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.