1. Supervisor: Gisela Garrido Veron
Dr. Christine Arnold Word Count: 7,998
21st
August 2015
Bachelor Thesis
g.garridoveron@student.maastrichtuniversity.nl
EUROPEANIZATION OF WELFARE:
SPEED TRANSPOSITION OF DIRECTIVE 2011/24/EU ON
PATIENTS’ RIGHT IN CROSS-BORDER HEALTHCARE IN
DENMARK AND THE NETHERLANDS
2. 1
TABLE OF CONTENTS
I. INTRODUCTION .................................................................................................. 2
II. BACKGROUND ..................................................................................................... 5
EU HEALTH POLICY
III. INTRODUCTION TO THE DIRECTIVE 2011/24/EU .................................................. 6
CROSS-BORDER HEALTH CARE .................................................................................. 6
POLITICAL CONTEXT ................................................................................................ 6
THE ADOPTION OF DIRECTIVE 2011/24...................................................................... 8
CONTENT OF DIRECTIVE 2011/24.............................................................................. 8
TRANSPOSITION AND IMPLEMENTATION OF DIRECTIVES ................................................ 9
IV. THEORETICAL FRAMEWORK .............................................................................10
CAUSES OF NON-CORRECT IMPLEMENTATION OF DIRECTIVES .......................................10
a. EU level....................................................................................................10
b. National level ............................................................................................12
c. Incapacity or opposition level ....................................................................13
d. Hypotheses and final framework.................................................................13
V. CASE STUDIES ....................................................................................................14
ELECTION OF COUNTRIES ........................................................................................14
IMPLEMENTATION OF DIRECTIVE 2011/24 IN DENMARK...............................................15
IMPLEMENTATION OF DIRECTIVE 2011/24 IN THE NETHERLANDS...................................17
VI. DISCUSSION........................................................................................................19
VII. CONCLUSION .....................................................................................................22
VIII. REFERENCES......................................................................................................25
IX. ANNEX ...............................................................................................................29
3. 2
I. INTRODUCTION
Although there was a European Economic Community (EEC), it was not until the
emergence of the European Union (EU) that Member States (MSs) decided to cooperate in the
development of further social policies. In the 1950s, when six European countries united to
create an economic community, they focused mainly upon creating a common market.
Therefore, “little attention was given to issue[s] concerning social policy” (Visinsky, ny). The
Treaty of Rome brought, however, the first steps in social security, since “economics depended
upon giving people the ability to work flexibly within the active European labor market” (ibid).
Therefore, issues on social policy became important to the development of the economic union.
The progress of integrating social policies in a mainly economic institution was
achieved during a long and complex process since “Member States of the European
Community [EU] deepened their mutual economic integration and gradually branched out into
new policy areas” (Visinsky, ny). This process is the so-called ‘Social Europe’ in which the
EU works to improve the “living standards, supporting the socio-economically weak and
equalizing chance in life” (Martinsen S. a., 2014); (Kellerman, 2009). However, this form of
Europeanization of social welfare “has been one of the few policy areas where national
governments have usually resisted integration” (Martinsen S. a., 2014) (Falkner, 1998). It is
important to understand that the unlikeness of integration has played an important role in
implementation of EU legislation, since MSs are reluctant to lose sovereignty.
Since EU health policy does not have full competences in MSs; it is interesting to
analyze the implementation process of EU legislation concerning health policy. A way of doing
so, is focusing on the implementation of directives which “are not directly applicable at a
national level…but have to be incorporated into national law”(ibid). Since EU health policy
falls under the four fundamental freedoms concerning the functioning of the European Single
Market, this thesis concentrates on one of the main steps on cross-border healthcare legislation
which “concerns the organization and financing of national healthcare systems” (Vollaard &
Martinsen, 2014).This is Directive 2011/24/EU, also known as Patients’ Rights Directive
(PRD). This Directive comprises the reimbursement of healthcare costs in another MS. The
establishment of the PRD was preceded by a long debate concerning whether the free
movement of services includes healthcare. Its transposition seems to have been problematic,
demonstrated by the large amount of MSs that experienced delay in its implementation1
.
1
See Annex
4. 3
The aim of this paper is to analyze the causes for implementation delay concerning the
PRD by observing the transposition process in the Netherlands and Denmark. Previously,
authors such as Kostera(2008) and…predicted that the implementation speed of this Directive
would chiefly depend on the national healthcare system, claiming that Bismarck-oriented
systems facilitates the implementation of the PRD. However, in retrospect this was not always
the case. The fact that Denmark --having a Beveridge-healthcare system-- correctly
implemented the PRD before the Netherlands --who has a Bismarck-oriented healthcare
system-- make their implementation processes interesting to analyze. Moreover, the
Netherlands and Denmark are seen as two relatively well-organized MSs, which besides
making them suitable for comparison, raises the question why they experienced late
implementation. Thus, this thesis aims to answer the question: Why did MSs experience
implementation delay regarding the PRD? In other words, what are the main causes that make
a country take longer than another? Consequently, this paper claims that the transposition
process of the Netherlands and Denmark is not directly affected by the type of healthcare
system, as was thought previously, but on arrangements made at national level.
Many scholars have contributed in transposition studies. Falkner et. al. (2004) claim
that “implementation problems should occur when Member States failed to assert their interest
in the European decision-making process” (p.452). It is important to study the implementation
process since non-correct implementation of directives may have significant consequences “on
the functioning of the Single Market, as defined in Articles 26 and 114(1)
TFEU2
”(Commission, 2015). In other words, the relevance of this paper relies on
understanding national positions when touching non-EU competence areas and how MSs
cooperate in order to safeguard the well-functioning of the Internal Market
(IM).
This thesis is divided in six chapters. The first chapter embodies the historical
development of EU health policy since the Maastricht Treaty onward, considering the concept
of Social Europe. This section provides a historical framework in order to understand the
skeptical behavior of the Union regarding the adoption of further social policies (Falkner, G
1998). The second chapter explains the PRD, from its origins until today, answering questions
such as why was it necessary to adopt this Directive. The third chapter deals with the
implementation of directives presenting existing scholars’ arguments for non-correct
2
Treaty on the Functioning of the European Union
5. 4
implementation. This chapter builds a theoretical framework based on existing literature, the
hypothesis of “Goodness-of-fit” and the ‘Push-and-Pull’ theory.
The fifth chapter analyses the different implementation processes of Denmark and the
Netherlands by using the theoretical framework established. This part is crucial to understand
the differences in implementation and whether the different healthcare systems facilitated the
PRD implementation. Finally, this thesis concludes with a discussion section where
summarizes all the findings leading to the conclusion where the answer of the research question
is given.
This thesis contributes to the understanding of the field of a non-competency policy
inside the EU in which, however, the idea of cooperation is highlighted in order to ensure the
free movement of persons and services.
