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Published online by Cambridge University Press: 16 July 2019
Free movement of patients has been criticised from the moment that the first patient cases reached the Court of Justice of the European Union (‘CJEU’). The moving patient supposedly increases consumerism, reduces national solidarity, and has a negative impact on the quality of healthcare provided in some Member States. This article challenges the empirical foundations of such criticisms. An empirical analysis of all patient cases before the CJEU shows that a significant number of patients required urgent treatment, that their medical condition was life-threatening, and that they were supported by their treating doctor in seeking treatment in another Member State. Moreover, free movement of patient cases regularly lead to positive changes to national healthcare systems. Therefore, the negative attitude towards free movement of patients should be reconsidered. Patients, doctors, and lawyers must think more strategically about how free movement can be used to improve the quality of healthcare in the EU.
Assistant Professor in EU Law, Durham University (UK). I am grateful to Emma Cave, Shaun Pattinson, and Robert Schütze for the comments and discussions.
1 Directive 2011/24/EU on the application of patients’ rights in cross-border healthcare (‘Cross-Border Healthcare Directive’). See, for a detailed discussion of this Directive, de la Rosa, S, ‘The Directive on Cross-Border Healthcare or the Art of Codifying Complex Case Law’ (2012) 49 Common Market Law Review 15Google Scholar.
2 See, most prominently, Newdick, C, ‘Citizenship, Free Movement and Health Care: Cementing Individual Rights by Corroding Solidarity’ (2006) 43 Common Market Law Review 1645Google Scholar; Hatzopoulos, V, ‘Killing National Health and Insurance Systems but Healing Patients? The European Market for Health Care Services after the Judgments of the ECJ in Vanbraekel and Peerbooms’ (2002) 39 Common Market Law Review 683CrossRefGoogle Scholar.
3 Hatzopoulos, note 2 above, pp 688–94; Newdick, note 2 above, pp 1654–56; Davies, G, ‘Welfare as a Service’ (2002) 29 Legal Issues of Economic Integration 27CrossRefGoogle Scholar. For a more recent perspective, see Rieder, C, ‘Cross-Border Movement of Patients in the EU: A Re-appraisal’ (2017) 24 European Journal of Health Law 390CrossRefGoogle Scholar.
4 Newdick, note 2 above, pp 1658–64.
5 Hatzopoulos, V, ‘Some Thoughts on the Fate of Poorer Member States’ Healthcare Systems after the Ruling in Elena Petru’ (2016) 41 European Law Review 423Google Scholar; Frischhut, M and Fahy, N, ‘Patient Mobility in Times of Austerity: A Legal and Policy Analysis of the Petru Case’ (2016) 23 European Journal of Health Law 36CrossRefGoogle ScholarPubMed.
6 COM (2015) 421 final, Commission Report on the Operation of Directive 2011/24/EU on the Application of Patients’ Rights in Cross-Border Healthcare.
7 Raymond Kohll v Union des caisses de maladie, C-158/96, EU:C:1998:171.
8 In 2007, Tamara Hervey already analysed the implications of the early case law of the CJEU in the Cambridge Yearbook: Hervey, T, ‘The Current Legal Framework on the Right to Seek Health Care Abroad in the European Union’ (2007) 9 Cambridge Yearbook of European Legal Studies 261CrossRefGoogle Scholar.
9 For a detailed and nuanced analysis of the consumerism argument, see Hervey, T and McHale, J, European Union Health Law (Cambridge University Press, 2015), pp 73–97CrossRefGoogle Scholar
10 See Sheppard, M, ‘Treatments of Low-Priority and the Patient Mobility Directive 2011, an End to Legal Uncertainty for the NHS?’ (2013) 20 European Journal of Health Law 295, p 304CrossRefGoogle ScholarPubMed.
11 For a more nuanced perspective, see Flear, M, ‘Developing Euro-Biocitizens through Migration for Healthcare Services’ (2007) 14 Maastricht Journal of European and Comparative Law 239, pp 251–52CrossRefGoogle Scholar.
12 Hervey and McHale, note 9 above, p 82.
13 Newdick, note 2 above, p 1665.
14 Ibid, pp 1661–64. For a different perspective, see de Witte, F, ‘The Constitutional Quality of the Free Movement Provisions: Looking for Context in the Case Law on Article 56 TFEU’ (2017) 42 European Law Review 313, pp 329–31Google Scholar.
