The Harmonization of Health Policy in the European Union: An Integrated, Neo-Functional Explanation

Abstract

Health policy has been gradually integrated at the European level since Member States of the European Union (EU) started harmonizing their regulations and building a single market with freedom of movement for goods, people, and services. In the 1992 Maastricht Treaty, the European Union formally gained competence to protect public health. In the 1998 Kohll and Decker cases, the European Court of Justice ruled that the health sector falls under the single European market, enabling patient mobility and reimbursement rights across borders. The complex field of health policy, however, remains less integrated than many other policy areas in the EU as national governments maintain legal autonomy over the organization and delivery of health care. What factors have driven the gradual integration of health policy in the EU? This thesis explores the determinants of health policy harmonization in the EU by developing hypotheses based on two theories advanced by political science scholars of European integration to explain the factors that have driven the harmonization of policy between the Member States of the European Union. One theory, neo-functionalism, posits that policy harmonization occurs insidiously at the European level as a result of spillovers and is then forced upon Member States. Another theory, liberal intergovernmentalism, argues that EU policy progresses at the sole discretion of Member States who agree on a course of action based mostly on their national economic preferences. This thesis utilizes a qualitative, case-study design to shed light on the factors that have driven health policy harmonization in Europe. The Member States of Austria and Hungary were selected due to their shared history in the Austro-Hungarian Empire, geographic proximity, and cultural similarities. Existing literature, a history of national health reforms, and European-level activities were investigated in detail to understand whether neo-functionalism or liberal intergovernmentalism explains health policy change in the respective nations. With neo-functionalism, several conditions were utilized – such as whether or not policy change stemmed from a different social sector – to determine the type of spillover effect that best explains national legislation. The cases of Austria and Hungary demonstrate that health policy harmonization in the European Union is a neo-functional phenomenon. Furthermore, this thesis proposes a more integrated, neo-functional model for explaining the harmonization of national laws with EU policy. The cases showed that the type of spillover effect depends largely on the specific aspect of health care at play. The Commission, ECJ, and supranational agencies demonstrate functional and cultivated spillover effects in workers’ health, e-Health, patient mobility, and pharmaceutical regulations among others. Social and political spillover offer an explanation in other sectors, such as population health. Lastly, this thesis also found that the pre-accession stage enables unique, neo-functional pressures for health harmonization prior to official EU membership.