The Europeanization of Health Policy

1. The Europeanizationof Health Policy Monika STEFFEN Institute for Political StudiesUniversity of Grenoble (France) Fiocruz / ENSP, Rio de Janeiro 27th October 2010

2. Crossing complex concepts and realities • There are different conceptions of what is : • Europe: geographic, cultural, political • Europeanization: from 6 to 25 Member States (MS) • Health policy: a field without frontier • The twofold dilemma: • Exclusively national competency versus growing EU involvement and impact • Social solidarity systems versus market and competition requirements

3. Europeanization ? • Fashionable concept, concept stretching • Underlying hypothesis: harmonization, convergence, policy transfer • Conceptualizations: • Institution building (now agencies) • Top-down (“Brussels” dictates, hard law) • Bottom-up (lobbying, MS governments included) • Both interwoven (mutual process of influence) • Euro-compatibility of national policy (negativeintegr) • Learning (norms, epistemic communities, soft law) • Nouvelle opportunities for national policy making (defreeze conservative policymaking)

4. Different dimensions of health policy 1. Medical care system: service delivery, professionals 2.Financing, social security provision for illness 3. Public health and prevention (tobacco, alcohol, STD…): direct goal 4. Policies with health impact (agrifood, environment…): indirect goal 5. Health industries (pharma, medical equipment): employment, export

5. THREE different fields for EU policy, politics and law • Healthcare systems: part of national social Security systems, organization and funding is exclusively NATIONAL competency • Public health: national, international and growingly EU competency • Medical products: fall under EU regulatory competency and EU competition law

6. Embeddedness of Health: …. in 25 Member States

7. Complementary approachesto “EU health policy” • Historial development (EU literature) • Legal approach (E. Mossialos, T. Hervey) • Institutional approach (EU literature) • Political approach (S. Greer) • Identifying founding events (opportunity window, accidental logic)

8. Historical landmarks • 1957 Rome Treaty: Transportability of Social Security Reinforced 1971+72 • 1975 Mutual recognition of diplomas: « White Europe » • 1980s public health crises: AIDS, plasma, mad cows • 1993 Maastricht treaty : free open market, competition • Common safety standards for medical goods, medicines, food • Free market for insurances: private (complementary) medical insurance. What with compulsory health insurance ? • 1990s – 2000s : • Fall of communism: transborder public health issues • Eastern Enlargement: access and quality of care

9. Institutional landmarks • Les institutions concerned : • Commission • Court de Justice • Parliament • Council of the EU • Council of (health) ministers: networks, civil society • Competency : • national : organization et finance of health care • Union : public health, prevention, transnational issues, and « euro-compatibility » of care systems and finance

10. The easy part, Public Health:Institutionalization • Maastricht Treaty (1993): Art.129 “high level of health” • Amsterdam Treaty (2000) modifies Art 129, now Art 152 : public health dimension in all EU policies. EU “completes” national action. • New agencies as policy tools : EMEA 1993, EMCDDA 1993, EFSA 2003, EDCC 2004 • European Public Health Programs: Cancer, Aids, transmittable disease (Aids, VH, res.TB) M. Steffen - M2 PPS 2010

11. Internal distribution of competency • GD Social Affairs : traditionally in charge of health as part of social security, mobility of professionals, transportability of rights. Now: • Open method Coordination (OMC) • Electronic European HI-Carte. • Patients’ mobility issue.... • GD SANCO (Santé and Consumer Protection): created 1997, reinforced with Amsterdam treaty. « Food safety », center of intense networking • DG Industry and Rechearch:e-medecin, research funding, intense networking

12. The complicated part • EU mainstream policy: the 4 freedoms • Free movement for people, goods, capital and services. And free concurrence. • The meaning for Health: • Mobility of patients, health professionals and workers, • No public monopoly, no public subsidies, open competition for tendering • Working time directive

13. The main issues • I – Patient’s mobility • ECJ court decision • Home institution has to pay • Free will for ambulatory, goods, urgency • Prior authorization for non-urgent hospital care • Countries are opposed: limits their regulatory capacity • Little real impact. Now promoted as “safety issue” and “rights and protection of patients”

14. II -Public health insurance • All insurance are “in principle under the competition law, but…” • High political and public opposition in MS • ECJ rulings define exclusion: • Compulsory, solidarity, defined as: no link between risk and premium paid, no link between contribution and service benefit • No economic but clearly social goal • Regulation of private complementary Health insurance to avoid cream skimming

15. III - Service directive • Decision : health services are part of services, under competition law and free market • General problem: regulation from country of origin would apply to services delivered elsewhere. (Bolkenstein–crisis), • France fought for the general recognition of “services of general interest”, e.g. public services. • Each country could dress it’s list of “exceptions”, few do because no change possible • Health was taken out of the service directive in 2008

16. IV–What activity is subject to competition ? • A) Recent developments: decision according to the precise “activities”, and part of activity (not public or private type of organization) • To avoid cream-scimming, and strengthen the economic viability of public services • B) Decentralized application of European Law. • To avoid MS opposition and apply the traditional principle of subsidiary.

17. Explaining the puzzle • UE health competency : weakly treaty based, multiple ways, growing impact, hard and soft law • Three distinct sources with cumulating effects : • Public health crises • Market integration and compliance • Policy discourse, diffusion of norms • The Europeanization process is incremental and issue specific, thus often accidental, but logical • UE holds a “general” policy mandate, member states a “specific" mandate

18. Questions • What are the lessons for BIG federal countries like Brazil ? • For other Regional unions, like MERCASUD ? Further reading: Scott GREER, Tamara HERVEY, Elias MOSSIALOS