6. 5
II. BACKGROUND
EU HEALTH POLICY
This section provides an introduction of the EU health policy since the Maastricht
Treaty until today explaining the development of social policies(Social Europe). It intends to
give an overview on the health policy field explaining why Falkner stated that “social policy
seems an unlikely field for integration to succeed at this stage of the EUs history”(1998).
After the achievement of the economic and monetary union, the EU needed to improve
in social dimensions (Behning, 2002). However, it is important to note that “social policy seems
an unlikely field for integration to succeed at this stage of the EUs history”(Falkner, 1998).
This is because MSs do not want to renounce their “national sovereignty and political decision
capacities in areas of social and employment policy” (Behning, 2002). In the case of health
systems, MSs “do not only regulate the access to healthcare, but… also… the interests of the
pharmaceutical industry [and] the development of medical technologies” (Kostera, 2008).
The Maastricht Treaty(1993) introduced important changes. The establishment of a
common citizenship called for the implementation of further social policies especially
regarding health care. Article 129(1) of the Maastricht Treaty states that all MSs shall ensure a
high level of human health protection by cooperating among themselves.Moreover; it provides
the European Commission (EC) with a higher degree of legal competence in the area of public
health protection. This was the first time that public health was mentioned inside legal
competence in the Union (Eurocare, 2013).
Since 1998, the ECJ has faced important disputes trying to clarify “a long list of open
questions concerning the relationship between the Community’s fundamental free movement
provisions and the territoriality of national healthcare” (Martinsen D. S., 2005). Moreover,
Martinsen(2005) argues that cross-border healthcare is seen inside the free movement of goods
and services in which prior-authorization policies3
would constitute to a barrier to the free
movement of goods and services(ibid).The European Court of Justice has stated that
hospitalization of patients constitutes a service in the meaning of the treaty but regarding
hospital care “national authorization policies may in principle be justifiable in order to protect
the stability of national systems”(ibid, p. 1031).
Currently, the EU is working on further implementing the so-called ‘Social Europe’,
with health policy being a field for improvement. Many scholars argue that EU legislation for
3
“National healthcare systems reimburses the costs of non-acute treatment carried out abroad only if that
treatment has been authorized beforehand” (Martinsen D. S., 2005)
7. 6
welfare matters has been growing since the 1990s especially due to the increasing use of the
Qualified Majority Voting (QMV). Arguably, it is difficult for MSs to agree on harmonizing
measures inside a non-competence area. Instead, MSs opt to seek for a “non-binding soft law
or framework legislation, allowing them to select the policy instruments themselves”. (Vollaard
& Martinsen, 2014).
III. INTRODUCTION TO THE PRD
CROSS-BORDER HEALTH CARE
Cross-border healthcare has become a more prominent phenomenon in the EU
especially since European citizens are allowed to travel freely within the Union. Normally,
when a citizen is in need of medical treatment, s/he receives health care in the MS where s/he
lives through his/her national healthcare system where s/he probably is covered or insured.
However, in some cases, it may be necessary to obtain healthcare in another MS – for example
in countries where there is better expertise in a certain field, lower health costs, where waiting
times are shorter or simply because of an emergency case outside the national country. In other
words, free movement of patients –or patients’ mobility– “implies people accessing health care
services outside their home state” (Mossialos, Permanand, Baeten, & Hervey, 2009)
Cross-border healthcare does not only apply to patients or citizens with health problems
but also encompasses doctors and nurses, “who train and work abroad and increasingly
cooperates with colleagues abroad” (Wismar, Palm, Figueras, Ernst, & Ginneken, 2011).
Furthermore, medical doctors or paramedical professionals are motivated to leave their own
MS since –for instance– salaries in other MSs are higher, better working conditions, new
professionals experiences or training and career opportunities (Costigliola, 2011).
POLITICAL CONTEXT
The political willingness to establish Directive 2011/24 emerged during the legislation
process of Directive 2006/1234
on Services in the IM. The European Parliament excluded the
area of healthcare arguing that the Directive was “not suitable for something as specific as
healthcare” (Peeters, 2012). As a consequence, even more calls arose in order to establish a
Directive including aspects of healthcare(ibid). The new Directive intended to counterweight
4
Directive 20063/123/EC of the European Parliament and of the Council of 9 March 2011 on the services in the
IMOJL 376,27 December 2006 known as Bolkenstein Directive
8. 7
much jurisprudence56
accumulated and at the same time “safeguarding the Internal Market
principles of the Treaty of the Functioning of the European Union (TFEU)”(ibid); (Antonaki I.
, 2014, pp. 9-10).
EU law cases such as Kohll7
and Decker8
created the need for a “European legal
framework on planned cross-border healthcare” (Health, 2014). Since the ECJ stated that prior
authorization for cross-border healthcare was an infringement on the free movement of services
regarding Kohll’s case and a on the free movement of goods in Decker’s case law. Although
there was a need to solve cross-border health issues, it was not until 1998 that the ECJ decided
that there was a need to improve regulations on cross-border healthcare. There were three
attempts to establish such a directive until “the European Commission finally launched a
proposal for a directive on 2 July 2008” (Peeters, 2012). Peeters (2012) argues that the EC had
waited long before launching the new proposal because “it feared rejection of the Lisbon
Treaty”(p.31) after the negative approach to the European Constitution and especially
regarding the significant impact of the Bolkesntein Directive.
The creation of such a Directive aimed to facilitate the market access and to safeguard
the IM principles known as the four freedoms of the EU (Antonaki I. , 2014, p. 10). Therefore,
MSs should comply with the requirements on the transposition of such a directive since it will
affect the flow of the IM otherwise. Many MSs argue whether healthcare matters should be
included inside the IM principles. However, “European case law9
had already determined more
than twenty years ago that healthcare services are economic services and therefore fully subject
to the freedom of establishment and the freedom of services” (Peeters, 2012).
Directive 2011/24 is based on Article 114 (3) “as it has the primary aim of improving
the functioning of the internal market” (Quinn & Hert de, 2011). Article 114(3)states that “the
Commission, in its proposals envisaged in paragraph 1 concerning health, safety,
environmental protection and consumer protection, will take as a base a high level of
protection, taking into account in particular of any new development based on scientific facts.
Within their respective powers, the European Parliament and the Council will also seek to
5
Case C-120/95 Decker(1998)ECR I-I1831;section 2.2.1
6
Case C-158/96 Kohll(1998)ECR I-1931;section 2.2.1
7
Mr.Kohll brought his daughter to Germany in order to receive orthopedic treatment.Mr. Kohll’s health insurance
failed to reimburse the cost of the treatment because according to Luxemburg legislation Mr. Kohll needed prior
authorization to obtain the reimbursement for cross-border healthcare.
8
In Decker’s case he purchased a pair of glasses outside the country. Similarly to Kohll case law, the health
insurance failed to reimburse the costs of cross-border healthcare because Mr. Decker needed prior authorization
to obtain the reimbursement.
