Abstract This paper explores the tension at the heart of French Social Security between the expansion of healthcare coverage and the control of health insurance expenditure. The paradox of the French system lies in its effort to reconcile two seemingly irreconcilable imperatives: guaranteeing universal access to care while maintaining budgetary balance. Although successive reforms are justified in the name of urgency, efficiency, and morality, they have progressively redefined universality. Instead of disappearing, it has become fragmented and conditional, while existing as an ideal invoked to legitimize financial discipline. In practice, these reforms have shifted part of the financial burden from collective solidarity to households and complementary insurers, reinforcing inequalities of access. The article argues that this redefinition of universality results from a long-term process of reframing cost containment as an act of preservation rather than retrenchment.
Raphaëlle Sors (2026) studied this question.