As was the case with unemployment benefits, a basic distinction can be drawn between insurance-based and universalist healthcare systems. In the first instance, access to healthcare is derived from occupational status, with the frequent implication that an individual's benefits and contributions vary depending on occupation. Even more importantly, however, labour market outsiders (e.g. the unemployed, the informally employed, or caregiving spouseless women with atypical employment patterns) can end up falling through gaps in the system. Universalist healthcare systems, on the other hand, base access to healthcare not on occupational status but on citizenship or residency. Such systems therefore privilege equality of access and care across individuals and geographic regions, although the extent to which they achieve these goals clearly varies.

In drawing out a comparison of France and Italy, this chapter will present outcomes that contrast with the trajectory highlighted in Chapter 2. As has already been pointed out, with regard to benefits for the unemployed, France gradually filled the many gaps in the insurance system by building up benefit coverage via universally available means-tested benefits (engaging in residualisation, most dramatically from 1989 onwards); in Italy, by contrast, the insurance approach remains paramount and large coverage gaps persist. An alternative process arose in healthcare, however. Both countries built up semi-public insurance-based systems in the post-war period and were faced with coverage gaps and variations in benefit levels. Yet Italy made a complete transition to a Beveridgean system in 1978 (taking the universalisation route), while France opted to maintain and extend its Bismarckian system (most notably, yet again, via residualisation). In both the realm of healthcare and unemployment in France, therefore, one notes a greater focus on working within the current broader framework (what Hall refers to as ‘second order’ changes), but in Italy, paradigmatic (i.e. ‘third order’) changes in healthcare coexisted alongside a general failure to reform benefits for the unemployed (1993: 278-279). The Italian case in particular raises important questions, given the trend towards greater segmentation and coverage gaps in other social policy areas. Before examining what factors led to divergent outcomes across our two policy fields, however, we must investigate how to best explain the French and Italian divergence in healthcare.