Health costs and Democracy for Citizens in Europe

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More comment on the Government Green paper

Concerning support for health costs in the EU

An example of why the Britons Abroad  in Europe and elsewhere  need Democratic Representation.

I appreciate the comments by readers of my circulars which have caused me to consider a further analysis of the situation on the costs of health care in Europe.

It involves a digging out of information in the EU regulations.

The consultative Green Paper is entitled

“Sustaining services, ensuring fairness”

A consultation on migrant access and their financial contribution to NHS provision in England.”

1.   This Green Paper was issued in July with a date of August 28^th for the return of observations.  This is my immediate concern - The situation is unacceptable that people most affected by certain aspects are given no direct knowledge of this green paper, and no time at all to respond!

2.  The title gives no indication whatsoever that the contents also concern the health costs of British pensioners in the EU.  It is only by rare chance in October that I learned of its existence and quick action ensured that the contents were widely known.   

These concerns were particularly and rightly publicised (especially by The Connexion in France) because of the effect on the health costs of the ‘early retirees’ who would have their support for health care in the wider EU removed. 

Since then I have received comments which result in the analysis below.

The British State Pensioner abroad and treatment under the NHS.

The essence of this analysis is the ability of British State pensioners otherwise resident in other States of the EU to receive treatment under the NHS in Britain.

*See further note below for other British State Pensioners in the rest of the World.

At this present time – if you are a British State Pensioner and have at least 10 years of residence in the UK, but you happen now to be resident abroad, you are NOT entitled to free treatment under the NHS.  However many of us have received treatment in the UK.  Maybe only an eye test, sometimes more. 

[Confusion on this is introduced by the fact that the EHIC –health card – is issued by the UK to all British State Pensioners in the EU.  This card requires the UK to pay the health costs of those travelling to another EU State, which is not their resident State! Thus questioning the situation with regard to visits of pensioners to the UK.

Confusion also exists with the EU law which enables any citizen, retired or not, to travel to another State for treatment if that treatment is not available in one’s State of residence.]

The Green Paper in Annex A makes similar observations to some of the above.  It elsewhere suggests that in future the costing of  health for State pensioners in their resident  State within the EU could be thus affected:-

Clause 6.13  “The benefit to the UK of allowing state pensioners to return for their planned treatment would be a discount of 5% from payments to all countries to whom we make lump sum annual payments for our pensioners. “

The second phrase underlined relating to annual payments, refers to the EU Regulation 987/2009  and  to Annex 3 of that regulation.

This lists the States claiming payment for health treatment on the basis of fixed amounts. They are:- IRELAND, SPAIN, ITALY, MALTA, THE NETHERLANDS, PORTUGAL, FINLAND, SWEDEN, UNITED KINGDOM

It is to the countries listed above that the proposal to cut the fixed amount by 5% would apply.

All other countries claim the actual amount  and would not be affected. – e.g France, Belgium, Germany, Cyprus. etc in the EU…  The actual amount is the amount which the State of Residence has to find – not, as I have ascertained, the actual amount for the treatment as charged to the patient pensioner.  So in France the French State asks of Britain something considerably less than the full cost of the treatment to the patient.

The underlined phrase ‘planned treatment’ seems unnecessary. What is the significance of that phrase?

Then we need to look at EU Regulation 883/2004.  Annex IV to that regulation lists certain States where their Pensioner Nationals can return to their native land for health treatment [there is no reference to ‘planned treatment’ nor in the referenced article 27 here] – they are BELGIUM, GERMANY, GREECE, SPAIN, FRANCE, ITALY, LUXEMBOURG, AUSTRIA and SWEDEN.

Note that the United Kingdom is not listed.  The Green Paper would one supposes result in the UK being included in Annex IV. 

One of my correspondents has informed me that this is indeed what the Government is considering.

The result would be that qualifying Pensioners in the EU beyond the UK  could return quite legally to receive treatment under the NHS  and the confusion and uncertainties which has previously existed would be removed.