9
Cases 286/82and 26/83, Luisi and Carbone (1984) ECR377, case C-159/90, Society for the Protection of
Unborn Children Ireland/Grogan (1991)ECR I-4685 and case C-158/96, Kohll(1998)ECT I-1931.
9. 8
achieve this objective”(TFEU). Although there were attempts to include Article168 as another
legal basis, this was ultimately not added as such (Antonaki I. , 2014).
THE ADOPTION OF DIRECTIVE 2011/24
On the 9th
of march 2011, directive 2011/24/EU was agreed on by the European
Parliament and the Council. The Directive contains 23 articles which are divided over 5
sections. This Directive presented that each EU citizen has the right to receive health care in
any public or private hospital inside the EU and the European Economic Area. Furthermore,
this Directive had to be transposed before the 25th October 2013(CCOO).
CONTENT OF DIRECTIVE 2011/24
The main objectives of the Directive are firstly to facilitate access to a safe and a high
quality of cross-border healthcare within the Union. Secondly, to guarantee the patient's
mobility according to the principles established by the Union and thirdly, to promote the
cooperation between MSs. Moreover, Directive 2011/24 aims to counterweight older
jurisprudence by providing an extensive legal framework concerning rules on reimbursement
of costs of cross-border healthcare. Directive 2011/24 does not concern a) long-term services
and b) public vaccination programs against infectious diseases “which are exclusively aimed
at protecting the population living on the territory of that MS” (Quinn & Hert de,
2011)(European Commission).
Cross-border healthcare means “healthcare provided or prescribed in a Member State
other than the Member State of affiliation”(Article 3e of the Directive 2011/24). Meaning that
“Today is an important day for patients across the European Union. As of today, EU law in
force enshrines citizens’ right to go to another EU country for treatment and get reimbursed
for it. From today, all EU countries should have transposed the Directive on Patients’ rights
in Cross-border Healthcare, adopted 30 months ago, into their National law. For patients
this Directive means empowerment: greater choice of healthcare, more information, easier
recognition of prescriptions across-borders. The Directive is also good news for Europe’s
health systems, improving cooperation between Member States on interoperable eHealth
tools, the use of health technology assessment, and the pooling of rare expertise”.
Hektra Antonaki “The EU Legal Framework on Cross-border Healthcare After the Adoption of the Patients Mobility
Directive (2014) University of Warsaw Journal of Comparative Law 1(1) pp 42-62.
10. 9
this Directive is about patient mobility; a patient receives medical treatment or purchases
medicines or even medical devices outside his/her country of affiliation. It is important to state
that the PRD also considers non-physical movement, the so-called “telemedicine”. In this case,
healthcare is “considered to be provided in the Member State where the healthcare provider is
established” (Article 3d) (Peeters, 2012) (Antonaki I. , 2014, p. 10)
In sum, Directive 2011/2410
especially comprises the reimbursement of healthcare costs
in another MS. The general rule in this new Directive is that MSs are obligated to ensure
patients reimbursement of the healthcare costs (Quinn & Hert de, 2011).
TRANSPOSITION AND IMPLEMENTATION OF DIRECTIVES
The transposition of Directives is the process of turning policy into practice since
“(d)irectives are not directly applicable at the national level, but have to be incorporated into
national law first” (Beek ter, p. 5). According to EU legislation, the transpositions of directives
are fundamental for the good and smooth functioning of the IM. Moreover, the “effectuation
of EU policies relies on national instruments, resources and willingness, the fragility of EU
implementation process is expected to be higher under such conditions” (Martinsen &
Vollaard, 2014, p. 686). Therefore, “the transposition must be correct and carried out within
the time limits laid down by the Directive” (European Commission, 2005). However, in many
cases MSs have faced problems in the transposition of EU Directives into national legislation
(Haverland, Setunenberg, & Waarden van, 2011)
IV. THEORETICAL FRAMEWORK
10
See Annex for Articles to be transposed
11. 10
This section presents existing scholar’s arguments for non-correct implementation of directives
giving the definition for the term ‘implementation’. Furthermore, a description is given for
what is seen as wrong and slow transposition of Directives.
Bekkers(1993) defines the term ‘implementation as “different kinds of processes and
actions that take place by the introduction of Community [EU] law in the national system of
law”. These processes differ among countries since MSs are free to choose which methods and
instruments they use to implement a directive; “Directives leave the Member States a certain
time limit, which varies each directive, to realize the implementation” (Koopmans, 2002). Once
a MS has submitted a proposal of a directive, the EC has the responsibility to ensure its correct
implementation. In other words, the EC has the responsibility to check whether the proposal
allows for a correct transposition of the directive in question.
Correct transpositions require MSs to apply the directive in time and under the
conditions required by the EC. These conditions are set under the directive which needs to be
transposed. Non-correct or Wrong implementation of directives is thus, the non-compliance
with measures stated by the EC. This can result in delay or slow implementation. In case of
non-correct implementation, the Commission is tasked with notifying the MS of this. The MS
in question then has to re-assess the directive and submit it again. In case the Commission
“finds that the national measures [adopted by the MS] are incomplete, [the Commission] opens
an infringement case” (European Commission at Work, 2014).
CAUSES OF NON-CORRECT IMPLEMENTATION OF DIRECTIVES
This sub-section explains scholars’ arguments regarding the possible reasons for the
non-correct implementation of directives. The causes for non-correct implementation that have
been suggested by scholars are divided into three main clusters in this subsection. These are:
EU Level, National Level and issues regarding Incapacity or Oppositional Level.
1.1 EU level
There are several factors on an EU level that can lead to wrong or delayed transposition
of directives. One main cause concerns the characteristics of certain directives. The decision-
making procedure of directives allows for two ways of creating a directive. Council directives
are adopted by the Council, occasionally together with the European Parliament. These kinds
of directives generally involve main policy matters. Commission directives are, on the other
hand, directives adopted by the Commission which “tend to be of a more ‘technical’ character”
(Haverland et al 2014 p. 276). Moreover, given that these kinds of directives are of a more
12. 11
technical nature, MSs will “on average not meet the same degree of government opposition as
Council directives and should therefore take less time to transpose” (ibid) (Steunenberg, 2005,
p. 13) In other words, Commission directives may take longer than Council directives since
Commission directives seem to be more complex in nature.
Scholars such as Bekker (1993) and Falkner (2004) argue that there are interpretation
problems during the draft transposition of a directive. Falkner (2004) states that “due to the
multitude of factors and arenas involved in the EU decision-making processes and to the
ensuing variety of different views,…European Directives are often loosely worded in order to
accommodate differences in the decision making-process”(p.1). As a consequence, directives
are prone to misinterpretation. Steunenberg (2005) seems to agree with this argument, since he
claims that one of the important factors that create implementation delay is the complexity of
a directive, “the expectation is that the more recitals a directive has, the more time is needed to
transpose the directive” (p. 13).
