3.2 Population coverage and basis for entitlement
Health is consolidated in the Greek Constitution as a social right. Among the principal health-related provisions are the following:
- all people are entitled to protection of their health and genetic identity (Article 5.5);
- the state cares for the health of citizens and adopts special measures for the protection of youth, old age, disability and for the relief of the needy (Article 21.3);
- people with disabilities are entitled to benefit from measures ensuring their self-sufficiency, professional integration and participation in the social, economic, and political life of the country (Article 21.6); and
- everyone has the right to work and the state provides for the social security of workers (Article 22.5).
At the present time there are two main principles of entitlement: one is entitlement on the basis of citizenship in the case of outpatient services provided by the ESY, and the other is entitlement on the basis of occupational status and insurance contributions for services which are provided and/or financed by insurance funds. Entitlement on the basis of citizenship involves two types of provider settings which both belong to the ESY: rural health care centres providing primary health care, and ESY hospital outpatient departments for both ambulatory care and emergency services. According to law, any Greek citizen (as well as any citizen of an EU country) can receive services at any outpatient department of an ESY hospital or at a rural health centre. In practice, any person from any country (excluding illegal immigrants) can receive care in these two provider settings.
Entitlement on the basis of occupational status and insurance contributions applies to all other provider settings. These include urban polyclinics owned by insurance funds, inpatient care provided by ESY hospitals and private providers (whether private practices or diagnostic centres or hospitals) contracted with insurance funds. Coverage for these services is provided only for insurance fund members and their families. Membership in the funds is compulsory, therefore there is no freedom of choice of fund, nor is there any competition among funds. Pensioners continue to be covered by the fund they belonged to while working, and pay in their own contribution. The unemployed belong to an unemployment fund financed by the central government budget, and are covered by IKA services for a period up to 12 months. There is also entitlement to services by virtue of being poor. The needy uninsured and the poor are entitled to free access to health centres and public hospitals. Citizens who fall into this group are means tested to ascertain entitlement and they receive from the prefecture authorities a document indicating their status.
Besides citizenship, occupation and need, ability and willingness to pay is another principle of access to health services in Greece. A person, whether covered by a health insurance fund or not, is free to choose a private health provider that is not contracted with a public third payer if he or she is willing to pay the cost directly. In addition, individuals, depending on their income, can benefit from supplementary PHI, where products and contractual arrangements differ according to the subscriber’s characteristics. The main programmes offered by private insurance include the coverage of outpatient and hospital expenses, cash benefits, disability income insurance and managed care programmes. Dental care, plastic surgery, ophthalmological services as well as pre-existing conditions are not covered.
Over the past two decades Greece has been transformed in terms of migration – changing from a source country to a destination country. After the rapid political changes of 1989, Greece became the destination of hundreds of thousands of immigrants from eastern and central Europe, the former Soviet Union and developing countries. In this context, the entitlement of migrants to health care was put on the health agenda. Immigrants who are documented and legally resident in Greece are entitled to the same access to health care as Greek citizens. Formal access to the free services of the national health system is dependent on registered employment and regular status. On the other hand, undocumented migrants are entitled only to access hospital emergency services for the treatment of life-threatening conditions and until their health has stabilized. They also have free access to primary health care offered in a small number of local authority settings and to services provided by NGOs. Asylum seekers are also entitled to the same access to health care as Greeks. However, until they succeed in obtaining asylum seeker’s status they are only entitled to emergency care, like undocumented migrants.
The establishment of the ESY aimed at comprehensive and universal coverage of the population based on the principle of equity. However, this objective has been achieved only partially due to the fact that there are still significant differences among health insurance organizations regarding the level of coverage (content, procedures and quality) and freedom of choice. Most insurance funds provide coverage for primary, secondary and pharmaceutical care, and in some cases also coverage for spectacles, and diagnostic and laboratory tests. IKA, the largest social health insurance fund, offers the most comprehensive package, which includes almost everything except cosmetic surgery. In addition, most of the funds provide income allowances for lost income due to illness, maternity benefits, spa treatment, and others.