*Other qualifying  British State Pensioners resident elsewhere in the World would also benefit from a change in the regulations enabling treatment under the NHS on their occasional visits.  

The relationship of all this to the need for Representation in the Westminster Government.

If we had someone to represent us in Government then this rigmarole would not be necessary.  The DoH could consult with the representatives who would seek opinion from certain groups within each country.  A real democracy could come into being.

It is quite wrong in my view that the Government can produce such a ‘green paper’ and be apparently quite incapable of making appropriate contacts with the people most affected.

This is also so patently obvious with regard to the proposed Referendum.  This would affect the British Abroad in Europe very closely and yet are not in line to be consulted.

It is essential that we are Represented.

http://epetitions.direct.gov.uk/petitions/55085

The address of the DoH is

International Healthcare Team

Department of Health

3rd Floor

Wellington House

133-155 Waterloo Road

London SE1 8UG

Email    migrantaccess@dh.gsi.gov.uk

(Remember that the consultation on the green paper closed on August 28^th 2013)

The green paper is viewable at

 http://www.lefourquet.net/DoH-07-13-healthcosts.pdf

Health Payments in Europe

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French & European Health payments by the UK for British Pensioners

A/. It is appropriate that the retired citizens who live in France know exactly what expenses are paid  by the British Government for their health care in France.

I am eighty years old, retired, and have never earned any money in France and therefore have never subscribed to the French social security system. The UK is by EU law the ‘competent State’ for the support of our Social Security.  

Like so many others I find the costs of our health care ever rising. Some elderly couples are needing to find beyond 2,000 euros a year  for a top-up health insurance.

Under EU law France is required to ask the UK for the actual costs of our health treatment.  What is meant by ‘actual costs’?

I decided to find out the position.  This is possible via a Freedom of Information request to the Department of Health, London.   I have received very courteous mails from that department and was able to obtain details of all payments to France concerning my health payments since August 1998.  These are confidential and were sent to me by recorded delivery.

I have selected one item here which I have cross checked with details I received from the CPAM (French social security department).

Item  24^th January 2012

CPAM detail

Acte Biologie      

montant dépense (actual cost)      82.08€      taux 60% (amount paid by the French State)

montant payé  (amount paid to the  institution of treatment)          49.25€

participation forfaitaire à retenir   (‘tax’ retained for future collection from patient)   -4.00€

Soins infirmiers  

montant dépense (actual cost)       4.73€      taux  60% (amount paid by the French State)

montant payé  (amount paid to the  institution of treatment)             2.84

Reglé au Laboratoire   (Amount for final settlement to the Laboratory – A sum of  34.72€ was paid by my health  insurance  making up the total of  86.81€ =82.08+4.73€)      

 52.09€.  This is equal to the above 49.25€+2.84€

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Breakdown on Claim from France sent to me from the Department of Health, London on items between 15/12/2011 to 22/06/2012.

Soins paramedicaux                           2.84€

Analyses biologiques                        49.25€   i.e = 52.09€

It is clear that the French State seeks repayment of the costs which the French State would find for a French Citizen.  .

B/.The added burden of French taxation on the cost of health.

The above  CPAM detail indicates a ‘participation forfaiture’ of 4€ .   This is a tax which the French Government levies on most health transactions.  It is 1€ for each visit to a G.P. and 0.5€ for collection of a drug at a pharmacy. 

The cost out of one’s pocket for the ‘Acte Biologie’ was therefore increased by 4€. 

The cost to me of this ‘Acte +soins’  was therefore 34.72€+4€= 38.72€. The 4€ was not paid by my insurance.

Over a year, the taxes on health costs accumulate. Together with the above taxes on each medical act as indicated above one must add the taxes on health insurance. During 2012 these taxes amounted in my case to towards 200€.  The more one requires drugs and medical care the higher the taxes. Some pensioners are paying out a great deal more than this in taxes on their health. The more ill you are the more tax you pay!  The French should be ashamed of this taxation on sick people.

