Residential Tourists and Healthcare Shopping in the EU: Italy, Belgium, and the Netherlands

Introduction

EU citizens staying in an EU Member State (“MS”) other than their home country can access emergency care in a rather straightforward way. At the same time, permanent residents from a different country are fully integrated into their host’s healthcare system. European and National norms that regulate access to cross-border health care make this possible.

The present contribution aims to provide an overview of the state of implementing the EU healthcare regulations by comparing three different case studies. Moreover, this article aims to analyze healthcare shopping: due to the structure of the EU legal framework on healthcare, an individual may—seeking care abroad—be entitled to a refund on medical treatment otherwise unavailable in his home state.

Section 1 will motivate the choice of Italy, the Netherlands, and Belgium as case studies; moreover, it will hermeneutically address the EU framework on healthcare provision. Section 2 is the Discussion. It will, first, provide a practical perspective on access to cross-border healthcare; then, it will focus on access to healthcare by medium-term residents and healthcare shopping. Conclusions will follow in Section 3.

Case Studies and Normative Framework

The Case Studies

Italy is a manifold system, with some literature even hinting at the existence of 20 different regional sub-systems (Toth, 2021). However, Italian healthcare is firmly rooted in the Beveridge tradition and relies on public health insurance. On the contrary, Belgium and the Netherlands follow some variations of the so-called Bismarck model of social health insurance, based on private insurers and citizens’ contributions. Overall, a comparative analysis that considers most different countries allows one to pinpoint countries’ specificities and cross-context consistencies (Siems, 2018). Comparing Italy, on the one hand, Belgium, and the Netherlands, on the other, will allow us to study the similar dynamics that developed in reaction to the medium-term presence of European citizens.

Regardless of healthcare financing, a convergence exists (1) regarding the problems faced by citizens who are neither tourists nor citizens; and (2) regarding the solutions adopted under different healthcare models.

For example, Glinos, Doering, and Maarse (2012) found that students in Maastricht (the Netherlands) during their stay abroad prefer to travel home to see both specialists and general practitioners, while the language barrier can be a plausible reason to schedule a specialist visit in the home country, for common conditions (e.g., flu, earache, conjunctivitis, etc.) students could have benefited from talking to a local general practitioner.

The EU Normative Framework

When discussing the existence of a right to healthcare in the EU, it is important to define which aspect of health needs to be considered. In fact, a distinction needs to be made between health and healthcare, as the two terms acquired significantly different meanings within the EU legal framework.

Although the EU lacks a single authoritative legal text defining health, it has contributed to its internal definition through various means and the right to health is recognized within the EU at many levels (de Ruijter, 2019). Externally, each and every MS of the EU has signed and ratified the Universal Declaration of Human Rights – which mentions health as part of the right to an adequate standard of living in its Article 25 – and the International Covenant on Economic, Social and Cultural Rights, which again recognizes the right to health as a human right in its Article 12. Internally, the EU incorporates the right to health into its legal framework. Article 3(1) of the Treaty on the European Union (“TEU”) sets the promotion of health. Furthermore, Article 168 of the Treaty on the Functioning of the European Union (“TFEU”) mandates a high level of human health protection in all Union policies and activities.

The EU’s action in this regard primarily falls under public health policy, rooted in Article 168 TFEU. Such article confers legislative and policy-making powers to the Union in the area of public health, emphasizing population-level measures over individual healthcare access (Greer et al., 2022). This focus is evident in the article’s objectives, which explicitly mention alcohol and tobacco control, indicating a shift away from individual healthcare concerns (Greer et al., 2022).

When it comes to healthcare, defined as “the activity or business of providing medical services” to individuals, the EU is excluded from the harmonization competence, as Article 168(7) of the TFEU reinforces the principle of subsidiarity in this regard. Hence, whereas in the domain of public health, the Union has some competencies and rights entrenched in its Treaties, the situation is different in the field of healthcare. In fact, the first time the EU dealt with a right to healthcare was in 2009, with the integration of the EU Charter on Fundamental Rights (“CFREU”) and Article 35 in the EU Legal framework, which recognizes the right to access to healthcare under the conditions established by national laws. Moreover, the EU recalled the importance of a “right to timely access to (…) healthcare of good quality” by adopting the non-binding European Pillar of Social Rights in 2017. However, such commitments seem to reinforce the idea that the EU shall respect the MSs delivery of healthcare rather than establishing a proper EU right to healthcare.

