spending on health
(1991–2017)135
Fig. 5.3 Relationship between private health insurance coverage and
voluntary health insurance (VHI) spending. Data 2011—(e)
estimate137
Fig. 5.4 Change in the number of M&A transactions inside and
outside the EU (1997–2018) 144
Fig. 5.5 The top three insurers’ market shares by country (CR3) in
2006 and 2011 145
Fig. 5.6 Pattern of evolution of the M&A count in the five most active
countries (1997–2018) 151
Fig. 5.7 Deals by type of concentration, in %. Number of transactions
in which the country is the acquiror 153
Fig. 5.8 Opening and vulnerability of health insurance markets
in Europe 154
Fig. 7.1 The “distribution rule of cost” in the French health insurance
system, its functioning and aggregate final distribution
between financers 195
xi
xii List of Figures
Fig. 10.1 Changes in distribution by level of coverage of beneficiaries

between 2006 and 2013 305
Fig. 10.2 Rate of coverage by complementary health insurance, based
on income per consumption unit and the type of coverage
in 2012 306
List of Tables
Table 2.1 The “three generations” of EU Insurance directives 30

Table 3.1 Weighted average solvency coverage ratios in health by
category in four EU countries 75
Table 5.1 The five types of private health insurance markets in Europe 138
Table 5.2 Nature of voluntary health insurance contracts in countries
where supplementary voluntary insurance prevails 140
Table 5.3 Number of private health insurers by status (2011) 147
Table 5.4 M&A deals by country (number and percentage:
1997 –2018) 150
Table 5.5 Type of concentration according to the role of private
health insurance 156
Table 6.1 Number of affiliates per Sickness Fund in Belgium (2013) 169
Table 6.2 Number of affiliates per Sickness Funds in Belgium
(2013–2017)184
Table 7.1 Number of independent firms and groups operating on
French PHI market (2017) 206
Table 8.1 Risk equalization premium credits 228
Table 8.2 Community rating stamp duties 228
Table 8.3 Profitability of insurers on the Irish Private Medical
Insurance (PMI) market in 2014 229
Table 10.1 Percentage of the population who have reported to have
foregone care in 2014, in accordance with their insurance
situation304
xiii
CHAPTER 1
Introduction: The European Union,

the Insurance Industry and the Public-Private
Mix in Healthcare
Cyril Benoît, Marion Del Sol, and Philippe Martin
1 Introduction
Over the last 20 years, European Union (EU) healthcare policies and their
effect on healthcare systems and politics at national level have attracted
significant attention from social, legal and political scientists (Anderson
2015, chapter 7; Greer and Kurzer 2016, Mossialos et al. 2010; Steffen
2005; see also Coron 2018). In this domain, treaties are categorical as to
C. Benoît (*)
Centre for European Studies and Comparative Politics, Sciences Po (Paris),
CNRS, Paris, France
e-mail: cyril.benoit1@sciencespo.fr
M. Del Sol
Intitut de l’Ouest: Droit et Europe, Université de Rennes 1, Rennes, France
e-mail: marion.del-sol@univ-rennes1.fr
P. Martin
Centre for Comparative Labour Law and Social Security, Université de
Bordeaux, CNRS, Pessac, France
e-mail: philippe.martin@u-bordeaux.fr
© The Author(s) 2021 1

C. Benoît et al. (eds.), Private Health Insurance and the European
Union, https://doi.org/10.1007/978-3-030-54355-6_1
2 C. BENOÎT ET AL.
the limited competencies of supranational provisions, and Member States

ostensibly retain power over a number of crucial aspects of their health
policies (Vollaard et al. 2016). Unsurprisingly, what research has essen-
tially reported in this broad context is a rather gradual development of EU
healthcare policies, with more or less perceptible (and often indirect)
effects at national level. Due to its frequently unanticipated nature, such
development has typically taken circuitous routes and mainly manifested
in two ways: first, by the dissemination of standards and guidelines or
through the regulation of certain goods or commodities—knowing that
the EU has a number of regulatory prerogatives in relation to vital health
products, such as pharmaceuticals (Permanand 2006); and, second,
through the court’s application of internal market law which, in turn, may
affect several segments of health services delivery, policies or rules govern-
ing healthcare professionals (Duncan 2002). EU fiscal governance was
recently recognized as a “third face” of EU health policy (Greer 2014).
Indeed, and after the financial crisis, the EU has gained new powers to
enforce budgetary austerity. Through a series of coercive policy recom-
mendations to Member States about the governance of their healthcare
systems, fiscal policy became in turn more “rigorous and intimate”, pro-
voking significant shifts in healthcare decision-making at national level
(Greer et al. 2016).
There is an important segment of the healthcare sector that arguably
lies at the crossroads of these three dimensions—in the sense that it is
influenced by supranational standards and regulatory provisions, marked
by tensions between EU and domestic law and affected by post-crisis reg-
ulation—yet it has received very limited attention to date (though see
Thomson and Mossialos 2007). It is the private (usually voluntary) health
insurance (PHI) industry, a term that refers to the variety of firms offering
either or both types of substitutive health coverage (that would otherwise
be provided by a national health insurance or system); complementary
coverage (for services excluded from or not fully covered by the public
purse); or supplementary coverage, which essentially supplies consumers
with greater freedom of choice and faster access to care (Thomson and
Mossialos 2007). In several EU countries, PHI accounts for a significant
share of health expenditure and is even the main provider of care for some
benefits. Crucially, it has faced major transformations over the last 30
years, and this as a result of changes in EU law and regulations, often in
combination with more or less explicit forms of budgetary constraints or
retrenchment efforts at the domestic level.
1 INTRODUCTION: THE EUROPEAN UNION, THE INSURANCE INDUSTRY… 3
There is an obvious reason why PHI has largely remained under the
radar of scholarship on EU healthcare politics. In effect, it is essentially
through a series of directives aimed at governing the insurance industry as
a whole that EU law has remodelled PHI. A similar reason arguably
accounts for the rather limited interest of students of the public-private
mix in healthcare in the study of this issue—a term that we use in the fol-
lowing pages both to describe the combination of public and private actors
in health coverage (see Ebbinghaus 2011), but also in health benefits and
services delivery (see also Benoît and Coron 2019). As amply documented
in the following pages, the potential implications of insurance regulation
for the health sector were indeed regularly underestimated or simply dis-
regarded, a statement that applies both to academic research and, criti-
cally, to policy-making at domestic level—with policymakers often unaware
of the prior effects of EU law and regulation on private health insurers. In
turn, this relative ignorance was a source of recurrent mismatches and
unexpected effects of policy choices, with a number of implications for the
PHI industry. Crucially, this eventually contributed to changing the
public-private mix in healthcare.
In an attempt at filling this gap, this collective book gathers a multidis-
ciplinary team of specialists in social policy and the insurance industry. On
this basis, our ambition is to provide a broader account of the diverse
long-term effects EU provisions had on the private health insurance indus-
try—and their important implications for the political economy of con-
temporary Welfare States. In this book, we are more formally motivated
by three series of research questions. The first relates to the influence of
EU law and regulation on the nature and the place of PHI, which con-
tributors intend to prove and to characterize. We are also seeking to deter-
mine if and how the effects of these directives and regulations interacted
with both the outputs and the outcomes of health policy in several coun-
tries (Belgium, France, Ireland and the Netherlands), particularly in a
well-documented context of “permanent austerity” (Pierson 1998) and
where retrenchment efforts are now firmly entrenched in Welfare State
reform (Pierson 2001). Thirdly (and ultimately) our goal is to evaluate if,
how and to what extent the interactions between EU law and regulations
and health policy at domestic level affected the nature and scope of health
coverage in the countries under study.
Overall, the story that we narrate here is that of a growing “decou-
pling” (Trein 2017) between insurance regulation and health policy,
entailing a number of side effects for the private health insurance industry,
4 C. BENOÎT ET AL.
for the structure of the public-private mix in healthcare and for the nature
of health coverage, yet with contrasting effects from one country to
another. At a more conceptual level, such a broad finding might seem
quite trivial to readers familiar with existing scholarship on Europeanization
(see Graziano and Vink 2007). What we describe is indeed an umpteenth
story in which a series of directives are adopted with the explicit aim of
harmonizing domestic rules applying to an industry that eventually results,
after a conflictual implementation process, in multiple unintended effects
due to its interactions with a variety of national institutional dependencies.
There are, however, a number of lessons to draw from this seemingly clas-
sical conclusion due to the compound nature of the private health insur-
ance industry. Indeed, our findings echo a number of burgeoning debates
related to EU influence on health policy on the one hand and to the role
played by private providers in social policy at national level on the other.
Together, they delineate future research agendas discussed in greater
length below.
The rest of this Introduction is organized as follows. In Sect. 2, we start
by positioning our research questions and our contribution in the wider
literature. We then introduce the main analytical structure permeating the
various contributions of the book. Section 3 provides an overview of our
research design and case selection process. To understand how the
European “matrix” affected PHI and the public-private mix in healthcare,
we have undertaken an analysis of its genesis and of its effects at national
level, through a comparative analysis of four countries. Section 4 present
the contributions to the book, grouped into three parts—the first on the
political economy of EU law and regulation related to PHI, the second
based on large-n comparisons of the effect of these provisions on PHI and
the third part dedicated to in-depth, country case studies. We also reflect
in this section on how our findings echo wider debates in the literature.
2 Private Health Insurance in the European

Union: Marketization Embraced?
2.1 EU Insurance Law and Regulation as a Potential Vehicle
for the Marketization of PHI
This book maps the transformation of the private health insurance
industry in the EU over a period of around 30 years, starting with the
debates that led to the passage of “Insurance” directives in 1992. The

choice of this point of departure is justified by the ambition of these
texts, with the explicit aim of creating a unified legal framework for
insurance activities in Europe, in order to facilitate competition between
insurers in an increasingly unified Single Market. European integration
is pushed a step further some five years later, with the opening-up of a
12-year process of fierce political battles around the reform of solvency
rules governing insurance companies, resulting first in the adoption of
two directives in 2002 (known as the “Solvency I” system) and, more
significantly, of the Solvency II directive in 2009—which finally came
into effect in January 2016. Presented as a response by EU authorities
to the financial crisis, this text’s most explicit goal was to set up a risk-
based approach to insurance regulation, involving a number of changes
in terms of capital requirements, risk management and governance
structures of insurance activities.
As already suggested by this very brief outline of the European poli-
cies considered in greater detail throughout the book, PHI was not the
principal target of these different texts. Intriguingly, healthcare as a
policy matter was not a salient issue in the debates surrounding the
building of such a “European government” (Jullien and Smith 2014) of
the insurance industry, especially as compared with other life and non-
life insurance activities. Part of the reason for that situation lies in the
relatively marginal status of PHI in the wider insurance industry in
Europe—where in most Member States, a significant share of health
expenditure is covered by the public purse. Private health insurance
companies are thus typically small or medium sized firms. They are also
less financialized than most of the insurance industry. Moreover, they
also tend to cover a much more limited array of risks than the dominant
insurance companies, essentially circumscribed to health coverage and
occupational welfare. In turn, and when the largest insurance firms
operating across the continent do offer health-related products of some
kind, they rarely constitute the core of these companies’ growth
strategy.
There is another set of peculiarities of PHI in Europe that explains its
rather peripheral position in the industry and, by extension, in regula-
tory policy agenda. Most private health insurers across the continent are
indeed non-profit companies organized along solidarity-based or
6 C. BENOÎT ET AL.
democratic principles—meaning that they are usually run by a demo-