C/. Insurance costs

During 2012 the cost of health insurance per month was for me 128.78€ (for a couple – being 64.39€ for one person).  It has since risen in 2013 to 135.78€/month -1629.36€/year).  198.15€/year of this latter sum is a tax paid to the French Government – i.e about 12%.

D/. The EU Laws on the position of health costs.

Regulations 883/2004 and its ‘implementing regulation 987/2009 are those that concern Social Security matters. My interpretations are indicated in orange.

Basic EU Regulation No 883/2004 defines ‘institution’ as ---

"institution" means, in respect of each Member State, the body or authority responsible for applying all or part of the legislation."

The EU laws below are interpreted as referring to the ‘actual costs’ to the institution of the State not the actual costs of the institution that provided the treatment.

EU Regs 883/2004 Article 24 covers the situation relating to Pensioners who have retired to live in another State…I quote verbatim.

“No right to benefits in kind under the legislation of the Member State of residence

1. A person who receives a pension or pensions under the legislation of one or more Member States and who is not entitled to benefits in kind under the legislation of the Member State of residence shall nevertheless receive such benefits for himself and the members of his family, insofar as he would be entitled thereto under the legislation of the Member State or of at least one of the Member States competent in respect of his pensions, if he resided in that Member State. The benefits in kind shall be provided at the expense of the institution referred to in paragraph 2 by the institution of the place of residence, as though the person concerned were entitled to a pension and benefits in kind under the legislation of that Member State.”

[Observations/Interpretation :- It states that one should receive medical treatment in the same manner as one would expect under the legislation of the UK as if the patient resided in the UK.

                                    The costs are to be borne by the UK – the ‘competent State’ for your social security.

                                    The medical care is supplied as to a French person under French legislation as though he/she were a state pensioner of France.]

Continue....

“2. In the cases covered by paragraph 1, the cost of benefits in kind shall be borne by the institution as determined in accordance with the following rules:

(a) where the pensioner is entitled to benefits in kind under the legislation of a single Member State, the cost shall be borne by the competent institution of that Member State;”

[Interpretation – The UK is bound to pay the medical costs]

“Article 35

Reimbursements between institutions

1. The benefits in kind provided by the institution of a Member State on behalf of the institution of another Member State under this Chapter shall give rise to full reimbursement.”

-----------------------

From the Complementary ‘Implementing’  EU Regulation 987-2009 we read..

“Article 62

Principles

1.  For the purposes of applying Article 35 and Article 41 of the basic Regulation, the actual amount of the expenses for benefits in kind, as shown in the accounts of the institution that provided them, shall be reimbursed to that institution by the competent institution, ………….”

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Commentary.

The difficulty lies in the interpretation of the clause: copied in above--

“The benefits in kind shall be provided at the expense of the institution referred to in paragraph 2 by the institution of the place of residence, as though the person concerned were entitled to a pension and benefits in kind under the legislation of that Member State.”

I observe that this clause has no mention of costs.  It relates to the provision of the medical treatment.  This has to be provided as though one is a French citizen.

One notes the contradiction with  the previous clause which states that

‘the pensioner’  shall nevertheless receive such benefits for himself …., insofar as he would be entitled thereto under the legislation of the (United Kingdom) [Member State] competent in respect of his pensions, (as) if he resided in (the United Kingdom) [that Member State].

And…

the cost shall be borne by the competent institution (DoH) of that Member State (the United Kingdom).

So we should get treatment as though we lived in the UK and the UK should cover the cost.

The law appears to me contradictory – It is written that one should receive the medical treatment as though one lived under the legislation of the UK and ALSO as a French citizen pensioner would receive it under the legislation in France.

Many French Citizens – those on 100% CMU cover – pay nothing for their health care.  In short –  the cost to the patient is variable according to the circumstances of the patient! Since the British pensioner has costs covered (in theory!) by the Department of Health, London, it would be reasonable to suppose that these patients should also fall into the 100% cover category. I explore that thought ina European context……

E/. Other European National Citizens in France.