Nonetheless, while the EU does not explicitly recognize a right to healthcare within its legal framework, it incorporates principles akin to healthcare rights through its regulations and jurisprudence concerning the free movement of services and goods. This is evident in court cases where healthcare-related issues intersect with the principles of free movement, thereby indirectly shaping access to healthcare services within the EU.

Since 1971, the European Economic Community adopted legislation aimed at facilitating the well-functioning of the internal market, such as Regulation 1408/71, which established a system of coordination of social security schemes for employed individuals moving within the Community based on a system of pre-authorization. However, since the 1990s abolition of internal borders, the systematic need for prior authorization from the individual’s home country foreseen in Regulation 1408/71 became a key issue affecting the citizens of the Union (CJEU, 2018). Such a problem led to the 1998 Kohll and Decker decisions, whereby the ECJ (now CJEU) held that the provision of healthcare-related goods and services has to comply with the internal market law, even when financed through publicly financed healthcare systems. Hence, rendering payment for scheduled outpatient treatment subject to prior authorization, or in the case of purchase of medical products, constitutes a barrier to freedom to provide services. Through its caselaw, the CJEU contributed to establishing criteria to be considered in safeguarding the EU citizens’ access to healthcare¹.

Such criteria have been codified by the EU legislator with the adoption of Regulation 883/2004 and Regulation 978/2009 (altogether called “Social Security Regulations”), and Directive 2011/24 (“the Directive”), which offer the detailed rules on cover for medical treatment and medical purchases which take place in another MS. More specifically, the Social Security Regulations offer a system of coordination of different social security systems of the MSs and introduces the European Health Insurance Card (“EHIC”), while the Directive directly crystallizes the access to healthcare regime elaborated through the Court’s caselaw and based on the free movement of goods and services. Subsequently, the Court clarified that national health authorities can demand prior authorization for hospital care, regardless of whether patients seek treatment abroad under Regulation 883/2004 or under free movement principles for reimbursement based on national rules (de Ruijter, 2018).

In such a framework, while two distinct schemes for access to cross-border health care exist, one being dictated by Regulation 883/2004 and one by the crystallization of the court’s market-supporting action in the Directive, an EU citizen can access healthcare when staying or residing in another MS either under the Regulations or under the national laws implementing the Directive, and the Directive itself presents coordination clauses between the two regimes. In fact, the Directive maintains two avenues for patients to access cross-border care: one under the Social Security Regulations and the other under the Directive itself, regulated by Article 8(3). Prior authorization is first assessed based on conditions under the Regulation, with exceptions listed in Article 8(2) of the Directive 2011/24. While the Court previously limited the MS’s ability to deny the authorization to the sole hospital care obtained in another MS, the Directive expands it to healthcare subject to planning requirements, one-night hospital stays, and high-cost medical infrastructure. The Directive provides more specific grounds for refusal, including patient safety risks and concerns raised by healthcare providers (de Ruijter, 2018).

Discussion

Access to Healthcare in the EU: Practical Perspective

Different categories of individuals may be interested in accessing healthcare abroad. This contribution revolves around the rights granted to EU citizens; for this reason, we will only consider individuals that have the citizenship of an MS of the EU, and hence, also an EU Citizenship.

As already stated, those who, in the EU, are covered by the social security system of a MS are eligible for an EHIC (Pacolet & De Wispelaere 2016). The EHIC is – on the most basic level – proof that one is insured in another member state. De Wispelaere and Berki (2021) confirm that the current legislation addresses three scenarios regarding cross-border healthcare: (1) unplanned care during temporary stays abroad; (2) healthcare planned in another Member State; (3) healthcare needs of individuals residing in a Member State different from their own, including cross-border workers.

This contribution focuses on the latter group, defined as “residential tourists” by De Wispelaere and Berki (2021), as their particular position within the EU normative framework makes them likely to being able to exploit the characteristics of EU cross-border healthcare access, as we will further refine later on in this contribution. An example of a residential tourist can be, for instance, a student coming from MS “A” (e.g., Italy), studying and staying in MS “B” (e.g., the Netherlands), in the context of a study exchange, or any other individual whose purpose for staying in another MS is not the one purposely seeking for healthcare, with an expectation not to establish permanently in such MS.

