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Health care and mobility

by JakeS Wed May 27th, 2009 at 07:23:46 AM EST

In another diary, this comment sparked some discussion of the difficulties of harmonising European health care.

Now, don't get me wrong. I'm all for harmonising European health care. It would be neat if I could go to Finland to get surgery, if they have spare capacity while Denmark has none. Or if a Polish construction worker could get access to the French hospital system.

But (and of course you knew there'd be a 'but') only if it's done properly. Just as I'm all for harmonising European train services, provided it's being done by Deutsche Bahn, not AnsaldoBreda (more [.pdf]) or Arriva. And when something is being pushed by an ALDE member using "competition" newspeak, I reflexively check my wallet to see if I'm being robbed.

The underlying difficulty, as I see it, in harmonising health care provision across Europe is that there is a multitude of different systems in use, and each national system is funded and controlled by country-level political bodies. Changing this is presumably off the table, as providing a centralised health care authority for the EU would require (given the kind of funding we're talking about here) giving Parliament the power to levy taxes directly upon European citizens and disburse funds directly to operators.

Assuming that such a solution is dead on arrival, I see three broad ways to harmonise health care. And I frankly don't like any of them.

promoted by whataboutbob

Most favoured citizen: Possibly the simplest option, a most favoured citizen system would mean that you could go anywhere in the EU, get any treatment that the locals get, on the same conditions that apply to the locals, with the bill paid by the locals (I stole the name from the WTO's policy of "most favoured nation status," which it resembles in many important respects). This is the track chosen to harmonise access to education. The issues with this model are fairly obvious, but they are worth reiterating.

- Race to the bottom: Every state has an incentive to limit access, raise direct fees and generally cause its citizens to go elsewhere, because it can then off-load the cost on someone else. Conversely, countries that invest in keeping a healthy (you should excuse the pun) health infrastructure will be "rewarded" by getting a heavy caseload from their neighbours.

With university education you at least have the saving grace that having an influx of foreigners to your universities increases your soft power, allows you to poach the best foreign talent and other Good Things. With medical treatment, the upsides are rather less clear.

- It's not neutral w.r.t. payment systems: In some countries, the government pays for medical treatment, in some countries your employer pays for medical treatment and in some countries the state and/or your employer pays for medical treatment at public hospitals, whereas you have to have insurance to get into private hospitals. And there are probably many other variations.

Broadly speaking, a most favoured citizen system seems to favour a system in which private insurance pays for health care, and where said private insurance is in turn paid for by employers, the state and/or the citizen herself. Not only does this create an unnecessary and unproductive overhead, it is also a necessary step on the road to eventual full privatisation. Which is undoubtedly something that the people who pay for ALDE would very much like to see.

Treat and bill: Under this kind of system, the patient would go abroad and get treatment as per the most favoured citizen system, but the bill would be shipped back to his country of residence. Assuming that the prices are right (and getting them right will be an exercise in and of itself...), that would largely remove the perverse incentives towards a race to the bottom. But it creates other kinds of problems.

- Financial risks: A wholesale migration of people from a country's medical system would impose a ruinous strain on public finances. A functioning health care system is not something that can be put up or torn down according to short-term supply and demand - many costs are sunk and many of the running costs are more or less fixed.

To take a very simple example, training doctors is not cheap, and there is a ten to fifteen year delay from the time you change admissions policies at medical schools until you see that change in terms of fully qualified doctors. And that's assuming that changes to actual admissions do not significantly lag the policy change. So you need to plan ahead by twenty years - at least.

- Differences in coverage: In Poland, for instance, abortion is illegal. In Denmark, it's a fairly routine operation. The Polish authorities might understandably be a tad - ah - miffed, shall we say, that Denmark could not only subvert their regulations; it could also be able to bill them for it.

Now, in the particular case of abortion, I happen to think that Poland should sit down, shut up and pretend to be civilised. But suppose that Luxembourg decides that it would be profitable to do chelation therapy for autism, or British lobbyists start pushing the UK as a flag of convenience country for scams like homeopathy?

Should they be able to start a carry trade of people who go there to get free quackery that they'd otherwise have to pay for because their home state doesn't want to sponsor bullshit pseudo-medicine? And then send the bills (along with the bother and cost of dealing with the inevitable complications of using quacks their nostrums instead of real medicine) back to the patients' home countries?