Steunenberg (2005) argues that the implementation time given for a directive often does
not comply with the complexity of its nature (ibid). Moreover, Moor-van Vught et al, argue
that sometimes directives are internally contradictory or contradict other Union’s legislation.
Moreover, Bekker (1993) seems to agree and he suggests relying on the jurists to deal with
such interpretation problems.
Communication seems to be another problem faced at European level. Voermans’
(2000) argument is based on miscommunications in Brussels. He addresses the problem stating
that it is important to receive proper feedback between decision-making actors and
implementation and enforcement bodies. When communication is not properly done, problems
in the implementation may occur since it will be more difficult for nationals to understand the
requirements of the EC.
Peeters(2012) argues that “the combination of variety between healthcare systems and
the lack of clarity about the responsibilities of different authorities could act as an obstacle to
patient mobility” leading to delay in the implementation process (p.43).
1.1 National level
At a national level there are different causes that can lead to problems in the
implementation process of directives. One of them concerns the national tools used in the
13. 12
transposition of directives. The kind of legal instruments indicates the degree on which the
“central government has the political capacity to control the transposition process” (ibid p. 277)
(Tallberg, 2002) According to Haverland et al (2011). There are two different tools used by a
central government in order to transpose a directive. One of them is the legislative procedures
for laws which tend to be stricter and therefore more likely to consume more time than
legislative procedures for cabinet decrees. “Thus sectors in which governments transpose
directives more frequently by laws or cabinet decrees than by ministerial orders may suffer
from longer transposition periods”(ibid).
Mastenbroek(2005) and Steunenberg(2005) argue that it is easier to transpose a
directive through policies that already exist at a national level. However, sometimes when the
implementation of a directive requires the adoption of national measures, MSs tend to think
that it is better to implement the directive simultaneously with the new national measure
(Steunenberg, 2005). National measures are mainly needed in policy fields where the EU does
not have full competence, such as in social policies (Martinsen & Vrangbaek, 2008). Moreover,
Steunenberg(2005) points out that certain policy areas may take longer to implement than
others, he adds that the newer the policy field is, the most likely it is for a MS to implement
national measures to adopt the directive. Furthermore, Haverland et al.(2011) claims that “new
directives take more time to implement than modifying [old] directives” (p.275).
Considering the fit or misfit of certain policy areas, the successfulness of a country to
implement a directive is closely linked to the “goodness of fit” hypothesis. Treib (2003) states
that “if a directive requires only minor changes to the arrangements already in place at the
domestic level, we should therefore expect smooth implementation without any major
problems. If considerable reforms to be existing rules and regulations are called for , however,
domestic resistance is likely to arise and implementation should hence be seriously hampered
by long delays or significant flaws in terms of substantive accuracy”(p.3). Steunenberg (2005),
Mastenbroek (2005) and Martinsen et.al. (2008), although not using the ‘Goodness of fit’
hypothesis; thus to agree with its content.
Furthermore, Börzel (2002) argues that the implementation is most likely to fail when
EU policies do not fit inside the domestic policies. Consequently, the “Push and Pull”
hypothesis is formulated, stating that “when the implementation of the EU polices imposes
substantial costs, compliance problems arise”. In other words, when the adaptation costs are
high, unwillingness to comply increases (Beek ter).This can be linked with the argument of
Martinsen et. al (2014) who claim that the European Crisis had an impact on the non-
compliance of transpositions. MSs have faced difficulties in the implementation process “when
14. 13
national budgetary means are… limited and when the boundaries of social integration are
increasingly polarized” (Martinsen S. a., 2014)
1.2 Incapacity or opposition level
Peeters (2001) argues that non-implementation can be seen as conscious opposition of
the directives. This is supported by Falkner who adds that deliberate opposition could cause
delays in the implementation process (2004). Moreover, Van Kreveld (1993) argues that the
national parliament has a significant influence in the decision-making process. Therefore, if a
directive is presented too late or is not important enough at a national level, it could cause delay
in the implementation process. This is due to the “lack of preferences regarding [aspects of]
the EU among implementation actors” and the complexity of the EU for some actors. (Vollaard
& Martinsen, 2014, p. 7). In addition to opposition, incapacity may also play an important role
in late implementation of directives. Mastenbroek (2005) suggests that some MS are incapable
to execute international agreements.
1.3 Hypotheses and Final Framework
From the theoretical framework, the seemingly most important arguments from
scholars are selected to form a final framework. This framework will be used to analyze the
transposition process in Denmark and the Netherlands. Besides the formulated hypotheses
below, it seems important to consider the differences between the two given healthcare system
since this thesis claims that the differences in the healthcare system does not entail the correct
implementation of the PRD. This will be done in the Case Study section.
The first hypothesis concerns the misfit of a Directive within a country: The misfit of a
Directive at National Level affects the transposition process, hence causing delay . This
hypothesis will be tested by using ‘Goodness-of-fit’, which explains that when a directive does
not fit inside national law, the MS in question may suffer delay in the implementation process.
The second hypothesis takes Steunenbergs’ argument (2005) regarding the re-
structuration of the law system in order to adopt the directive into account: If an important
misfit of a directive is given, economic problems may appear affecting the implementation
process of the directive. This hypothesis is tested by using the ‘Push-and-Pull’ theory, which
states that substantial costs emerge when a MS needs to restructure national-law. This theory
entails that these costs may cause problems during the implementation procedure, since the
unwillingness to implement such a directive increases when costs are relatively high.
15. 14
The third hypothesis embraces the opposition or incapacity level considering that : MSs
that encounter internal opposition or incapacity problems in the decision-making procedure
are more likely to suffer implementation delay. This hypothesis is tested by using four scholars
arguments. Peeters (2001) states that non-implementation means that there was opposition of
the directive, Mastenbroek (2005) addresses that non-compliance in transposing a directive is
a result of political calculation and Falkner (2004) argues that deliberate opposition can affect
the implementation process of a directive, meaning that the MS in question wants to maintain
the older national patterns without “any dispute at the prior decision-making stage” (Beek ter).
Incapacity problems are tested by using Mastenbroek’s argument (2005) addressing that some
MSs do not have the enough experience in transposing directives at certain policy areas.
V. CASE STUDIES
The case study section embodies the analysis of the transposition speed of the PRD in
two countries; Denmark and the Netherlands. An introduction of the adoption of the Directive
will be given followed by the difficulties both MSs faced in transposing the Directive. In the
Discussion section the theoretical framework will be tested by using the hypothesis and
authors’ arguments hereinabove mentioned.