From the point of view of a residential tourist, access to healthcare is more or less complex, depending on its need. We will take, for instance, Aldo, a 23-year-old Italian citizen. Aldo is a university student and is set to spend a semester abroad in the context of an Erasmus+. Before going abroad, Aldo tries to understand how he will have to deal with potential health issues to be ready. As his potential destinations, Aldo selected, conveniently for us, Belgium or the Netherlands. Being an Italian citizen, Aldo possesses an EHIC, which in Italy is automatically incorporated into the “Tessera Sanitaria Nazionale”, a document needed to access medical care in Italy.

Aldo finds out that there are two ways to obtain treatments in another EU MS: the first is the so-called “Direct Healthcare” – regulated by the Social Security Regulations. Since the purpose of Aldo’s stay in the other MS is not to obtain medical treatment, Aldo’s research focuses on unplanned healthcare abroad. In fact, under EU law, this is the regime applicable to individuals who, while staying abroad, need unplanned necessary medical care. Aldo has an EHIC, and hence his situation is going to be regulated by the Social Security Regulations. Belgium and the Netherlands’ healthcare systems are different from the Italian one but, thanks to the EHIC, Aldo’s medical expenses will be covered by his own MS, in the same amount they would have been covered if he was a citizen of the host MS – that is, Belgium or the Netherlands. By consulting the EU website portals, he finds out what can be covered or not by the Dutch and Belgian healthcare systems after the presentation of the EHIC.

On the other hand, Nadine, a citizen of the Netherlands, is making sure she is ready for her Erasmus+ in Italy. Specifically, she is pondering whether she should apply for an EHIC. In the Netherlands, she is covered by a health insurance package. She finds out that without an EHIC, she would still be entitled to receive unplanned medical care under the Directive but would have to pay fully upfront according to the Italian tariffs. Then, she would have to apply for a reimbursement according to her coverage plan, provided that the treatment is covered in the Netherlands, which, however, could refuse the reimbursement or will, in any case, reimburse only up to the amount that Nadine would have paid if she was receiving the treatment in the Netherlands (depending on the case, the actual refund may be lower than the medical expenses faced in Italy).

Having an EHIC would mean that Nadine would have to pay only for the mandatory contribution that the Italian citizens pay for (“ticket”) rather than for the full treatment, which may not be reimbursed. Hospitalization for hospital emergency care in the Netherlands is subject to a deductible, meaning that should she break her leg in the Netherlands, Nadine would pay the first €385 of the bill (Government of the Netherlands, 2024). Instead, if the same care has to be provided by an Italian hospital within the Italian National Healthcare Service’s (“SSN”) circuit, the EHIC would lead to Nadine’s admission to the hospital, where she would pay only the ticket – in most cases some €25. Without an EHIC, Nadine would not receive such compensation as she would be subject to the same coverage she is subject to in the Netherlands.

Hence, from a practical perspective, in the case of unplanned medical care for residential tourists, the most viable way to obtain cross-border medical care seems to be through the EHIC, which is released for free from healthcare institutions.

Access to Healthcare in the Italy, Belgium, and the Netherlands

The healthcare needs of residential tourists are generally connected to common conditions, and the competent figure is the general practitioner. However, before seeing a physician, some form of registration or selection of the practitioner might be necessary. A scoping review of the indications provided by universities in Belgium, Netherlands, and Italy shows that students – a sub-population of residential tourists – have different requirements to fulfill. Table 1 summarizes the results.

Table 1. Healthcare access: different requirements in Belgium, Italy, The Netherlands

In Belgium, to access healthcare, it is enough to present the EHIC at any General Practitioner’s office. Holders pay upfront and are subsequently reimbursed through their country’s system. Italy operates under a similar system. However, individuals with a valid EHIC can receive care without upfront payment, and before the visit, they must select a General Practitioner through the ASL or the equivalent regional authority.