Before you dismiss that example, I would remind you that the alt-med lobby is quite widespread and just as full of vicious thugs as any other organised, large scale propaganda operation.

Subcontracting: Under this kind of system, an EU citizen could travel abroad and get treatment, and his country of residence/insurance company would be billed for it, but only if the treatment in question could have been billed to the country/insurance company in the country of residence in the first place. The good thing about this system is that it does little harm.

Except for the unavoidable cream skimming (there will inevitably be procedures that are priced too low and some that are charged too high), the only major drawback is that it prevents countries from refusing to fund private hospitals as a matter of policy, because the patients can always go to private hospitals abroad and send the bills home.

Of course, the main problem with the subcontracting approach is that it wouldn't actually harmonise health care provision in the Union, which was the stated objective of the exercise...

In conclusion, there is a number of highly non-trivial issues here that need to be fleshed out before any plan to harmonise health care union-wide is proposed. And appeals to "competition" strike me as being more an example of the belief in the power of incantation than in the power of evidence.

- Jake

... on health care planning, from the Scienceblogs collective.

Money quote:

But well-regulated is the key phrase. The insurers are highly-incentivised to provide inexpensive care and strictly forbidden from discriminating against very sick and chronically-ill patients. By most accounts the system actually does the opposite, and chronically ill patients are actually sought after by the Dutch insurers. We can't just force everyone into private insurance plans and hope we'll get this result, the Dutch market is very carefully planned and designed to prevent the frail and desperate from falling through the cracks, while risk-sharing distributes the potential harm caused by more costly individuals.

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Tue May 26th, 2009 at 08:28:33 AM EST
I have a European health insurance card, issued by the national swedish insurance agency. As I understand it I should bring it and in case I need emergency care when visiting another EU-country I will get it. It is a good question how the bill is treated.

It does not cover planned health care.

Sweden's finest (and perhaps only) collaborative, leftist e-newspaper Synapze.se

by A swedish kind of death on Wed May 27th, 2009 at 03:33:09 AM EST
I have private insurance costing about € 80 a year that covers all emergency medical expenses (including dentistry) occurred outside Finland.

You can't be me, I'm taken
by Sven Triloqvist on Wed May 27th, 2009 at 03:56:39 AM EST
[ Parent ]
But do you need this for the EU, or it mainly for travel outside the EU?

I had something similar in Germany, but the problem was that the small print excludes countries of which you are a citizen, which would have made it nearly useless for me. Fortunately, I had a colleague who managed to negotiate an exception.

by gk (gk (gk quattro due due sette @gmail.com)) on Wed May 27th, 2009 at 04:33:33 AM EST
[ Parent ]
Anywhere outside Finland. In Finland I am covered (like all Finns) under the (almost free) National Health scheme.

You can't be me, I'm taken
by Sven Triloqvist on Wed May 27th, 2009 at 05:32:15 AM EST
[ Parent ]
In Denmark - and I suspect that the Swedish system is similar - unplanned treatment in another EU country (as in, you fall and break your leg while skiing) is done according to local procedures, and the bill is sent to the Danish health system. Transportation home is also covered. Planned operations can be scheduled to foreign hospitals if there is no Danish hospital capable of treating you within a reasonable time - in which case they are paid for by the Danish state.

There appears - but I am not quite clear on this - to be an EU rule that essentially implements what I call "most favoured citizen" status for people who live and work in another EU country, under the mobility of labour thing. But since this is tied to actually living and working in the country you're being treated in, it avoids many of the problems I note in the diary (of course, it also loses many of its appeals...).

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Wed May 27th, 2009 at 04:01:09 AM EST
[ Parent ]
It is similar, though health care in Sweden is primarily the responsibility of the regions. I tried to google for the EU rule and found something at least:

EU-kort - Region Skåne

Den 1 juni 2004 införs ett Europeiskt sjukförsäkringskort (EU-kortet) som ger rätt till sjukvård vid tillfällig vistelse i ett annat EU-land. Kortet ersätter intyg E 111 och övriga liknade intyg (E128, E 110 och E 119). Införandet sker inte samtidigt i alla medlemsländerna.  Det betyder att intyg E 111, EU-kortet samt särskilda övergångsblanketter och provisoriska intyg kommer att existera parallellt till och med december 2005.