ELECTION OF COUNTRIES
There are several reasons why these countries were chosen. Firstly, since they differ in
national health systems. While the Netherlands has a Bismarck healthcare-system, Denmark
possesses the so-called Beveridge healthcare-system. Previously it was assumed that the speed
transposition would mainly be determined by the national healthcare system (Kostera, 2008)
Secondly, the Netherlands and Denmark have relatively strong administrative capacities in
which, however, they differ “on policy fit and veto actors” (Vollaard & Martinsen, 2014)
.Nevertheless, the Netherlands seems to be stronger administratively; therefore, Denmark is
expected to face greater difficulties in transposing the PRD (ibid). Thirdly, Vollaard and
Martinsen(2014) argue that the Netherlands have more experience in cross-border healthcare,
since Dutch nationals seem to seek healthcare more often in adjacent countries (ibid). For all
the reasons mentioned above, one would predict that implementation of the PRD would have
16. 15
been smoother in the Netherlands, however in reality the Netherlands took longer than
Denmark to correctly implement the PRD11
.
IMPLEMENTATION OF DIRECTIVE 2011/24 IN DENMARK
Denmark possesses the Beveridge health care system, as do several other EU MSs. It
was named after William Beveridge’s idea for the restructuration of the Britain’s National
Health Service. This system is characterized by being provided and financed by the government
“through tax payments, just like the police force or the public library” (Physicians for a
National Health Program, 2010). In other words, National Health Services (NHS) offer
“healthcare as benefit-in-kind, tax financed, largely free of charge and publicity
supplied”(Martinsen and Vrangbaek 2008).
Cross-border healthcare in Denmark was rather limited before the PRD, since Denmark
refused to treat patients without prior-authorization from other countries (Vollaard &
Martinsen, 2014). However, “about 500 Danish patients per year seek medical treatment
abroad, and citizens living in border regions might seek medical treatment in either Germany
or Sweden” (Kostera, 2008). Since 2003 the ministry of health allowed non-nationals to receive
healthcare under regulation 883/2004 with previous authorization, by means of the EU health
insurance card (Vollaard & Martinsen, 2014); (Kostera, 2008). However, cross-border health
care was only allowed as long as patients accounted for part of the costs, since “hospital-care
is particularly costly and requires planning” (Kostera, 2008). The Danish ombudsman and the
Danish Social Appeal Board criticized this, pressuring the Danish government to take
necessary measures (Vollaard & Martinsen, 2014). Hence, Denmark voted in favor and entered
the Council’s negotiations for the PRD (Vollaard & Martinsen, 2014).
Transposition and Implementation
The implementation of Directive 2011/24/EU began in the summer of 2011 with the
minister of health as responsible actor(Vollaard & Martinsen 2014). However, during the
transposition process, the Danish government faced significant challenges which caused delay;
firstly in January 2013 and later in April 2013. Vollaard et al (2014) argue that this is due to
the lack of experience at national level and uncertainty regarding the content of the
Directive(p.17). This may reflect on the national tools used in order to transpose the Directive.
Kostera (2008) argues that “Denmark shows a very low degree of institutional adaptation”
11
See table
17. 16
confirming that it takes longer for Denmark to transpose directives in general (p.28). It is
important to note that the inexperience in cross-border healthcare may have also had an impact
on the implementation process. The proposal was submitted under the Danish courts on the 3rd
of October 2013 and finally adopted on the 20th December 2013 (and in force since 2014) ,
meaning that Denmark did not meet the transposition deadline set by the Commission (25
October 2013).
Danish transposition of the PRD seems to have faced problems concerning the content
of the Directive (Vollaard & Martinsen, 2014). Interpreting Vollaard &Martinsen article, the
difficulties of transposing the PRD seem to be related to the adaptation of the Directive into
the Danish legal framework; since the national government had to establish significant
structural changes in order to adopt the Directive. This is seen in an interview in Vollaard and
Martinsen’s (2014) article where one of the main actors responsible for the implementation of
the Directive stated the following: “This is a big change. Potentially it can affect many. The
whole system is in play(…)…This is about all the doctors and nurses out there, who also have
to be able to handle the situation when a foreign patient comes in. Advice and guide them. We
need to set up a system that can issue invoices and send payment remainders. We are not exactly
used to this”(p.16). Although it was relatively difficult for Denmark to transpose the PRD, it
seemed the Danish government concentrated its efforts in implementing the Directive on time,
firstly by submitting the first proposal in December 2012, then in January 2013 and finally in
April 2013. However it did not succeed until the 20th
December 2013 with correctly
implementing the PRD.
IMPLEMENTATION IN THE NETHERLANDS
The Netherlands has the so-called Bismarck-oriented Healthcare system, named after
the Prussian Chancellor Otto-von-Bismarck. This healthcare system implies the use of an
insurance system (“Sickness funds”) which are “usually financed jointly by employers and
18. 17
employees through payroll deduction” (Physicians for a National Health Program, 2010). The
Dutch care system consists of three components:
Transposition and Implementation
In the Netherlands, Cross-border healthcare remained limited and mainly was “for
clients from a relatively isolated border region who could more easily access Belgian hospital
care” (Vollaard & Martinsen, 2014, p. 20). Since the early 1990s and especially since free
movement of persons was established, the AWBZ sought for a solution of the health
consumption regarding cross-border healthcare primarily in southern provinces such as
Limburg(ibid). Indeed, there was a significant increase of cross-border patients from Belgium
and Germany to the Netherlands and vice versa. As a consequence, the Dutch health ministry
decided to collaborate with border regions in order to protect health care in cross-border
situations. Therefore, “Dutch health insurers had contract with 21 hospitals and 136 other
health providers abroad”(ibid).
Cross-border health care statistics have shown that between 2007 and 2010 Dutch
patients received around 28,000 treatments per year in other countries (Observatorium voor
Patiëntenmobiliteit, 2012) .Furthermore, in the Netherlands “10,536 hospitalizations involved
foreigners [especially from] Belgium, Luxemburg and Germany” (ibid). Thus, cross-border
healthcare in the Netherlands has been an important challenge ever since the establishment of
the four freedoms.
The Dutch Health ministry perceived the PRD as an opportunity to safeguard patient
mobility and the national health care system. In 2006, the new system of ZWV annulated the
1st
Component
AWBZ (Algenene Wet Wijzondere Ziektekosten) National Exceptional Medical Expenses Act.
Obligatory national insurance for long-term and unaffordable care
2nd
Component
ZVW (Zorgverzekeringswet) Insurance
Obligatory basic insurance for essential curative care
3rd
Component
Supplementary insurance
Voluntary insurance, range of cover
Source: Health Insurance in the Netherlands (EDITED by author)
19. 18
system of prior authorization for hospital care basis stating that the level of reimbursement
should “not discourage clients from obtaining healthcare within the EU” (ibid).
When the Commission launched the draft directive in 2008, the Dutch government
seemed reluctant towards it. This was mainly due to the referendum concerning the European
Constitutional Treaty in 2005(ibid). However, the Directive was accepted “for member states
that did not comply with CJEU case law”(ibid). In other words, regarding past’s jurisdictions.
The Netherlands voted in favor of the Directive although there were movements where
the Dutch parliament resulted negative and denied the principle of subsidiarity in the directive.