cratically elected board or by employer and employee representatives,
and that they generally use their gains to increase the benefits or the
coverage provided to their members. There are historical reasons for
that: in many Western European countries (particularly in continental
Europe), PHI has developed before the formation of contemporary
Welfare States, often as emanations of churches, charities, trade unions
or employers’ associations. In several countries, various compromises
were adopted to integrate these entities after the formation of modern
Welfare State institutions, sometimes through the delegation to these
entities of all or part of the management of healthcare systems or ser-
vices, sometimes by providing them with a more minor role. This means
that PHI has almost always kept strong ties with or within the Welfare
State and by the same token, is usually heavily regulated or even gov-
erned at domestic level. As a consequence, the public-private mix in
healthcare in Western Europe tends to be integrated into fixed and rigid
regulatory frameworks.
EU insurance law and regulation hits this balance. As of 1992,
Insurance directives opened up the PHI market to competition, notably
to for-profit insurance companies. More importantly, a number of provi-
sions maintaining PHI close to public healthcare systems were consid-
ered selective advantages and gradually removed. With Solvency II,
private health insurers now have to comply with stricter solvency require-
ments. They also need to make additional financial provisions and find
ways to increase the value of their funds—which, in a broader context of
low interest rates, often means searching for further (potentially riskier)
diversification benefits (Standard and Poor’s 2016). Additionally, this
text conveys a more explicit alignment of their governance with for-
profit insurance companies and, more broadly, financial firms. In sum-
mary, EU laws and regulations, at least formally, seem to induce a
growing marketization of PHI—with the openness of the health insur-
ance market to new actors, posing a number of threats for the business
model of non-profit entities, with an intensification of (possibly price-
based) competition and by potentially paving the way for the increased
financialization of the sector.
In this context, tracing the political sources of these formal provisions
and determining whether they effectively translated into an actual mar-
ketization of private health insurers is the guiding thread of the different
contributions of this volume. Symmetrically, the notion of marketization

permeates the three research questions addressed in the following chap-
ters. In determining whether EU law and regulation changed the nature
of PHI and if so, how, we are primarily interested in elucidating whether
it was in the sense of increased marketization and, critically, with which
measurable effects on the industry. By looking at whether and how these
same provisions interacted with health policy at domestic level, our moti-
vation is predominantly to evaluate whether it introduced more market
logics, behaviours and strategies in the public-private mix in healthcare.
The answer to our third question, on how these interactions eventually
(re)shaped the nature and scope of health coverage is also driven by a simi-
lar concern—do the principles that originally governed the private side of
health coverage now resemble more those of a market, as is the case in
numerous countries outside Europe?
2.2 Marketization: A Multidisciplinary Approach

for a Multifaceted Concept
The growth of market forces in the Welfare State or social welfare institu-
tions has been the subject of endless amounts of research over the last
three decades. More recently, this topic was examined in closer connection
to European integration (Crespy 2017). This book largely builds upon
these various contributions. In particular, we draw from these the state-
ment according to which marketization might come with a diversity of
institutional features and that it can perform widely different (and some-
times contradictory) functions. This particularly applies to our case, where
the provisions of EU insurance law and regulation are capable of generat-
ing different marketization paths as they interact with institutional orders
stabilized at domestic levels.
This claim also rests on well-established findings reported by the litera-
ture on the forging of markets in the Welfare State per se. In an authorita-
tive contribution in the field, Gingrich (2011) identified six ideal types of
markets in the Welfare State. Her approach combines the allocation
dimension (is the responsibility for access collective or individual?) and the
production dimension (who—namely the state, users or producers—has
effective control over the market?). The multiple configurations between
these two dimensions are capable of generating significant variations in
market types, ranging from “austerity markets” (where there is individual
8 C. BENOÎT ET AL.
responsibility for access and State control, as in Dutch healthcare markets)

to “pork barrel markets” with collective responsibility for access and where
producers are in capacity to extract rents (typified in Gingrich’s study by
the elderly care market in England in the 1980s).
A related feature of marketization is that it is fundamentally multifac-
eted. It can operate at the level of formal provisions while not necessarily
translating into effective practices of firms and organizations. Similarly,
there can be marketization when some actors endorse market logics in
their strategies and behaviours or when these same logics penetrate their
cognitive frames—yet, and crucially, this can be a result (or not) of legal or
more explicit political impulses. There may be obvious attempts from
political actors to marketize public or private entities’ way of operating by
changing the institutional rules governing their activities; but for various
reasons, an actual market might not emerge at the end as older practices
prove enduring (see also Schelkle 2019). These rather familiar statements
call for an analytical disambiguation of the different stages and the differ-
ent processes through which marketization is liable to occur and to draw
appropriate inferences from these various possible marketization pro-
cesses. This motivates the multidisciplinary approach retained in this book,
which brings together economists, legal and political scientists. Accordingly,
each of our four case studies are drafted by at least two authors from dif-
ferent disciplinary backgrounds, who are addressing our research ques-
tions by considering the plural forms marketization often takes in the
country under study. This includes its most obvious, formal and policy
appearances—typically when there is a number of legal provisions that
generate the conditions for the increasing marketization of the private
health insurance industry. But marketization is also measured through the
lens of the economic strategies and behaviours deployed by the actors
exposed to it, principally private health insurers in different countries.
Marketization is also envisioned as a possible unexpected outcome of the
interaction between EU law and regulation and health policy at domestic
level. As such, we also assume that it can be an outcome without necessar-
ily having been a purpose of public policy—as we will see, this particularly
applies to significant portions of the interaction between the legal matrix
established through EU insurance law and regulation and health policy at
the domestic level.
While most studies on marketization have focused on the transforma-
tion of Welfare State institutions, this book uses this concept to study a
more atypical configuration, since we are essentially considering broad
patterns of marketization through the lens of what happens within the

private health insurance industry. In the literature, marketization has
indeed often been discussed by authors primarily concerned with the
privatization of the Welfare State—with the former phenomenon often
seen as eventually leading to the latter, typically through an increase in
public spending paralleled with discrete support for market solutions
(Jensen 2011). In effect, marketization was often regarded as a particular
case of “hidden politics of [Welfare State] retrenchment” (Hacker 2004).
Here, we report patterns that differ from these classical accounts for obvi-
ous reasons, as the health insurance industry considered throughout the
book is private. Yet, and as already suggested, it is not necessarily mar-
ketized due to its non-profit commitment, the institutional setting in
which it operates and the principles governing its activities. This does not
mean that the transformations of this industry never interacted with poli-
cies explicitly aimed at privatizing or introducing market mechanisms
within the Welfare State. Moreover, and as repeatedly shown in the book,
the effects of the marketizations of the private health insurance industry
are often amplified by retrenchment efforts at domestic level. Nevertheless,
by retaining this case, our ambition with this book is also to depart from
the canonical debates around privatization that have dominated a signifi-
cant body of scholarship on the Welfare State. In so doing, we intend to
reflect more explicitly upon the actual practices and logics that lie behind
public and private providers in order to appreciate their overall impact on
the organization and division of solidarities and the associated power rela-
tions within the public-private mix in healthcare.
2.3 Making the Case for the Contingency of Europeanization

and its Usages
If EU insurance law and regulation is likely to marketize the private health
insurance industry, and possibly a share of the public-private mix in health-
care, by which mechanisms is it likely to do so? In brief, what this book
describes is the development of a sizeable legal and regulatory structure
for the insurance sector that gradually institutionalizes at domestic level,
generating a set of transformative effects affecting the private health insur-
ance industry. In this way, this overall process entails numerous unprece-
dented interactions with domestic healthcare reform—which, in turn,
affects both the public-private mix in healthcare and the nature and scope
of health coverage.
10 C. BENOÎT ET AL.
We were not, though, expecting to observe automatic effects at play or

institutions mechanically colliding with each other here, for two main
series of reasons. One is associated with the case under scrutiny. Despite its
magnitude and density, EU law and regulation in this domain strikes a
richly textured environment, moulded by several decades of reforms that
have given the public-private mix in healthcare its current shape in the dif-
ferent countries analysed in this volume. Stated differently, there are a
number of interest groups, veto points and more broadly, beneficiaries of
past policy choices or compromises that are more than likely to intervene
in the course of this implementation process (including private health
insurers themselves) and that are more than likely, too, to deflect EU poli-
cies from their initial purpose.
A second, deeper reason relates to the very process by which EU law
and regulation is transposed and implemented. It is indeed widely acknowl-
edged that implementation always involves different sets of actors which,
through their mobilizations, interpretations and usages, shape the con-
tours of this overall process—meaning that the same policies or legal pro-
visions can be constructed and used in many different ways (Hay 2007)
from one country to another, or even within a single country. This funda-
mentally implies that transposition always involves “translation” in the
broadest sense of the term (Smith 1997). For our research design, a wider
implication of embracing such conception is that we expect the outcomes
of these transformations under study to be highly contingent, a statement
that equally applies to our three research questions.
Stated differently and more generally, we assume here that EU insur-
ance law and regulation should be regarded as creating a number of con-
straints and opportunities for a large range of actors that are in a position
to use tools and resources (possibly offered by European integration itself)
to politically shape both the implementation and the likely effects of EU
policies—in summary, there is always a range of possible (and possibly
multiple) “usages” of Europe in each situation under study (Graziano
et al. 2011).
Accordingly, it is through a focus on (individual and collective) actors’
political work that the different contributors to this volume grasp and
draw inferences from the transformations of the private health industry
and the interactions between EU and domestic levels—in particular by
paying special attention to the legal, financial, cognitive, political or insti-
tutional resources these same actors may possess and actually use to shape
this overall process (Jacquot 2008). This is not to suggest that actors and
actions are favoured over institutional factors by the different contributors

(see also Exadaktylos and Radaelli 2012 on this distinction). On the con-
trary, actor-related and institution-related variables are studied in their
intimate connection, according to the basic assumption that institutional
rules and norms are effective when they actually appear in practices.
Institutional or legal factors are thus considered and reported when they
are observable and are actual prescriptions for behaviour, and their relative
effect is appreciated through the lens of their practices (Itçaina et al. 2016).
3 Research Design and Case Selection
3.1 The Structure of the Book

To approach the transformation of the private health insurance industry
under the effect of EU law and regulation—and ultimately, its implica-
tions for the public-private mix in healthcare and health coverage—we
have organized this book in three parts. Each part corresponds to a spe-
cific analytical level and addresses our research questions from a particu-
lar angle.
In Part I, two chapters narrate the political genesis of the two sets of
European directives that directly affected PHI, namely “Insurance” direc-
tives in 1992, then “Solvency I” and “Solvency II” directives in 2009.
These chapters focus on the participants and the various motivations of
the individual and collective actors involved in the development of this
far-reaching European architecture. As such, the two chapters describe the
landscape of the government of the insurance industry in Europe. They do
so through the lens of the political work undertaken by the various actors
that shaped it, with special reference to the regulatory politics at play, and
coupled with broadest reflections on the governance of financial services
in the EU (see Quaglia 2010).
Part II is also formed of two chapters that consist of large-n studies of
the impact of this matrix on private health insurers per se. In 1992,
Insurance directives essentially consisted of changes in legal and formal
provisions that modified the status and the governance of private health
insurers, particularly vis-à-vis the rest of (essentially public) health cover-
age providers. Thus, the first chapter of this part uses legal methods to
appreciate the differentiated impact of EU law in a large set of European
countries and healthcare systems, describing a sizeable array of possible
(and actual) combinations of public and private provisions. By contrast,
Solvency II mostly concerned a change of the prudential regime govern-

ing the daily activities of private health insurers, with likely impacts on the
scale of their business model, their strategies and corporate governance.
The second chapter of this part thus involves quantitative analyses of the
transformations that have affected the private health insurance industry
over the recent period.
Part III consists of four in-depth country case studies allowing for the
comparison of the different trajectories followed by Belgium, France,
Ireland and the Netherlands in this domain. These chapters more frontally
address the question of the collision of the EU framework with national
(mostly health or social policy-related) political agendas. As such, these
chapters not only examine the potential marketization of the private health
insurance industry from the perspective of firms, but also from the vantage
point of the public-private mix in healthcare. The fifth and last chapter of
Part III adopts a more prospective stance, reflecting on the relation
between private health insurance, occupational welfare and the distribu-
tion of solidarities in the public-private mix in healthcare, also on the basis
of national experiences in these domains.
3.2 A Multimethod Perspective