15 Georgi Elchinov v Natsionalna zdravnoosiguritelna kasa, C-173/09, EU:C:2010:581.
16 Elena Petru v Casa Judeteana de Asigurari de Sanatate Sibiu, C-268/13, EU:C:2014:2271.
17 Hatzopoulos, note 5 above. See also Sokol, T, ‘Rindal and Elchinov: An (Impending) Revolution in EU Law on Patient Mobility?’ (2010) 6 Croatian Yearbook of European Law and Policy 167CrossRefGoogle Scholar.
18 Hatzopoulos, note 5 above, p 430.
19 Article 168(7) TFEU.
20 See, for example, Hervey, T, Young, C, and Bishop, L (eds), Research Handbook in EU Health and Policy (Edward Elgar, 2017)CrossRefGoogle Scholar; Ruijter, A de, EU Health Law and Policy (Oxford University Press, 2019)CrossRefGoogle Scholar. The strong public policy focus of these books is also reflected in the emphasis on the term ‘health law’ rather than ‘medical law’.
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23 The term ‘EU medical law’ is rarely used. This might be a direct consequence of the lack of competence of the EU in this area of law. For more background, see Hervey, T, ‘Telling Stories about European Union Health Law: The Emergence of a New Field of Law’ (2017) 15 Comparative European Politics 352CrossRefGoogle Scholar.
24 Regulation 883/2004 on the coordination of social security systems.
25 On the implementation of the Cross-Border Healthcare Directive in the Member States, see the special issue of the European Journal of Health Law: EU Cross-Border Healthcare Directive (2014) 21 European Journal of Health Law.
26 See S de la Rosa, note 1 above.
27 Hervey and McHale, note 9 above, pp 85–91.
28 See also D Sindbjerg Martinsen, ‘Governing EU Health and Policy – On Governance and Legislative Politics’ in Hervey, Young, and Bishop (eds), note 20 above, pp 36–60.
29 Kohll, note 7 above; Abdon Vanbraekel v Alliance nationales des mutualités chrétiennes, C-368/98, ECLI:EU:C:2001:400; B.S.M. Geraets-Smits v Stichting Ziekenfonds VGZ and H.T.M. Peerbooms v Stichting CZ Groep Zorgverzekeringen, C-157/99, EU:C:2001:404; V.G. Müller-Fauré v Onderlinge Waarborgmaatschappij OZ Zorgverzekeringen and E.E.M. van Riet v Onderlinge Waarborgmaatschappij ZAO Zorgverzekeringen, C-385/99, EU:C:2003:270; Patricia Inizan v Caisse primaire d'assurance maladie des Hauts-de-Seine, C-56/01, EU:C:2003:578; Ludwig Leichtle v Bundesamstalt für Arbeit, C-08/02, EU:C:2004:161; The Queen (on the application of Yvonne Watts) v Bedford Primary Care Trust, C-372/04, EU:C:2006:325; Manuel Acereda Herrera v Servicio Cántabro de Salud, C-466/04, EU:C:2006:405; Aikaterini Stamatelaki v NPDD Organismos Asfaliseos Eleftheron Epangelmation, C-444/05, EU:C:2007:231; Elchinov, note 15 above; Elena Luca v Casa de Asigurari de Sanatate Bacau, C-430/12, EU:C:2013:467; Petru, note 16 above.
