Revisiting the subsidiarity principle in health

The below article was translated into French and Published in the November 2017 France Forum Publication (nr 67) www.institutjeanlecanuet.org

An EU citizen suffering from cancer, diabetes or Alzheimer’s, no matter where in the EU, suffers all the same and yet today depending on where one lives in Europe, the level of care, the quality and delay of treatment and the expenses covered differ from one member state to the other. Indeed, the scope for EU action in health policy is set in Article 168 of the Treaty on the Functioning of the EU and makes clear that the EU shall fully respect the responsibility of individual Member States to define their health policies and organize and deliver their health services and medical care, including any resources assigned to them¹. However, as the healthcare ecosystem is rapidly and ever evolving, it is relevant to question whether the needs of the European citizens are being appropriately met by this subsidiarity constraint and whether this model is sustainable. The borderlessness of health-related challenges and the reality of common practice argue in favour of a holistic European-wide healthcare system.

The expectations of patients regarding their health, the emergence of multiple health-stakeholders, the rise of healthcare costs and the overall ageing population are common to European citizens across the EU. Medicine is moving from a reactive to a proactive discipline and P4 medicine (Predictive, Personalized, Preventive and Participatory) is fuelled by systems approaches to disease, emerging technologies and analytical tools². Whilst current healthcare practices essentially rely on the emergence of signs and symptoms of human pathologies prior to initiation of interventional modalities, medical progress means people are asking more and more for support in navigating through their health journey from anticipating the risks they are exposed to until post-treatment care. Trust and choice of health players that can help manage one’s health efficiently while staying healthy are driving this new model. Human genome mapping, the omics revolution and empowering sequencing technologies have led to a switch from population medicine to individual therapies, from curing the disease to preventing it. Patients already hope for a perfectly adapted treatment to each of their individual illnesses.

Consequently, health care is one of the fastest-expanding and largest industries. It thus has the largest labour force³ and whilst doctors’ activities dominate public perceptions they only represent a small fraction (circa 1 in 10) of the multiplicity of actors working in the industry⁴. Further, recognizing the growing non-State dimension is crucial in understanding the changing nature of global health management. “Non-State actors play significant and increasingly influential roles”⁵. As such, health expenditures are exponentially growing driven by wealth increase resulting in a reduced acceptance of disease and a growing awareness of health issues. Healthcare demand is rising due to consumerization linked to higher education and access to more information. To meet that demand, innovation (new treatments) and specialization (tailored new products and services) in a mostly “fee for service model” are rising further fuelling healthcare costs inflation.

Further, changes in demographics (e.g. ageing population) and in lifestyles (e.g. higher incidence of obesity) are additional engines of healthcare expenditures increase. According to the Global Health and Ageing report presented by the World Health Organization, “The number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050, with most of the increase in developing countries⁶.” The number of cancer cases is expected to increase to 17 million by 2020 and 27 million by 2030⁷. These increases are not restricted to cancer: according to the International Diabetes Federation, 35 million adults were living with diabetes in Europe in 2011⁸. This is expected to increase by 23%, to 43 million, in 2030 and the likelihood of developing dementia in people aged 65+ roughly doubles every 5 years in Europe⁹.

This context, common to all EU citizens irrespective of national borders, challenges the principle of subsidiarity that seeks to safeguard the ability of the Member States to take decisions and actions¹⁰. Instead, EU intervention should be authorized precisely because “the objectives of health policy cannot be sufficiently achieved by the Member States, but can be better achieved at Union level¹¹”. Indeed today, health policy in the EU has a fundamental contradiction at its core: whilst health care is the responsibility of the Member States, their individual health systems involve interactions with people, goods and services, all of which are granted freedom of movement across borders. Many national health activities are in fact subject to EU law and policy¹². When national health systems seek to purchase medicines or medical equipment, or to recruit health professionals their scope to act is now determined largely by EU legislation. Further, when the citizens of a Member State travel outside their national frontiers, they are now often entitled to receive health care should they need it, and have it reimbursed by their home (national) authority¹³. In 2010, 20 million Europeans received medical treatment in another EU country than their own¹⁴. Lately, Central Europe is attracting patients mostly from other European countries. Hungary is a chosen destination for serious procedures, like heart transplants and prostate cancer treatment. According to a survey conducted by portal Treatment Abroad in 2012 on 1,045 Europeans shopping for procedures abroad (half of them British), the top three most popular locations were Hungary, Belgium and Poland, followed by Spain and Czech Republic¹⁵. Thus, whilst national health care systems officially fall outside EU law, elements relating to their financing, delivery and provision are directly affected by EU law¹⁶.