Main actors argued that the organization and finances of healthcare systems should be
principally a national competence (Vollaard & Martinsen, 2014). The main reasons why the
Netherlands decided to vote in favor was “as it believed that the directive confirmed the Dutch
interpretation of CJEU case law” and because the Netherlands did not have to implement
important changes since their national legislation met the PRD conditions (ibid,p.22).
The draft proposal for the implementation of the PRD in November has shown that
there were no necessary changes “except for the establishment of a National Contact Point
(NCP)” and the recognition of prescriptions (ibid). The Dutch transposition process should
have therefore been an easy process ,according to Vollaard and Martinsen(2014). However,
they argued that Dutch representatives did not want to “play an active role in Brussels
Committees for reasons of limited administrative capacity and the prevailing Eurosceptic
political climate”(ibid, p.21).Since there was the impression that the Netherlands was fully
prepared to afford the transposition process, it suffered from a lack of priority at national level
as Van Kreveld (1993) argued.
The Dutch ministry of Health faced important matters regarding the NCP since “they
were not interested in offering information to clients from abroad” (ibid).However, institutional
pressure obliged the Dutch government to seek for a NCP. They appointed the College voor
Zorgverzekeringen (CVZ) –Health Insurance Board – which established a website and a
telephone number in order to inform patients about healthcare quality and give additional
information. The Dutch government was satisfied about the CVZ’s program and they
established it as the new Dutch NCP (Vollaard & Martinsen, 2014, p. 23)
On December the 18th
2013, the Netherlands decided to summit the total transposition
of the PRD to the EC. However, the Dutch transposition caused criticisms from the outset
particularly regarding the reimbursement of cross-border costs. This contradiction emerged
since the Dutch government wanted to limit the reimbursement of health care costs to
foreigners “violating the principal of free access” (Vollaard & Martinsen, 2014). Moreover,
20. 19
another criticism came with the mutual recognition of prescriptions which together with the
NCP were not implemented before the 25th
October 2013.
A letter from the Dutch minister of health, E.I. Schippers, directed to the chairman of
the Tweede Kamer der Staten-Generaal, revealed that the EC pronounced a reasoned opinion
concerning inadequate implementation of the PRD in the Netherlands on the 26th
November
2014 (Commission, Press Release Database, 2014). The last official statement made on this
subject, dates from 10 February 2015, where minister Schippers informs the Tweede Kamer
der Staten-Generaal about the further course of procedure. Here she states that the Netherlands
has taken the opportunity to issue a response. Consequently, the Netherlands is up until now
waiting for a verdict from the EC (Schippers, 2015).
VI. DISCUSSION
Both Denmark and the Netherlands seem to have faced problems in transposing the full
Directive in time. In the case of Denmark, the transposition of the directive was delayed and in
the case of the Netherlands, the transposition was delayed and incomplete. There were different
reasons; however, all were strictly at national level. In case there were problems at EU level, it
would have been difficult to observe them due to a lack of transparency during the negotiation
process.
This section tests the hypothesis mentioned with the theoretical framework hereinabove
mentioned. Hypothesis one: the transposition process differs among countries due to its misfit
with national laws. In case there is an important misfit, problems in the implementation may
occur. Hypothesis two: once a misfit is given, the MS in question has to invest in re-structuring
the system in order to adopt the Directive. Hypothesis three, opposition or incapacity can also
lead to implementation delay. These hypotheses are tested by using the theoretical framework
hereinabove mention of the four elements: ‘Goodness-of-fit’ hypothesis, Steunenberg (2005),
‘Push-and-pull’theory and Opposition or incapacity by Falkner (2004) Peeter (2001) and
Mastenbroek(2005) respectively.
TESTING THE HYPOTHESES
Denmark
Denmark faced problems in the transposition of the directive mainly due to the misfit
of the Directive in the Danish healthcare system. This can be seen since significant changes in
21. 20
the national healthcare system were made (Vollaard & Martinsen, 2014). This statement proves
hypothesis one which stated: ‘The misfit of a Directive at National Level affects the
transposition process, hence causing delay'. ‘Goodness-of-Fit’ has shown that when a directive
is not compatible with the national law further structural changes are needed in order to adopt
a directive. This structural changes leads the MS in question to take further decisions which
may cause significant costs. This is linked with hypothesis two: If an important misfit of a
directive is given, economic problems may appear affecting the implementation process of the
directive. The so-called ‘Push-and-Pull’ theory has proven that when countries need to invest
capital in order to adopt a directive, implementation delays may occur. Kostera(2008) supports
this argument by stating that “relatively high costs…will occur for institutional
adaptation”(p.29). Denmark had to invest in adaptation measures which proves hypothesis two.
This economic problems did not just affect the implementation process but also the
opinion during the decision-making procedure. The Danish government was concerned that the
reformation of the healthcare system would somehow affect the quality of healthcare in
Denmark. This statement brings up hypothesis three: MSs that encounter internal opposition
or incapacity problems in the decision-making procedure are more likely to suffer
implementation delay. Defending national interests is often a cause for delay and as
Mastenbroek(2005) stated, the non-correct implementation can be the result of internal disputes
regarding the national order. However, it is important to note that Denmark has made an
important effort to adapt its healthcare system in order to fit the PRD in time. This is seen in
the times Denmark submitted its draft to the EC.
The question arises in whether a Beveridge system would face more complications
during the implementation of the PRD, compared to a Bismarck system. This thesis has shown
that in the case study of Denmark, the administrative problems and the misfit of the directive
defined the implementation time of the Directive. Other MSs with a Beveridge healthcare
system such as Spain and Finland also experienced problems in the implementation of
directives12
. However, countries such as Italy or the United Kingdom which also have a
Beveridge healthcare system did implement the directive in time.. Kostera (2008) points out
that the Beveridge system would face more problems concerning the implementation of this
Directive. This does not concern the ‘goodness of fit’ hypothesis but structural costs; since
governments –and not insurance companies– account for the extra cost of adaptation.
Therefore, in reality problems at national level seem to be a bigger delaying factor such as the
12
See annex
22. 21
misfit of the complexity of the conditions. This is proven due to the fact that other countries
with a Beveridge system, such as Italy, managed to implement the Directive in time. In
conclusion, the framework stated is proven and so part of the claim of this thesis.
The Netherlands
In the case of the Netherlands, there also was a gap at a national level. Considering this case
study with the theoretical framework, the gap at national level in the Netherlands was mainly
provoked by internal actors opposing the total reimbursement of healthcare costs. Thus, one
should refer to hypothesis three stating that: MSs that encounter internal opposition or
incapacity problems in the decision-making procedure are more likely to suffer implementation
delay. Although the Netherlands was in favor of the Directive and the Directive fitted in their
national legal-framework, there were parties aiming for the opposition of some articles such as
the reimbursement of costs or the establishment of a NCP. This led to the non-correct
implementation of the PRD. Hypothesis three is therefore proven since the deliberated
opposition of a directive can affect the implementation process of a directive, meaning that the
MS in question wants to maintain the older national patterns or safeguard its interests as
Peeters(2001) and Falkner(2004) stated.
