Why do Romanian mobile EU citizens in Sweden lack the European Health Insurance Card?

Transcription

1 Why do Romanian mobile EU citizens in Sweden lack the European Health Insurance Card?

2 Content Introduction... 1 The EHIC... 2 The healthcare system in Romania... 2 Insurance Incitements... 3 Structural discrimination... 3 Access... 4 Case: Jenny s road to an EHIC... 5 Analysis, policy suggestions and conclusions... 6 The road to the EHIC... 6 Sources... 7 Abbreviations EHIC European Health Insurance Card ESF European Social Fund EU European Union MdM Médecins du Monde NHI National Health Insurance NHIC National Health Insurance Card NHIH National Health Insurance House SEK Swedish Krona 2018 Läkare i Världen/MdM Sweden By Niclas Hell, with research assistance and interviews by Nataliia Tsekhmestruk Developed with funding from FEAD and Mac Aids. FEAD is the Fund for European Aid to the Most Deprived, helping EU countries toprovide material assistance and education to those who lack basic means of living. The Mac Aids fund works globally with hiv prevention and supporting those affected in most marginanlized groups of society. Introduction As care providers for mobile EU citizens and undocumented migrants, Läkare ivärlden/médecins du Monde Sweden meet people every week being denied their basic right to health. In Swedish law, undocumented migrants have the right to care that cannot be deferred, which includes primary and some types of secondary care. EU citizens are expected to provide a European Health Insurance Card (EHIC) in order to receive subsidized healthcare. Without this card, EU citizens pay the full price for care, often tens of thousands of SEK or more. Most mobile EU citizens from Romania and Bulgaria do not have an EHIC. This report asks the question why? The Landsting (county councils) in Sweden have different solutions for this problem. They have a legal responsibility to provide care to Swedish citizens, migrants with residence permit and migrants during the asylum process, undocumented migrants and EU citizens with EHIC, while others are expected to pay the full price. However, the Landsting have the right to exceed this amount of subsidized care. Therefore, some Landsting, such as Jämtland, have decided, on a political level, to extend the level of care provided to EU citizens without EHIC to the care that cannot be deferred level. This creates an important relief on a group already facing several vulnerabilities including poverty and racism. At Läkare i Världen, we provide testimonies from people lacking healthcare access. Among the politicians, social workers, NGOs and care providers working with mobile EU citizens, some are aware that many lack the EHIC. However, we have met very few who know why. This report is an attempt to bridge that gap of knowledge in Swedish society, as well as abroad in EU member states facing a similar situation. 1