On June 1, 2004 a European Health Insurance Card (EU-card) is introduced which gives the right to health care during a temporary stay in another EU country. The card replaces the certificate E 111 and other similar certificates (E128, E 110 and E 119). The introduction is not simultaneously in all member countries. This means that the certificate E 111, European card and transitional forms and provisional certificates will exist in parallel to and including December 2005.

And the Stockholm region had some more information:

Planerad vård

I vissa fall kan du även få planerad vård utomlands, men då gäller inte EU-kortet. Det gäller främst specialistvård och viss rehabilitering som inte går att få i Sverige och som din läkare bedömt att du behöver. Vården betalas då att ditt landsting. För mer information, kontakta Hälso- och sjukvårdsnämndens förvaltning, tel 08-123 132 00.

Du kan ha möjlighet till ersättning i efterhand från Försäkringskassan, för vårdkostnader du haft i samband med en planerad behandling utomlands. Den rätten baseras på EG-fördragets fria rörlighet för tjänster.

Om din läkare bedömer att du behöver vård utomlands kan du även söka om ett förhandstillstånd för planerad vård hos Försäkringskassan innan din resa.

Kontakta Försäkringskassan för mer information.

Planned treatment

In some cases, you can also receive scheduled treatment abroad, but then does not apply to the European card. It is mainly specialized services and some rehabilitation is not available in Sweden and your doctor determined that you need. The care paid for your county. For more information, contact Health and sjukvårdsnämndens management, tel 08-123 132 00.

You may be able to get reimbursement after the care from Försäkringskassan, for health costs you have had in connection with a planned treatment abroad. This right is based on the EC Treaty free movement of services.

If your doctor determines that you need treatment abroad, you can also apply for a decision from Försäkringskassan before your trip.

Contact Försäkringskassan for more information.

(My Tribext is not working properly, I am not sure why.)

Sweden's finest (and perhaps only) collaborative, leftist e-newspaper Synapze.se

by A swedish kind of death on Wed May 27th, 2009 at 05:05:33 AM EST
[ Parent ]
It is similar, though health care in Sweden is primarily the responsibility of the regions.

That is also the case in Denmark. I used the term "state" loosely here, because I didn't want to go into the utter train wreck that is the last Danish municipal reform...

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Wed May 27th, 2009 at 05:42:30 PM EST
[ Parent ]

EUROPE: EU edges closer towards cross-border healthcare

The European Parliament has approved plans to give EU (European Union) patients the right to seek healthcare within the bloc more easily and be reimbursed for the costs. MEPs (Members of the European Parliament) also want patients to be properly informed about their rights when they are treated outside their home member state.


E.U. Moves Ahead With Medical Mobility Law
The central disagreement over the proposed directive concerns whether cross-border patient mobility should be understood as a matter of the E.U. doing something tangible to enhance patients' rights, or as a new form of economic liberalization that will ultimately threaten national health care systems. This caused a predictable split on the committee (whose composition mirrors that of the chamber as a whole):

--The European Parliament's Conservative and Christian Democratic (EPP-ED) and Liberal (ALDE) groups support the measure.

--Socialist members abstained, opposing the measure in its current form. While they support strengthening patients' rights to seek health care in other member states, they are concerned at the effect on national health care budgets and wish to extend member states power to demand prior authorization for treatment abroad.

--Green members opposed the directive on principle because it treats health care as an economic service, rather than as an integral part of national social policy. They fear that the proposal would pose a serious threat to the functioning of national health care systems and principally benefit wealthy "health tourists."

by Trond Ove on Wed May 27th, 2009 at 06:01:16 AM EST
European Health Insurance Card

The EHIC can be used to cover any necessary medical treatment due to either an accident or illness within the European Economic Area and Switzerland. The card entitles the holder to state-provided medical treatment within the country they are visiting and the service provided will be the same as received by a person covered by the country's 'insured' medical scheme. This may not cover all of the services you would expect within the UK and you may have to make a contribution towards the care you receive.

