Rethinking the EU health policy space

A regulatory and deregulatory approach grounded in subsidiarity and the construction of a single European market might be logically coherent and well

established in practice, but it has its limits. There are multiple contradictions in the politics of EU health policy. On the one hand, surveys show popular desire for EU policies that improve health, and working for better health is an obvious way to show the citizens of Europe the benefits of the EU. On the other hand, there is very little support for a bigger EU budget or ambitious EU actions that might infringe on Member State responsibility for health policy. Likewise, the EU does much for health, but much of that is understood as something else – as environmental policy, or labour law, or health and safety law, or consumer protection law. Those actions, beneficial for health, often manifest as additional regulation which can irritate people with affected interests. The result is a set of tensions: the most effective EU actions for health are not always understood as health policies, while general popular support for EU actions to improve health collides with weak treaty bases and weaker political support for explicit EU health actions. But simply announcing that the EU will cease to emphasize public health does not solve the problem, since the EU has powerful tools to influence health that it uses in the course of regulating markets, ensuring environmental protection and health and safety, and striving for fiscal sustainability. The existence of EU policies affecting health is unavoidable. The question is whether the EU will use them explicitly for health.

In terms of health policy issues on which the EU is acting, but with questionable policy and uncertain effects, policies to do with ageing are an important issue.

The third face of EU health policy, fiscal governance, is concerned about the liabilities of governments and the Semester has over various years produced repeated calls for later retirement ages and often-unspecified policy changes to ensure the fiscal sustainability of health systems (see section 5.2). There is scope for this debate to be more sophisticated, understanding the promotion of active and healthy ageing not just as a way to enable later retirement ages or reduce healthcare needs among older people, but as a way to invest in people across their lifecourse in order that they may make the greatest and most satisfying contribution to their own and others’ lives. The Semester has become much more sophisticated in its recommendations, but it, and the EU’s overall role in promoting thinking about ageing and health, could still be improved.²

If there were support for a stronger and more health-focused EU policy, there is legal space and a range of creative political possibilities. The State of Health in the EU is an instrument to shape the whole narrative of health policy in the EU and the Member States. One way is through direct, visible, EU health policies with output legitimacy, such as initiatives for research and action against cancer,

2 Cylus J, Normand C, Figueras J, 2019. Will population ageing spell the end of the welfare state? A review of evidence and policy options. Copenhagen:WHO Regional Office for Europe, on behalf of the European Observatory on Health Systems and Policies; and Greer SL et al. (forthcoming). The politics of ageing and Health (provisional title). Cambridge: Cambridge University Press.

antimicrobial resistance or the communicable diseases that climate change is bringing back to Europe. Another is through the utilization of powerful EU powers that are not part of Article 168 but name health. Public concern about chemicals and about the safety of the food system is important across Europe, as is public health concern for the effects of contemporary diets. These are core areas of EU competence and activity, especially in veterinary, agricultural, environmental protection, chemical regulation and food safety issues, and there is great scope for EU leadership should the key political interests align. Likewise, EU law affecting the economy and labour is a powerful force, with consequences for important social determinants of health including hours of work, gender equality and occupational health and safety.

There might be support for a stronger and more focused EU health policy. The 2019 institutional renewal – with new leaders in every top job, a new European Parliament without the grand coalition that had held since 1979 and a shift of focus away from austerity – offers a great deal of potential. Challenges such as populism, threats to the rule of law and popular dissatisfaction with many different issues all give leaders at the EU level opportunities to formulate more ambitious plans that can legitimate the EU by addressing major issues in popular and visible ways. Brexit, finally, will change the politics of the EU by removing one of its most consequential, and liberal, Member States.³ There is scope to imagine something new and better in EU health policy: approaches that focus on health and well-being, on rule of law and protection of the vulnerable or on fulfilling the Pillar of Social Rights and SDGs are all possibilities. If the EU institutions were to declare that good health for all is a priority, this book has shown that it would be easy to both demonstrate EU success to date and identify powerful new policy options for the future. Likewise, a renewed commitment to well-being (Box 1.5) or to the European Pillar of Social Rights (section 3.5.3 and Box 3.5) could put the spotlight on existing EU achievements and potential policy options in health.

One way to emphasize the real and potential contribution of the EU to health is through the Sustainable Development Goals (Box 2.6). The European Union has a history of developing ambitious policy agendas as a way to give coherence and political force to its projects: the market integration of the Single Europe Act, the Lisbon Agenda, Europe 2020. The SDGs are somewhat different; they are goals agreed globally by the United Nations. While often associated with lower- and middle-income countries, they are also goals that no country has fully achieved, such as gender equality, good work and a sustainable environment,

3 Cylus J, Normand C, Figueras J, 2019. Will population ageing spell the end of the welfare state? A review of evidence and policy options. Copenhagen: WHO Regional Office for Europe, on behalf of the European Observatory on Health Systems and Policies; Greer SL, Laible J (eds.) (forthcoming). The European Union After Brexit. Manchester: Manchester University Press.

as well as good health and well-being. The EU’s adoption of the SDGs (section 2.4), including as Semester goals, means that the fulfilment of the SDGs might be an opportunity to shape an agenda and narrative in which health becomes directly and indirectly a focus of EU policies. There is also abundant space for the EU to shape global health, including by replacing an increasingly withdrawn United States in many areas of standard-setting, reproductive health aid, and surveillance that are valuable.

The important thing to remember with all of these statements and agendas is that the EU, like any sophisticated political organization, can easily rebadge its existing and planned activity as part of a new agenda.⁴ It is easy to be cynical, more so since anything as large and complex as the EU always has many agendas that might have little to do with one another – a frustration to any politician who seeks a coherent theme and agenda. The Juncker Commission sought to be

“big on the big things and small on the small things”, with health apparently a small thing. By the end of 2019 there was only one open legislative dossier in health and that was not moving quickly (HTA: section 4.6). Did that mean that EU policies affecting alcohol or food safety vanished? Of course not, and in fact DG SANTE continued to work on the many health issues discussed in chapter 3.

Health lost strength as a constituency and a policy goal and its advocates in and outside the EU institutions have had to work to regain prominence over the last five years. Comparing the narrow mission letter sent to Commissioner Andriukaitis in 2014 (Appendix IV) to the activity discussed in this book shows the extent of their success. By the same token, though, declaring a new political priority that includes health will be an effective way to bring resources, energy and atten tion back.

6.3 Conclusion

The message of this book can ultimately be summarized in a few sentences. First, European Union health policy exists and affects both health and health systems.

It is an awkward shape and has unusual features, procedures and priorities, but that is the case for most policy areas in any political system. This does not mean that there has ever been any pressure for a European health system, whether that is taken to mean financing of healthcare delivery, standard European entitlements or homogenization of the organizational features of healthcare systems. There is an almost complete absence of political or intellectual support for such an agenda.

Today, the EU is at something of a crossroads. It does much for health, in ways that stretch far beyond Article 168 and are not always regarded as health policy.

It also misses many opportunities to improve health, whether through its weak

4 For example, European Commission (2019). Reflection Paper towards a Sustainable Europe by 2030.

Brussels: European Commission.

system for regulating medical devices or through fiscal governance agendas that have been a threat to health budgets. There is public support for an EU that improves health, but little interest in EU healthcare services policy and resistance to some of the key EU regulatory policy tools for health. A decade of policy focused on exiting the financial crisis and promoting growth reshaped priorities and elaborated policy tools that can work across many fields. The legal space for EU action to improve health is enormous and by no means fully used, so much remains to be done.