Healthcosts.html   (political files/Health & EHIC)

The Costs of Health Care in the EEA

With special reference to

British Old Age Pensioners resident in France.


The Current situation

The costing of health care

The current basis for costing health-care between the France and the UK follows from the agreement signed between these countries on December 8th 1998. [This is listed in EU Regulation 883/2004]

This agreement is based on Article 95 of Regulation 574/1972  and is in essence identical to that.

The original Regulation was (as the title indicates) drawn up in 1972.  This was 38 years ago.

a.                   The United Kingdom joined the EEC a year later in 1973. So the regulation was formulated without consideration of the interests of the British Citizen. Yet the UK signed  up to it in 1973 and adopted the procedures of Article 95 which still apply today in 2010, reaffirmed in the 1998 agreement..

b.                  The original Regulation has been replaced by Reg 883/2004 but  the 1998 agreement has not been replaced.

c.                   In 1973 electronic transfer of data was not possible.  This is an important development.

d.                  There were just SIX nations within the EEC .

e.                   The EU has now expanded to 27 nations.

f.                    The number of British Old Age Pensioners  living in France has grown exponentially since the UK joined the Union.

In 1973 -  2,200           

In 2002 -  19000.                      

In 2009 -  49000.      One can view the exceptionally revealing graphs at the link below

Information from Dept. of Work and Pensions UK.


This 1972 regulation and thus it follows the 1998 agreement is flawed.  Further on in this document is displayed in tabulated form the actual sums of money exchanged in 2006/7.  A study of the Agreement of  1998 states (Article 7) that ‘an advance of 80%’ shall be paid on he average cost of health care for pensioners.  Article 7-2 of the same document then seems to infer that the difference is to be paid later.  A letter of March 25th 1977 from the Dept. of Health to France says that all health costs will be refunded.  This letter was later taken into consideration in the 1998 agreement, which then revoked the 1997 letter.

Under Article 93 of EU Regulation 574/1972 it is required that the ACTUAL COST of health care shall be refunded, from the ‘competent’ institution of the ‘competent’ State.

Article 95 of the same document says that the actual sums should be reduced by 20%.

The Agreement of 1998 between France and the UK is not straightforward and the information given to me from the Department of Health indicates that only 80% of the costs are in fact transferred

Under the EU Regulations, the institution of the ‘competent State’ for supporting the social welfare of the  British pensioner is the Department of Health of the U.K.

The original regulations were first formulated without knowledge of how the inclusion of other States into the EEA would affect the demographic movement of British OAPs, and the implementation of further regulations.  Its implementation is to the advantage of France and to the undoubted detriment of the British Elderly Citizen within France.  There is clearly some confusion in the implementation of the agreements.

The information given implies that in the case of the UK, the Department of Health  asks France for 80% of the average cost of ALL  (the total population) pensioners’ health care in the UK and to apply that  for the 85 (sic.) French pensioners resident in the UK (2006 figure).  The cost requested is very likely widely divergent from the true cost.

Similarly in the case of France, the UK is asked for 80% of the averaged health care cost of ALL pensioners in the system, and France applies that to the 34000 British pensioners (2006 figures, now >49,000) resident in France.  This again creates a considerable distortion and the estimated costings do not reflect the true costs of health care. These estimates are surely too high. A review would save the UK exchequer many millions of pounds.  On the UK side the 80% clause – if truly implemented-  is ridiculous. 


This agreement going back 38 years (1972/3 renewed in 1998) is furthermore inconsistent with the requirements of EU Regulation 883/2004 which came into effect on May 1st 2010.


The 1998 Agreement can be viewed at

The 1977 letters between France and the UK at


Further, your attention is drawn to a proposed Directive tabled in Brussels which draws attention to the defects in current implementations of health care costs between the nations of Europe.


on the application of patients' rights in cross-border healthcare.   This can be viewed at…. Proposed re Health.pdf


Below is an extract taken from the EU website (address below),  which relates  to this proposed Directive.