The question whether a Bismarck-oriented healthcare system facilitates the
implementation of the PRD better, is answered by the fact that countries such as Germany and
France, which also possess the Bismarck health system, likewise experienced delay in
implementation. In case of Germany, the implementation of the PRD was seen as non-correct
and thus delayed. Other MSs such as Austria and Belgium – also having a Bismarck system --
did not implement the Directive in time11
. This proves that the orientation of the healthcare
system does not significantly influence the implementation of this Directive. However, it is
important to note that inside a Bismarck-oriented system, insurances – and not the MS in
question-- should deal with the re-structuration in order to adopt the Directive.
VII. CONCLUSION
Transposition studies have shown the difficulty some MSs have regarding the correct
transposition of directives. As Falkner(1998) stated, Europeanization of welfare seems to be
an unlikely field of integration. The adoption of the PRD had an important impact not just on
national health systems but also on the IM. Thus, the reluctance of some MSs to obey Union’s
legislation can be allocated to the fact that MSs do not want to lose their sovereignty in social
23. 22
policies. As Kostera(2008) pointed out, there are many influencing factors in the health policy
arena, such as the pharmaceutical industry and the financing of the entire healthcare system.
Therefore, the combination of both elements may result in a significant gap between both
national and EU’s perspective.
The Directive analyzed --Directive 2011/24/EU on Cross-Border Healthcare—
especially comprises the reimbursement of healthcare costs in another MS and aims to
safeguard the IM facilitating the access to a safe and a high quality of cross-border healthcare
within the Union by strengthening cooperation between MSs. This paper analyzed the
implementation process and the speed transposition of the PRD in Denmark and the
Netherlands by creating a theoretical framework based on existing literature of previous
transposition studies. The state of art was divided into three main clusters: EU level, National
level and Opposition and Incapacity level. The relevant arguments were simplified and
collected as hypotheses. This thesis aims to answer the question: Why did MSs experience
implementation delay regarding the PRD? In other words, what are the main causes that make
a country take longer than another? Claiming that the transposition process of the Netherlands
and Denmark is not directly affected by the type of healthcare system, as Kostera stated, but
on arrangements made at national level. In order to prove this claim, a theoretical framework
was created from several hypotheses, and applied to the case studies.
It is clear that both MSs were particularly interested in safeguarding their sovereignty.
Therefore, the gap encountered in the transposition process was mainly at a national level.
Why countries differed in the implementation time of the PRD depended mainly on the
hierarchy of actors involved at a national and EU level. It is however difficult to state whether
there was an internal gap at an EU level, since there is no transparency during the negotiations
in implementation processes. Thus the main analysis relies on how both MSs transposed the
PRD.
The formulation of the hypotheses embodied issues at national level which intended
to support the central claim of this thesis. The first hypothesis concerned the misfit of the
Directive which causes delay since structural changes have to apply. This thesis has shown
that the articles to transpose of the PRD were compatible with the Dutch domestic legislation.
However, national actors were reluctant and did not comply with the conditions, since there
apparently was a lack of priority concerning the Directive. Denmark’s legislation, however,
was not compatible with the Directive causing significant challenges adapting the system to
adopt the PRD into national law. Hypothesis two reflected the extra costs Denmark had to
face in order to reform its national healthcare system. The ‘Push-and-Pull’ approach has
24. 23
demonstrated that extra reforms implicates delay in transposition processes. Finally,
hypothesis three was confirmed since Dutch authorities are still facing internal debates
concerning the adoption of the PRD. Arguments from Falkner(2004) and Peeters(2001) have
been proven correctly.
Kostera(2008) pointed out that Beveridge-oriented-systems would face more
complications in adopting PRD than Bismarck-oriented systems. However, this thesis has
shown that this statement is not reliable since the Netherlands and other MSs with this system
have faced equal or more delay in its implementation process. In theory the Bismarck-oriented
system would face less problems of structuration since measures concerning adaptation are
not taken by the MSs in question, but at an insurance level. In other words, the Beveridge-
oriented system would in theory face significantly more challenges, because institutional
adaptation takes place directly at a national level, meaning that structural costs may be higher
and the process more complex.
This thesis concludes that the smooth transposition of the PRD depends mainly on
national preferences. If a country agrees with the Directive and it is compatible with their
legal framework, the implementation of such a Directive is expected to be smooth and
probably in time. However, the reluctance over social policies would often causes discussion,
lack of preference or even opposition which may cause delay as Falkner(1998) stated.
However, it would be interesting to analyze the national healthcare system of the 28
MSs, in order to observe whether a system facilitating the PRD’s implementation exists and
their transposition process. Moreover, further research at EU level is needed in order to
conclude if an internal gap between national actors and EU actors influenced the transposition
speed of the PRD.
This paper has contributed to the understanding of ‘Social Europe’s’ evolution
explaining why countries are unlikely to integrate in social policies. Moreover, different
causes were given in order to explain the non-compliance in the transposition process
especially in social policies. Cross-border healthcare is however a significant matter that not
only concerns the European Single Market but also every single European citizen.
25. 24
VIII. REFERENCES
Antonaki, H. (2014). The Legal Framework on Cross-Border Healthcare After the Adoption
of the PAtients Mobility Directive . University of Warsaw Journal of Comparative
Law , 42-62.
Antonaki, I. (2014). The EU Legal Framework on Cross-Border Healthcare after the adoption
of the Patients' Mobility Directive. University of Warsaw Journal of Comparative
Law, 42-62.
Beek ter, E. (n.d.). The Slow Implementation of EC Directives. University of Twente.
Behning, U. (2002). Trends of Europeanization in Social Welfare Politics. Reihe
Politikwissenschaft, 1-10.
Bekkers, V. (1993). Success- en faalfactoren bij de uitvoering van EG-beleid in: .
Bestuurkunde vol2, 192-200.
Bongers, L., & Townend, D. (2014). The Implementation of the Directive on the Application
of Patient's Rights in Cross-border Healthcare in the Netherlands. European Journal
of Health Law , 65-78.
Börzel, I. (2002). National Adaptation of European Integration: Institutional vetoes and
Goodness-of-fit . Journal of European Public Policy, 791-811.
Börzel, T., & Risse, T. (2000). When Europe Hits Home: Europeanization and Domestic
Changes. European Integration Online Papers.
CCOO. (n.d.). ¿Por qué se hace esta regulación sobre asistencia sanitaria transfronteriza?
Retrieved March 15, 2015, from Confederación Sindical de Comisiones Obreras:
http://www.ccoo.es/comunes/recursos/1/pub114163_Asistencia_sanitaria_transfronter
iza__Preguntas_y_respuestas_mas_habituales..pdf
Commission, E. (2015, April). European Commission. Retrieved May 14, 2015, from The
EU Single market : Single Market Scoreboard :
http://ec.europa.eu/internal_market/scoreboard/performance_by_governance_tool/tran
sposition/index_en.htm
Costigliola, V. (2011). Mobility of Medical Doctors in Cross-border Healthcare. EPMA
Journal, 333-339.