As suggested by this brief outline, the different chapters use a variety of
quantitative and qualitative methodologies drawn from the three disci-
plines participating in the book (economics, law and political sciences). All
chapters are formed of a similar empirical bedrock obtained through doc-
umentary analysis, systematic content analysis of press releases (including
the professional press of the insurance industry), an extensive review of
public and organized interests’ positions in each policy debate under con-
sideration and when applicable, preliminary expert interviews. This first
empirical stage is completed with additional evidence generated through
more specific methodologies, depending on the scope and the specific
questions posed in each chapter.
Chapters 2 and 3 (first part) mapping the development of EU law and
regulation add to this basis a range of semi-structured interviews with key
participants in these processes, notably civil servants, staff of European
administrative services and directorates, as well as ministerial and European
Commission officials. They also rely on second-hand academic sources,
mostly on the basis of an extensive review of articles published in actuarial
journals where a variety of stakeholders expressed opinions and shared

alternative propositions as these processes were unfolding.
In Part II, Chap. 4 assesses the differentiated impact of EU law on pri-
vate health insurance and its regulation on the basis of a systematic and
exhaustive analysis of EU and national legal databases, which roughly con-
sisted of an examination of the national transposition of European direc-
tives and the application of European Court of Justice (ECJ) rulings.
Chapter 5, on the impact of Solvency II on the private health insurance
industry, mobilizes a range of time series analysis techniques based on an
original dataset including 23 countries, for a timeframe between 1997 and
2018. It is completed with the identification of specific patterns for the
more active countries of the sample, estimated through regression models.
Part III (Chaps. 6, 7, 8, 9 and 10) combines different methodologies,
in line with our ambition to identify the diverse forms that marketization
might (or might not) take in different countries, as well as to grasp from
various angles the broader consequences of the coevolution of insurance
law and regulation and health policy. As such, all chapters are informed by
an exhaustive review of the legislation produced in the country in ques-
tion, descriptive statistics and semi-structured interviews with a diverse
range of actors, including civil servants and administrative officials, private
health insurers and their representatives as well as healthcare professionals.
Using data from interviews with representatives of key organizations or
players has become quite common in social policy analysis and in political
economy, notably for case-oriented studies involving several countries
(Ebbinghaus and Naumann 2018). In this part, the combination of differ-
ent methodologies and data sources more fundamentally allows for a bet-
ter description of the sequencing of policy decisions and policy change, a
crucial point when it comes to evaluating the effects of EU law and regula-
tion on an industry heavily institutionalized at national level.
3.3 Case Selection
While the first part of the book deals with the different pieces of the
European regulatory architecture, the second part involves large-n com-
parisons of its legal and economic impacts on PHI. By contrast, in Part III
we address our research questions (especially related to the public-private
mix in healthcare and the nature and scope of health coverage) through a
limited number of in-depth country case studies. The ultimate goal of
these chapters is to characterize causal mechanisms, yet not to identify a
single scheme of linear causality. Instead, our ambition is to uncover traces

of causal mechanisms within the context of the cases under study (Bennett
and Elman 2006), by providing for each case “an accurate picture of causal
constellations” (Roger 2013) between a range of intervening variables
(such as the prior effects of past healthcare reforms, the mobilization of
key veto players or interest groups and the ties that private health insurers
might possess in political parties—each providing grounds for various pos-
sible “usages of Europe”). As discussed before, we are expecting the out-
comes for each case to be highly contingent upon the political work of a
number of actors evolving in compact institutional settings. We are also
expecting the EU matrix to be subjected to a variety of potential interpre-
tations and framings. As such, we are adopting throughout the book a
rather classical approach in healthcare Europeanization, where the goal of
the analysis is to understand “how, why and to what extent” this process
has taken a given form in the cases under study, assuming that a lot of
national specificities are at play from one country case to another
(Martinsen 2012).
Our three research questions involve a number of underlying assump-
tions that do matter when it comes to case selection. Determining whether
and how EU law and regulation changed the private health insurance
industry obviously requires retaining cases where this industry exists and
where it accounts for a significant (which does not necessarily mean large)
share of health expenditures. In addition, measuring how the outcomes of
this matrix interacted with prior or simultaneous effects of past policy
choices is better achieved, we think, through selecting cases where there
are some explicit and institutionalized linkages between the public and the
private sides of health coverage. Arguably, this same statement equally
applies to our third research question, namely whether and how health
coverage changed in nature or scope as a result of the interactions between
the European framework and health policy at domestic level.
Moreover, an overall expectation underlies these three research ques-
tions. We are indeed hypothesising that the institutionalization of the EU
framework results in a growing marketization of private health insurers, of
the public-private mix in healthcare and, eventually, health coverage. This
requires selecting cases where the private health insurance industry is
potentially exposed to such a transformation, at least formally—and sym-
metrically, not selecting cases where it is already marketized. It is notice-
able that cases where there exists a fully marketized private health insurance
industry are quite rare in Europe. Granted, there are some countries where
there exists a (rather small) market for private health insurance. Yet it gen-
erally has no particular institutional linkages with public coverage (this is,
e.g., the case in Spain). In accordance with our research questions and
hypotheses, we have therefore decided not to include such cases in our
country case analysis (see further).
On the basis of these statements, we have retained for our analysis
most-similar cases (Seawright and Gerring 2008), to compare the relative
effects of factors that we expect to be present in the different cases under
study, but crucially, interacting and being at play differently. We combine
this approach with a most-likely case selection strategy (Rohlfing 2012),
namely by selecting national cases which are most likely to be impacted by
EU law and regulation. Here, our ambition is to maximize our chances of
observing the PHI marketization process in order to be better able to
identify a wide set of different mechanisms—knowing that we expect this
process to be an input of EU law and regulation, despite its interaction
with other institutional features of healthcare systems that are not directly
affected by this initial source of change.
It is on this broad basis that we have retained the four countries under
study (Belgium, France, Ireland and the Netherlands), which all comply
with this twofold requirement (see Chap. 5 for an extensive discussion). In
each of these countries, the share of health expenditure covered by PHI is
significant (above 12%). These are also countries where “governments rec-
ognize that [PHI] can contribute significantly to social protection”
(Mossialos and Thomson 2004) and thus where there exist strong ties
between PHI and the Welfare State. Lastly, the private health insurance
industry is marked by the presence of a large number of non-profit firms
in these four countries, and thus particularly exposed to different forms of
marketization. Crucially, there are also for-profit insurance companies
offering health coverage in each of these cases, thus allowing an apprecia-
tion of the effect of EU law and regulation on these entities, and their
potential conflict-provoking effects on “institutionalized relationships”
(Jullien and Smith 2008) within the industry.
It is also worth mentioning that if these four cases are both most-similar
and most-likely from the angle of our research questions and assumptions,
they are not usually considered as such by comparative research on Welfare
States or health policy. If Belgium, France and the Netherlands are all
Bismarckian systems to a certain extent, this is not the case of Ireland, clas-
sified as a Beveridgian (tax-financed) system. In terms of health expenses,
one can also note a significant decrease in the share of health expenditure
covered by the public purse in Ireland and the Netherlands during the
period examined, while this share remained relatively stable in Belgium
and France. There are, in addition, a number of differences in terms of the
status, governance and organization of non-profit health insurers per se
from one selected country to another. We expect these second-order dif-
ferences to provide meaningful insights into the mechanisms accounting
for the penetration and effects of EU law and regulation in this domain.
4 The Book in a Nutshell

There are two ways of seeing the story narrated in this book and to envi-
sion the answers it provides to our research questions. Readers primarily
interested in health policy will find in the subsequent chapters a discussion
of the interactions of two trends (marketization and privatization) that
arguably stand at the forefront of the debates related to this field, yet that
have been subjected to only scant discussion in conjunction with EU influ-
ence. Those who are mostly interested in the insurance industry and more
broadly, financial services regulation, might also find an interest in reading
this volume. Scholars are now paying increasing attention to this sector of
prime importance for our understanding of the political economy of con-
temporary capitalism. Still, the literature has to date mainly focused on
large transnational firms and on life insurance, arguably at the forefront of
the changes affecting the wider industry (see Graz 2019). Here they will
find an analysis of its transformations from a different standpoint, allowing
for an appreciation of some of the many side effects associated with the
regulatory and industrial changes it has experienced in Europe over the
last 30 years. After introducing the different contributions to this book,
we return to these questions in a discussion of the wider implications of
our findings for current debates on these two broad classes of issues.
4.1 Contributions to the Book

The book opens with Gaël Coron and Marion Del Sol’s analysis of the
long march towards a unified European government for insurance activi-
ties, starting off with the adoption of “first generation” (1973) and culmi-
nating with “third generation” Insurance directives in 1992—the latter
having constituted a critical juncture for the private health insurance
industry in most countries (Chap. 2). Coron and Del Sol particularly insist
in this chapter on the proactive role played in this domain by European
Commission services in charge of financial institutions and corporate law,

who have made an intensive use of ECJ rulings to advance their own
visions and agendas for the sector. More generally, what he describes is a
process leading to a twofold trivialization. On the one hand, and as a result
of the Commission officials’ political work, insurance activities were grow-
ingly assimilated to financial services and treated as such, leading to vari-
ous implications for their regulation in the Single Market. This overall
trend was paralleled with a more discrete yet significant trivialization of
private (mostly non-profit) health insurance companies, gradually associ-
ated with the rest of the insurance activities—notably through Insurance
directives in 1992.
In Chap. 3, Cyril Benoît examines the fierce political battles that led to
the far-reaching reform of solvency rules governing insurance activities in
the EU between 1994 and 2016, with special reference to the private
health insurance industry. Focusing on the prudential regime laid down in
EU law and regulation, he shows that the adoption of Solvency II in 2009
amplified the movement described by Coron, albeit through a renewed
approach. While previous directives were essentially preoccupied with
finding common rules to organize competition within the Single Market,
Solvency II developed as a more conceptual architecture, with rules,
requirements and standards aimed at becoming ingrained in insurers’ daily
activities. This shift was essentially legitimized as providing greater trans-
parency and safety to financial investors and policyholders. Benoît shows
that this transformation is fundamentally more likely to induce major
changes for private health insurers (notably non-profit and smaller firms),
as their activities have developed using different principles, values and rul-
ing structures.
After a focus in Part I on the sizeable European regulatory infrastruc-
ture that developed over the last three decades, Part II starts with an
extensive, large-n study of the differentiated implications it may have on
PHI in various Member States (Chap. 4). In this regard, Marion Del Sol
and Philippe Martin, with a particular focus on the competitive framework
created by Insurance directives, arrive at a twofold conclusion. First, EU
law and regulation might effectively be considered as a potential vehicle
for the increasing marketization of the sector, particularly in those coun-
tries where private health insurers are non-profit firms and closely inte-
grated into Welfare State institutions. Yet, and crucially, it should be
symmetrically regarded as providing a matrix rather than being a source of
vertical integration—as it is actually flexible and open to interpretation,
and as it leaves a wide latitude for national regulation of the PHI industry,
including its relation with public providers. As such, one can expect a high
degree of contingency and many possible usages of this legal framework in
its transposition at domestic level.
In their study of the impact of Solvency II, Philippe Abecassis and
Nathalie Coutinet draw a similar conclusion from the vantage point of the
insurance industry per se (Chap. 5). It is right, they assert, to expect that
EU law and regulation result in an increasing homogenization of private
health insurers, in the sense of their growing alignment with the behav-
iours, strategies and logics already in play in significant segments of the
sector. Yet, the pattern suggested by their data is more complex than what
this broad-brush picture suggests. Indeed, the financialization of PHI
(and notably, mergers and takeovers) does not coincide with the business
cycle of the rest of the industry. This does not mean that the impact of EU
law and regulation was neutral. Insurance directives provided strong
incentives for PHI to develop transnational activities; Solvency II, as it
involves stricter solvency requirements, incentivized larger dominant firms
to diversify their risk portfolios, leading to alliances with PHI or to the
development of health-related products—as the latter are less demanding
in terms of solvency requirements. However, this matrix, Abecassis and
Coutinet argue, is better understood as providing a basis for various strate-
gies than as an exogenous shock implying a standardised response. For the
time period considered, it even appears that national reforms played a
more decisive role in providing constraints and opportunities to PHI.
These converging statements are followed in Part III by in-depth coun-
try case studies. Cyril Benoît and Marion Del Sol (Chap. 6) first consider
the case of Belgium, where the “public” side of health coverage is dele-
gated and organized around non-profit private health insurers, namely
mutual benefit societies—and as such is excluded from the perimeter of
EU insurance law and regulation. Over the last two decades, and as a
result of various governmental attempts at reducing health expenditure,
mutual benefit societies nevertheless developed and managed on their
own a variety of complementary coverage, initially without any formalized
legal boundaries. This situation was challenged during the 2000s by for-
profit insurance companies seeking to penetrate the market. In this con-
text, they used both Insurance and Solvency II directives in their search
for supranational support, in order ultimately to challenge the position of
mutual benefit societies. In turn, the latter responded by working politi-
cally to secure their position at domestic level. As a result of these political
struggles, a reform adopted in 2010 reinforced several features of the