Healthcare provided in another Member State

The Member State of treatment (i.e. in this case France) organises and provides the healthcare. They are responsible for ensuring the quality and safety of the healthcare provided, in particular by implementing control mechanisms. They also ensure the protection of personal data and equal treatment for patients who are not nationals of their country.

Following the provision of care, it is the Member State of affiliation (i.e. in this case the U.K) who takes care of the reimbursement of the insured person on the condition that the treatment received is provided for in their national legislation. The amount of the reimbursement is equivalent to the amount which could have been reimbursed by the statutory social security system if the care was provided in their country. It must not exceed the actual costs of the care.

Summary -- This Agreement of December 8th 1998 surely needs annulment and a new Agreement made.  The EU has greatly changed, the populations have greatly changed.  It is derived from regulations written before the involvement of the UK in the EEA and it is certainly outdated.



Who should pay for and who provides the health care for the British expatriate  pensioner in France

Regulation 883/2004 which came into effect on May 1st 2010, covers this matter.

This Regulation largely replaces Regulation 1408/1971, and the article 24 printed below is a rewrite of Article 28 of the latter Regulation with no material changes.


Article 24 of  EU Regulation 883/2004 …..

[In having] -- “No right to benefits in kind under the legislation of the Member State of residence.

(Italics are introduced by the author of this paper)

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.


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;……………”


The author corresponded with the EU Citizens Signpost Service on this matter. [reference Enquiry 73723 of  09/04/2010]  It is clear that this service is not aware of the full scenario on this matter nor of the significance of Regulation 883/2004 which was about to come into operation in a few weeks time. 



Anomalies consequent on the above Regulation   883/2004

1. From the Interpretation of the italicised sentences (above in Article 24)  of this regulation…

The first italicised sentence indicates that a British Old Age Pensioner who receives a pension under the legislation of the UK but who has no inherent rights to health care in France, shall receive such health care as he would in the UK (if he resided there).

The second italicised sentence says that the costs are borne by the Health Department of the UK- but the health care is provided by France as though the pensioner was a pensioner subject to the health care provisions of France.

It is immediately apparent that the two sentences contain an inherent contradiction. 

It is not possible to receive the health care (that is to say -100% care free of charge to the pensioner as in the UK) and at the same time receive the health care at variable costings between 60% to 100% according to the drugs, the service provided, the particular illness, or the income of the pensioner as would a pensioner of French nationality.


This incompatibility makes financially the free movement of the British Old Age Pensioner between the UK and France not straightforward.   It means that the British pensioner must find funds for the purchase of  a ‘top-up’ health care insurance.  These costs are for a married couple over 1,200 euros a year and can be as high as 2,000 euros (one couple has since reported 2800 euros).   This contradicts the concept of Freedom of Movement without constraint inherent in the EU Treaty.


An ARGUMENT  Reductio ad absurdum’

The argument pursued by the UK and France up to and beyond May 1st 2010 is that the British Pensioner resident in France is supported by the UK (the Competent State for his Social Security) to the level of the citizen in the resident country of the EEA.

  If an EEA State (X) had perchance no minimal support for health care but demanded that each citizen had a compulsory health insurance, then the UK Government would give no support to the health care of its citizen within the State X, whilst in reverse the State X would have to pay 80% of the costs of the Elderly Citizen of State X residing within the UK..

Both situations are clearly absurd. 

If the Citizen were supported as the Regulation asks, ‘insofar as he would be entitled thereto under the legislation of the Member State competent in respect of his pensions, if he resided in that Member State.’, this situation would not arise.



2.  The  anomaly which arises with the introduction of new rules relating to the European Health Insurance Card under Regulation 883/2004.

This Card ensures that all health costs are paid by the ‘competent State’ (the UK in this instance) if the pensioner requires health care whilst on a temporary visit within the EEA outside of his resident State.

