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BMJ. 1999 May 1; 318(7192): 1157–1158.
PMCID: PMC1115568

Cross border health care in Europe

European court rulings have made governments worried
Panos Kanavos, Lecturer in international health policy
London School of Economics and Political Science, London WC2A 2AE
Martin McKee, Professor of European public health
London School of Hygiene and Tropical Medicine, London WC1E 7HT
Tessa Richards, Associate editor

It’s been an eventful year for the European Union. The resignation of the European Commission may have been a debacle, but January saw the launch of the Euro, and the new Treaty of Amsterdam is on its way to ratification by national parliaments. Both events will have an impact on medicine. A common currency will highlight the disparity in levels of healthcare costs and expenditure across the member states. The new treaty, which paves the way for enlarging the union, will, among other things, fuel the free movement of health-care professionals, especially from east to west Europe. Meanwhile the impact of European Union legislation continues to grow, from the 48 hour working time directive to the directive enshrining mutual recognition of professional qualifications which is spurring harmonisation of professional training.

Healthcare shopping in the union may not yet be commonplace, but last year’s landmark European Court rulings coupled with the price transparency that the Euro will bring will give it a boost. On the face of it the rulings were not exciting. In the first1 a man was given a prescription for spectacles in Luxembourg, bought them in Belgium, and when his insurance fund failed to reimburse him took his case to the European court and won. The court upheld the view that refusing reimbursement violated the Treaty of Rome on free movement of goods. In the second2 when a Luxembourg man tried to get orthodontic treatment for his daughter in Germany, he was refused on the grounds that it was not urgent and appropriate treatment was available in Luxembourg. He disputed this, took his case to the European Court, and won. The Court ruled that economic issues cannot justify obstructing the free movement of services.

Until these rulings reimbursement for reciprocal medical care between member states has hinged on individuals having to get prior authorisation from their health authority or insurance fund. By doing away with this requirement in the interests of the single market these rulings have potentially opened the door to cross border healthcare shopping and put national health services under the scrutiny of Europe’s consumer orientated citizens. The growing recognition that services or goods are cheaper or more readily available and reimbursable in some member states but not others is bound to provoke debate. In states where rationing is explicit and widespread governments are likely to face growing dissatisfaction among their electorate.

Unsurprisingly several governments have been alarmed—and their fears are not misplaced. Because of differences in the perceived quality of health services patients may want to obtain treatment in another member state. The same may happen because of capacity shortages or rationing in patients' own countries. In this case, local payers will have to reimburse patients who travel abroad to circumvent this problem. Patients may also want to receive treatment in another country if it is cheaper there and they have to pay for it themselves (because it is not reimbursed under national systems).

Rationed pharmaceuticals may also become the subject of shopping trips by patients who pay out of pocket, given the current enormous price differentials across member states (see table). In the United Kingdom, in particular, drug prices are often twice as high as in continental European countries. Although the court left the possibility open for providers to refuse non-emergency treatment, in some parts of Europe cross border patient movements already exist.3,4 Although these are currently relatively small, the rulings seem likely to increase them.

Beyond citizens’ rights to obtain quality care also lies the ability and willingness of payers to fund and reimburse services. The rulings increase the transparency of reimbursement decisions for health goods and services. This will undoubtedly raise questions as new and expensive treatments become available. Payers and providers may then be interested in obtaining medical goods from cheaper sources, thus defying national health policies.

Health policy has traditionally been a national responsibility under the principle of subsidiarity. The fact that goods and services are reimbursed in one country but rationed in another is likely to stimulate debate about whether there should be a standard package of care offered across the European Union and, if so, what it should include. By suggesting that health care should be freely available across borders without restriction, the rulings clash with the principle of subsidiarity.

While important barriers remain, the court rulings have changed the ground rules considerably. In the short term there are practical implications for patients and healthcare systems. In the long term the rulings could be the first steps towards much closer European healthcare integration. More than ever, those concerned with developing health policy or commissioning or providing care need to be aware of the European dimension to their work.

Average prices of selected branded pharmaceuticals in three European countries (Euros per packet at 1997 values)


1. European Court of Justice. Case C-120/95 [Nicolas Decker v Caisse de Maladie des Employes Prives]. 28 April 1998.
2. European Court of Justice. Case C-158/96 [Raymond Kohll v Union des Caisses de Maladie], 28 April 1998.
3. France G. Cross border flows of Italian patients within the EU. Eur J Publ Health. 1997;7 (suppl):18–41.
4. Mossialos E, McKee M, Rathwell T. Health care and the single market. Eur J Publ Health. 1997;7 (suppl):235–237.

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