Sweden reveals myth of EU healthcare 'freedom'

When it was first introduced in 2004, the EU's European Health Insurance Card was hailed as a major step forward in facilitating the free movement of people throughout the European Union.

By flashing the blue credit card-sized document, any EU citizen in need of medical care would be ensured their treatment would be covered by the public health care system, regardless of whether they were in their home country or visiting another EU member state.

But the recent case of Johanna, a Swedish woman residing in Germany who was left with 130,000 kronor ($18,500) in medical bills after she gave birth prematurely while visiting family in Sweden, shows that the system doesn't always work, especially for mobile Europeans who divide their time between more than one EU country.

“Someone has to take responsibility. If you’re an EU citizen, it shouldn't be a problem to receive healthcare,” Moderate Party MEP Christoffer Fjellner tells The Local.

Fjellner's frustration stems from what he sees as failings in the EU health system that in dealing with the medical needs of mobile EU citizens – precisely the sort of people whose lives were supposed to be made easier by a more harmonized system across member states.

In many ways, Johanna – whose case was highlighted recently by the TT news agency – embodies the modern "EU citizen": born in an EU country (Sweden), working in another (Germany) for an employer based in yet another (the UK).

But because she was pregnant when she moved to Germany, health authorities there said she had a "pre-existing condition" and thus wasn't covered by Germany's public health insurance system.

And after her baby came six weeks early during a visit to Sweden, Johanna was shocked when she received a bill from the Swedish hospital for more than 120,000 kronor for the delivery and two weeks of neo-natal care that health authorities in Sweden, Germany and the UK refused to cover.

“It’s idiotic to let people suffer and force them to borrow money to pay bills," says Fjellner, who has devoted significant time toward issues related to mobility and healthcare access within the EU.

According to him, existing legislation on the matter is clear but huge problems remain in how the rules are implemented in Sweden and elsewhere.

In theory, EU legislation entitles citizens carrying an EU health insurance card to emergency healthcare in any EU member state without having to pay more than the standard patient fees which apply in their country of residence.

Even without the card, EU citizens can get reimbursed later by the agency which manages the country's health insurance system, which in Sweden is the National Social Insurance Agency (Försäkringskassan).

The rules are somewhat different when it comes to planned medical procedures, however.

For example, patients are allowed to receive medical treatment in another EU country if there are long queues to receive medical treatment in their country of residence. Again, patients don't need to pay any other fees than they would pay at home.

But obtaining reimbursement is not always straightforward and, despite the legislation, there are several cases in Sweden where people's requests to have their medical expenses covered have been denied by the National Social Insurance Agency, forcing people to take their cases to court.

Some of these cases at the administrative court include a woman who went to Finland to receive a treatment not used in Sweden, a radiological scan to identify an illness. Another person was treated in France, but not reimbursed because the method used was not recognized amongst Swedish practitioners.

The agency's point person on international healthcare issues, Andreas Stjernberg, explains that part of the issue stems from differences of opinion about what counts as medically accepted and internationally recognized methods of treatment.

“If you have a broken left arm we don’t accept a treatment that results with you also having your right arm put in plaster," he says, taking up a case involving emergency care.

"The diagnosis should be treated in the same way it's treated in Sweden. If the method is not the same, you won't be reimbursed."

But Fjellner disagrees with the Swedish health insurance agency's interpretation of EU rules.

“This is a misinterpretation of the law that states that you can be treated for an internationally recognized diagnosis. The method used is irrelevant,” Fjellner explains.

“It doesn’t matter what treatment is used.”

And Fjellner is not alone in criticizing the agency, which was forced to adjust how they interpret the rules following a slew of complaints last year about reimbursement denials.

"We implemented changes in March 2012. Previously, the medical treatment needed to be identical to the one carried out in Sweden, but now that definition is broader,” says Stjernberg.

The EU Commission representation in Stockholm also agrees that information and procedures for reimbursements in Sweden under the EU healthcare system need to be improved.

“We get around thirty calls from desperate people each month," says the Sigrid Jonason of the EU Commission's offices in Sweden.

"People complain and tell us they have been waiting over three months for the national insurance agency to reimburse them."

This is something Fjellner also recognizes as a problem, and is quick to point out that Sweden's national insurance agency is not as efficient as it should be.

“There is no reason why the national insurance agency can’t pay you earlier or even before,” he says.

But the agency's Stjernberg counters that his colleagues are doing everything according to legislation requiring to review each case before deciding if someone should be reimbursed or not.

In addition, most cases are dealt with expediently.

“Between April and June around 62 percent of the cases were cleared within sixty days,” he says.

Despite gradual improvements in how Sweden's national insurance agency handled reimbursement claims, Fjellner blames hospitals for adding to reimbursement confusion when it comes to seeking planned care in another EU country.

“The big problem is that hospitals decide not to tell people that they are entitled to treatment in another country,” Fjellner explains.

Another obstacle to patient's EU-mandated freedom of choice when it comes to healthcare, according to Fjellner, is the difficulty patients have if they need treatment only offered in certain parts of the country.

Cancer patient and Stockholm resident Therese Vesterlund, whose case was highlighted recently in the Dagens Nyheter (DN) newspaper, has been unable to get the treatment she wants.

While health authorities in several Swedish counties have approved the drug Yervoy for treating melanoma, the Stockholm County Council (Stockholms Länstinget) has yet to do so, meaning Vesterlund's only option is to pay for the treatment out of pocket.

Gunilla Gunnarsson, a cancer treatment coordinator at the Swedish Association of Local Authorities and Regions (SALAR), points out that each county in Sweden has the power to decide what treatments are available.

“Every county sets their own priorities. That’s why different counties offer different healthcare options,” she explains.

But Fjellner nevertheless remains critical of the system, arguing that everyone should be given full freedom of choice when it comes to accessing healthcare within the EU and within Sweden.

He claims Swedish healthcare providers are refraining from fully informing patients about their options due to concerns about costs.

“A county sometimes decides not to treat someone for cancer not because there is no treatment but because the medication is too expensive,” he says.

“This is the sad truth, but it happens."

And Göran Stjärnstedt, head of healthcare at SALAR, agrees, adding that having a doctor refer a patient from one county to another, while theoretically possible, is a rarely used option as it pits the care in one county against another.

"Since the 1990s, patients have been able to apply for medical treatment in another county, but it’s not easy and it’s unlikely that doctors would admit that another county offers better treatment,” Stjärnstedt explains.

Cost considerations also play a part in Swedish health providers' reluctance to let patients know they can also seek treatment in other EU member states.

“A leg operation in Austria will be double the cost. That’s enough reason why a county or the national insurance agency will not pay up,” he explains.

Despite the system's current shortcomings, Stjärnstedt is optimistic that things will improve as patients in Sweden and elsewhere in the EU become more accustomed to exercising their rights.

"It's of course hard for a patient to assert his or her right, but I hope more people will do that in the future. That's what we're pushing for," he says.

Salomon Rogberg