Health without frontiers

The European Commission initially included healthcare in its proposal for a services directive - the proposal that came to be denigrated as "the Bolkestein directive".

One of the reasons why that proposal did not command strong support from the Council of Ministers and the European Parliament was that health services were deemed too complicated and sensitive to be lumped in with other services.

So when a revised proposal for a services sector was published in April, healthcare was exempted from its scope.

The Commission now has to find other ways of making it easier for citizens to avail themselves of healthcare services outside their own country.

At the same time it must reassure governments worried about a potentially expensive threat to the financial organisation of 25 different national health services.

A Commission debate on Tuesday (5 September) discussed ways of opening up dialogue with governments and health experts on how to deal with EU health services, while avoiding the kind of controversies that bedevilled the services directive.

In theory, Europeans have benefited from cross-border healthcare for decades. Back in 1971 EU legislation stated that doctors could not refuse treatment to patients from any member state.

But the practical difficulties in making the principle of EU-wide healthcare are only gradually becoming understood.

Cash-strapped governments and under-resourced hospitals fear ‘healthcare tourism’ in which EU citizens shop around for free treatment. And the Commission will have to find a way of explaining to patients if and how they can get their money back for treatment away from home.

For almost 30 years it was unclear whether health services in a citizen’s home state had to refund patients for treatment received abroad. Emergency hospitalisation was the one area where the patient was not expected to pay.

In 1998 two Luxembourg citizens set a precedent, when the European Court of Justice (ECJ) ruled that they were entitled to reimbursement for minor eye care and dentistry received in Germany.

Citizens can also claim refunds for operations received outside their own country if waiting lists at home are too long.

The UK is now embroiled in arguments over the definition of ‘undue delay’ when it comes to waiting lists. The ECJ ruled in May that British pensioner Yvonne Watts was eligible to have the cost of her hip replacement reimbursed at home, even though the operation was carried out in France.

The funding of health services differs between member states. In the UK and Scandinavia health services are funded by the taxpayer, which means that most healthcare is free at the point of use. In countries like Belgium individuals pay for at least some of their own healthcare and then apply to their insurance company for reimbursement. In the Netherlands bills go directly to the insurer.

The UK is at the forefront of countries concerned that their system might mean taxpayers paying for healthcare services in another country.

The Commission hopes to show governments that a more open health market need not be bad news. For treating some conditions, for example, it would be cheaper for a member state to send patients abroad for treatment than to build up the same level of expertise at home.

Encouraging the use of foreign ‘centres of excellence’, however, might provoke concerns over sharing data and comparing technologies.

With so many worries to assuage, arguments over the services directive may yet look like a happy memory.

The European Commission initially included healthcare in its proposal for a services directive - the proposal that came to be denigrated as "the Bolkestein directive".