European cross-border healthcare: origin, goals and challenges

One question which has gained a significant amount of scientific, political and public attention in the past decade is cross-border healthcare in the European Union. Is it efficient? Is it effective? Is it worth it? Currently, the area of European cross-border healthcare has been assessed mainly in qualitative terms in the social sciences – either in analyses of the national and EU-level legal frameworks, case studies of separate countries or in some older publications dealing with an economic viewpoint on the topic of cross-border healthcare, in a period when it was still broadly framed as a service rather than a right patients have [1,2,3,4].

The social desirability of adopting cross-border healthcare policies is indisputable on the level of the European community, as it promotes the reduction of high disparities in the quality of life of European citizens. This is a commonly known and pursued goal of EU policy-making, along with the establishing of a sense of true unified community within the EU borders [5,6]. Still, as the lengthy process of adopting a common European policy on the coordination of social security systems and healthcare provision has demonstrated, the matter is much more complicated, be it regarding emergency care, planned treatments or standard healthcare services while a citizen is temporarily working in another EU state. Nearly 10 years ago, after many deliberations, changes and delays, two major pieces of European law reached their final form and started on the long hard road to effective implementation – the updated Regulations on Coordination of Social Security Systems and Directive 2011/24/EU on Patient’s rights in Cross-Border Healthcare. 

Today, despite being officially incorporated in the national law of all member states, heaps of anecdotal evidence supported by case studies and the data from two Eurobarometer surveys point to an ineffective and cumbersome practical implementation in some instances. This prevents citizens from experiencing the advantages presented by the agreements reached at the European level [7,8].

 As one example, it has been established that the required National Contact Points meant to provide information, guidance and advice to patients interested in cross-border healthcare (acc. to Art. 48 / 49 of Directive 24/2011/EU) range, in practice, between hard to find and non-existent. Generally, the value of protecting national economic interests, for instance, may take prevalence, or the worry that healthcare providers will find themselves forced to cover additional services which are not part of the national healthcare package, among other possibly unwanted changes to national law [7,9,10].

The question about differing levels of practical compliance in implementing EU law on the national level is tightly connected to that of the legitimacy of the European Union as an international organization. In the last few years, leading up to Brexit, the question of non-British EU citizens receiving healthcare services by the National Healthcare System (NHS) has been a major talking point. Both the media and campaign leaders have instrumentalised the insufficient public understanding of European reimbursement schemes to frame internal European migration as a threat to the economic wellbeing of the country, particularly in the context of healthcare. 

This has not been the only example of country-specific resistance either. For years, countries like Poland, Portugal and Malta have been opposed to the adoption of further EU-wide healthcare regulations, perceived as encroaching on national decision-making autonomy in both budgetary and legislative matters [7,10].

It is still hard to judge whether those fears are founded – no absolute number of patients having received medical care abroad is available, as only certain instances are recorded. No data is available on cases in which the Directive has been invoked or the European Health Insurance Card has been used, although those two scenarios should account for a sizable portion of all cases. Thus, neither a statistical nor a precise cost-benefit analysis are possible. 

The two instances in which figures have been reported by member states are those associated with Forms S1 and S2 (based on the Regulations). Still, even for them, anecdotal evidence from multiple member states (the UK and Bulgaria among others), point to incomplete recording of the cases, which leads to inconsistencies on all further levels of recording. 

Furthermore, the levels of aggregation of the data currently reported vary from year to year, thus rendering temporal quantitative analysis impossible, which also necessitated the use of Eurobarometer survey data instead of actual figures for the independent variables. Numerous reports of the European Commission in the last decade discuss the need for better reporting on the part of the appropriate institutions of the member states (European Commission 2014; 2015; 2016; 2017). Realistically, however, the collection of exhaustive data would be a cumbersome effort that would possibly require sweeping institutional and bureaucratic changes in most Member States.

[1] Frischhut M., Levaggi R., (2015). “Patient mobility in the context of austerity and an enlarged EU: The European Court of Justice’s ruling in the Petru Case”, Health policy (Amsterdam, Netherlands). 119, 1293–1297

[2] Vasev, N., Vrangbaek, K. (2014). “Transposition and National-Level Resources: Introducing the Cross-Border Healthcare Directive in Eastern Europe”, West European Politics 37(4), 693-710

[3] France, G., (1997). “Cross-border flows of Italian patients within the European Union. An international trade approach” European Journal of Public Health Vol. 7(3), 18-25

[4] Hermans, H., (1997). “Patients’ rights in the European Union. Cross-border care as an example of the right to health care” European Journal of Public Health 7(3), 11-17

[5] Baeten, R., Spasova, S. en Vanhercke, B. (2019) “Access to healthcare in the EU: an overall positive trend but important inequalities persist”, Belgisch Tijdschrift voor Sociale Zekerheid 1/2019, 199-219

[6] Faist, T. (2014). “On the transnational social question: How social inequalities are reproduced in Europe.” Journal of European Social Policy, 24(3), 207–222. 

[7] Kowalska-Bobko I., Mokrzycka A., Sagan A. (2016). “Implementation of the cross-border healthcare directive in Poland: How not to encourage patients to seek care abroad?”, Health Policy 120, 1233-1239

 [8] Peralta-Santos A., Perelman J., (2018) “Who wants to cross borders in the EU for healthcare? An analysis of the Eurobarometer data in 2007 and 2014.” European Journal of Public Health Vol 28(5), pp. 879-884 

[9] Azzopardi-Muscat N., Baeten R., Clemens T. (2018) “The role of the 2011 patients’ rights in cross-border health care directive in shaping seven national health systems: Looking beyond patient mobility”, Health Policy Vol. 122(3), 279-283

[10] Helena, R., (2016). “Cross-border Healthcare Directive: Assessing Stakeholders’ Perspectives in Poland and Portugal”, Health Policy 120(4), 369-376

European Commission. Regulations No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems.

European Commission, (2014), Report from the Commission to the Council and the European Parliament compliant with the obligations foreseen under Article 20(3) of Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare, Brussels: Directorate-General for Communication

European Commission, (2015), “Planned Cross-border Healthcare. PD S2 Questionnaire”, Brussels: Directorate-General for Communication

European Commission, (2017), “Cross-border Healthcare in the EU Reference Year 2016”, Brussels: Directorate-General for Communication.

European Commission, (2018), “Cross-border Healthcare in the EU Under Social Security Coordination Reference Year 2017”, Brussels: Directorate-General for Communication.