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Implementation is often neglected in comparative analyses of the regulation of healthcare systems and expenditures. Taking this aspect into account reintroduces the national diversity of the reform paths, whereas approaches focused on the institutional models and financial data soften the differences and highlight the international transfer of ideas and the common economic constraints. The comparison set forth herein of the implementation of reforms aiming at the regulation of healthcare expenditure in the countries with Bismarckian systems (France, Germany, The Netherlands) reveals unequal capacities to implement change, depending on the players and, in particular, the relationship between the State and the healthcare insurance providers. The study distinguishes structural reforms, aimed at modifying the original architecture to benefit new actors, from management reforms, which try to depart from the previous opaque management style and promote a medico-economic approach that blends managerial rigor with medical quality. Finally, there are three levels to be distinguished in the carrying out of reforms, each requiring specific conditions for their implementation: the political arbitration between the financial and the social, the withdrawal of the State in favour of a regionalisation or privatisation of the systems’management and, finally, the introduction of new models of medico-economic management.