Belgian public-private mix by safeguarding the position of mutual benefit
societies for complementary coverage. But this same reform also opened
the supplementary side of health coverage to competition and aligned it
with EU provisions, thus marketizing a share of the public-private mix in
Belgium—with recent figures suggesting that this new pillar is now rapidly
expanding.
Mutual benefit societies might also be found in France, as explained by
Gaël Coron, Thomas Houssoy and Cyril Benoît in their contribution
(Chap. 7). Historically, however, their activities were circumscribed to the
complementary share of health coverage, where they have to compete
with other non-profit entities and (increasingly) for-profit insurance com-
panies. What has happened in the country, Coron, Houssoy and Benoît
argue, is an early and manifold marketization process of private health
insurers as a result of the application of EU law and regulation—but deci-
sively, this trend was markedly reinforced and shaped by a series of policies
adopted at national level. Indeed, over the last 20 years, successive French
governments have tried to increase health coverage without expending the
share already covered by the public purse. This strategy ostensibly involved
private health insurers in achieving several governmental objectives, yet
the prior effects of Europeanization on these entities were poorly acknowl-
edged by policymakers. As such, the many consequences associated with
the rise of a “European-driven” market now increasingly conflict with a
“State-driven” market.
While Europeanization was associated with greater marketization of the
public-private mix in healthcare in Belgium and France, this has initially
not been the case in Ireland, as argued by Pascale Turquet and Philippe
Martin in their contribution (Chap. 8). In this “two-tiered” system, pri-
vate health insurance duplicates public coverage by offering additional
benefits and services such as access to private hospitals. While there is
competition on the PHI market in Ireland in application of EU legal pro-
visions, the Irish government succeeded in maintaining strong regulation
of the sector due to the important role it plays in the provision of care.
This was notably achieved through an exemption of (semi-public) non-
profit firms from compliance with Insurance directives and through a risk-
equalization scheme. However, this initial compromise was increasingly
contested in the 2000s, with new entrants on the market trying to use
European provisions to challenge the position of their competitors. This
also coincided with debates on whether Voluntary Health Insurance
(VHI) Healthcare, the non-profit leading firm of Irish PHI market, should
comply with solvency requirements. These turbulences were amplified by
the consequences of the financial crisis, which significantly raised the cost
of insurance policies over the last few years.
Turquet and Martin then turn to an examination of the case of The
Netherlands, a country where health policy has been market-oriented
since the beginning of the 1990s. The system is now characterized by
managed competition between health insurers, and the government only
retains regulatory and supervisory prerogatives (Chap. 9). In this country,
EU law and regulation was thus not the only—or the main—source of
marketization. In addition, there seems to be no contradiction between
the latter’s most market-like dimensions since similar features are arguably
in play in the Dutch healthcare system. However, and crucially, Turquet
and Martin show that it does not necessarily mean that Europeanization
has had no effect on the country. Solvency rules on insurance activities as
well as the degree of openness of the market (in close relation to the poli-
cies pursued by the Dutch Central Bank) notably constituted major issues,
with collateral implications for the public-private mix in the course of
recent years.
In the last contribution to the book, Thomas Houssoy, Marion Del Sol
and Philippe Martin adopt a more prospective stance by reflecting on
some additional repercussions of the transformations observed in the pre-
vious chapters (Chap. 10). In the four countries under study, PHI is now
more marketized than it was at the beginning of the 1990s, even if the
shape and the very reasons for the development of health insurance mar-
kets differ from one country to another. What are the specific implications
of such changes when PHI turns out to be acquired at corporate level, and
thus becomes part of occupational welfare? More precisely, how do firms
and trade unions behave in such marketized environments when they
become purchasers of private health coverage? What are the related impli-
cations of their choices for the distribution of solidarities within the public-
private mix? After a discussion of the many ramifications of these questions
(which ostensibly resonate with the literature on pension reform and the
pillarization of social protection), Del Sol, Martin and Houssoy consider
the French case, viewing it as a quasi-natural experiment. Indeed, while
once limited in scope, corporate PHI grew significantly in this country
after a reform in 2013, which introduced an obligation for employers to
provide their workers with a PHI scheme. Crucially, it came into force in
an environment already reshaped in the sense of a greater marketization of

PHI by prior reforms.
Each of these chapters comes with its own conclusions and series of
responses to our research questions. Additionally, we think that the book
in itself generates further insights on two broader debates in the literature
that are worth briefly introducing before allowing the reader to enter into
the many complexities of the relationship between private health insurance
and the European Union.
4.2 Understanding the Presence of Financial Firms

in Social Policy
The various conclusions raised in the aforementioned chapters explicitly
echo a wider controversy in the political economy literature. Political
economists have indeed long debated whether and why capital—often
equated with employers—tended to express support for or oppose social
protection (see Hall and Soskice 2001). More recently, scholars have
argued that our understanding of “capital” should also include financial
firms, since as potential competitors of social insurance, they can reason-
ably “be expected to be key proponents of retrenchment” to become inte-
gral participants of social coverage (Naczyk 2013). The book provides this
burgeoning literature with additional accounts on why financial firms—
here insurance companies—might have an interest in prospering in social
protection or policy, particularly in a more protected and less lucrative
market, as health insurance undoubtedly is.
Admittedly, and by paving the way for a removal of some of the barriers
that integrated PHI into the Welfare State, EU provisions considerably
eased access to this market to other (essentially for-profit) insurance com-
panies. One can note that their presence increased in the four countries for
the period under study, but crucially, this was not as a result of an explicit
(or an implicit) European political agenda—as health insurance, as shown
in Chap. 2, was a theme of particularly little importance during the debates
surrounding Insurance directives. In a similar vein (and more fundamen-
tally) several chapters of the book argue that this also has to do with the
incentives created by Solvency II, while the goal of this text was initially to
strengthen regulation and improve regulatory standards. What is described
in the following pages is that by imposing stricter requirements, EU provi-
sions created a very powerful incentive for for-profit insurance companies
to diversify, notably on more secured markets such as healthcare (see
Chaps. 2, 3 and 4). As such, the presence of insurance companies (and

their demands, as exemplified by the case of Belgium, for government to
facilitate their access to the health insurance market—see Chap. 6) also
appear to be a side effect of an overall increase in regulatory requirements.
Put differently, an apparent consolidation of regulatory demands for
the wider industry here resulted, at least in some of its segments, in increas-
ing pressures and financialization. This does not necessarily contradict the
finding reported by studies identifying more explicit attempts by financial
companies to gain access to social protection, and country case studies in
Part III provide evidence of more direct and more classical forms of inter-
est group politics. But this arguably provides a set of additional factors of
the formation of the structure of opportunity that shape financial firms’
behaviours and motivations in this domain—as we highlight how social
protection might be unintentionally affected by wider transformations of
financial services regulation. A similar statement arguably applies to related
debates on the financialization of social protection. Here also, we report,
especially in Chaps. 3, 4 and 7, an increasing financialization of health
insurers, notably non-profit insurance companies. And here again, we
show how it is an outcome (and to some extent a side effect) of the stricter
solvency requirements demanded by Solvency II. In our view, such find-
ings should invite political economists to pay greater attention to multi-
level changes and unexpected outcomes of past regulatory choices when
they seek to understand why and how there is a rise of financial firms or
financialization in social protection.
4.3 The EU and the Shifts in the Public-Private Mix

in Healthcare
As already suggested at the beginning of this Introduction, the literature
on EU healthcare politics has essentially focused on the propensity of
Europeanization to diffuse a number of (notably regulatory) standards, to
alter health services delivery and policies through the application of inter-
nal law and to stimulate budgetary austerity—three features largely exhib-
ited in the case of PHI. This book hopefully helps to make another aspect
more explicit, which complements rather than disputes the already known
faces of EU healthcare politics as documented in the literature. This aspect
relates to how Europeanization contributes to the reshaping of the public-
private mix in healthcare in two ways, amply discussed in Chaps. 6, 7, 8
and 9. Firstly, it can introduce competition within the sector (or facilitate
competition where it already exists), together with the alignment of non-

profit and for-profit providers. Secondly (and less noticeably), because
Europeanization might result in an institutional decoupling between PHI
and Welfare State institutions. This, in turn, renders public and private
coverage more sealed off from each other. In addition to modifying the
nature of health coverage, such reconfiguring might also affect the scope
of health policy (as illustrated by the case of France studied in Chap. 7). As
a result, Europeanization here is not necessarily “shifting the public-
private mix” (Seeleib-Kaiser et al. 2012), but rather reinforcing its institu-
tional (and possibly financial) sedimentation. This latter statement will
certainly sound familiar to those who know the literature dedicated to the
political economy of pension reform and policies, where scholars are
accustomed to speaking in terms of pillarization and multi-pillar struc-
tures—and where they are accustomed, too, to studying marketization in
close connection with privatization in broad “multi-pillar” settings (see
Ebbinghaus 2015). There are a number of issues involved when the
public-private mix in healthcare is analysed in the language of pillars, as
discussed in Chap. 10. But we strongly think that there is something to be
gained from keeping a watchful eye over some similar transformations
arguably at play between the two sectors, in close connection with the role
of the EU and, more broadly, Europeanization. We also believe that this
holds true even if, in stark contrast with pension reform, the changes that
are described here are mostly unintended outcomes of the interactions
between various EU and national policy choices, and are not (or not yet)
part of an explicit political agenda to combine pillarization with various
forms of privatization and marketization of the public-private mix in
healthcare. Yet some critical outcomes (that prominently include marketi-
zation, a segmentation of coverage and growing presence of financial
firms) are now changing both sectors, which are arguably at the crossroads
of national “growth regimes” (Hassel and Palier 2020).
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PART I
The Political Roots of EU Insurance

Legislation
CHAPTER 2
Insurance Directives and the Single Market:

Towards a Trivialisation of Private
Health Insurance?
Gaël Coron and Marion Del Sol
1 Introduction
The health insurance market has an economic reality in all Member States
of the European Union (EU), though the place and role of the private
insurance sector in covering health care expenditure varies, sometimes
considerably, from one country to another (Sagan and Thomson 2016).
The health insurance market is also a legal reality: the various private
health insurance actors pursue their activity within a common legal envi-
ronment that was forged, from 1973 onwards, by the “insurance” direc-
tives adopted by the EU.
G. Coron (*)
Arènes (UMR CNRS 6051), EHESP, Rennes, France
e-mail: Gael.Coron@ehesp.fr
M. Del Sol
Intitut de l’Ouest : Droit et Europe, Université de Rennes 1, Rennes, France
e-mail: marion.del-sol@univ-rennes1.fr
© The Author(s) 2021 29

C. Benoît et al. (eds.), Private Health Insurance and the European
Union, https://doi.org/10.1007/978-3-030-54355-6_2
30 G. CORON AND M. DEL SOL
This normative environment is the fruit of a long political process seek-

ing to create a single insurance market. The common framework was con-
structed gradually via the adoption of three generations of directives. The
first two sets of directives sought to allow insurance actors to exercise two
fundamental economic freedoms laid down by the Treaty: freedom of
establishment and freedom to provide services. The third generation of
directives adopted in 1992 brought the process to completion and, in a
way, formally established the internal insurance market (Table 2.1).
To a great extent, these texts were due to the activism of the European
Commission, more specifically, to that of the Directorate-General in
charge, at the time, of the portfolio “Financial Institutions and Company
Law” (hereinafter DG 15).1 From the outset, it should be highlighted that
this Directorate-General held significant power and wielded considerable
political sway, which are both essential levers for moving European proj-
ects forward (Smith 2016; Georgakakis and Rowell 2013; Greer et al.
2019). For this particular project, DG 15 placed its actions within the
European Commission’s transverse single market project. With regard to
services, the three generations of directives contributed towards this goal.
Consequently, the political horizon of the “insurance” directives was not
sector-specific; it was part of the project to ensure the free movement of
financial services within the European area. This would prove to be deci-
sive in the progress of the political process; as it would be for the
provisions adopted, these giving little consideration to the specificities of
Table 2.1 The “three generations” of EU Insurance directives

First generation— Second generation— Third generation—
freedom of freedom to provide completion of the
establishment services internal market
Non-life insurance Directive 73/239/ Directive 88/357/ Directive 92/49/EEC