Thus a UK resident pensioner who visits France would obtain 100% cover from the UK, whilst a UK pensioner resident in France obtains far less cover in France.  On this point the UK Pensions Service continues to promulgate an error that the UK are duty bound to only cover the proportion of  costs which is normally covered  for the citizen resident in the EEA State which is visited [i.e. 80% or so in the case of France]. The following link gives the Opinion of the Advocate General of the EU on this matter (25th February 2010)

This principle should be applied by a ‘competent’ State with regard to the all the citizens of  that State for whom this ‘competency’ in social security is recognised.



3. Anomalies across the EEA.

If a British pensioner resides in different countries of the EEA his health care cover is very variable.

In Spain, Italy and Germany he receives 100% cover.

In France he receives approximately 70%/80% cover – variable.


Summary.   In consequence, the British pensioner resident in France is in this regard discriminated against vis-à-vis a British pensioner resident in Britain or in other major nations of the EEA.



The current effect of the implementation of Article 95 of Regulation 574/72

On Cross Border Health-care payments in and out of the UK for each E121 holder.


Figures originate from The Freedom of Information Team,  Department of Health,  Room 317, Richmond House,  79 WhitehallLondonSW1A 2NS


Figures are for the year 2007 except for Italy where it is 2006. (the last figures available in May 2010)

THE AVERAGE COSTS of health care for all resident elderly persons as calculated



ITALY  (2006)



Amount in Euros/head

5202.72 euros




Payments  of 80% demanded of the UK in 2007

4162.22 euros

Not known

Not known

Not known

Global sum requested by France

139,123,616. euros

(over £102 million)




 % Care cover provided







Numbers of pensioners provided

About 34,000 (2006 – now over 49,000)





Payment demanded by  the UK of France (sums would be the same for any other EEA country.)


The £/euro exchange rate used it that of the French Tax Authority in 2007

£0.733378964 = 1 €

The DoH gave current exchange rates to me.

These distort the picture and indeed make things appear worse for the UK.

  Amount in £s /head

£3368.98  =

4594 euros

Payment of 80% requested  of France

£2695.2 =

3674 euros

Global sum requested


312685 euros

% care cover provided.


Numbers of  French pensioners provided





The method of calculation of the costs of health care is not at all transparent and therefore unaccountable by the recipient country.  The actual costs must be different.  It needs reform.



Summary.   It is apparent that  care costs vary hugely and also the care provided.

It is apparent that France asks 60% more than Spain and towards 90% more than Italy.

It is apparent that France offers less care cover than any large State in Europe and at a much higher cost.

Extraordinarily, we ask France for an apparent 80% of the average cost falling on the NHS and yet we give the French pensioner resident in the UK 100% cover.  (UK asks France 3674 euros for 100% cover)

In comparison we give the French Government  13% more per head for each British pensioner resident in France and the pensioner gets only 80% cover and has to find another extra 20% out of his own pocket.  [13%= 100*(4162.22-3674/3674)]   (France asks the UK 4162 euros for 80% cover)

It is quite extraordinary that the UK is, under this ancient EU regulation, required to reduce costs by 20%.   This unaccountable, opaque system of accounting needs reform.



The actual costs of health care in France for the British pensioner resident in France.

Introduction..   The first account below is based on personal records for health-care costs for myself and my wife jointly over the past ten years. I am 77 and my wife 74. [These records include some items ‘non-reimbursable’ purchased at the pharmacy. Therefore  a ‘<’ ‘less than’ sign is included in the figures below.]

For three years we carried a ‘top-up’ health insurance  (known as a mutuelle) We abandoned this  outlay because it was too expensive.  However after a spell in hospital in 2009 we subscribe again.  This now costs 105 euros a month for  myself and my wife.  The cost remains burdensome.


1.                              Costs based on personal records.

My figures below are converted from Euros to £s. at an assumed exchange rate of 1.14 euros=£1

From my records, between 2001 and May 2010 the total out of pocket expenditure on health care top-up costs was  <£7809  i.e about <£780 a year or in euros <889- FOR TWO PEOPLE.  i.e <444 euros per head.