3 The EHIC is valid for different amounts of time in different countries 1. In The UK, it is valid for five years, whereas in Romania, it expires six months after issuing date. The Healthcare System In Romania In Romania, the national health insurance is not universal. Individuals gain access to the system either through their employment status, family members, by social security, or by paying. Most adults are insured from their workplace % of the income is paid to access the National Health Insurance, guaranteeing full access to the employee and his/her family 2 (spouses and parents). Children under 18 years are automatically covered, as well as people registered as disabled, unemployed, or for social benefits. The 6 boom of private health institutions followed the failed 2011 government proposal to privatize the healthcare sector entirely. Additional private insurance grants access to private hospitals, offering mainly primary care. Well over a million Romanians pay the extra insurance, costing 9 to 350 Euro per month 7, depending on insurance plan. Specialists are still mainly found in public institutions, due to higher wage and treatment costs, which is mirrored in the low number of hospital nights compared to the number of private hospitals. In order to get subsidized healthcare abroad, Romanian citizens generally need the EHIC. To receive the EHIC in Romania, the certificate of a five year payment must be provided. Alternatively, private travel insurance is available, constituting a third separate payment to be made for Romanians wanting a high grade healthcare. Payment problems Roma people are economically disadvantaged in Romania 11. The 5.5 % of 11 minimum wage payment puts strain on poor families. It equals 270 euros per year, which may be a considerable amount for some families. Perhaps even more difficult, however, is that bills will be sent to a person s registered home address. Not everyone has a registered address, not everyone has the required amount before the bill is due, and the mobile citizens visiting Sweden are clearly not at their registered address to pay bills while in Sweden. Structural discrimination Roma people face heavy structural discrimination in all over Europe. The EHIC The European Health Insurance Card was introduced in 2006 as a part of the EU s strife to create a union where people could move freely, and to create incentives to live and work abroad. By showing the card, citizens of the EU, Norway, Liechtenstein, Iceland and Switzerland may visit a publicly funded clinic in any of the other countries and receive the same level of care as nationals, for the same cost as nationals in that country. The home country health insurance system is billed for the healthcare. In theory, every EU citizen with access to their national health insurance system may order the EHIC. In many EU member states, as in Sweden, access to the public health system isuniversal for nationals. Obtaining an EHIC is simply the matter of typing your ten-digit personal number into a website and waiting for a few days. This is not the case everywhere. In some EU member states, the public health insurance is conditioned. Access may cost money, or require tax-paying employment. For those who do not fall into one of these categories; adults not employed by tax-paying workplaces, and not part of any of the social programs in the Romanian state, there is the alternative of paying 5.5 % of the minimum wage (the minimum wage being 1,900 lei/month, circa 410 euro, as of January ). In theory, contributing to (and benefitting from) health insurance is mandated by law in Romania 4. When accessing healthcare, the patient must provide a certificate proving that their insurance has been paid, on time, for the past five years 5. Penalties and unpaid bills can be paid, to some extent, when seeking care. From 2011 on, private hospitals have increased rapidly as a complement to the public healthcare system. Today, more than a third of all hospitals in Romania are private, although they only account for some 4 % of the hospitalizations Government decision 846/ Asigurările medicale private, preferate de tot mai mulţi români, Adevărul, 16 juni 2011 Insurance Incitements 51% of Romanian Roma, compared to 85% of the non-roma, are connected to the NHI 8. Many Romanian Roma experience one, many, or all of the following obstacles to joining the NHI: Unaware that insurance exists or what it does Do not trust authorities such as doctors or public servants Cannot afford health insurance Do not have a hospital nearby 9 The closest hospital is a private institution demanding additional insurance Are illiterate in a paper form-based system Are asked for large bribes Do not have identity papers 10 making insurance impossible Are denied care based on ethnicity or culture Do not have a permanent address Where hospitals are placed Language barriers Lacking education 12 Corruption 13 All are part of a larger system to limit Roma people s access to public services in Romania. In addition to this, Roma face a widespread, open racism 14. The challenges of living in a hostile society include housing, employment, health, and more 15. MdM Sweden s patients testify about being asked for unproportionally large bribes, or being denied healthcare altogether. 7 ibid Romania, a report by the European Roma Rights Centre /2038(INI) Committee on Civil Liberties, Justice and Home Affairs /2038(INI) Committee on Civil Liberties, Justice and Home Affairs. 15 Romania, a report by the European Roma Rights Centre 2 3

4 Romanian measures to support Roma causes is low. There are very few NGO s in Romania working close to the Roma community, and the will to change the situation is weak. Available EU funds, dedicated for work with Roma, have been underused16. Despite lowered requirements for applicants and extra funding, the social programs are few. Access Those insured still face multiple difficulties. The access to hospitals and other healthcare facilities is limited, as Roma societies are often isolated geographically17. The access to healthcare has also been affected by the increasing level of private health insurance18. The additional insurance grants access to private hospitals, offering mainly primary care. Furthermore, many Roma people do not possess any kind of identity papers19. A rural, illiterate person in Romania with no papers has a very long road toward an EHIC. Even those with some parts in place, such as identity papers19 and a tax-paying workplace within the family, still need to contact several authorities, wait for five years after entering the insurance system, and still only get a card valid for six months. Case study Most of the mobile EU citizens we meet at MdM Sweden are not entirely clear about what services are provided, and what is expected to stay insured. Lack of knowledge is limiting access for anyone not in regular contact with authorities. Maria, 47 years, is from a small town in Eastern Romania. She has been living in Sweden for six months. She came to Sweden when she lost her job as a cleaner at the local social services, a job she held for seven years. When we ask her about her right to healthcare, she states that the social services in her town helped her with the NHIC, but that it is unclear whether they provided it as her employer or as local social services. She does not know what rights come with the NHIC, but that it has worked well when she visited doctors in Romania. Hökerberg, J., Här fastnar EU:s miljarder till romerna Romania, a report by the European Roma Rights Centre, 2013, page 7 pp. 18 Asigurările medicale private, preferate de tot mai mulţi români Maria believes that many people get the NHIC without being employed she does not know if she paid taxes or not, and she has not paid anything for the NHIC since she came to Sweden. The paperwork around healthcare was always done by someone else, with few explanations, as Maria is illiterate. The social services gathered the people who could not read or write in her district and applied for the NHIC on their behalf at one single occasion. She does not know about the EHIC when we meet her. Probably, her NHIC is expired due to lacking payments for the last six months. Maria has proper identity papers. The interview with Maria was conducted at a homeless shelter in Stockholm. This, and similar interviews, show that the knowledge is low not just about the EHIC, but about the rights and requirements of healthcare in Romania over all. 5