EU laws must be applied equally to all nationals across Europe.  The provision of health care for a state pensioner varies widely from  Estonia to Portugal.   It would seem almost impossible to provide health care for every ‘mobile’ pensioner under two systems of legislation at the same time.  The current interpretation seems inadequate.

It is also a restriction and distortion on free movement of pensioners.   The pensioner nationals who move from most other European countries to the UK obtain free health care.  Clearly with the UK pensioners moving to other countries in Europe, it is very often and usually not so. 

F/. Reform? And a solution?

Would it not be sensible to transfer 100% of the costs from the State of Residence  to the administration of the  ‘competent States’ for the support of Social Security and then that administration should seek appropriate repayments according to the legislation of that State from the  pensioner patient ‘as though they lived in their home country’?  Is this indeed that which the EU regulations are seeking? i.e the costs should be  borne by the 'competent State?

The pensioner should then settle their bills (if appropriate so to do) in a manner according to the legislation of the ‘home’ State.

G/. The need for Representation on these matters at a political level.

There is no-one in the British Government or Administration with any responsibility to look after the interests of British Pensioners in mainland Europe.  

There should be someone who has the responsibility to negotiate with the EU or other national governments concerning the condition of British Pensioners abroad in Europe.

How do the British Pensioners live in France?

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UPDATE -  The posting 'Shopping in France' is a useful accompaniment to this post.  It compares a shopping list in the UK and France from time to time, and  gives figures for inflation and the effect of the exchange rates.  ***View it here***.   Last update June 2015

In 2012 I met a British pensioner of long acquaintance in our local supermarket at Gourdon, my home town in the Department of the Lot, France.  I had not met him for some years and at first did not recognise him.  He looked much older than I remembered and appeared distressed.   ‘We’re selling up’ said  Jerry ‘if we can find a buyer for our house’.  I knew he and his wife Anthea had been resident in France for at least 15 years and before that had owned a second home here during the time he was teaching in Britain. 

‘Why do you want to go back?’ I enquired.  ‘Its just too expensive here’, he said.  ‘We can’t manage any more’.

It is indeed expensive.  The food costs are more here than in the UK.   I keep a price comparison list.   You can easily view the prices in Tesco online and similarly discover the general price of petrol in the UK.

In March 2012 I began such a comparison –See the link above. The basket of goods cost the equivalent of 92.07 euros in Tescos, and the same list was 104.23 euros here in Gourdon. That is to say 13% more expensive compared to Britain.  Even four star petrol was fractionally higher in price in March than in Britain.  Fifteen years ago everything was so much cheaper in France. The repeated exercise in March 2013 was far worse.  The £ dropped in value by 10% since December 2012 and French inflation soared to 12% (on my figures). The same basket of goods cost 108 euros, which was 17% higher than in the UK. [ n.b. June 2015. The situation has improved since 2014 - but is still not equitable with UK prices.]

The difference in price is enough that many Britons living in France buy various large items, clothes and the like  via the internet from England,  Nowadays, Marks and Spencer’s, John Lewis,  and even much smaller stores will send goods to France and even with the delivery costs it is still cheaper to buy this way.(* see comment 5 below)

From personal knowledge I know that small pieces of machinery such as parts for a chain saw  can be purchased more cheaply from Britain than in the local shops.  Electric fencing and garden ‘seep’ hoses can be so purchased similarly from Britain at a cheaper price than locally. Clothes, china and so on are all frequently available more cheaply from the UK.

Why is this?  The exchange rate has much to do with it.  We hear so often through the British radio and television that the Euro is in dire trouble.  My inkling is that we should pay more attention to the markets than to the economic soothsayers of the press and the somewhat biased pronouncements from any Government voice.   The undoubted fact is that the Euro has stayed strong against the pound although since 2014 the rate has improved  The £ stood in 2012 any where between 0.87 (April 2012!) (as in the price comparison linked above) to about 0.83 pence to the euro.  In 2015 it has been about 0.73.  It would be more equable in buying power today at about 0.67 - 0.70 pence.  The more the UK Government go on ‘printing’ money the more it will stay weak and even get worse.  [update note- on May 26th 2012 - From April, to July the £  climbed dramatically .  From July to December it fell back again.  Can we be sure of anything in this world?]

