Building the weak hand of the state: Tracing the market boundaries of high pharmaceutical prices in France

Prices for new medications have strongly increased over the last decades, reaching levels that could endanger healthcare insurance systems. Focusing on the French case, this article builds on the structural approach of business power and investigates how this situation results from the construction of market boundaries that created unassailable spaces for high pricing. Starting from the 1990s, it traces how high drug prices relied on the construction of a market setting first designed to increase pharmaceutical prices, in which the negotiating position of the state was deliberately weakened. But the politics of maintaining such high drug pricing quickly required reshaping the boundaries of the pharmaceutical market and concentrating the favourable negotiation framework on a small number of innovative medicines. Most recently, the spiralling of prices for these medicines have necessitated yet another revisiting of these market boundaries. High drug prices do not result from direct business power by the pharmaceutical sector; rather, the pharmaceutical sector depends on boundary-work performed in cooperation with state institutions to carve out domains for favourable market pricing. Emphasising the politics of this boundary-work thus ultimately also signals its potential reversibility.