The Europeanization of Health
PolicySTEFFEN Monika
CNRS Senior Research Fellow
PACTE/Science-Po, Grenoble University (France)

European Studies Conference
24th January 2014

Jean Monnet Center of Excellence for EUStudies
KEO University, Tokyo

Four Points
1. Concepts, paradoxes
2. Free market and health in the Treaties
3. The Europeanization process, in two selectedfields:
 Public health (transmittable disease) Health care

4. Explaining the complex process

24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo1

A European Health Policy ?
A series of paradoxes:• Limited EU role, but growing EU impact• No specific treaty provision (until 1992), butinvolvement since the first treaty (Rome 1957)• No neat body of legislation, but many goals,instruments, Directives• “Health” is the biggest single heading within
EU Research funding…
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Jean Monnet EU Excellence Center, KeioUniversity, Tokyo2

The EU... what is it?
• Less than a State (unlike the USA or Brazil)• More than an intergovernmental organization(unlike Mercosul or ASEAN)• Conceptualized as “Regulatory State” (G.Majone1994)

An economic unioncomposed of national Welfare States

24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo3

EU is “Constitutional Asymmetry”
1. Between the strong economic mandate andweak social and health competency.
2. For Scharp (2002), European integration isasymmetric in general, because:– Weak “positive” integration (by legal obligation)– Strong “negative” integration (by Eurocompatibility)

3. Member States (MS) can do what they like,as long as it is compatible with EU demands
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Jean Monnet EU Excellence Center, Keio
University, Tokyo4

Health and social security are the exclusivecompetency of Member State• Therefore:– Soft law– Negative integration– Low politics• What can the EU do to gain power over theMS’s national health policy? Take side ways!

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UE interest in the health sector• Cross border issues• Multiple connections to EU main stream
policies:– The free market– Fundamental rights for the Individual• Similar life (and market) conditions
throughout the EU• Public finance: Health source of public debtis(10 % of GDP)
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University, Tokyo

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The Health Policy Field
Health industries,
products: EU
Prevention, publichealth: national+EU
Financing, social
security: national

Healthcare, LTC:
national

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Jean Monnet EU Excellence Center, Keio
University, Tokyo

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The EU has a direct impact on
approximately <25 %Distribution of national healthexpenditure (% of total)

France, Germany

Japan

Medical care and auxiliary

58 %

65 %

Pharmaceuticals and goods in
outpatient care

20 %

22 %

Long term care (LTC)

10 to 12 %9.2 %Administration

5 to 7 %1.7 %Prevention

2 to 4 %2.5 %24 Jan 2015 / M. Steffen

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Social + Health in the Treaties
1. 1957 Rome: transportability of social security benefits.
Reinforced 1971-72
2. 1975: “White Europe”, mutual recognition diplomas.
Renewed in 2005
3. 1980s: Trans-border public health crises (Aids, tainted plasma,“mad cows”, Chernobyl)
4. 1990s-2000: Bad public health situation in the East,transmittable diseases, drop in life-expectancy– 1993 Maastricht: EU mandate for public health– EU norms for quality and safety (pharmaceutics, food..)– New EU agencies
5. Lisbon 2009: recognizes the “Method of Open Coordination”
24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo

9The EU is engaged in:• Research, big programs (bio-med, social sc)• Priority programs: Cancer, Aids, Alzheimer• Rare pathologies: Network of Reference Centers• Organ donation and attribution systems• Health inequalities• Healthier work conditions• Information technology, e-medecine, e-health• lnterconnectability of systems
24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo10

The EU is an Economic Union• Unified market, concurrence, free movement• Four fundamental “freedoms”:– persons– goods– capital– Services• How articulate the economic and the socialpolicies ?
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EU tool for social and health policy:
Open Method of coordination (OMC)• Intergovernmental process, legally not binding, nosanction, but potentially important• Based on mutual learning, critical discussion, andbench marking (naming and shaming)• Created with the European Employment Strategy,treaty based (Amsterdam Treaty 1997)• Baptized and generalized at Lisbon Summit, 2000
• Followed OMCs on:– Social Inclusion – Poverty– Education – Professional training– Immigration – Integration– Health (2004)
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The Health OMC• The Parliament proposed to the Commission “Healthand Long Term Care”• Commission reframed: relate to the EES, modernizeorganization and financing• Participation: employers’ unions, trade unions,health professionals, health insurance specialists• Main task: agreed indicators for comparable data
• Works with 2-years “country reports”, and “NationalAction Plans” to improve situation• At present: OMC reformed, unclear picture.
• Since financial crisis: EU imposes budget savings,
impact on health policy
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Jean Monnet EU Excellence Center, KeioUniversity, Tokyo

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The European Center of Disease
Control (2005)• From AIDS to the ECDC
• How did an unexpected epidemic lead toa new sustainable UE policy?
• How was this achieved despite nationalcompetency ?
• How did the new policy extend to theenlarged EU (and beyond) ?
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University, Tokyo14