Direcctive 2011/24/EU of the European Parliament and of the council of 9 March 2011 on
the Application of Patients' Rights in Cross-Border Healthcare. (2011). Official
Journal of the European Union.
26. 25
Eurocare. (2013). Eurocare. Retrieved February 2015, from European Alcohol Policy
Alliance: http://www.mtv.es/fotos/lengua-chica-larga/sopk43#de56cf50-a540-4fd1-
a6cf-09c6ef76fc61
European Commission. (2005, May 27). Retrieved May 25, 2015, from Summaries of EU
legislation:
http://europa.eu/legislation_summaries/internal_market/internal_market_general_fra
mework/l22021_en.htm
European Commission at Work. (2014, December 9). Retrieved May 29, 29, from European
Commission.
Falkner, G. (1998). EU Social Policy in the 1990s: Towards a coporatist policy community.
Routledge Research in European Public Policy.
Falkner, G., Hartlapp, M., Leiber, S., & Treib, O. (2004). Non-Compliance with EU
Directives in the Member States: Opposition through the Backdoor? West European
Politics, 452-473.
Greer, S. (2006). Uninvited Europeanization: Neofunctionalism and the EU in Health Policy.
Journal of European Public Policy, 134-152.
Haverland, M., Setunenberg, B., & Waarden van, F. (2011). Sectors at Different Speed:
Analysing Transposition Deficits in the European Union. JCMS Journal of Common
Market Studies , 265-291.
Health, M. o. (2014, Novermber 21). History on Directive 2011/24. Retrieved May 27, 2015,
from National Contact Point on the application of Patients' Rights on Cross Border
Healthcare.
Kellerman, S. a. (2009). Europe on the Way to Social Europe? The EU Social Agenda in the
Context of European Welfarism. Berling Friedich Elber Stiflung .
Koopmans, F. (2002). Het beslissingsmodel van 348/350. Kluwer-Deventer.
Kostera, T. (2008). Europeanazing Healthcare: Cross-border Patient Mobility and its
Consequences for the German and Danish Healthcare Systems. Bruges Political
Research Papers.
Martinsen, D. S. (2005). The Europeanization of Welfare - The Domestic Impact of Intra-
European Social Security. JCMS, 1027- 1054.
Martinsen, S. a. (2014). Implementing Social Europe in Time of Crisis: Re-establishment
Boundaries of Welfare? West European Politics, 677-689.
Martinsen, S., & Vollaard, H. (2014). Implementing Social Europe in Time of Crises: Re-
establishment Boundaries of Welfare? . West European Politics vol.37, 677-689.
27. 26
Martinsen, S., & Vrangbaek, K. (2008). The Europeanization of Health Care Governance:
Implementing the Market Imperatives of Europe. Public Administration, 169-184.
Mastenbroek, E. (2005). EU Compliance: Still a 'Black Hole'? . Jornal of European Public
Policy, 1103-1120.
Moor van Vught, J. C. (n.d.). Implementatieproblemen: Gekissebis in het Vooronder?
Nederlands Juristenblad, 601-607.
Mossialos, E., Permanand, G., Baeten, R., & Hervey, K. (2009). Health Systems Governance
in Europe: The Role of EU law and Policy. Cambridge: Cambridge University Press.
Observatorium voor Patiëntenmobiliteit. (2012). Retrieved May 12, 2015, from
Volksgezondheid, Veiligheid van de Voedselketeb en Leefmilieu:
http://health.belgium.be/eportal/SearchResults/index.htm
Peeters, M. (2012). Free Movement of Patients: Directive 2011/24 on the Application of
Patients' Rights in Cross-Border Healthcare. European Journal of Health Law , 29-60.
Physicians for a National Health Program. (2010). Retrieved May 10, 2015, from Physicians
for a National Health Program: www.pnhp.org
Quinn, P., & Hert de, P. (2011). The Patients' Rights Directive (2011/24/EU) Providing
(some) rights to EU residents seeking healthcare in other Member States. Science
Direct.
Steunenberg, B. (2005). Turning Swift Policy Marking into Deadlock and Delay: National
Policy Coordination and the Transposition of EU directives.
Tallberg, J. (2002). Paths to Compliance: Enforcement, Management, and the European
Union. International Organization, 56(3), 609-643.
Treib, O. (2003). EU Governance, Misfit, and the Partisan Logic of Domestic Adaptation: An
Actor-Centered Perspective on the Trasposition of EU Directives .
van Kreveld, J. (1993). Uitvoering van EG-regelingen in Nederland: Nationale en
Communautaire Wetgevingsproblemen .
Visinsky, R. (ny). History of European Social Policy - The Social Dialogue from Rome
through the Single European Act (SEA) and the Treaty of Maastricht (TEU).
University of Pittsburgh , npp.
Voermans, J., & al., e. (2000). Quality, Implementation and Enforcement: A Study into the
quality of EC Rules and the Impact on the Implementation and Enforcement within
the Netherlands.
Vollaard, H., & Martinsen, D. (2014). Bounded Rationality in transposition processes: The
case of the European Patients' Right Directive. West European Politics, 711-731.
28. 27
Vollaard, H., & Martinsen, S. D. (2014). West European Politics, 711-731.
Wismar, M., Palm, W., Figueras, J., Ernst, K., & Ginneken, E. (2011). Cross-border Health
Care in the European Union : Mapping and analysis practives and policies. European
Observatory Studies Series.
29. 28
IX. ANNEX
1. TABLE 1: ARTICLES TO BE TRANSPOSED
*Created by the Author
Article to be transposed Relevant content
4
- A national contact point where the
patients can receive relevant
information on standards and
guidelines (section a)
- “Relevant information to help individual
patients to make an informed
choice.”(section b)
- The right to understand complaints
procedures in case of harm (sect.c)
- “Systems of professional liability
insurance”…” (sect. d)
- The right to “respect the fundamental
right of privacy…personal data”
(sect.e)
- The right to obtain a medical record in
order to ensure continuity of care in
the Member State affiliated sect.(f)
5
The Member State of affiliation (health
insurance) is obliged to inform patients of their
cross-border rights and entitlements.
6
MS are obliged to establish a National Contact
Point
7
Transparent mechanisms in order to calculate
the cost of the treatment
8
If prior-authorization applies it should be
justified
11
Mutual recognition of prescriptions
30. 29
2. TABLE 2: COUNTRIES AND ITS IMPLEMENTATION DATE
Created by the Author: Communication via e-mail to the 28 NCP13
1)Autumn 2014: before the 26th
November 2014 retrieved from: Press-Release (European Commission)
13
More information upon request
