©  The Author(s) Journal Compilation ©  Blackwell Publishing Ltd,  Garsington Road, Oxford OX DQ , UK and  Main Street, Malden, MA , USA S P & A  0144–5596 V. 41, N. 6, D 2007, . 574–596 Blackwell Publishing Ltd Oxford, UK SPOL Social Policy & Administration 0144-5596 © Blackwell Publishing Ltd. 2007 XXX Original Articles S⅔¾⅝P⅔⅝¾ ffi& A⅞¾⅓¾  ¾⅔⅓, V⅔⅝. 41, N⅔. 6, D ⅞ 2007 S⅔¾⅝P⅔⅝¾ ffi& A⅞¾⅓¾  ¾⅔⅓, V⅔⅝. 41, N⅔. 6, D ⅞ 2007 Towards Neo-Bismarckian Health Care States? Comparing Health Insurance Reforms in Bismarckian Welfare Systems Patrick Hassenteufel and Bruno Palier Abstract Germany, France and the Netherlands all have specific ‘Bismarckian’ health insurance systems, which encounter different and specific problems (and solutions) from those of national health systems. Following a relatively similar trajectory, the three systems have gone through important changes: they now combine universalization through the state and marketization based on regu- lated competition; they associate more state control (directly or through agencies) and more com- petition and market mechanisms. Competition between insurers has gained importance in Germany and the Netherlands and the state is reinforcing its controlling capacities in France and Germany. Up to now, continental health insurance systems have remained, however, Bismarckian (they are still mainly financed by social contribution, managed by health insurance funds, they deliver public and private health care, and freedom is still higher than in national health systems), but a new ‘regulatory health care state’ is emerging. Those changes are embedded in the existing institutions since the aim of the reforms is more to change the logic of institutions than to change the institutions themselves. Hence, structural changes occur without revolution in the system. Keywords Welfare state; Reforms; Health care system; Health insurance Introduction The specificities of health policies – as against welfare policies in general – have often been remarked on, because of the role of health professionals (especially doctors) on the one side and of the medical industry on the other. The collective protection of risks and the promotion of solidarity are not the only policy issues in the health care sector; professional and economic issues also play a great role. This is why ‘health care politics are more than a subset of welfare politics and the health care state is more than a subsystem of the welfare state’ (Moran : ). Address for correspondence: Bruno Palier, Sciences-po, Cevipof,  Rue de l’Université,  Paris, France. Email: bruno.palier@sciences-po.fr