Dental care provides a typical illustration of the wide variations in the range of services provided by social insurance funds. IKA beneficiaries are covered only for fillings, dentures and mobile prostheses provided by dentists in IKA polyclinics. OGA beneficiaries have very limited dental coverage offered by health centres (which are often poorly staffed) and public hospitals. Beneficiaries of some insurance funds visit contracted dentists, paying the necessary co-payments. In cases where the insurance fund offers a free choice of dentist, the beneficiary pays the dentist and is reimbursed by the fund, usually at rates lower than market prices.
In 2014 legislation was issued in an attempt to extend coverage to all uninsured Greek citizens and legal residents. However, the uninsured could claim free inpatient healthcare only if they could prove that they could not afford it and other bureaucratic procedures created barriers to access. In addition, the uninsured were still required to pay the same copayments for pharmaceuticals as the insured population, with negative effects for those in difficult economic situations. See Health Policy Update: The uncertain effectiveness of efforts to increase the accessibility of health care services (published 1/26/2015).
In an effort to do away with these barriers, the new government has recently abolished these measures and replaced them with new provisions. According to the new legislation, uninsured Greeks, expatriates, citizens of European Union Member States and of third countries, legally and permanently residing in Greece, who do not fulfill conditions for health coverage, as well as specific categories of people who do not have residency papers (such as pregnant women, refugees and minors) will be able to receive public health care and medicines without having to contribute to their cost from 1 June 2016.
The free cover includes clinical and diagnostic tests, hospital treatment, prenatal care, rehabilitation, transfer abroad for specialist treatment and the handing out of medicines and other consumables. Any individual earning less than EUR 2,400 per year will not have to pay anything for medicines or health care. This threshold rises for families, depending on the number of children they have. The National Health Services Organization (EOPYY), will be responsible for covering the cost of the free medical care.
Economou C., 2015. Barriers and facilitating factors in access to health services in Greece. WHO Regional Office for Europe, Copenhagen.
Joint Ministerial Decision A3(g)/GP/oik. 25132/2016, “Regulations to ensure access of the uninsured to the Public Health System”, Official Government Gazette, Issue B, No 908 / 4-4-2016.
Law 4368/2016, “Measures to speed up government work and other provisions”, Official Government Gazette, Issue A, No 21 / 21-2-2016.
From 2011 a user charge of €5 was imposed for visits to outpatient departments of public hospitals and primary health care centres. Exempted from this obligation were emergencies, holders of poverty booklets, patients with chronic diseases, political refugees and asylum seekers. In April 2015, this provision was abolished by the government and visits to National Health System primary health care units and hospital outpatient departments for those insured under the National Organization for the Provision of Health Services (EOPYY) are now free of charge.
Joint Ministerial Decision Y4a/oik.165114, “Determination of user charges for visits to public hospital outpatient departments and health centres”, Official Government Gazette, Issue B, No 2080 / 31-12-2010.
Joint Ministerial Decision A3(g)/GP/oik.23754, “Abolition of 5 euros payment obligation for visits to public structures of the National Health System”, Official Government Gazette, Issue B, No 490 / 1-4-2015.
In August 2014, a Health Minister's decision was issued enabling private diagnostic centres contracted with the National Organization for the Provision of Health Services (EOPYY) to impose extra co-payments, beyond the official level, on highly innovative diagnostic tests such as digitized radiographs or digitized mammograms. The result was an additional burden on the insured, particularly as the higher co-payments were arbitrarily determined by providers. In June 2015, a new Health Minister's decision repealed this provision.
Minister of Health Decision Y9/oik.70521, “Short-term and long-term measures for the control of the prescription and performance of diagnostic tests”, Official Government Gazette, Issue B, No 2243 / 18-8-2014.
Minister of Health Decision G3g/28034, “Amendment of Ministerial Decision for short-term and long-term measures for the control of the prescription and performance of diagnostic tests”, Official Government Gazette, Issue B, No 1021 / 3-6-2015.
