Germany, France and the Netherlands all have specific ‘Bismarckian’ health insurance systems,which encounter different and specific problems (and solutions) from those of national healthsystems. Following a relatively similar trajectory, the three systems have gone through importantchanges: they now combine universalization through the state and marketization based on regulatedcompetition; they associate more state control (directly or through agencies) and more competitionand market mechanisms. Competition between insurers has gained importance in Germanyand 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 arestill mainly financed by social contribution, managed by health insurance funds, they deliver publicand 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 institutionssince the aim of the reforms is more to change the logic of institutions than to change theinstitutions themselves. Hence, structural changes occur without revolution in the system.