(including health EEC of 24 July EEC of 22 June of 18 June 1992
insurance) 1973 1988
Life insurance Directive 79/267/ Directive 90/619/ Directive 92/96/EEC
EEC of 5 March EEC of 8 November of 10 November 1992
1979 1990
Source: author(s)
1
In later reforms, this Directorate-General would be included within the scope of the DG
Market, in charge of the internal market.
2 INSURANCE DIRECTIVES AND THE SINGLE MARKET… 31
the insurance sector. In other words, this initial context configured to a

great extent the course of the European framework: a kind of trivialisation
of the activity and the institutions of the insurance sector, which was sub-
sumed into the far greater financial services sector (2).
When examining the insurance sector and, notably, the third genera-
tion of directives (1992), the matter of taking into consideration intrasec-
toral specificities inevitably arises. These directives had a blanket scope of
application that only distinguished between two large classes of insurance
on the basis of a technical criterion:2 life insurance, which includes all types
of insurance for which risk is linked to the duration of the insured person’s
life (insurance payable on death or survival); and non-life insurance, which
includes all types of insurance that are not linked to the person’s life (prop-
erty insurance, liability insurance, health insurance, etc.). Given that these
texts set out to forge a common framework of practice for all insurers, the
matter of intrasectoral adaptations arose in the course of the political pro-
cess. This was the case for health insurance, notably owing to national
specificities (e.g. the existence of mutual benefit societies in France);
Method
The results presented in this chapter are derived from four sources:
–– a review of the legal literature concerning the three genera-
tions of directives;
–– a series of semi-structured interviews conducted in 2018 with
former members of the European Commission who were
involved in drawing up the directives and with former manag-
ers from the private health insurance sector;
–– private archives collected by a former civil servant of the
Commission, which allowed us to access the speeches present-
ing the second- and third-generation texts to various bodies
and also the Commission’s preparatory documents;
–– concerning the French situation, the minutes of executive
committee meetings and the general assembly of the Fédération
Nationale de la Mutualité Française (the leading federation of
French health mutual benefit societies, hereinafter FNMF).
2
Several classifications exist for insurance. The directives adopted the classification based
on the modalities of managing premiums, by capitalisation (life insurance) or by-distribution
(non-life insurance).
nevertheless, the issue never assumed a central role, to the extent that one
can once again speak of trivialisation in another form, that of the actors
and activities of the health insurance sector (3).
2 The Political Horizon of the “Insurance”

Directives: Realisation of the Internal Market
One might reasonably expect that the “insurance” directives were drawn
up in response to the specific concerns of the insurance sector and the
needs expressed by representatives of this industry and/or end consumers.
The reality is however very different. The normative framework created
was a component of the transverse project to realise the single market.
Furthermore, these directives were the outcome of a historical process in
which the availability of technical solutions to institutional actors was pri-
marily determined by their political feasibility. The process is detailed
below. The directives also demonstrated the adaptability of the European
Commission (Jabko 2006), a strategic actor, and also the decisive role
played by the Court of Justice in constructing the cognitive frameworks,
which underpin political projects (Weiler 1994).
2.1 First Attempts to Construct a European Insurance Market

on the Basis of Freedom of Establishment
For the construction of the European insurance market, three legal bases
could be mobilised. They corresponded to three fundamental economic
freedoms recognised by the Treaties:
–– freedom of establishment, by virtue of which an economic actor

(here, an insurer) registered in one Member State can access national
(insurance) markets via the creation of a durable establishment in the
territory of one or more other Member States. Non-national actors
must not be discriminated against; they must be able to access
national markets under the same conditions as local economic actors.
–– freedom to provide services, by virtue of which an economic actor
can pursue cross-border activities without needing to have a durable
or permanent establishment in the territory of another State. In
other words, the freedom to provide services allows an insurer regis-
tered in one Member State to access the insurance market of another
State without being required to have a local establishment. The State

regulating the market cannot impose as a prerequisite the existence
of an establishment in its territory.
–– free movement of capital, which enables the implementation of an
integrated financial system. This freedom permits the movement of
funds necessary for insurance financial products and links policies in
the insurance field with the legislation applicable to financial services
and instruments (e.g. mutual funds).
The diversity of these legal bases explains a large part of the political
game that preceded the adoption of legislation for insurance at the
European level (Dehousse 1998). The legal techniques for implementing
a unified, then single, market, changed over time as a result of a complex
game between States and European institutions. The life insurance/non-
life insurance dichotomy adopted by the first-generation directives is a
perfect illustration of this political game.
The first generation of directives (1973 and 1979) employed freedom
of establishment as their legal basis. They sought to coordinate the condi-
tions of access and of exercise that insurers had to fulfil in order to estab-
lish themselves in another Member State, whether as a primary undertaking
(registration of headquarters) or a secondary undertaking (creation of
agencies or branches). Supervisory mechanisms and conditions varied,
sometimes quite substantially, between Member States. For example,
authorisation was required in some States but not in others; some States
issued broad authorisations, whereas others issued special authorisations
(for specific types of insurance activity) (De Fruto Gomez 1991). The
notion of supervision could also vary between countries, notably in terms
of financial requirements.
With the stated aim of facilitating freedom of establishment, the direc-
tives sought to eliminate areas of divergence between national legislations
with regard to supervision. Particular attention was given to coordinating
the provisions concerning financial guarantees; securing the undertakings
made by insurers is an essential means of protecting insured parties. The
question was even more essential in view of the fact that the first directives
systematised administrative authorisation as a prerequisite and entrusted
Member States with the competence of granting authorisation to insurers
who wanted to become established in their territory whether as a primary
or secondary undertaking.
From this period, the texts incorporated requirements related to tech-

nical provisions, that is, reserves that had to be sufficiently high to fully
settle all contractual undertakings towards insured parties. They corre-
sponded to financial assets appearing in the liabilities balance sheet and
that allowed the insurer to cover the cost of claims. Hence they represent
a debt to insured parties. The first-generation directives made a sufficient
level of technical provisions a prerequisite for obtaining administrative
authorisation in all Member States. This represented a process of coordi-
nation but also of convergence of national legislations. However, conver-
gence was minimal because the texts granted States the power to determine
the amount of technical provisions required for obtaining authorisation.
The importance that the first directives attached to financial guarantees
had another concrete manifestation. In addition to having sufficient tech-
nical provisions, the insurer was required to have a sufficient solvency mar-
gin, that is, holdings free of predictable undertakings, with incorporeal
(own funds) elements deducted. The sufficient solvency margin covered
all of the insurer’s activities and had to be determined in accordance with
methods laid down by the directives. In this regard, the distinction
between non-life insurance (1973 directive) and life insurance (1979
directive) raised the issue of simultaneous pursuit (accumulation) of activi-
ties in both categories. This led the European legislator to establish, in the
1979 directive, the specialisation principle which, in essence, is a principle
of non-accumulation of a life insurance activity with a non-life insurance
activity. The specialisation principle “gate-crashed” the political process.
As Guy Levie, principal administrator of the “Insurance” division of the

European Commission, explained in an article published in 1980, the con-
tinuation of “multi-activity” businesses was an important issue in the discus-
sions that culminated in the 1979 directive. The United Kingdom, Belgium
and Luxembourg lobbied the Commission to permit multi-activity, whereas
the other countries wanted pluriactivity abolished within fifteen to twenty
years. (Levie 1980)
The provisions of the final text represented a kind of compromise

between these two positions: on the one hand, article 13(3) allowed insur-
ers who accumulated both categories before the announcement of the
directive to continue to pursue both activities but on the condition that
they adopted independent management (with separate technical provi-
sions and solvency margins for each activity); on the other hand, article
13(6) gave States the option to end accumulation situations that predated
the directive over a period that they determined.
Application of the first-generation directives had contrasting effects.
Officials of the European Commission have frequently considered that
national authorities did not fully apply the principle of equal treatment to
national and non-national insurers. It seemed that the authorisation pro-
cedures also provided a mechanism for States to control access to their
insurance market by granting no or few authorisations to non-national
insurers to establish themselves in their territory. In this respect, the weak-
ness of the chosen legal basis (freedom of establishment) for constructing
a European direct insurance market was revealed: it left open the possibil-
ity of national resistance.3
2.2 Revival of the Political Process via Mobilisation