In the Netherlands, registering with a General Practitioner entails either (1) joining the non-resident records database for stays under four months or (2) joining the municipality’s personal records database for stays longer than four months. This registration provides the Citizens Service Number (“BSN”). Prospective patients must then present the BSN, along with an identity document and the EHIC, when registering with healthcare providers.

However, despite the similar challenges that the countries have to face, access to health insurance for “residential tourists” without the EHIC (be they nationals of a third country or European citizens) works differently. In the Netherlands and Belgium, a person can purchase local health insurance.

In Italy, next to private insurance, there is the possibility of enrolling in the National Healthcare Service (“SSN”); however, the voluntary enrolment to the Italian SSN is subject to a residency requirement similar to the one in the Netherlands, even though the rigid procedure does not suit the time framework of a temporary resident. It must also be noted that the contribution a foreigner faces to voluntary enrolling in the Italian system has been significantly raised pursuant to Article 1, paragraph 240, of Law 213/2023.

In all these countries, further rules for workers apply pursuant to national law, so workers must register with the country’s health insurance system.

Unplanned medical care is, in nature, unforeseen and urgent. For hospital care, the ECJ found that the free movement of services should be balanced against the logistical needs of hospitals (de Ruijter, 2019). A prior authorization is compliant with EU law; however, the grounds for the denial are limited. What if the cost of a treatment abroad is higher than in the home state? For hospital care, the Court found that authorization could be given even if the refund at home is higher than the refund abroad (i.e., even if abroad, it costs more).

Finally, non-hospital care never requires authorization. For non-hospital care, patients could access healthcare and later ask for a refund from their home institution. However, this suggests that there might be situations where “residential tourists” are better off: that is, it could be that a student receives care “as a national” – thanks to the EHIC – in a Member State where more treatments are included.

Consider dentists: Belgian citizens can claim a reimbursement of up to 75% of the visit cost. A European citizen in Belgium (e.g., an Italian father visiting his expatriate son and grandson for a couple of months) is entitled to the same treatment as a national: should they go to the dentist, they would pay upfront: but if they bring the bill to any local health insurance fund, they can get – through the EHIC – a 75% refund.

This might seem in contrast with the fact that European citizens pay upfront and subsequently seek reimbursement from their home institution: the Italian father of the example above would not be able to get a refund for the dentist in Italy since dentists are private clinicians and are paid in full by patients. Nevertheless, the reimbursement can be claimed from the Belgian health institution, which in turn will deal with the reimbursement from the Italian State.

Overall, there is a possibility of “healthcare shopping”. European citizens insured in an MS where a service is not covered could benefit from the more generous coverage provided by foreign rules. Whilst healthcare shopping might not be convenient for ordinary citizens (because the costs of the travel and accommodation offset any savings), residential tourists might actually benefit from choosing to pick a local provider.

Conclusive remarks

In conclusion, this article delved into the realm of healthcare access for EU citizens temporarily residing in Italy, Belgium, and the Netherlands, all under the umbrella of the EU legal framework.

Despite lacking a specific competence in this sense, the EU plays a key role in coordinating cross-border healthcare efforts while offering mechanisms like the European Health Insurance Card (EHIC) to ease access to medical care across borders. Nonetheless, navigating different healthcare systems and reimbursement procedures can be a complex task. However, thanks to its twofold legal arrangement, with the juxtaposition of the Directive-based system and the Social Security Regulations, the Union made it easier for individuals to access cross-border healthcare, getting rid of the cumbersome pre-authorization system in place during the earlier phases of EU health policy development.

Moreover, this contribution shed light on the issue of “healthcare shopping”, where some EU citizens might enjoy better coverage and costs by seeking care in another EU country rather than in their own one–such as in the case of residential tourists.

The extent to which healthcare shopping is exploited, however, remains unchartered. We deem further studies in this sense to be necessary in understanding whether and how the EU legal framework on cross-border healthcare successfully balances the need for harmonized access to healthcare for citizens throughout the Union – in concordance with the principles of free movement of goods and services – with the burden posed on the social security systems of those MSs which face more presence of temporary residents or residential tourists.

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1. Regulations: Vanbraekel and Others, C-368/98; Watts, C-372/04; Petru, C-268 /13; Elchinov, C-173/09; IKA, C-326/00; Keller, C-145/03; Commission v Spain, C-211/08.