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)
Date: 2003-06-18
Institutions: European Economic and Social Committee
Subjects: European citizenship, administrative formalities, health card, health insurance

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Official Journal of the European Union

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4.13.
Finally the EESC wishes to reaffirm its support for a
knowledge-based approach to legislation and encourages the
Commission to strengthen the collection of relevant data
across Member States. These should include primary indicators
of public health and crop damage to ensure that measures

taken are having the desired effect. The progress of individual
Member States to meeting their target emission reductions
under existing legislation should also be carefully monitored
and reported.

Brussels, 18 June 2003.

The President

of the European Economic and Social Committee

Roger BRIESCH

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

Great care will have be taken to protect personal data

1.4.
in Phases 2 and 3, especially the latter.

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.

2.

Introduction

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.

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 coordi-
nation of statutory health-insurance systems (1).

At its 59th plenary session in January 1967,

2.2.
the
Economic and Social Committee adopted an opinion (2) con-
cerning the regulation, and a number of comments were made
on the text presented.

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) OJ L 149, 5.7.1971.
(2) OJ C 64, 5.4.1967.

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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.

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

In 1992, the Edinburgh European Council (1) recog-
2.4.
nised the need to carry out a general review of the legislation
in order to simplify the rules for coordination. More specifi-
cally, an action plan for free movement of workers was
presented (2).

3. Gist of the communication

In its opinion of 28 May 1998 (3), the Committee
2.5.
welcomed the reform of Regulation (EEC) No 1408/71,
expressing its agreement with the simplification and improve-
ment of coordination of EU Member State social security
systems.

As it now stands, following all the modifications and
2.6.
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.

Access to care and reimbursement is currently provided
2.7.
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.

( 1) Edinburgh European Council of 11 and 12 December 1992.

Presidency conclusions (SN 456/92).

( 2) COM(97) 586 final.
( 3) OJ C 235, 27.7.1998, p. 82.

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.

After providing an overview, noting the wide diver-
3.1.1.
sity 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.

The communication explains that the card must have
3.1.2.
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.

Initially, the European card will carry in visually
3.1.3.
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.

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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 pre-
paratory phase is crucial.

4.2.
The European Economic and Social Committee wel-
comes 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, conse-
quences of enlargement, etc.) (1).

for other

The practical effect of the initiative will be to enable
4.2.1.
the public to take advantage more easily of the essential facility
provided by the coordination of statutory health-insurance
schemes
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.

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 pro-
posals 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.

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:

5.2. Validity period

— 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 inte-
gration 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

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

One of the main weaknesses of the forms presently
5.2.1.
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.

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5.3.

The insured person and others involved

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

— alignment of entitlement to ‘necessary care’ for all categor-
ies 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.

Brussels, 18 June 2003.

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 elec-
tronic 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.

The President

of the European Economic and Social Committee

Roger BRIESCH