Opinion of the European Economic and Social Committee on the "Communication from the Commission concerning the introduction of a European health-insurance card"

(COM(2003) 73 final)

(2003/C 220/11)

On 17 February 2003 the Commission decided to consult the European Economic and Social Committee, under Article 262 of the Treaty establishing the European Community, on the above-mentioned communication.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 28 May 2003. The rapporteur was Mr Dantin.

At its 400th plenary session of 18 and 19 June 2003 (meeting of 18 June), the Economic and Social Committee adopted the following opinion by 79 votes to one with three abstentions.

1. Summary

1.1. The Committee welcomes the creation of a health-insurance card. The facilities which the initiative will provide will contribute significantly to free movement, thereby strengthening European citizenship.

1.2. The longer term objective must be to introduce a single card performing both national and European functions. In order to prevent unexpected expiry of cards, they should be automatically renewed by the issuing body provided the entitlements remain valid or, as a default option, they should have a period of validity equivalent to that of the national cards where these exist.

1.3. The visual design of the card must be "Europeanised" so that it symbolises European citizenship and strengthens a feeling of belonging to the European Union, in exactly the same way as the "European passport" and the euro.

1.4. Great care will have be taken to protect personal data in Phases 2 and 3, especially the latter.

2. Introduction

2.1. On 14 June 1971 the European Economic Community adopted Regulation (EEC) No 1408/71 on the application of social security schemes to employed persons and their families moving within the Community, which organises the coordination of statutory health-insurance systems(1).

2.2. At its 59th plenary session in January 1967, the Economic and Social Committee adopted an opinion(2) concerning the regulation, and a number of comments were made on the text presented.

2.3. Since their entry in force, both the above-mentioned regulation and Regulation (EEC) No 574/72 which fixes the procedure for its implementation have been modified on a number of occasions, updating their content to reflect changes in national legislation, bilateral agreements between Member States and the EU's successive enlargements since 1971.

2.4. In 1992, the Edinburgh European Council(3) recognised the need to carry out a general review of the legislation in order to simplify the rules for coordination. More specifically, an action plan for free movement of workers was presented(4).

2.5. In its opinion of 28 May 1998(5), the Committee welcomed the reform of Regulation (EEC) No 1408/71, expressing its agreement with the simplification and improvement of coordination of EU Member State social security systems.

2.6. As it now stands, following all the modifications and simplifications, Regulation (EEC) No 1408/71 includes a provision that all persons staying temporarily in a Member State other than that where their rights are held may have access to "immediately necessary" or "necessary" care under the same conditions as nationals of that country.

2.7. Access to care and reimbursement is currently provided by the social security body of the Member State of origin issuing - at personal request - various forms (E 111, E 128, E 110 or E 119) depending on whether the beneficiary is travelling, posted abroad by their employer or studying, an international road transport driver, or job seeking.

2.8. When it approved the action plan for removing obstacles to geographical mobility by 2005, the March 2002 Barcelona European Council took a policy decision to establish a European health-insurance card which "will replace the current paper forms needed for health treatment in another Member State". It will also "simplify procedures, but will not change existing rights and obligations".

2.9. In this connection, the European Council asked the Commission to submit a technical proposal on how to implement the Barcelona Council's policy decision.

The present communication sets out to do this. It is also intended to facilitate the future work of the Administrative Commission on Social Security for Migrant Workers (CASSTM), one of whose responsibilities is to provide a basis for decision-making.

3. Gist of the communication

3.1. The content represents the outcome of a first in-depth consultation with the CASSTM in the wake of the Barcelona European Council, as well as with the Member States.

3.1.1. After providing an overview, noting the wide diversity of national situations, the communication goes on to list the Community policies which will contribute to the introduction of a European health-insurance card: the eEurope 2005 Action Plan, the Netc@rds project and the 6th research and development Framework Programme.

3.1.2. The communication explains that the card must have a series of common features enabling it to be recognised and used in all Member States, regardless of which one issues the card. These features concern the information carried, the model, period of validity, and how the card operates for the insured person, the care provider and the social security body.

3.1.3. Initially, the European card will carry in visually readable form the information needed for the granting and reimbursement of health care provided in a Member State other than that in which the recipient is insured.

3.1.4. The Barcelona European Council wished to make a powerful gesture in favour of mobility for European citizens: in response, the Commission is putting forward a proposal based on three aspects:

- free choice of type of card;

- flexible methods of introduction;

- phasing-in in three stages, comprising: firstly, legal and technical preparation; secondly, a two-step launch phase from 2004 onwards, the first replacing the E 111 form only and the second leading to the replacement of the other forms used for temporary stays; and a third stage leading ultimately to an electronic version of the relevant forms.

4. General comments

4.1. The establishment of a European health-insurance card is an ambitious project which will help create a real citizens' Europe. It meets a real need. However, if it is to be fully accepted, implementation must be practical and effective, implying thorough preparation. The legal and technical preparatory phase is crucial.

4.2. The European Economic and Social Committee welcomes and supports the initiative. It is particularly pleased to see that in part, it ties in with issues raised by the Committee in its own-initiative opinion on health care, in particular those concerning free movement of patients (volume and structure of movements, mobility factors, sociology of cross-border patients, financial consequences of patient mobility, consequences of enlargement, etc.)(6).