If we assume that this represent about 20% of the true costs then one might say that the true health care costs are nearer to <£1950 or in euros <2223 per person per year.



            2.  Costs based on Actuarial Analysis.

The costs of top-up mutuelle insurance societies.

Again let us assume, correctly I think, that the Insurance Societies who provide the mutuelle support of 20% of the health care costs run an efficient system and  have their actuarial figures about right and also make enough to pay their staff and also create a  small profit.

They charge 105 euros a month (1260 euros per year) FOR TWO PEOPLE aged 77 and 74.

If this represents 20% of the true costs then the true cost of 100% health care per person is about 3150 euros  [5 x 1260/2]  (less if one were to discount organisational expenses and profit.)


The French State claims that the true 100% cost of health care for the elderly Briton is 5202 euros/year (2007)

Experience suggests it is <(less than) 2223 euros (averaged from spread over 10 years)

Evidence from an Insurance Society (2010) suggests 3150 euros. 80% would be 2520 euros.


The French State demanded 4162 euros in 2007 for 80% cover. This suggests that this supposed 80% figure exceeds the true 100% cost by over 1000 euros/person/year.


This is prima facie evidence that something is wrong.  If the French demand is out by only 1000 euros a year then the British Government is possibly being overcharged by something like 49 million euros (£42 million) a year to support the health care of all the British pensioners in France.

An added item.

It needs also to be added that the French State impose a tax on all payments for health. This is 1 euro for doctor’s visits and 0.5 euros for all pharmacy transactions.  These sums are paid by the person who is ill and not by the mutuelles.




It would not be difficult for the British Government to pay the actual health care costs of the British Pensioner in France.  The procedure would be extremely simple.  Every pensioner in France carries a ‘Carte Vitale’.  The costs of health care is administered through this vehicle.  The Social Security  have records of all ‘mutuelle’ agreements for the pensioner.  The Social Security offices charge the 20% top-up directly to the ‘mutuelle’.

[If one were to use any private ‘non-conventionné  doctor  or non- reimbursable medicine then these costs would NOT pass through the Carte Vitale system.  There is no danger that such expenditure would pass to the UK.]


Some mechanism already exists for transferring data in this manner.  If a British visitor [non-resident in France] uses his European Health Insurance Card (EHIC) the costs are transmitted eventually back to the UK.  .


It would be very simple for the French Social Security to possess some NHS code and charge the NHS directly all the costs  by means of electronic transfer.  The NHS would be treated by the French Social Security as a form of ‘mutuelle’ but paying 100% of the expenditure.  The ease and importance of the means of electronic transfer is emphasised in various introductory paragraphs (viz. page 3 item 3-4 & pp 39 et seq.) of the recently implemented Regulation 883/2004.



1.  The British Government would find the costs greatly reduced. Taking the 2007 figures of about 34,000 pensioners this saving would be somewhere between £24 million and £48 million.

On the 2009 figures of 49,000 the figure is somewhere between £49 million and £95 million.

Moreover the British Pensioner would save about 20% on his/her health care ‘top-up’ costs.


2.  The French State would have all costs paid for the health care of British resident pensioners and therefore could not complain.  This is the condition required by the new EU Regulation 883/04.  At the present time I am confident that the French State is being subsidised by the UK.


3.   The British Pensioner resident in France would not need a ‘mutuelle’ insurance and would save well over 1,000 euros  a year for a husband and wife.



Disadvantages  - NONE.


However, the French State will not be interested in energetically discussing a change.  It and its mutuelle Insurance Societies are benefiting unfairly from the current arrangements. 



It is no doubt an unwitting consequence of the complexity and inherent contradictions within EU regulations and agreements drawn up over 38 years that the current situation has arisen.  The UK and the elderly British Citizen are nevertheless overcharged.. 

The end to this situation whereby the United Kingdom is subsidising the French State and the French Insurance Companies [indirectly via the premiums of the British Old Age Pensioners] is to be welcomed.