of Case Law
Two events contributed to revival of the process for integration of the
insurance sector. The first was not specific to the field and occurred some-
what in the background: publication of the Commission’s White Paper
Completing the Internal Market in 1985. The second event did concern
the insurance sector, more specifically the activity of brokers; it consisted
of a series of rulings by the Court of Justice in 1986. These two events
acted upon the consequences of another essential event in the construc-
tion of Europe that occurred in 1979: the Rewe-Zentral ruling also known
as the “Cassis de Dijon” ruling.4
The window of opportunity opened by the Court with the Cassis de Dijon
ruling. The case concerned the marketing of alcohol produced in one
Member State in the territory of another Member State, which therefore
engages the principle of free movement of goods. The Court considered
that “in the absence of common rules relating to the production and mar-
keting of alcohol […], it is for the Member States to regulate all matters
relating to the production and marketing of alcohol in their territory”
(point 8). In other words, with exceptions limited to those enumerated, if
3
In contrast, it is noteworthy that, in the field of reinsurance, the principle of freedom to
provide services was established in 1964 (Council Directive 64/225/EEC of 25 February
1964 to eliminate, in reinsurance and retrocession, restrictions on the freedom of establish-
ment and the freedom to provide services).
4
ECJ 20 February 1979, Rewe-Zentral AG, Case 120/78, ECR 1979, p. 649.
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cry—
“They have killed my Luc, brother—my Luc, who took me from
your wards of mercy, sins and all. They have killed my sweet singing
cricket, my merry, merry cricket, that had no guile in all its roguish
heart. They put their heel upon him in the path—what are songs to
them!—and left my summer desolate. If I weep one moment, I know
that blood will scald my cheeks and drain my heart, and I shall die
before I act. O, brother! keep back my tears a little. Show me what to
do!”
She clutched in agony at his robe.
“Come,” he said; “the way is clear.”
*****
The feast was served to the tick of the hour by lay brothers,
another blank-envisaged form directing them. The tables smoked
with cheer, and de Regnac rubbed his hands. There were the joints
of fat kid and the flagons of old Malaga—salmis of quail, too; truffled
sausages; herrings with mustard sauce, things of strong flavour meet
for warriors. The steam itself was an invitation—the smell, the
sparkle. Only one thing lacked—the Prior’s grace. De Regnac,
bestial always, but most like a tiger in the view of unattainable
meats, crowded the interval with maledictions and curses. His
courtesy stopped anywhere on the threshold of his appetites.
Baulked of his banquet, he would be ready to make a holocaust of
the whole hospital. Yet he dared not be the first to put his fingers in
the dish.
“Where is our host?” he growled. “Doth he fear the test—or death
—a coward faint with indecision?”
Even with the word, he found him at his elbow—an old, dry pipe of
a man, wheezing thin air. The father’s face under its dropping cowl
(no doubt his lungs were too crazy for the vizor) showed stark with
rime; his forehead was streaked with it; his eyes were half-thawed
pools. He spoke. Hoarse and feeble, his voice seemed to crow from
the attics of a ruined tenement, high up among the winds.
“Fall to, soldiers, fall to! There is no grace like honest appetite. Fall
to! And they tell me ye have travelled far to claim our hospitality. Fall
to!”
De Regnac smacked his shoulder boisterously, so that he
staggered.
“Not till you have blessed our meal for us, old father.”
The Prior raised his trembling hands. The other caught at them.
“Not that way. We ask the taster’s grace. It was a bargain.”
“Be seated, señor,” said the old man, with dignity. “I do not forget
my obligations.”
He went round, bent and stiffly, taking a shred from each dish, a
sippet dipped in the gravy.
“Bella premunt hostilia,” he expostulated. “Intestine wars invade
our breast. What a task for our old digestion!”
His roguery pleased and reassured his company. They attacked
the viands with a will. He never ceased to encourage them, going
about the board with garrulous cheer.
“And ye come over the hills?” said he. “A hungry journey and a
dangerous. It was the mountains, and the spirits of the mountains,
that were alone invincible when the Moorish dogs overran all Spain
—all but the mountains. The heathen crests were lowered there—
rolled back in a bloody foam. Dear God! I’m old.”
“Not so ancient, father,” cried de Regnac, “but that good liquor will
revitalize you. There remains the wine.”
“Ah me!” sighed the Prior; “must I?”
They swore him to the toast by every bond of honour. Their throats
were ragged with drought.
“Well, well,” he said. “I’ll first dismiss these witnesses to their
father’s shame. I’ll be no Noah to my children.”
He drove the servitors, with feeble playfulness, into the passage;
pursued them a pace or two. In a moment he was back alone, his
cowl pulled about his face.
“Give me the draught,” he said hoarsely, “nor look ye upon the old
man’s abasement. I am soon to answer for my frailties.”
Cheering and bantering, they mixed him a cup from every flagon,
and put it into his hand, which gripped it through the cloth. He turned
his back on them, and took the liquor down by slow degrees,
chuckling and gasping and protesting. Then, still coughing, he
handed the cup, backwards, to the nearest.
“Bumpers, all!” roared de Regnac. “We toast old Noah for our king
of hosts!”
Even as he drank, as they all drank, thirsty and uproarious, the
great door of the refectory clanged to, and the Prior spun with a
scream to the floor. De Regnac’s cup fell from his hand; a dead
silence succeeded.
Suddenly the Colonel was on his feet, ghastly and terrible.
“Something foul!” he whispered; “something foul!”
Staggering, he swerved out, and drove with all his weight against
the door. It had been locked and bolted upon them. Not a massive
panel creaked. They were entombed!
Hush!
Solemn, low, mystic, arose without the chaunt of voices in unison
—the prayers for one sick unto death: “Receive, O Lord, the sacrifice
we offer for thy servant, who is near the end of her life.”
With a scream, de Regnac threw himself towards the body on the
floor, and lifted it with huge strength in his arms. As he did so, the
cowl fell away, and revealed the face of Pepino. The shadow of
death was already fallen on it; but she spoke, and with a smile.
“When he pursued them, I was waiting and took his place. Curse
him not. He observed the letter. ’Twas I poisoned the wine. Take
back thy wages, dog! O, I go to find my Luc—if thou darest follow
me!”
He roared out—a spasm took his throat. He tried to crush her in
his arms. They relaxed in the effort. Howling, he dropped her, and
fell beside in a heap.
Then, from out a mortal paralysis, arose sobbing and wailing at the
table. Some seized salt, some the wet mustard from the fish, and
swallowed it by handfuls. Others ran hither and thither aimlessly,
screeching, blaspheming, beating the walls, the obdurate door.
There was a regimental doctor among them; he was the first dead.
None found help or hope in that ghastly trap. The venom had been
swift, gripping, ineradicable. Within half an hour it was all a silent
company, and the Miserere long had ceased.
Somewhere in a book I read of a tale like this, which was headed
“Patriotic Fanaticism.” Those were certainly the deadly days of
retaliation; but in this case Love, as always, was the principal fanatic.
THE GHOST-LEECH
Kelvin, not I, is responsible for this story, which he told me sitting
smoking by his study window.
It was a squalid night, I remember, wet and fretful—the sort of
night which seems to sojourners in the deep country (as we then
were) to bring rumours of plashy pavements, and the roar of rain-
sodden traffic, and the wailing and blaspheming of women lost and
crying out of a great darkness. No knowledge of our rural isolation
could allay this haunting impression in my mind that night. I felt ill at
ease, and, for some reason, out of suits with life. It mattered nothing
that a belt of wild woodland separated us from the country station
five miles away. That, after all, by the noises in it, might have been a
very causeway, by which innumerable spectres were hurrying home
from their business in the distant cities. The dark clouds, as long as
we could see them labouring from the south, appeared freighted with
the very burden of congregated dreariness. They glided up, like vast
electric tramcars, and seemed to pause overhead, as if to discharge
into the sanctuary of our quiet pastures their loads of aggressive
vulgarity. My nerves were all jangled into disorder, I fear, and
inclining me to imaginative hyperbole.
Kelvin, for his part, was very quiet. He was a conundrum, that
man. Once the keenest of sportsmen, he was now for years become
an almost sentimental humanitarian—and illogical, of necessity. He
would not consent to kill under any circumstances—wilfully, that is to
say; but he enjoyed his mutton with the best of us. However, I am not
quarrelling with his point of view. He, for one—by his own admission,
anyhow—owed a life to “the blind Fury with th’ abhorred shears,” and
he would not, from the date of his debt, cross her prerogatives. The
same occasion, it appeared, had opened in him an unstanchable
vein of superstition, which was wont to gush—bloodily, I might say—
in depressing seasons of the mind. It provoked me, on the evening
of the present anecdote, to a sort of peevish protest.
“Why the devil,” I said, “are spectral manifestations—at least,
according to you fellows—everlastingly morbid and ugly? Are there
no gentle disembodied things, who, of their love and pity, would be
rather more anxious than the wicked, one would think, to
communicate with their survivors?”
“Of course,” said Kelvin; “but their brief sweet little reassurances
pass unnoticed. Their forms are insignificant, their voices
inarticulate; they can only appeal by symbol, desperately clinging to
the earth the while. On the other hand, the world tethers its
worldlings by the foot, so that they cannot take flight when they will.
There remains, so to speak, too much earth in their composition, and
it keeps ’em subject to the laws of gravitation.”
I laughed; then shrugged impatiently.
“What a rasping night it is! The devil take that moth!”
The window was shut, and the persistent whirring and tapping of a
big white insect on the glass outside jarred irritably on my nerves.
“Let it in, for goodness’ sake,” I said, “if it will insist on making a
holocaust of itself!”
Kelvin had looked up when I first spoke. Now he rose, with shining
eyes, and a curious little sigh of the sort that one vents on the receipt
of wonderful news coming out of suspense.
“Yes, I’ll open the window,” he said low; and with the word threw
up the casement. The moth whizzed in, whizzed round, and settled
on his hand. He lifted it, with an odd set smile, into the intimate range
of his vision, and scrutinized it intently. Suddenly and quickly, then,
as if satisfied about something, he held it away from him.
“Ite missa est!” he murmured, quoting some words of the Mass (he
was a Catholic); and the moth fluttered and rose. Now, you may
believe it or not; but there was a fire burning on the hearth, and
straight for that fire went the moth, and seemed to go up with the
smoke into the chimney. I was so astonished that I gasped; but
Kelvin appeared serenely unconcerned as he faced round on me.
“Well,” I exploded, “if a man mayn’t kill, he may persuade to
suicide, it seems.”
He answered good-humouredly, “All right; but it wasn’t suicide.”
Then he resumed his seat by me, and relighted his pipe. I sat
stolidly, with an indefinable feeling of grievance, and said nothing.
But the silence soon grew unbearable.
“Kelvin,” I said, suddenly and viciously; “what the deuce do you
mean?”
“You wouldn’t believe,” he answered, at once and cheerily, “even if
I told you.”
“Told me what?”
“Well, this. There was the soul of little Patsy that went up in the
smoke.”
“The village child you are so attached to?”
“Yes; and who has lain dying these weeks past.”
“Why should it come to you?”
“It was a compact between us—if she were summoned, in a
moment, without time for a good-bye. We were close friends.”
“Kelvin—excuse me—you are getting to be impossible.”
“All right. Look at your watch. Time was made for unbelievers.
There’s no convincing a sceptic but by foot-rule. Look at your watch.”
“I did, I confess—covertly—in the instant of distraction caused by
Kelvin’s little son, who came to bid his father good night. He was a
quiet, winning little fellow, glowing with health and beauty.
“Good night, Bobo,” said Kelvin, kissing the child fondly. “Ask God
to make little Patsy’s bed comfy, before you get into your own.”
I kissed the boy also; but awkwardly, for some reason, under his
frank courteousness. After he was gone, I sank back in my chair and
said, grudging the concession—
“Very well. It’s half-past eight.”
Kelvin nodded, and said nothing more for a long time. Then, all of
a sudden, he broke out—
“I usen’t to believe in such things myself, once upon a time; but
Bobo converted me. Would you like to hear the story?”
“O, yes!” I said, tolerantly superior. “Fire away!”
He laughed, filling his pipe—the laugh of a man too surely self-
convinced to regard criticism of his faith.
“Patsy,” he said, “had no Ghost-Leech to touch her well. Poor little
Patsy! But she’s better among the flowers.”
“Of Paradise, I suppose you mean? Well, if she is, she is,” I said,
as if I were deprecating the inevitably undesirable. “But what is a
Ghost-Leech?”
“A Ghost-Leech,” he said—“the sort, anyhow, that I’ve knowledge
of—is one who has served seven years goal-keeper in the hurling-
matches of the dead.”
I stared at him. Was he really going, or gone, off his head? He
laughed again, waving his hand to reassure me.
“You may accept my proof or not. Anyhow, Bobo’s recovery was
proof enough for me. A sense of humour, I admit, is outside our
conception of the disembodied. We lay down laughter with life, don’t
we? You’d count it heresy to believe otherwise. Yet have you ever
considered how man’s one great distinctive faculty must be admitted
into all evidence of his deeds upon earth, as minuted by the
recording angel? It must be admitted, of course, and appreciatively
by the final assessor. How could he judge laughter who had never
laughed? The cachinnatory nerve is touched off from across the Styx
—wireless telegraphy; and man will laugh still, though he be
damned.”
“Kelvin! my good soul!”
“The dead, I tell you, do not put off their sense of humour with their
flesh. They laugh beyond the grave. They are full of a sense of fun,
and not necessarily the most transcendent.”
“No, indeed, by all the testimony of spiritualism.”
“Well; now listen. I was staying once in a village on the west coast
of Ireland. The people of my hamlet were at deadly traditional feud
with the people of a neighbouring hamlet. Traditional, I say, because
the vendetta (it almost amounted to one) derived from the old days
of rivalry between them in the ancient game of hurling, which was a
sort of primitive violent “rugger” played with a wooden ball. The
game itself was long fallen into disuse in the district, and had been
supplanted, even in times out of memory, by sports of a gentler,
more modern cast. But it, and the feud it had occasioned, were still
continued unabated beyond the grave. How do I know this? Why, on
the evidence of my Ghost-Leech.
“He was a strange, moody, solitary man, pitied, though secretly
dreaded, by his neighbours. They might have credited him with
possession—particularly with a bad local form of possession; to
suspect it was enough in itself to keep their mouths shut from
questioning him, or their ears from inviting confession of his
sufferings. For, so their surmise were correct, and he in the grip of
the hurlers, a word wrung from him out of season would have
brought the whole village under the curse of its dead.”
I broke in here. “Kelvin, for the Lord’s sake! you are too cimmerian.
Titillate your glooms with a touch of that spiritual laughter.”
Agreeably to my banter, he smiled.
“There’s fun in it,” he said; “only it’s rather ghastly fun. What do
you say to the rival teams meeting in one or other of the village
graveyards, and whacking a skull about with long shank-bones?”
“I should say, It doesn’t surprise me in the least. Anything turning
upon a more esoteric psychology would. What pitiful imaginations
you Christmas-number seers are possessed of!”
“I dare say. But I’m not imagining. It’s you practical souls that
imagine—that common sense, for instance, is reason; that the top-
hat is the divinely-inspired shibboleth of the chosen; and so on. But
you don’t disappoint me. Shall I go on?”
“O, yes! go on.”
“The hurlers meet under the full moon, they say, in one or other of
the rival graveyards; but they must have a living bachelor out of each
parish to keep goal for them.”
“I see! ‘They say’? I see!”
“The doom of the poor wretch thus chosen is, as you may
suppose, an appalling one. He must go, or suffer terrors damning out
of reason. There is no power on earth can save him. One night he is
sitting, perhaps, in his cabin at any peaceful work. The moor, mystic
under the moonlight, stretches from miles away up to his walls,
surrounding and isolating them. His little home is an ark, anchored
amid a waste and silent sea of flowers. Suddenly the latch clinks up,
advances, falls. The night air breathing in passes a presence
standing in the opening, and quivers and dies. Stealthily the door
gapes, ever so little, ever so softly, and a face, like the gliding rim of
the moon, creeps round its edge. It is the face, he recognizes
appalled, of one long dead. The eyeplaces are black hollows; but
there is a movement in them like the glint of water in a deep well. A
hand lifts and beckons. The goal-keeper is chosen, and must go. For
seven years, it is said, he must serve the hurling-matches of the
dead.”
“State it for a fact. Don’t hedge on report.”
“I don’t. This man served his time. If he hadn’t, Bobo wouldn’t be
here.”
“O? Poor Bobo!”
“This man, I say, survived the ghastly ordeal—one case out of a
dozen that succumb. Then he got his fee.”
“O, a fee! What was that? A Rachel of the bogs?”
“The power to cure by touch any human sickness, even the most
humanly baffling.”
“Really a royal reward. It’s easy to see a fortune in it.”
“He would have been welcome to mine; but he would take nothing.
He made my little boy whole again.”
“Kelvin! I dare say I’m a brute. What had been the matter with
him?”
“Ah, what! He simply moaned and wasted—moaned eternally.
Atrophy; meningitis; cachexy—they gave it a dozen names, but not a
single cure. He was dying under slow torture—a heavy sight for a
father.
“One day an old Shaman of the moors called upon me. He was
ancient, ancient—as dry as his staff, and so bent that, a little more,
and he had tripped over his long beard in walking. I can’t reproduce
his brogue; but this is the substance of what it conveyed to me:—
“Had I ever heard speak of Baruch of the lone shebeen—him that
had once kept an illicit still, but that the ghosts had got hold of for his
sins? No? Well, he, the Shaman, was come too near the end of his
own living tether to fear ghoulish reprisals if he told me. And he told
me.
“Baruch, he said, was suspected in the village of keeping the
dead’s hurling-goal—had long been suspected—it was an old tale by
now. But, och, wirrastrue! if, as he calculated, Baruch was nearing
the close of his seven years’ service, Baruch was the man for me,
and could do for my child what no other living man, barring a ghosts’
goal-keeper, could do likewise.
“I humoured him when he was present; laughed at him when he
was gone; but—I went to see Baruch. It’s all right: you aren’t a
father.”
“You went to see Baruch. Go on.”
“He lived remote in such a little cabin as I have described. Lord!
what a thing it was!—a living trophy of damnation—a statue
inhabiting the human vestment! His face was young enough; but
sorrow stricken into stone—unearthly suffering carved out of a block.
It is astonishing what expression can be conveyed without a line.
There was not a wrinkle in Baruch’s face.
“All scepticism withered in me at the sight—all the desperate
effrontery with which I had intended to challenge his gift. I asked him
simply if he would cure my child.
“He answered, in a voice as hoarse and feeble as an old man’s,
but with a queer little promise of joy in it, like a sound of unborn rain,
‘Asthore! for this I’ve lived me lone among the peats, and bid me
time, and suffered what I know. In a good hour be it spoken! Wance
more, and come again when the moon has passed its full.’
“I went, without another question, or the thought of one. That was
a bad week for me—a mortal struggle for the child. The dead kept
pulling him to draw him down; but he fought and held on, the little
plucked one. On the day following the night of full moon, I carried
him in my arms to the cabin—myself, all the way. I wouldn’t let on to
a soul; I went roundabout, and I got to Baruch unnoticed. I knew it
was kill or cure for Bobo. He couldn’t have survived another night.
“I tell you, it was a laughing spirit that greeted me. Have you ever
seen Doré’s picture of the ‘Wandering Jew,’ at the end of his journey,
having his boots pulled off? There is the same release depicted, the
same sweet comedy of redemption—the same figure of fun, if you
like, that Baruch presented.
“He put his hands on Bobo’s head, and——”
“Well?”
“Bobo walked home with me, that’s all.”
Kelvin got up from his chair to relight his pipe at the fire. As he
moved, the door of the room opened, and a decent woman, his
housekeeper, stood, with a grave face, in the entrance.
“Patsy’s dead?” said Kelvin.
“Ah, the poor mite!” answered the woman, with a burst of tears.
“She passed but now, sir, at half after eight, in her little bed.”
POOR LUCY RIVERS
The following story was told to a friend—with leave, conditionally, to
make it public—by a well-known physician who died last year.
I was in Paul’s type-writing exchange (says the professional