The current set up is not sustainable and results in severe inequalities whereby life expectancy still varies by around 9 years between EU countries¹⁷. Healthcare policy will be increasingly at the heart of every citizens’ concerns and governments’ mandates in the years to come. The EU should use this as a driving force to foster more Europe, strengthen the EU and better meet the needs of its citizens in helping them live longer, healthier, happier lives.

Dr. Raphaela Kitson-Pantano

1 Directorate-General for Communication (European Commission), (2014), EU publications: Public health, Improving health for all EU citizens, https://publications.europa.eu/fr/publication-detail/-/publication/b1ccb988-a3a6-4e67-9dcf-72d444971bbc accessed September 2017
2 Hood, L. and Friend, S.H., (2011), Predictive, personalized, preventive, participatory (P4) cancer medicine, Nat Rev Clin Oncol 8(3):184-7
3 Marmor, T.R., (2013) Health Care Politics and Policy: The Business of Medicine: A Course for Physician Leaders, Yale J Biol Med. 2013 Sep; 86(3): 407–411.
4 Marmor, T.R., (2013) Health Care Politics and Policy: The Business of Medicine: A Course for Physician Leaders, Yale J Biol Med. 2013 Sep; 86(3): 407–411.
5 The Authority of the House of Lords, (2008), Diseases Know No Frontiers: How effective are Intergovernmental Organisations in controlling their spread?, https://publications.parliament.uk/pa/ld200708/ldselect/ldintergov/143/143.pdf accessed September 2017
6 Garza, A., (2016), The Aging Population: The Increasing Effects on Health Care, PharmacyTimes, http://www.pharmacytimes.com/publications/issue/2016/january2016/the-aging-population-the-increasing-effects-on-health-care accessed September 2017
7 Garza, A., (2016), The Aging Population: The Increasing Effects on Health Care, PharmacyTimes, http://www.pharmacytimes.com/publications/issue/2016/january2016/the-aging-population-the-increasing-effects-on-health-care accessed September 2017
8 Directorate-General for Communication (European Commission), (2014), EU publications: Public health, Improving health for all EU citizens, https://publications.europa.eu/fr/publication-detail/-/publication/b1ccb988-a3a6-4e67-9dcf-72d444971bbc accessed September 2017
9 Directorate-General for Communication (European Commission), (2014), EU publications: Public health, Improving health for all EU citizens, https://publications.europa.eu/fr/publication-detail/-/publication/b1ccb988-a3a6-4e67-9dcf-72d444971bbc accessed September 2017
10 Raffaelli, R., (2017), Fact Sheets on the European Union, http://www.europarl.europa.eu/atyourservice/en/displayFtu.html?ftuId=FTU_1.2.2.html accessed September 2017
11 Raffaelli, R., (2017), Fact Sheets on the European Union, http://www.europarl.europa.eu/atyourservice/en/displayFtu.html?ftuId=FTU_1.2.2.html accessed September 2017
12 Mossialos, E., Permanand, G., Baeten, R. and Hervey, T., (2010), Health systems governance in Europe: the role of European Union law and policy http://www.euro.who.int/__data/assets/pdf_file/0007/138148/E94886_ch01.pdf?ua=1 accessed September 2017
13 Mossialos, E., Permanand, G., Baeten, R. and Hervey, T., (2010), Health systems governance in Europe: the role of European Union law and policy http://www.euro.who.int/__data/assets/pdf_file/0007/138148/E94886_ch01.pdf?ua=1 accessed September 2017
14 Directorate-General for Communication (European Commission), (2014), EU publications: Public health, Improving health for all EU citizens, https://publications.europa.eu/fr/publication-detail/-/publication/b1ccb988-a3a6-4e67-9dcf-72d444971bbc accessed September 2017
15 Oleszczuk, L., (2013), Central Europe Becoming A Big Destination For Medical Tourism, Forbes, https://www.forbes.com/sites/luizaoleszczuk/2013/10/22/central-europe-becoming-a-big-destination-for-medical-tourism/#366b81b46b14 accessed September 2017
16 Mossialos, E., Permanand, G., Baeten, R. and Hervey, T., (2010), Health systems governance in Europe: the role of European Union law and policy http://www.euro.who.int/__data/assets/pdf_file/0007/138148/E94886_ch01.pdf?ua=1 accessed September 2017
17 Directorate-General for Communication (European Commission), (2014), EU publications: Public health, Improving health for all EU citizens, https://publications.europa.eu/fr/publication-detail/-/publication/b1ccb988-a3a6-4e67-9dcf-72d444971bbc accessed September 2017