When Europa Meets Bismarck

Université libre de Bruxelles Faculté de Sciences sociales et politiques – Département de Science politique

When Europa meets Bismarck

Cross-border Healthcare and Usages of Europe in the Austrian Healthcare System

Tome I

Dissertation présentée en vue d’obtenir le titre de Docteur en Sciences politiques et sociales

Par Thomas Kostera Sous la direction du Professeur François Foret

Membres du jury Prof. Ramona Coman, Université libre de Bruxelles Prof. Janine Goetschy, Université libre de Bruxelles Prof. Sabine Saurugger, Sciences Po Grenoble Prof. Dorte Sindbjerg Martinsen, Københavns Universitet

Année académique 2013-2014

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Contents

1. Introduction 4 1.1. Method, Case Selection and Structure 8 1.2. Institutional Regimes and Agency in a Bismarckian Healthcare System 15 1.2.1. Building Welfare Institutions and Healthcare Systems 15 1.2.2. Welfare States as Institutional Regimes 16 1.2.3. Bismarckian Welfare Regimes and Healthcare Systems 19 1.2.4. Actors’ Interests in a Bismarckian Healthcare Systems 22 1.3. European Integration and Cross-border Healthcare 24 1.3.1. European Limits to Member States’ Social Sovereignty 24 1.3.2. European Integration and Cross-border Healthcare 27 1.3.3. The EU as a Quasi-Federal Opportunity Structure in Healthcare 32 1.4. National Actors’ Usages of Europe 37

2. The Historical Development of the Austrian Welfare State and Healthcare System 45 2.1. The Creation of Social Insurance under the Austro-Hungarian Empire (1880s – 1918) 47 2.2. Social Insurance and Change(s) of the Political Regime (1918-1945) 53 2.2.1. The First Republic (1918-1934) 53 2.2.2. The Corporative State (Ständestaat) and Nazi Occupation (1934-1945) 57 2.3. Consolidation of the Welfare State in the Second Republic(1945-1980s) 61 2.3.1. Political Consolidation and the Role of Political Parties 62 2.3.2. Social Partnership 64 2.3.3. The General Social Security Act: Centralisation and Expansion of the Austrian Welfare State 65 2.3.4. The Welfare State and the Kreisky Era (1970-1983) 68 2.3.5. 15a Agreements: Cooperative Federalism in Healthcare since the 1970s 70 2.4. Austria and Initial Reforms of the Welfare State (1983-1995) 74 2.4.1. Political and Economic Transition (1983-1986) 74 2.4.2. Grand Coalitions and Ambiguous Welfare State Reforms (1986-1995) 75 2.5. Adaptations to Europe and Welfare State Reforms (1995-1999) 80 2.5.1. EU Membership and Welfare State Reforms 80 2.5.2. Europeanization Effects 83 2.6. Austerity and Reforms of the Welfare State during the 2000s 86 2.7. Interim Conclusion: the Different Phases of Welfare State Development 90

3. Dynamics in the Austrian Healthcare System: Governance, Funding and Provision 95 3.1. Austrian Healthcare Governance: a complex and fragmented System 96 3.1.1. Main Actors in Healthcare Governance 96 3.1.2. Inert Structures and Practices: path-dependent Governance Reforms 101 3.2. The Financing Structure of Austrian Healthcare 112

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3.2.1. Financial Flows and Actors’ Interests in the Healthcare System 112 3.2.2. The Financial Interplay between the national and the regional Level in Inpatient Care 117 3.3. The Provision of Healthcare in Austria and Cross-border Patient Mobility 122 3.3.1. The Structure of Healthcare Provision 122 3.3.2. Patient Satisfaction and Cross-border Patient Mobility 129 3.4. Interim Conclusion: Institutional Dynamics, Actors’ Practices and Cross-border Healthcare 138

4. Usages of Europe in the Austrian Healthcare System 143 4.1. Challenging Boundaries? Cross-border Hospital Collaboration and Regional Experiences 143 4.1.1. Cross-border Collaboration between Austria and Germany 147 4.1.2. Cross-border Collaboration between Austria and the Czech Republic 156 4.1.3. Lower Austrian Usages of Europe at European Level 163 4.1.4. Cross-border Healthcare: More of a Burden than an Opportunity for Regions? 167 4.1.5. Discussion: Regional Usages of Europe and Cross-border Healthcare 178 4.2. Usages of Europe by Corporate Actors and Patient Ombudsmen 188 4.2.1. Payers: Perception and Management of Cross-border Healthcare 193 4.2.2. Payers’ Usages of Europe 203 4.2.3. Providers: the Medical Profession and Cross-border Healthcare 209 4.2.4. Providers’ Usages of Europe at National and European Level 215 4.2.5. Patient Ombudsmen and Cross-border Healthcare 225 4.2.6. Discussion: Usages of Europe by Corporate Actors and Patient Ombudsmen 230 4.3. Interim Conclusion: Usages of Europe and National Boundaries 235

5. Austria’s Rejection of the EU’s Patients’ Rights Directive 243 5.1. Policy-Making at European Level 245 5.1.1. The European Commission’s Proposal 245 5.1.2. A Rocky Negotiation Process 248 5.1.3. The Final Text of the Directive 251 5.2. Position-Building in Austria 255 5.2.1. Coordination at Federal Level 255 5.2.2. Subnational Influence and Negotiating Austria’s Position at European Level 260 5.2.3. Interim Conclusion: Past Rejection and future Implementation 265

6. Conclusion 269

7. References 279 7.1. Primary Sources 279 7.1.1. Official and Public Documents 279 7.1.2. Newspaper Articles 285 7.2. Secondary Sources 286 7.2.1. Analytical Reports, Working Papers, Conference Papers 286

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7.2.2. Articles 288 7.2.3. Books and Book Chapters 293 7.3. List of interviews 304

Volume II: Annex (Interview Transcriptions)

List of Figures, Tables and Maps

1. List of Figures Figure 1: Wider Institutional context of the Austrian Healthcare System 95 Figure 2: Financing structure of the Austrian healthcare system 112

2. List of Tables Table 1: Resources for Usages of Europe 41 Table 2: Percentage of Austrian population covered by health insurance 66 Table 3: Reforms of the 1970s 68 Table 4: Ambiguous Reforms 1988-1993 77 Table 5: Reforms of the Structural Adaptation Acts (1995-1997) 81 Table 6: Welfare State Reforms of the ÖVP-FPÖ governments 87 Table 7: Historical Development of the Healthcare System 90 Table 8: Main actor groups in Austrian healthcare governance 101 Table 9: Healthcare Expenditure 1990-2010 102 Table 10: Structural reforms in the inpatient sector, 2005 reform 104 Table 11: Patient flows to / from Austria (inpatient and outpatient care) in 2009 131 Table 12: Most important diagnoses for EU patients in hospitals in Vorarlberg (2009) 133 Table 13: Percentages of Patients (inpatient care) with reimbursement by private health insurance in 2011 136 Table 14: Usages of Europe in Cross-border Hospital Collaboration 179 Table 15: Usages of Europe by Payers, Providers and Users 231 Table 16: Usages of Europe by Actors in the Austrian Healthcare System 236 Table 17: Usages of Europe by Austrian Healthcare Actors 271

3. List of Maps Map 1: Austria-Hungary in 1867 49 Map 2: The succession states of the Austro-Hungarian Empire 54 Map 3: Geographical position of the Austrian hospital (KH Braunau) and the German hospital (KH Simbach) 148

VII

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