narrator), seeing about some circulars I required, when a young lady
came in bearing a box, the weight of which seemed to tax her
strength severely. She was a very personable young woman, though
looking ill, I fancied—in short, with those diathetic symptoms which
point to a condition of hysteria. The manager, who had been
engaged elsewhere, making towards me at the moment, I intimated
to him that he should attend to the new-comer first. He turned to her.
“Now, madam?” said he.
“I bought this machine second-hand of you last week,” she began,
after a little hesitation. He admitted his memory of the fact. “I want to
know,” she said, “if you’ll change it for another.”
“Is there anything wrong with it, then?” he asked.
“Yes,” she said; “No!” she said; “Everything!” she said, in a
crescendo of spasms, looking as if she were about to cry. The
manager shrugged his shoulders.
“Very reprehensible of us,” said he; “and hardly our way. It is not
customary; but, of course—if it doesn’t suit—to give satisfaction——”
he cleared his throat.
“I don’t want to be unfair,” said the young woman. “It doesn’t suit
me. It might another person.”
He had lifted, while speaking, its case off the type-writer, and now,
placing the machine on a desk, inserted a sheet or two of paper, and
ran his fingers deftly over the keys.
“Really, madam,” said he, removing and examining the slip, “I can
detect nothing wrong.”
“I said—perhaps—only as regards myself.”
She was hanging her head, and spoke very low.
“But!” said he, and stopped—and could only add the emphasis of
another deprecatory shrug.
“Will you do me the favour, madam, to try it in my presence?”
“No,” she murmured; “please don’t ask me. I’d really rather not.”
Again the suggestion of strain—of suffering.
“At least,” said he, “oblige me by looking at this.”
He held before her the few lines he had typed. She had averted
her head during the minute he had been at work; and it was now with
evident reluctance, and some force put upon herself, that she
acquiesced. But the moment she raised her eyes, her face
brightened with a distinct expression of relief.
“Yes,” she said; “I know there’s nothing wrong with it. I’m sure it’s
all my fault. But—but, if you don’t mind. So much depends on it.”
Well, the girl was pretty; the manager was human. There were a
dozen young women, of a more or less pert type, at work in the front
office. I dare say he had qualified in the illogic of feminine moods. At
any rate, the visitor walked off in a little with a machine presumably
another than that she had brought.
“Professional?” I asked, to the manager’s resigned smile
addressed to me.
“So to speak,” said he. “She’s one of the ‘augment her income’
class. I fancy it’s little enough without. She’s done an occasional job
for us. We’ve got her card somewhere.”
“Can you find it?”
He could find it, though he was evidently surprised at the request
—scarce reasonably, I think, seeing how he himself had just given
me an instance of that male inclination to the attractive, which is so
calculated to impress woman in general with the injustice of our
claims to impartiality.
With the piece of pasteboard in my hand, I walked off then and
there to commission “Miss Phillida Gray” with the job I had intended
for Paul’s. Psychologically, I suppose, the case interested me. Here
was a young person who seemed, for no practical reason, to have
quarrelled with her unexceptionable means to a livelihood.
It raised more than one question; the incompleteness of woman as
a wage earner, so long as she was emancipated from all but her
fancifulness; the possibility of the spontaneous generation of soul—
the divina particula auræ—in man-made mechanisms, in the
construction of which their makers had invested their whole of
mental capital. Frankenstein loathed the abortion of his genius. Who
shall say that the soul of the inventor may not speak antipathetically,
through the instrument which records it, to that soul’s natural
antagonist? Locomotives have moods, as any engine-driver will tell
you; and any shaver, that his razor, after maltreating in some fit of
perversity one side of his face, will repent, and caress the other as
gently as any sucking-dove.
I laughed at this point of my reflections. Had Miss Gray’s type-
writer, embodying the soul of a blasphemer, taken to swearing at
her?
It was a bitterly cold day. Snow, which had fallen heavily in
November, was yet lying compact and unthawed in January. One
had the novel experience in London of passing between piled
ramparts of it. Traffic for some two months had been at a discount;
and walking, for one of my years, was still so perilous a business
that I was long in getting to Miss Gray’s door.
She lived West Kensington way, in a “converted flat,” whose title,
like that of a familiar type of Christian exhibited on platforms, did not
convince of anything but a sort of paying opportunism. That is to say,
at the cost of some internal match-boarding, roughly fitted and
stained, an unlettable private residence, of the estimated yearly
rental of forty pounds, had been divided into two “sets” at thirty-five
apiece—whereby fashion, let us hope, profited as greatly as the
landlord.
Miss Gray inhabited the upper section, the door to which was
opened by a little Cockney drab, very smutty, and smelling of gas
stoves.
“Yes, she was in.” (For all her burden, “Phillida,” with her young
limbs, had outstripped me.) “Would I please to walk up?”
It was the dismallest room I was shown into—really the most
unattractive setting for the personable little body I had seen. She
was not there at the moment, so that I could take stock without
rudeness. The one curtainless window stared, under a lid of fog, at
the factory-like rear of houses in the next street. Within was scarce
an evidence of dainty feminine occupation. It was all an illustration of
the empty larder and the wolf at the door. How long would the bolt
withstand him? The very walls, it seemed, had been stripped for
sops to his ravening—stripped so nervously, so hurriedly, that
ribbons of paper had been flayed here and there from the plaster.
The ceiling was falling; the common grate cold; there was a rag of
old carpet on the floor—a dreary, deadly place! The type-writer—the
new one—laid upon a little table placed ready for its use, was, in its
varnished case, the one prominent object, quite healthy by contrast.
How would the wolf moan and scratch to hear it desperately busy,
with click and clang, building up its paper rampart against his
besieging!
I had fallen of a sudden so depressed, into a spirit of such
premonitory haunting, that for a moment I almost thought I could
hear the brute of my own fancy snuffling outside. Surely there was
something breathing, rustling near me—something——
I grunted, shook myself, and walked to the mantelpiece. There
was nothing to remark on it but a copy of some verses on a sheet of
notepaper; but the printed address at the top, and the signature at
the foot of this, immediately caught my attention. I trust, under the
circumstances (there was a coincidence here), that it was not
dishonest, but I took out my glasses, and read those verses—or, to
be strictly accurate, the gallant opening quatrain—with a laudable
coolness. But inasmuch as the matter of the second and third
stanzas, which I had an opportunity of perusing later, bears upon
one aspect of my story, I may as well quote the whole poem here for
what it is worth.
Phyllis, I cannot woo in rhyme,

As courtlier gallants woo,
With utterances sweet as thyme
And melting as the dew.
An arm to serve; true eyes to see;