30 Geraets-Smits, note 29 above, and Müller-Fauré, note 29 above, were both joined cases.
31 Graziana Luisi and Giuseppe Carbone v Ministero del Tesoro, C-286/82, EU:C:1984:35.
32 Nicolas Decker v Caisse de maladie des employés privés, C-120/95, EU:C:1998:167.
33 Kohll, note 7 above, para 2.
34 Vanbraekel, note 29 above, para 12.
35 Judgment of Centrale Raad van Beroep of 20 July 2004, NL:CRVB:2004:AQ5957.
36 Ibid.
37 Ibid.
38 Peerbooms, note 29 above, para 33.
39 Judgment of the Centrale Raad van Beroep of 20 July 2004, NL:CRVB:2004:AQ6215.
40 Ibid.
41 Ibid.
42 Opinion of Advocate General (‘AG’) Ruiz-Jarabo Colomer in Müller-Fauré, note 29 above, para 2.
43 Ibid.
44 Ibid, para 5.
45 Opinion of AG Ruiz-Jarabo Colomer in Inizan, note 29 above, para 2.
46 Ibid, para 4.
47 Ibid, para 6.
48 Opinion of AG Ruiz-Jarabo Colomer in Leichtle, note 29 above, para 2.
49 Ibid.
50 Ibid, para 4.
51 Secretary of State for Health v R (on the application of Yvonne Watts) [2004] EWCA Civ 166, paras 11–12.
52 Ibid, para 16.
53 Ibid, para 13.
54 Judgment of the Tribunal Superior de Justicia de Cantabria of 5 October 2006, ES:TSJCANT:2006:212.
55 Acereda Herrera, note 29 above, paras 18–20.
56 E-mail correspondence with lawyer from the Legal Service of the European Commission (1 March 2018).
57 Stamatelaki, note 29 above, para 9.
58 Ibid, para 11.
59 Opinion of AG Cruz Villalon in Elchinov, note 15 above, para 10.
60 Elchinov, note 15 above, para 17,
61 C Chifu, ‘Bolnava de cancer care a pierdut procesul cu CAS a ajuns la CEDO’ Desteptarea (2 September 2014), https://www.desteptarea.ro/bolnava-de-cancer-care-a-pierdut-procesul-cu-cas-a-ajuns-la-cedo.
62 Luca, note 29 above, para 13.
63 Opinion of AG Cruz Villalon in Petru, note 16 above, para 5.
64 Ibid, para 6.
65 Ibid, para 7.
66 In two of the non-urgent cases, the condition of the patient was life-threatening.
67 Opinion of AG Ruiz-Jarabo Colomer in Müller-Fauré, note 29 above, para 2.
68 Opinion of AG Ruiz-Jarabo Colomer in Leichtle, note 29 above, para 2.
69 Judgment of the District Court of Roermond of 6 December 2001, NL:RBROE:2001:AD9781.
70 Elchinov, note 15 above, paras 16–17.
71 van Leeuwen, B, ‘The Doctor, the Patient and EU Law: The Impact of Free Movement Law on Quality Standards in the Healthcare Sector’ (2016) 41 European Law Review 638, pp 652–53Google Scholar.
72 For more background see Straus, S et al. , Evidence-Based Medicine: How to Practise and Teach EBM (Elsevier, 2010)Google Scholar.
73 See van Leeuwen, B, European Standardisation of Services and its Impact on Private Law (Hart Publishing, 2017), ch 4Google Scholar.
74 See Flear, note 11 above, p 250.
75 Ibid.
76 Newdick, note 2 above.
77 See also Berki, G, Free Movement of Patients in the EU: A Patient's Perspective (Intersentia, 2018)CrossRefGoogle Scholar.
78 B van Leeuwen, note 71 above.
79 Ibid, p 652.
80 Montgomery, J, ‘Impact of European Union Law on English Healthcare Law’ in Dougan, M and Spaventa, E (eds), Social Welfare and EU Law (Hart Publishing, 2005), p 154Google Scholar.
81 See also Conant, L, Justice Contained: Law and Politics in the European Union (Cornell University Press, 2002)Google Scholar, who argued that the most common reaction of Member States to losing cases before the CJEU is ‘contained compliance’ – ie limiting or minimising the impact of a case to its individual circumstances, and only making the absolute minimum number of changes to comply with EU law. For an application of this argument to the healthcare sector, see Greer, S and Rauscher, S, ‘Destabilization Rights and Destabilization Politics: Policy and Political Reactions to European Union Healthcare Services Law’ (2011) 18 Journal of European Public Policy 220CrossRefGoogle Scholar.
82 For an analysis of the broader impact of Elchinov in Bulgaria, see Vasev, N et al. , ‘The End of Eastern Territoriality? CJEU Compliance in the New Member States’ (2017) 15 Comparative European Politics 459, pp 470–71CrossRefGoogle Scholar.
83 E-mail correspondence with the Bulgarian lawyer of Mr Elchinov (10 April 2017).
84 Ibid.
85 Montgomery, note 80 above. See also Greer and Rauscher, note 81 above, pp 230–31, who argued that the impact of Watts has remained limited.
86 Petru, note 16 above, para 33.
87 Ibid, para 35.
89 Van Leeuwen, note 71 above, pp 646–47.
90 Greer, S and Sokol, T, ‘Rules for Rights: European Law, Health Care and Social Citizenship’ (2014) 20 European Law Journal 66, pp 83–84CrossRefGoogle Scholar.
91 Peerbooms, note 29 above, paras 6–10.
92 Ibid, paras 94–98.
93 Judgment of the District Court of Roermond of 6 December 2001, NL:RBROE:2001:AD9781.
94 Judgment of the Centrale Raad van Beroep of 20 July 2004, NL:CRVB:2004:AQ6215.
95 Ibid.
96 Ibid.
97 See Vollaard, H, ‘Patient Mobility, Changing Territoriality and Scale in the EU's Internal Market’ (2017) 15 Comparative European Politics 435CrossRefGoogle Scholar.
98 Article 8(2)(c) of the Cross-Border Healthcare Directive.