My acquaintance and his wife were teachers.   Because of the extraordinary law on taxation this means that they are taxed on their pensions by the United Kingdom.  The law is most decidedly an ‘ass’.  My enquiries to the HMRC as to why this should be so, get the answer ‘Because the pension comes from public funds.’  This is an absolute bananas of a reply.  The Old Age State pension quite transparently comes from public funds, yet that is not, for the British pensioner living in France – I repeat is not - taxed in the UK but is exportable for taxation to France! 

The utter stupidity of the laws on taxation of pensions is repeated elsewhere in Europe.  Would you not agree that the pensions of nurses comes via the public purse?  Yet those nurses who retire to France and Spain can have it taxed in France or Spain.  Those who retire to Germany must by law have it taxed in the U.K. 

The consequence for my acquaintance is that they pay far more income tax to the UK than they would if they were taxed in France.  Moreover as they are clearly of advanced years and I know that Anthea suffers severely from arthritis, they need the aid of a ‘home-help’.   In France the costs of this employment are 50% deductible against tax.  Since their income tax is collected by the UK, this relief is not possible for them.   To add extra absurdity the French take the teachers pensions into consideration when viewing their liability to taxation on their State Pension and their local property taxes.

So, through the complexity of archaic laws which derive from the United Kingdom they get a double whammy of an artificially distorted exchange rate and the hard luck of being suspended between two different sets of laws on taxation.

Because they have been non-resident in the UK since before 1998 they had not received the Winter Fuel Payment {see note at end].

Then again, our two aged people have to subscribe to their health care in France.  This will cost them more than 1500 euros a year and possibly 2,000 (about £1650).  I am convinced that this is because of a misinterpretation of European law.   The EU regulations on health say that the British pensioners should receive health care in France as any French person should receive it and that the cost should be borne by the U.K. Now the exact wording of the law on costs says and I quote……  

“ For the purposes of applying Article 35 and Article 41 of the basic Regulation, the actual amount of the expenses for benefits in kind, as shown in the accounts of the institution that provided them, shall be reimbursed to that institution by the competent institution.”  [EU Regulation 987-2004, Article 62]

The competent institution is the U.K. Department of Health.  The U.K. is responsible under EU law for the Social Security costs of all British Pensioners living in the EU who have never paid into any social security of their host country but only into the British system.   It is beyond belief that the precise wording of this regulation can be so ignored. (*The EU Regs need examination by a trained legal mind, especially 987-2004 Article 24 - residence in a State )

Here is part of an email, written on the 10^th February, from another acquaintance. “Just as I was yesterday, I am typing Emails sitting up in bed. I am  fully clothed in three jumpers, two pairs of trousers and a track suit. 
My dear husband, similarly dressed, is tucked up beside me.  He is eighty-six, and suffers from epilepsy and  a certain amount of mental confusion.
Outside the temperature is minus 2 degrees, and is expected to fall to minus 10 degrees tonight - a big improvement on the  minus 14 degrees we had last night.”

And another (let’s call her Ethel) who wrote to me about the non-receipt of the Winter Fuel Payment.  I know that their health insurance costs them over 2,000 euros a year.

“As you can imagine, this past year has been extremely hard on both of us and it is only with the support of the excellent French health professionals as well as the kindness of our friends and neighbours (both French and British) that we have managed to cope.   We live on a joint pension income of 12,000 pounds sterling per annum and have to draw on our very modest savings to supplement this.   Because of our low income, we downsized seven years ago to a tiny, one-bedroomed house which my husband converted from a carpenter's workshop but his illness and treatment cause him to feel the cold in the extreme and, in spite of the size of our house, I dread to think what our heating bill will be this Winter.  It is so dreadfully unfair that we and others in our situation are not allowed to receive the Winter Fuel Payment [see note at end] from the British government when our compatriots do!  And, of course, there is nothing we can do about it as, having lived in France for more than fifteen years, we are now disenfranchised as well!”