4.2.1. The practical effect of the initiative will be to enable the public to take advantage more easily of the essential facility provided by the coordination of statutory health-insurance schemes for other thirty years under Regulation (EEC) No 1408/71. In particular, it will make it possible for patients who have to pay a doctor on the spot to be reimbursed more quickly by their own scheme, and will provide the body financing the health system in the country visited with a guarantee that the patient is fully insured in his or her own country and that they can rely on being reimbursed by their counterparts.

4.3. However, in order to avoid any confusion and increase clarity, the communication should explicitly state if, in relation to Regulation (EEC) No 1408/71:

- entitlements of all categories to "medically necessary" care have been aligned, with "scheduled care" remaining beyond its scope;

- while the E 111 and subsequent forms were addressed to right holders and their beneficiaries, the card will be strictly non-transferable.

5. Specific comments

5.1. The model for the card

5.1.1. The communication offers two options: either integration into an existing national car, or the issue of a new card. The Committee believes that under current circumstances, this choice is for the Member States to make. However, as the communication points out, the card will initially have to carry visible information, making its integration into a national card (whether it contains a chip or a magnetic strip) more difficult, since both sides of the card are often used.

5.1.2. As matters stand at present, and in the light of the existing diversity between the Member States, a European health-insurance card generally appears more likely to provide a satisfactory response to the issue raised by the Barcelona Council decision.

5.1.3. Nevertheless, this situation should be viewed as being temporary. The longer term objective should be to introduce a card performing a dual function - national and European - and automatically issued for a period equivalent to the validity of entitlements.

5.1.4. The Committee agrees with the Commission's proposals regarding the information to be included on the card, although it would stress the need to "Europeanise" the card's visual design and presentation. As a minimum, a visible European logo would be helpful in ensuring that the card is easily recognised in each Member State. This would symbolise European citizenship and strengthen a feeling of belonging to the European Union, in exactly the same way as the "European passport" and the euro.

5.2. Validity period

5.2.1. One of the main weaknesses of the forms presently in use - and of form E 111 in particular - is their specified validity period, which depends on the date of issue.

5.2.2. Although the specified validity period does not cause major problems for people only travelling occasionally within the EU, the same is not true for those who visit other Member States on a frequent, regular and sometimes extended basis.

5.2.3. Since no systematic renewal arrangement or early warning of an approaching expiry date are included, potential patients may often find themselves in possession of a form which is no longer valid.

5.2.4. In order to stop this from happening, the European health-insurance card must in any case have the same validity period as the national card. This would in practice lead to parallel renewal of both cards, thereby avoiding the expiry problem. Automatic renewal of the card on expiry by the issuing body, at the request of the holder, might also be envisaged.

5.3. The insured person and others involved

5.3.1. In order to make the procedures for introducing the card as straightforward as possible, the communication suggests two measures which would require amendment of Regulation (EEC) No 1408/71 and its implementing Regulation (EEC) No 574/72:

- alignment of entitlement to "necessary care" for all categories of insured. This is a precondition for the introduction of the card. The EESC hopes that this change will be made as soon as possible, since the differences which at present justify the distinction between "necessary care" and "immediately necessary care" cannot reasonably be interpreted by practitioners from a practical or ethical point of view;

- removal of the obligation to go to the social security institution of the place of stay before approaching a care provider.

5.3.2. On the basis of the information presently available, the Committee generally endorses these simplifications. It will make a fuller and more detailed assessment of this point in its future opinion on the text amending Regulations (EEC) No 1408/71 and No 574/72.

5.3.3. The links and operating methods governing relations between the various parties are not made clear. Until an electronic card is introduced, there are questions about how patients (card) and practitioners will interact in practice, and how practitioners and the bodies paying them will be linked.

These points must clearly be properly resolved if the European health-insurance card is to work properly, be accepted and become a success.

5.4. Timetable

5.4.1. Phases 1 and 2 of the timetable as presented are ambitious, but realistic. In view of the present situation, the deadlines set may be considered to be tight. However, the possibility of an 18-month transitional period for the second phase, allowing for parallel circulation (forms + cards) provides a valuable degree of flexibility. The timetable concludes in 2008: it would therefore be helpful to indicate how, under what conditions and with what deadlines the EU accession countries are to be fitted into this process.

5.4.2. Phase 3 involves the introduction of an electronic card. According to the communication, this could integrate "functions linked to personal health data". The EESC would point out that the Barcelona mandate is not to create a health card, but a European health-insurance card. This proposal therefore appears premature in terms of form and content.

5.5. Data protection

5.5.1. Both the card introduced in Phase 2 and the electronic card will contain a certain amount of personal data. It is essential to ensure that such data are secure and that, as a minimum, cannot be cross-checked with other existing files.

Brussels, 18 June 2003.

The President

of the European Economic and Social Committee

Roger Briesch

(1) OJ L 149, 5.7.1971.

(2) OJ C 64, 5.4.1967.

(3) Edinburgh European Council of 11 and 12 December 1992. Presidency conclusions (SN 456/92).

(4) COM(97) 586 final.

(5) OJ C 235, 27.7.1998, p. 82.

(6) Opinion currently under preparation on health care, SOC/140.