5 Conclusions and Suggestions For mobile EU citizens, paying NHI bills sent to their official address (if there is one), on time, and ordering a new card every six months, are difficult obstacles, even for the small minority that manages to get an EHIC before leaving Romania. Treating a large majority of EES citizens at subsidized rates in Sweden, while sending this marginalized group of Romanian citizens away, is not ethical. MdM Sweden would like to propose these changes of policies in order to satisfy the universal right to healthcare, defined in the Universal Declaration of Human Rights: Include EU citizens staying more than three months in Sweden without permits in the undocumented migrant category, granting the healthcare in accordance with the 2013:407 law. Make orientation about the right to care (according to the 2013:407 law and others) a compulsory part of the introduction at workplaces providing healthcare. Make EU citizenship the only prerequisite for EHIC application. Create more incentives for applicants of the Romanian ESF funding aimed at Roma people. This can be done by simplifying the application process or lowering the self-investment proportion smaller. Sources Romania, a report by the European Roma Rights Centre, 2013, European Roma Rights Centre. Hökerberg, J., Här fastnar EU:s miljarder till romerna, Dagens Nyheter, Draft report on fundamental rights aspects in Roma integration in the EU: fighting anti- Gypsyism (2017/2038(INI)) Committee on Civil Liberties, Justice and Home Affairs. Rapporteur: Soraya Post Bara, A. C., van den Heuvel, W. J. A., Maarse, J. A. M., Bara, A. C., Maarse, J. A. M. (2002). Reforms of health care system in Romania. Croatian Medical Journal, 43(4), Gender roles and HIV sexual risk vulnerability of Roma (Gypsies) men and women in Bulgaria and Hungary: an ethnographic study (Kelly et. Al. 2004) Vlãdescu C, Scîntee SG, Olsavszky V, Hernández-Quevedo C, Sagan A. Romania: Health system review. Health Systems in Transition, 2016; 18(4): Asigurările medicale private, preferate de tot mai mulţi români, Adevărul, 16 juni 2011, läst The road to getting an EHIC as a deprived Roma person in Romania can be a long and difficult one. Without the card, the access to healthcare in other EU countries is limited or nonexistent. The EHIC does not work as intended, despite the legislator s sympathetic intention of granting every EU citizen the right to extensive healthcare in the union. Our reports in cooperation with research teams from University of London and Sorbonne show that the number of destitute EU citizens leaving the country to seek healthcare abroad is negligible 20. A majority of our patients suffer from simple, primary care ailments which could be treated cheaply, with large public health gains. The laws regulating the EHIC were ratified before Romania joined the EU in Romanian citizens low access to the NHI, and even lower access to the EHIC, show deficits in the Union s common healthcare system. The road to the EHIC Get identity papers and official registration* Apply for NHI, either through tax-paying workplace, public social program* or by registering separately for minimum payment insurance* Stay within the NHI for five years Obtain certificate for five-year complete payment* Apply for EHIC from NHIH->Renew EHIC every six months, and stay within the NHI 20 Robert W Aldridge, Anna Miller, Bethany Jakubowski, et al. Falling through the Cracks: The Failure of Universal Healthcare Coverage in Europe de-paturi-la-public paturi-la-privat-doar-4-din-cei-4-24-milpacienti-internati-la-privat , Radiografia spitalelor: 367 publice, 187 private; de paturi la public, paturi la privat; doar 4% din cei 4,24 mil. pacienţi internaţi, la privat Applying for a card, European Commission read Romania: Government decision 846/2017. Page visited Romanian law 95/2006, art

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