This letter from Ethel, just about sums up the predicament.  The EU is supposed to allow free movement of people, with neither loss of privileges nor obstructions placed in one’s path.   Yet the British Governments since 1973 have not considered in any manner at all how the diaspora of British folk are faring in the wider Europe.  Most of the pensioners are ordinary folk, some rich, some poor, but mostly in the middle income brackets.  Most moved to the continent because housing was cheaper and they felt sure that the pound would stay strong.. But the fact is that they are treated as non-existent citizens by their own country.   The UK Governments still tax many of them. The Government ignores it responsibility towards their health care. The Governments have disallowed  the Winter Fuel Payment [see note at end] to the most elderly.  And to cap it all the Governments have not allowed them to be appropriately represented in Parliament [see note at end].  

And now some are forced because of financial difficulties to attempt to return to the UK where no doubt they will add to the population pressure on the health service and the local social security departments.
 [The Winter Fuel Payment - AUGUST 2012 -- Because of pressure from the EU helped along by certain knowledgeable expatriates - the Government DWP has caved in and accepts that the WFP is payable to all those in the EU/EEA who would receive it if their residence were otherwise in the UK.]
BUT----
[Further note  on the WFP - January 2014- The Government has decided that France is a HOT country and on that basis will not pay the WFP to those of us living in France - But Italy is defined as 'not hot' -
View a relevant link here!] 
[The disenfranchisement is being strongly fought -- 
visit and comment www.votes-for-expat-brits.com ]

New Directive on Cross-Border Healthcare

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 January 2011.

There are unfortunate differences between the Draft of this Directive published in 2008 and the latest version published very recently in 2011. The new Directive will be operative in 2013.

The devil in the detail is the definition of ‘State of Affiliation’. I quote it here in full. All the heavy print has been added in the recent version and seriously undermines the position of the expatriate in France.

"Member State of affiliation" means the Member State where the patient is an insured person or the Member State where the patient resides if this Member State is not the same as the former.

Where, due to the application of Regulation (EEC) No 1408/71 and Regulation (EC) No 883/2004 respectively, the health insurance body in the Member State of residence of the patient is responsible for the provision of benefits in accordance with the legislation of that state, then that Member State is regarded as the Member State of affiliation for the purposes of this Directive;

This is bad news for British expatriates in France. It means that for this particular Directive then the Social Security of France is supposed to be our effective healthcare cost provider.

The situation becomes ridiculous! I explain step by step – this is for OAPS retired to France.
1. The UK is our State of Social Security Insurance.
2. If we visit the UK we get full health cover costs for medical treatment.
3. The UK provides us with an EHIC (European Health Insurance Card). If one journeyed to Spain then the UK covers us fully for health costs. In other countries it is likely to be variable. [The latter - A contentious point.]
4. The UK pays France for our health care…. The % amount is on the whole questionable. Up to now it has been at the French rate to a French insured person- usually about 80%, but a complicated calculation.

5. If British resident OAPs visit France on holiday and get treatment on the back of the EHIC, they are likely to be charged as though they were a French insured person.

6. If British resident OAPs visit France specifically for health care – then under this Directive they get treatment at the cost at which it would be provided in the UK! i.e 100% of approved costs.
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In my view this absurdity comes about because no-one in the British parliament or Civil Service has any interest at all in the British citizens resident in Europe.
There are inherent inconsistencies in the new Directive to which, I suspect, no British official or politician has given any thought at all. Which British official has the responsibility of vetting these things? None I fear. What MEP even understands that for which they vote?

However I await replies to my representations to the EU parliamentary committee on petitions.
This posting could need revision in due course.