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Boundaries Without Barriers: Cross-Border Health in the European Union

Public Citizen Health Letter


January 2008 

While U.S. government officials spend endless hours debating what should be the income limits for children’s health coverage; whether or not its citizens deserve universal health care; whether services should be national in scope or vary state-by-state; and what type of system to have, how to pay for it and how much choice to allow, developments on the other side of the Atlantic suggest the types of portable coverage and cooperation that are possible when health takes precedence over profits and practical concerns eclipse politics.

A Europe in which borders are not barriers, exemplified by the adoption of the Euro as a common currency, increasingly has its counterpart in the health field. More than 20 years ago, the Court of Justice of the European Communities held that the EC Treaty confers upon all European citizens the right to travel to other member states in order to receive medical services. Although this ruling gave patients freedom of movement, its practical meaning was not put to the test until 1998, when the Court further ruled that reimbursement for cross-border patients was a right rather than a privilege. Since 2004, access to cross-border care has been facilitated by a European Health Insurance Card (EHIC). While this is designed primarily for unplanned and unexpected care and is not designed to cover persons who are traveling for the express purpose of getting medical treatment, it allows the bearer access to any necessary health care in any of the member countries. In some cases, the card may cover services even in countries that are not members of the European Union but have acceded to participating in the health scheme (e.g., Switzerland, Norway). Although the card covers only non-elective care and some restrictions apply, the card entitles the holder to services across borders without having to get prior authorization or incur out-of-pocket payments. In the future, the EHIC is planned to be an electronic “smart” card, encoding patient information that is readable by computer. It is therefore not surprising that the card has been seen as a powerful symbol of European solidarity: like the Euro, it is “another piece of Europe in your pocket.”

While still an emerging and marginal phenomenon, crossing boundaries for the express purpose of seeking health care is rising as travel becomes easier and people gain greater knowledge of and access to services. Policy analysts have identified five main drivers motivating people within the European Union to opt for medical care outside their national borders: familiarity, availability of care, perceived quality, costs and bioethical legislation. While most countries provide universal coverage, not all are in position to provide all services for everyone. Some countries are too small to support an array of tertiary care services for their populations. Others lack the capacity to address all needs, resulting in long waiting periods or queues for specific medical services. Patients may find it easier to seek care in an adjacent country, and therefore rely on services provided outside their national boundaries. In some cases, national health services have formalized the exchange, crafting agreements to facilitate care elsewhere, either permanently or until they have developed the capacity to meet demand locally. And some of the mobility is generated by individuals who — seeking better, cheaper or quicker care — opt to cross borders to obtain health services. Finally, there are those who seek special services that are not available in their countries on ethical or legal grounds; these include abortion, some types of fertility treatments and euthanasia.

Just as patient mobility is prompted by different motives, it has assumed a variety of forms. The following examples suggest some of the novel ways patients are expanding their medical horizons and nations are addressing their long queues, unmet needs or under-capacity:

  • Because the population of Malta is too small to support high-technology care, Maltese patients go to England for highly specialized treatment. For Malta, this arrangement alleviates the need to develop costly facilities with low utilization rates and high stand-by costs; at the same time, English hospitals benefit from the opportunity to develop a more optimal case-mix of patients, address overcapacity in some areas and lower their costs per unit.
  • Austrians travel to neighboring Hungary for dental care, which is cheaper than in their own country. Similarly, patients from Finland and Sweden travel to Estonia for prosthetics, orthodontic appliances and advanced dental surgical procedures. 
  • The Netherlands and Belgium cooperate in serving those populations living in their border region, thereby avoiding the duplication of facilities. Moreover, some Dutch patients may find Belgian facilities closer than those in their own country, a case which has been described as “abroad being nearer to home.”
  • Residents of the Republic of Ireland have shortened the waiting list for some services by traveling to Northern Ireland or England for treatment.
  • The English National Health Service has contracted with Belgian hospitals to take care of NHS patients requiring hip- and knee-replacement surgery. Contract negotiations leading to this were long and intricate, requiring defining the details of treatment, patient pathways and cooperation between hospitals. Furthermore, a “buddy system” was set up to facilitate collaboration between English and Belgian doctors, as the former would be both referring patients and resuming responsibility for patient care upon discharge. In addition, non-medical liaison officers, EuroPals, have been employed to assist patients.
  • In the Pyrenees, the French national government and the Catalan regional authorities cooperate to provide health care to their common population, which is united by a shared culture and geography more than it is divided by national boundaries.
  • Denmark and Germany share facilities and co-finance medical equipment to insure that populations on either side of their borders have access to care.

These examples do not mean that boundaries have disappeared and that all national barriers have fallen. Each country within the European Union has its own idiosyncratic health services scheme; at present, standardization is neither likely nor desirable. Collectively, member countries have adopted different approaches with respect to financing, patient contributions and the monitoring of services. In some cases, bilateral agreements have been enacted only after protracted negotiations and the ironing out of multiple details. And some issues — e.g., different languages, liability in case of an adverse effect, fair payment to countries that are overwhelmingly at the “receiving” end of the exchange — continue to challenge and baffle authorities. Still, the health systems of the European Union adhere to basic overarching values of universality, access to good quality care, equity and solidarity. As a result, no one is barred access to heath care. That this goal has been achieved internationally is particularly commendable and noteworthy when the United States is still attempting to achieve this within its own boundaries. 

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