Entitlement to health care in Greece is based on occupational status and social health insurance contributions. Due to the increase in the unemployment rate from 9.6% in 2009 (484,700 unemployed) to 27.5% in 2013 (1,330,400 unemployed), and especially of the long-term unemployed (from 195,669 in 2009 to 892,736 in 2013), as well as the severe economic downturn, 2.5 million people have lost their rights to public health care cover through becoming unemployed for more than two years or in the case of self-employed people, not having the financial resources to pay their social contributions (Hellenic Statistical Authority, 2015).
Apart from the insured, only those who were eligible for Poverty Booklets, ie. those who are poor and uninsured through having exhausted their social insurance right, had access to free access to public hospitals, medical services and pharmaceuticals. The basic eligibility criteria for a Poverty Booklet are a) permanent and legal residency in Greece; b) the lack of insurance and c) low income (annual family income not exceeding €6,000, increased by 20% for a spouse and every dependent child, provided that this income does not come from employment giving access to insurance.
As an additional measure to increase access to health care, in June 2014 two new ministerial decisions were issued, according to which coverage for inpatient care and pharmaceuticals will be extended to all uninsured Greek citizens and legal residents (and their dependents) who do not have social or private health insurance, are not eligible for poverty booklets, or who have lost their right to social health insurance coverage due to their inability to pay their contributions. These population groups will now be covered for:
(a) Inpatient care, free of charge, funded under public hospital budgets, provided that patients have received a referral from a doctor working within the National Primary Healthcare Network or from an public hospital outpatient department and the special three-member medical committee which will be set up in each hospital, certifying the patient’s need for hospitalization (Joint Ministerial Decision Y4a/GP/oik. 48985/2014).
(b) Pharmaceuticals, funded under the state budget, provided that medicines are prescribed by a doctor working within the National Primary Healthcare Network or a doctor working within a public hospital. Nevertheless, beneficiaries are required to pay the same copayments that apply for the insured (Joint Ministerial Decision G.P./oik. 56432/2014).
Despite the potential positive impacts of this legislation on increasing access to health care to the defined population groups, a number of countervailing factors may undermine its effectiveness (Economou et al., 2014):
- Beneficiaries must undergo means-testing procedures which are overly bureaucratic and can be stigmatizing;
- Beneficiaries are not exempted from co-payments for pharmaceuticals;
- The absence of information on the new measures and lack of awareness by citizens will hinder uptake;
- Until now, the Ministry of Health has not provided guidelines and clarifications to public hospitals on how to implement these ministerial decisions.
Economou C., Kaitelidou D., Katsikas D., Siskou O., Zafiropoulou M., (2014), Impacts of the economic crisis on access to healthcare services in Greece with a focus on the vulnerable groups of the population, Social Cohesion and Development, 9(2): 99-115. (Available at:http://www.epeksa.gr/assets/variousFiles/file_1.Economou-Kaitelidou.pdf)
Hellenic Statistical Service, (2015), Living conditions in Greece, Athens. (Available at:http://www.statistics.gr/portal/page/portal/ESYE/BUCKET/General/LivingConditionsInGreece_0115.pdf)
Joint Ministerial Decision G.P./oik. 56432/2014, “Specification of preconditions, criteria and procedures for access by uninsured and financially vulnerable citizens to pharmaceutical care”, Official Government Gazette, Issue B, No 1753 / 28-6-2014.
Joint Ministerial Decision Y4a/GP/oik. 48985/2014, “Specification of preconditions, criteria and procedures for access by uninsured and financially vulnerable citizens to hospital care”, Official Government Gazette, Issue B, No 1465 / 5-6-2014.
From March 2015, for medicines that do not have a generic and whose retail price is higher than the price reimbursed by the national health insurer, EOPYY, patients will need to pay both the formal co-payment and the full difference between the reimbursed price and the retail price, where the difference is up to €6. Where this difference is higher than €6, the excess amount is covered by the patient (50%), the drug’s marketing authorization holder as a rebate (30%) and EOPYY (20%).
Ministerial Decision G5/oik. 6931, “Pharmaceuticals pricing regulation”, Official Government Gazette, Issue B, No 3676 / 31-12-2014.