Honour surpassing love;
These, for all song, my vouchers be,
Dear love, so thou’lt them prove.
Bid me—and though the rhyming art
I may not thee contrive—
I’ll print upon thy lips, sweetheart,
A poem that shall live.
It may have been derivative; it seemed to me, when I came to read

the complete copy, passable. At the first, even, I was certainly
conscious of a thrill of secret gratification. But, as I said, I had
mastered no more than the first four lines, when a rustle at the door
informed me that I was detected.
She started, I could see, as I turned round. I was not at the trouble
of apologizing for my inquisitiveness.
“Yes,” I said; “I saw you at Paul’s Exchange, got your address, and
came on here. I want some circulars typed. No doubt you will
undertake the job?”
I was conning her narrowly while I spoke. It was obviously a case
of neurasthenia—the tendril shooting in the sunless vault. But she
had more spirit than I calculated on. She just walked across to the
empty fireplace, collared those verses, and put them into her pocket.
I rather admired her for it.
“Yes, with pleasure,” she said, sweetening the rebuke with a blush,
and stultifying it by affecting to look on the mantelpiece for a card,
which eventually she produced from another place. “These are my
terms.”
“Thank you,” I replied. “What do you say to a contra account—you
to do my work, and I to set my professional attendance against it? I
am a doctor.”
She looked at me mute and amazed.
“But there is nothing the matter with me,” she murmured, and
broke into a nervous smile.
“O, I beg your pardon!” I said. “Then it was only your instrument
which was out of sorts?”
Her face fell at once.
“You heard me—of course,” she said. “Yes, I—it was out of sorts,
as you say. One gets fancies, perhaps, living alone, and typing—
typing.”
I thought of the discordant clack going on hour by hour—the dead
words of others made brassily vociferous, until one’s own
individuality would become merged in the infernal harmonics.
“And so,” I said, “like the dog’s master in the fable, you quarrelled
with an old servant.”
“O, no!” she answered. “I had only had it for a week—since I came
here.”
“You have only been here a week?”
“Little more,” she replied. “I had to move from my old rooms. It is
very kind of you to take such an interest in me. Will you tell me what
I can do for you?”
My instructions were soon given. The morrow would see them
attended to. No, she need not send the copies on. I would myself call
for them in the afternoon.
“I hope this machine will be more to the purpose,” I said.
“I hope so, too,” she answered.
“Well, she seems a lady,” I thought, as I walked home; “a little
anæmic flower of gentility.” But sentiment was not to the point.
That evening, “over the walnuts and the wine,” I tackled Master
Jack, my second son. He was a promising youth; was reading for the
Bar, and, for all I knew, might have contributed to the “Gownsman.”
“Jack,” I said, when we were alone, “I never knew till to-day that
you considered yourself a poet.”
He looked at me coolly and inquiringly, but said nothing.
“Do you consider yourself a marrying man, too?” I asked.
He shook his head, with a little amazed smile.
“Then what the devil do you mean by addressing a copy of love
verses to Miss Phillida Gray?”
He was on his feet in a moment, as pale as death.
“If you were not my father”—he began.
“But I am, my boy,” I answered, “and an indulgent one, I think
you’ll grant.”
He turned, and stalked out of the room; returned in a minute, and
flung down a duplicate draft of the poem on the table before me. I
put down the crackers, took up the paper, and finished my reading of
it.
“Jack,” I said, “I beg your pardon. It does credit to your heart—you
understand the emphasis? You are a young gentleman of some
prospects. Miss Gray is a young lady of none.”
He hesitated a moment; then flung himself on his knees before
me. He was only a great boy.
“Dad,” he said; “dear old Dad; you’ve seen them—you’ve seen
her?”
I admitted the facts. “But that is not at all an answer to me,” I said.
“Where is she?” he entreated, pawing me.
“You don’t know?”
“Not from Adam. I drove her hard, and she ran away from me. She
said she would, if I insisted—not to kill those same prospects of
mine. My prospects! Good God! What are they without her? She left
her old rooms, and no address. How did you get to see her—and my
stuff?”
I could satisfy him on these points.
“But it’s true,” he said; “and—and I’m in love, Dad—Dad, I’m in
love.”
He leaned his arms on the table, and his head on his arms.
“Well,” I said, “how did you get to know her?”
“Business,” he muttered, “pure business. I just answered her
advertisement—took her some of my twaddle. She’s an orphan—
daughter of a Captain Gray, navy man; and—and she’s an angel.”
“I hope he is,” I answered. “But anyhow, that settles it. There’s no
marrying and giving in marriage in heaven.”
He looked up.
“You don’t mean it? No! you dearest and most indulgent of old
Dads! Tell me where she is.”
I rose.
“I may be all that; but I’m not such a fool. I shall see her to-morrow.
Give me till after then.”
“O, you perfect saint!”
“I promise absolutely nothing.”
“I don’t want you to. I leave you to her. She could beguile a Saint
Anthony.”
“Hey!”
“I mean as a Christian woman should.”
“O! that explains it.”
The following afternoon I went to West Kensington. The little drab
was snuffling when she opened the door. She had a little hat on her
head.
“Missus wasn’t well,” she said; “and she hadn’t liked to leave her,
though by rights she was only engaged for an hour or two in the
day.”
“Well,” I said, “I’m a doctor, and will attend to her. You can go.”
She gladly shut me in and herself out. The clang of the door
echoed up the narrow staircase, and was succeeded, as if it had
started it, by the quick toing and froing of a footfall in the room
above. There was something inexpressibly ghostly in the sound, in
the reeling dusk which transmitted it.
I perceived, the moment I set eyes on the girl, that there was
something seriously wrong with her. Her face was white as wax, and
quivered with an incessant horror of laughter. She tried to rally, to
greet me, but broke down at the first attempt, and stood as mute as
stone.
I thank my God I can be a sympathetic without being a fanciful
man. I went to her at once, and imprisoned her icy hands in the
human strength of my own.
“What is it? Have you the papers ready for me?”
She shook her head, and spoke only after a second effort.
“I am very sorry.”
“You haven’t done them, then? Never mind. But why not? Didn’t
the new machine suit either?”
I felt her hands twitch in mine. She made another movement of
dissent.
“That’s odd,” I said. “It looks as if it wasn’t the fault of the tools, but
of the workwoman.”
All in a moment she was clinging to me convulsively, and crying—
“You are a doctor—you’ll understand—don’t leave me alone—
don’t let me stop here!”
“Now listen,” I said; “listen, and control yourself. Do you hear? I
have come prepared to take you away. I’ll explain why presently.”
“I thought at first it was my fault,” she wept distressfully, “working,
perhaps, until I grew light-headed” (Ah, hunger and loneliness and
that grinding labour!); “but when I was sure of myself, still it went on,
and I could not do my tasks to earn money. Then I thought—how can
God let such things be!—that the instrument itself must be haunted.
It took to going at night; and in the morning”—she gripped my hands
—“I burnt them. I tried to think I had done it myself in my sleep, and I
always burnt them. But it didn’t stop, and at last I made up my mind
to take it back and ask for another—another—you remember?”
She pressed closer to me, and looked fearfully over her shoulder.
“It does the same,” she whispered, gulping. “It wasn’t the machine
at all. It’s the place—itself—that’s haunted.”
I confess a tremor ran through me. The room was dusking—
hugging itself into secrecy over its own sordid details. Out near the
window, the type-writer, like a watchful sentient thing, seemed
grinning at us with all its ivory teeth. She had carried it there, that it
might be as far from herself as possible.
“First let me light the gas,” I said, gently but resolutely detaching
her hands.
“There is none,” she murmured.
None. It was beyond her means. This poor creature kept her
deadly vigils with a couple of candles. I lit them—they served but to
make the gloom more visible—and went to pull down the blind.
“O, take care of it!” she whispered fearfully, meaning the type-
writer. “It is awful to shut out the daylight so soon.”
God in heaven, what she must have suffered! But I admitted
nothing, and took her determinedly in hand.
“Now,” I said, returning to her, “tell me plainly and distinctly what it
is that the machine does.”
She did not answer. I repeated my question.
“It writes things,” she muttered—“things that don’t come from me.
Day and night it’s the same. The words on the paper aren’t the
words that come from my fingers.”
“But that is impossible, you know.”
“So I should have thought once. Perhaps—what is it to be
possessed? There was another type-writer—another girl—lived in
these rooms before me.”
“Indeed! And what became of her?”
“She disappeared mysteriously—no one knows why or where.
Maria, my little maid, told me about her. Her name was Lucy Rivers,
and—she just disappeared. The landlord advertised her effects, to
be claimed, or sold to pay the rent; and that was done, and she
made no sign. It was about two months ago.”
“Well, will you now practically demonstrate to me this
reprehensible eccentricity on the part of your instrument?”
“Don’t ask me. I don’t dare.”
“I would do it myself; but of course you will understand that a more
satisfactory conclusion would be come to by my watching your
fingers. Make an effort—you needn’t even look at the result—and I
will take you away immediately after.”
“You are very good,” she answered pathetically; “but I don’t know
that I ought to accept. Where to, please? And—and I don’t even
know your name.”
“Well, I have my own reasons for withholding it.”
“It is all so horrible,” she said; “and I am in your hands.”
“They are waiting to transfer you to mamma’s,” said I.
The name seemed an instant inspiration and solace to her. She
looked at me, without a word, full of wonder and gratitude; then
asked me to bring the candles, and she would acquit herself of her
task. She showed the best pluck over it, though her face was ashy,
and her mouth a line, and her little nostrils pulsing the whole time
she was at work.
I had got her down to one of my circulars, and, watching her
fingers intently, was as sure as observer could be that she had
followed the text verbatim.
“Now,” I said, when she came to a pause, “give me a hint how to
remove this paper, and go you to the other end of the room.”
She flicked up a catch. “You have only to pull it off the roller,” she
said; and rose and obeyed. The moment she was away I followed
my instructions, and drew forth the printed sheet and looked at it.
It may have occupied me longer than I intended. But I was folding
it very deliberately, and putting it away in my pocket when I walked
across to her with a smile. She gazed at me one intent moment, and
dropped her eyes.

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Private Health Insurance and the

European Union 1st ed. Edition Cyril

“This comparative study of private health insurance in Europe shines a welcome

ISBN 978-3-030-54354-9 ISBN 978-3-030-54355-6 (eBook)

1 Introduction: The European Union, the Insurance

Part I The Political Roots of EU Insurance Legislation 27

2 Insurance Directives and the Single Market: Towards a

3 Solvency II, the European Government of Insurance

Part II The Impact of the European Union Private Health

4 The Uncertain and Differentiated Impact of EU Law on

5 An Increasing Homogenisation of Private Health

Part III Shifting the Public-Private Mix in Healthcare?

6 Private Health Insurance in Belgium: Marketization

7 Europeanized, Marketized but Still Governed by the

8 Ireland: The Ambiguous Role of the Health Insurance

9 The Dutch Way: Experimenting with Competition

10 In Between the Market and Public Health Insurance:

Philippe Abecassis CEPN (UMR CNRS 7234), Université Sorbonne

Fig. 4.1 Overview of the different functions of private health insurance

Fig. 10.1 Changes in distribution by level of coverage of beneficiaries

Table 2.1 The “three generations” of EU Insurance directives 30

Introduction: The European Union,

Cyril Benoît, Marion Del Sol, and Philippe Martin

© The Author(s) 2021 1

the limited competencies of supranational provisions, and Member States

2 Private Health Insurance in the European

debates that led to the passage of “Insurance” directives in 1992. The

democratic principles—meaning that they are usually run by a demo-

contributions of this volume. Symmetrically, the notion of marketization

2.2 Marketization: A Multidisciplinary Approach

responsibility for access and State control, as in Dutch healthcare markets)

patterns of marketization through the lens of what happens within the

2.3 Making the Case for the Contingency of Europeanization

We were not, though, expecting to observe automatic effects at play or

actions are favoured over institutional factors by the different contributors

3 Research Design and Case Selection

3.1 The Structure of the Book

Solvency II mostly concerned a change of the prudential regime govern-

3.2 A Multimethod Perspective

journals where a variety of stakeholders expressed opinions and shared

single scheme of linear causality. Instead, our ambition is to uncover traces

4 The Book in a Nutshell

4.1 Contributions to the Book

Commission services in charge of financial institutions and corporate law,

struggles, a reform adopted in 2010 reinforced several features of the

an environment already reshaped in the sense of a greater marketization of

4.2 Understanding the Presence of Financial Firms

Chaps. 2, 3 and 4). As such, the presence of insurance companies (and

4.3 The EU and the Shifts in the Public-Private Mix

competition where it already exists), together with the alignment of non-­

Coron, G. (Ed.). (2018). L’Europe de la santé: enjeux et pratiques des politiques

The Political Roots of EU Insurance

Insurance Directives and the Single Market:

Gaël Coron and Marion Del Sol

© The Author(s) 2021 29

This normative environment is the fruit of a long political process seek-

Table 2.1 The “three generations” of EU Insurance directives

Non-life insurance Directive 73/239/ Directive 88/357/ Directive 92/49/EEC

the insurance sector. In other words, this initial context configured to a

2 The Political Horizon of the “Insurance”

2.1 First Attempts to Construct a European Insurance Market

–– freedom of establishment, by virtue of which an economic actor

State without being required to have a local establishment. The State

1 Introduction: The European Union, the Insurance

Part I The Political Roots of EU Insurance Legislation 27

2 Insurance Directives and the Single Market: Towards a

3 Solvency II, the European Government of Insurance

Part II The Impact of the European Union Private Health

4 The Uncertain and Differentiated Impact of EU Law on

5 An Increasing Homogenisation of Private Health

Part III Shifting the Public-Private Mix in Healthcare?

6 Private Health Insurance in Belgium: Marketization

7 Europeanized, Marketized but Still Governed by the

8 Ireland: The Ambiguous Role of the Health Insurance

9 The Dutch Way: Experimenting with Competition

10 In Between the Market and Public Health Insurance:

Table 2.1 The “three generations” of EU Insurance directives 30

competition where it already exists), together with the alignment of non-