Contributions to Publicly Financed Health Care and their Coordination in the European Union Filip Křepelka Masarykova univerzita, Brno, CZ

Private and public financing of health care Money for health care: direct payments – private insurance – public insurance – health care tax – general taxation. Who pays? individuals, family members, charity, employers, taxpayers in general. Organization: Insurers, charitable institutions, public funds, government. Public financing prevails in Europe

Explanation and justification of public health care insurance Traditional institutions Autonomous schemes – managed by insured persons. Social differentiation Private investment Competition among insurers and providers of health care.

Government Interventions Fixing model of public insurance. Setting construction and rates of contributions to public insurance. Redistribution with taxes on among funds. Requrements on private insurance, control if private insurers allow to manage public insurance. Control of prices of health care.

Etatisation tendencies Integration of contributions to public health care insurance with general taxation – substantive and procedural. Takeover and control of funds – making tham effectively part of government. Nationalization of health care providers. Direct financing of health care providers or government reimbursement.

Privatisation tendencies Health care providers largely privatized. Commercialization of public health care insurance funds. Increasing co-payment of patients. Privatization of health care and its financing increases inequality.

Nature of contributions to public health care insurance Competing tendencies, rapid reforms and importance of other private and government financing blurr nature of contributions to public health even on national level. It is difficult to compare correctly various models of financing including contributions on international level. Public insurance or specific health care taxes are the most important for financing of health care in Europe. However, it is difficult to categorize all models.

Financing of health care for migrants Short-term migrants remain uncovered in general, private insurance is often required for entry and stay, Middle-term migrants can be treated uneaqually if there is no requirement of equal treatment – resort to private insurance. Long-term migrants integrated in economy and society are usually treated equally (same taxes and same benefits). Law of the European Union requires equal treatment of nationals of other member states.

International Taxation and its Coordination Residents are taxed for worldwide income and enjoy personal deduction. Non-residents are taxed for income in the territory. Double taxation can endanger cross-border economic activities. Tax treaties exclude or limit double taxation. Tax treaties treat differently health care taxe and contributions to public health care insurance. The European Union has not supranationalized coordination of international taxation. Bilateral treaties among the member states are applied together with case law applying basic economic freedoms.

Coordination of social security Social treaties or supranational law of the European Union (regulation 883/2004) Principle of single state – every individual shall be protected by only one member state Member state of employment or individual business is priority, state of residence is secondary criterion. The principle of single state is applied also on contributions. Solely one member state shall collect contributions affecting also foreign incomes.

Problem 1: Parallel employment or individual business People having employment or individual business in two or more member states. States are free to decide whether income in other member state shall be lasted with contributions to health care. If yes, contributions shall be paid in the member state of residence according to its law also from incomes in the second (and other) member states. Administrations of social security shall cooperate in enforcement. Place of employment and residence can be easily manipulated to avoid burden if contribution as health tax.

Problem 2: minor and temporary employment There are numerous Slovak students at Czech universities (better quality, no fees, intelligible language, tradition, equal treatment based with both bilateral treaty and Czech Republic extended contributions to minor employments due to misuse. Slovak students having mini-jobs switch automatically to Czech public health care insurance. They do not want it and often do not know about it. Minor and temporary employments shall be excluded.