The EHIC can also be used to receive treatment for pre-existing illnesses and chronic diseases, but conditions do apply so please check with your healthcare provider before you travel. Maternity care is covered by the EHIC whilst you are away, but if you are travelling to a country specifically to have a baby then you will need to complete an E112 form. Again, ask your healthcare provider for more information before you travel.

The EHIC may not cover persons for all medical costs incurred, so you are strongly advised to also arrange travel insurance to ensure that you are covered for all possible eventualities. Furthermore, you will not be covered by an EHIC if the main purpose of your travel is to receive medical treatment.

The EHIC is valid within the European Economic Area, which includes the European Union countries, Iceland, Liechtenstein and Norway. Switzerland also has an agreement in place with the European Union to accept the EHIC.

Whether there's any cross-border billing behind the scenes, I don't know.  If so, it raises an interesting question, because when my mother had a minor heart attack in Germany some years ago, she received a local standard of care: far better and more costly than she would have received at home. I know that the UK and Australia have a reciprocal agreement (We'll look after yours if you'll look after ours), and, if it's restricted to emergencies only, I'd imagine this was more efficient than running a billing bureaucracy.

There may also be individual agreements between EU countries.  The UK, for instance, has a pre-EU agreement with Ireland where it pays a substantial annual amount into the Irish healthcare system to compensate for the Irish citizens who paid tax all their working lives in the UK, and then retired to Ireland.

by Sassafras on Wed May 27th, 2009 at 06:02:05 AM EST
The EHIC replaced the earlier "form E111" and does not introduce new citizens' rights, it just makes it easier to manage the system. The Regulations governing cross-border health care within the EU seem to date from 1971-2. See EUR-Lex: 2004/562/CE: Decision No 198 of 23 March 2004 concerning the replacement and discontinuance of the model forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 of the Council (E 110, E 111, E 111 B, E 113, E 114, E 119, E 128 and E 128 B).

The brainless should not be in banking. — Willem Buitler
by Carrie (migeru at eurotrib dot com) on Wed May 27th, 2009 at 06:13:03 AM EST
[ Parent ]
See also SCADPlus: Social security schemes and free movement of persons: Basic Regulation for 1408/71 and implementing rules for 574/72.

The brainless should not be in banking. — Willem Buitler
by Carrie (migeru at eurotrib dot com) on Wed May 27th, 2009 at 06:16:33 AM EST
[ Parent ]
That is actually interesting... The Danish insurance companies were making a big story about how these new rules limited the coverage compared to the old rules.

Of course, it did coincide with a decision to limit coverage (surprise, surprise - can I please have a new government over here? The one I have is only showing movies that I've seen before...), although not quite in the way the ads put it: The restriction was on coverage area, not coverage quality. Specifically, a couple of Mediterranean non-EU countries where people have brown skin and speak funny are no longer included. Hands up, anybody who's surprised by this... Yeah, that's what I thought.

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Wed May 27th, 2009 at 07:54:51 PM EST
[ Parent ]
Good article and discussion, Jake, thanks!

"Once in awhile we get shown the light, in the strangest of places, if we look at it right" - Hunter/Garcia
by whataboutbob on Wed May 27th, 2009 at 07:25:51 AM EST
we're talking about three core entities here:

  1. People/clients/patients - who have broadly similar health care needs subject to relatively minor demographic, environmental and genetic variations.  Bugs don't respect borders, accident rates are similar, and we all age.  Arguably the health care needs throughout the EU should converge with economic convergence and increased mobility.

  2. Health care service providers - hospitals, clinics, doctors, community care services, pharmaceutical industry etc.  Generally speaking the medical processes and protocols employed should converge as best practice medical science and health care standards are implemented more broadly.

  3. Resources to fund the above, and the price at which they are funded.  This is the most difficult area, because of the plethora of management structures, funding process employed in each country - which are often somewhat incoherent within countries, never mind across the EU.

The EU could promote convergence/harmonisation in 1. above through the development of patient rights charters or legislatively mandated minimal health care entitlements throughout the EU.

The development of standardised medical healthcare protocols and delivery standards is happening anyway, but could be promoted by the EU by way common codes of practice etc.  Countries with long waiting lists for essential Breast Cancer treatment services , for example, could be required to enable their citizens receive treatment abroad, and reimburse the service providing nation for the cost.

