This paper examines the actual (as opposed to potential) impact of European Integration on national healthcare systems as a result of rulings of the European Court of Justice (ECJ) with regard to patient mobility. It explains how the Europeanisation of healthcare systems through ECJ cases sets off a dynamic process of creative adaptation at the national level. Through leverage (and some learning) players alter the policies and politics of domestic healthcare systems. The rulings provoked a number of similar but far from identical responses across the Member States. These adaptation processes are not straightforward. Member States try to uphold their steering instruments as much as they can, whilst allowing patients to be treated abroad. Factors that may explain the considerable differences between the reactions of Member States - also between Member States with similar health systems - include the likelihood of an exodus of patients, the (mis-)fit between the EU and domestic level and the presence of reforms in the domestic system. The process of creative responses to EU law includes â€“ for Member States confronted with long waiting lists â€“ attempts to reduce the demand for exit, e.g. through contracting the domestic commercial sector. The study shows furthermore the agency by domestic players who draw legitimacy from the EU setting to reinforce their position (or acquire one) at the national level. It thereby confirms the assertion that the effects of these ECJ rulings regarding patient mobility go beyond the narrow issue of patient mobility itself and that it can have an important impact on the domestic care systems. As such this analysis illustrates the deregulatory dynamic of the applications of the free movement rules to healthcare, and therefore provides an example of negative integration.
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