Why and How?
• AIDS: an “ill-structured” problem• Health ministers need exchange on “bad” topics(addicts, sexual behavior)• The PH problem of Eastern Enlargement• AIDS provided the practical model, the treaties
the legitimacy, and the EU the money
 for a policy that goes beyond PH: participation,
Human Rights, liberal morals
 and beyond the EU (“Neighborhood policy”)
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Institutionalizing “EU Public Health”• Maastricht Treaty 1993, Art 129 “high level ofhealth”• Amsterdam Treaty 2000, modified Art 152:
“public health dimension in all EU policies”, theUE “completes” the national policies.
• New EU agencies : Medicines 1993, Drugs andAddicts 1993, Foodstuff 2003, Transmittable
Disease 2005
• Lisbon Treaty 2009: reinforces the trend, insistson coordination EU-MS, and between MS
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How was it done ?
Policy style, instruments, diffusion• “Cognitive Europeanization”, but how does it
become real policy?
• Cross-border Networking• Data harmonization: collection systems,
methods of collection, statistical categories• Peer-coached cross-border policy-making:innovation, local implementation
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Jean Monnet EU Excellence Center, Keio
University, Tokyo17

Data Harmonization
Benchmarking• Only professional expert can do it• They act in « bad » policy environments• Fostering collaboration from administrations• Based on grass-level local « experiments »• It builds up Europe from « beneath »• With blaming from « above »EU role: providing finance and legitimacy
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University, Tokyo

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The difficult part: Health Care
• “Spill-over” from Market to Healthcare• Impact of EU mainstream policies on national
healthcare systems:- Mobility of patients, health professionals andworkers- Euro-wide concurrence: prohibition of public
monopolies, and of subsidies- Working Time directive, Service directive, CrossBorder Patient’s directive…

THREE problems to solve
24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo

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Problem I – Mobility of Patients• National authorities opposed• European Court of Justice delivered:– Country of origin MUST reimburse– Free choice for ambulatory care
– Hospitalization only with prior authorization• Little real impact (few patients travel, lack ofinformation, unequal conditions)• Commission promotes mobility as « choice, quality,
right and protection for patients » (individual client)• EU favors regional “trans-border projects” in capacity
planning
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Jean Monnet EU Excellence Center, Keio
University, Tokyo20

The new Cross-border healthcare
Directive (2011)• Transposed into national law 25 Oct 2013, for “moregeneral application”• No “new” provisions• Confirms and generalizes ECJ case-by-case decisions• Same conditions imposed to all MS (who is “patient”,affiliation state pays,• but respect of the national competency(reimbursement tariffs, care basket, quality standards)• MS have to organize the information for patients• MS have to create a “national contact point”• MS have to aim at “interconnectability” of IT systems
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Jean Monnet EU Excellence Center, KeioUniversity, Tokyo21

Problem II – Social Health Insurances• EU principal: “all insurances are subject to the toconcurrence”, including health• Strong opposition from ALL member states• ECJ defined exclusion from concurrence: “if thegoal is clearly social”:– compulsory membership– no link between risk and premium– no link between contribution and benefits• For private non-for-profit complementary HI: “iflimitation of risk screaming”
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Jean Monnet EU Excellence Center, Keio
University, Tokyo

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Problem III – “Services”• EU principal: “Health services are services, and assuch under the competition and market law”• Conflict: Service Directive legalized “regulation of thecountry of origin” (Bolkenstein crisis)• France mobilized MS for “Services of generalinterest” (public services)• Compromise: each MS can give in his « list ofexceptions » (nearly none did)24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo

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The final answers, by the ECJ• Not organizations, but precise « activities », evenparts of activity are or not under market rules
Avoid cream-skipping to reinforce the economy ofpublic services• “Decentralized” application of EU-law
Back to the traditional principal of subsidiarity, toavoid opposition from MS

• Confirm the country-of-origin tariffs forimbursement. Confirm the prior authorization for
non-urgent hospital careProtect national planning capacity

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Jean Monnet EU Excellence Center, KeioUniversity, Tokyo

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Explaining the puzzle• EU health competency is treaty-based only forpublic health• In healthcare: Open Coordination, growing“spill-over effects” (soon EU budget review?)• Not a coherent policy, but multiple dynamics
with cumulative effects• Contrains for the laggars

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Jean Monnet EU Excellence Center, Keio
University, Tokyo25

Three sources of Europeanizationof health policy
1. Trans-border public health (crises create policies)
2. European integration (spill-over from Market policy)
3. Networking of professionals (statistics, best practice)
An incremental process:often accidental
problem specificnegotiated24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo

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Concepts describing theEuropeanization of health
1. Uninvited Europeanization (Greer): spill overs
2. Health Policy institutional Compound(Lamping, Steffen): shared competency
needs negotiation and mutual agreement
3. Chaordic (Steffen& Lamping): a crises driven
dynamic process, part of Europeanintegration.

It will grow
24 Jan 2015 / M. Steffen

Jean Monnet EU Excellence Center, Keio
University, Tokyo27

Authors• Political science, EU Health policy:– Scott GREER– Wolfram LAMPING– Monika STEFFEN• Legal aspects on EH health policy:– Tamara HERVEY– Elias MOSSIALOS• Retirement, social assistance, unemployment:– Maurizio FERRERA
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Jean Monnet EU Excellence Center, Keio
University, Tokyo28Thank you for your attention
Enjoy a view of the French Alps andGrenoble

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