Which brings me the the third and most difficult area: the funding and management of such services.  Different, public, private, for profit, and non-profit private models apply to varying degrees in different member states.  Perhaps the EU could make a start by agreeing a standard pricing structure for standard procedures and treatment protocols which could form the basis for inter-state financial transfers where a patient entitled to receive a service in one member state, actually receives that treatment in another.

No doubt there would be rows about what prices should apply, who is entitled to give/receive specific services, and to what extent "competition" should be allowed between service providers.  There is scope for a degree of regulated diversity between member states.

But what the EU should do is at least agree common entitlements and minimal treatment processes/protocols so that the debate can shift to the best way of delivering such services on a trans-national basis.  It may well be that one member state has a surplus of treatment capacity in one area, and shortage in another, so a truly transnational system could deliver better health outcomes for the same overall cost by optimising capacity utilisation across borders.

If the EU really is to win the hearts and minds of its citizens, it has to move beyond internal markets and corporate governance into areas which really matter to citizens in their daily lives.  And health care comes pretty close to the top of the list of core issues for all citizens.

notes from no w here

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed May 27th, 2009 at 12:00:26 PM EST
Your solution for 2) should, I think, be fairly uncontroversial.

The sticky point here is that 1) and 3) are interconnected. The choice of compensation scheme is not treatment-neutral and the choice of patient rights scheme is certainly not neutral w.r.t. the choice of compensation scheme.

The risks here are first that 1) and 3) are negotiated separately and that the solutions that are agreed upon create some unintended interference effect that is not obvious when each is considered in isolation. And second, that the issue will be treated as a federal trade issue, not as a federal health and infrastructure issue. The infrastructure people in the EU are reasonably sane. The trade people are, frankly, batshit crazy.

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Wed May 27th, 2009 at 06:22:02 PM EST
[ Parent ]
I'm not sure I understand your points.  My reason for separating out 1,, 2, and 3 is precisely because entitlements (to public healthcare, at least) should be "rights" and not privileges dependent on your citizenship, country of residence, or private insurance coverage.

The issue of how those entitlements are met through service delivery, and how those services are managed and funded should be entirely separate and can allow for some regional/national variation.  For instance the UK might deliver all public services through the NHS whereas in Ireland some might be delivered through public hospitals, and others by private hospitals under contract to the state to deliver certain services at standard prices.

I'm sure we all have our favourite models (mine is all public), but there are huge ideological issues here which would preclude progress any time soon if we tried to impose one model.

So why not focus on the EU defining entitlements and standard treatment protocols and prices, and let member states decide how best to manage the delivery of those services at standard prices?

notes from no w here

by Frank Schnittger (mail Frankschnittger at hot male dotty communists) on Wed May 27th, 2009 at 06:50:46 PM EST
[ Parent ]
Well, your scheme actually does consider pts. 1) and 3) at the same time: It specifies which treatment protocols citizens have an absolute right to, and it then specifies how treatment is to be funded: Bill it to the Treasury of the country of residence, and then they can have the fight with the insurance companies, governmental sub-units or whomever is in charge of funding these things.

What I'm afraid of is that the list of patient rights will be implemented, but no transfer scheme will be set up that enables the provider to bill somebody and be sure to get his money. And then you're essentially billing the good guys, because they take patients in without first checking whether they get paid for them, whereas the bad guys tell them to sod off if there's no money on the barrelhead.

And, of course, there's the perennial risk that a partial list of health care rights will be used as an excuse to underfund other health care provision ("well, Bruxelles says that we have to pay this sum of money to a French hospital, so that comes out of your budget..."). But I count that as a problem with a state-level democratic deficit, rather than a problem at the federal level.

- Jake

Friends come and go. Enemies accumulate.

by JakeS (JangoSierra 'at' gmail 'dot' com) on Wed May 27th, 2009 at 07:46:48 PM EST
[ Parent ]
They all look like Nirvana to me.  I hope, and expect, European citizens will fight to make sure that the god of "competion" gets called out at every turn.  Demand openness and tax the crap out of the extremely wealthy and you will be way ahead of the game.

"I said, 'Wait a minute, Chester, You know I'm a peaceful man...'" Robbie Robertson
by NearlyNormal on Wed May 27th, 2009 at 10:00:02 PM EST

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