The Europeanization of Health Policy Monika STEFFEN Institute for Political Studies University of Grenoble (France) Fiocruz / ENSP, Rio de Janeiro 27th October 2010

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

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)

D IFFERENT 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

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

Embeddedness of Health: …. in 25 Member States Cultural context Political context Economic context Institutional context Policy decision

Complementary approaches to “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)

Historical landmarks 1957 Rome Treaty: Transportability of Social Security Reinforced 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

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

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) 10M. Steffen - M2 PPS 2010

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

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

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”

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

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

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.

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

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