Political Economy of Migrant Health Care in the Czech Republic ****************************************************************************************** * Daniela Pěničková ****************************************************************************************** Článek v PDF ke stažení [ URL "LM-818-version1-penickovapolitical_economy.pdf"] The present time is marked by flux in the conceptualization of social relations and the or health care. The last couple of decades have witnessed fundamental changes in health insur worldwide. Despite the fact that Western European countries have experienced an unexpected problems with their systems of social insurance combined with the private sector, the post countries have largely followed the suit of adopting private-sector reforms to their forme health care systems while keeping the concept of national health care. However, the privat policies adopted by some of the post-socialist governments directly breach basic human rig conflict with the current EU non-discriminatory principle of foreign law. They are, in fac as primary boosters not for private but for national economies. In the Czech Republic this played out by state policies towards migrants from non-EU countries. While general health available to all EU citizens and migrants with permanent residency, migrants from non-EU c not have the status of an employee or who are students not covered by international agreem from participation in the Czech national health care system. Drawing on the author’s ethno out among Russian-speaking migrant parents living in the Czech Republic and on case studie gathered by the Consortium of Migrants Assisting Organizations in the Czech Republic (of w a member), this contribution opens a crucial debate on the process of individual responsib becoming enmeshed with privatization and commodification of health care based on ethnicity status. The phenomenon of migration in the Czech Republic has gained a new significance since the political regime in 1989. In 2012 the Czech Statistical Office registered close to 438,000 in the country. Only about 160,000 migrants come from EU member states.[1] This means that 64% of all migrants come from countries outside the EU – the so-called third nations. Abou people are migrants with permanent residency and their number has remained relatively stab past several years. The rest are foreigners with a long-term residency visa – a population annually. Therefore, the socio-economic and cultural integration of this pool of migrants the major focuses of immigration policies. The integration policy in the Czech Republic ha three stages that have some bearing on the development of the migrant health care policies Baršová and Barša’s analysis (2005: 231–237), the first stage (1990–1998) spurred out of s changes in Europe when the Czech Republic repatriated some 1,800 Volynian Czechs in the ye from the Ukrainian and Belorussian areas, especially those affected by the Chernobyl nucle explosion of 1986 on the Ukrainian side. The second stage also included the period of the (1992–1995) when close to 11,000 people found temporary refuge in the Czech Republic. Cons stage was marked by providing immediate medical assistance to the Bosnian and Herzegovinia and victims of war as well as temporary housing, courses in the Czech language and oriente Czech Republic. This period was formative for the later creation of bilateral agreements i covered health care for citizens of selected countries. For example, people from the forme currently reside in the Czech Republic can participate in the national health care system country is not part of the EU. It was not until the second stage (1999–2003) that a more holistic integration strategy on level was formed, including more specific roles of individual ministries and state departm the first time in the post-communist era state funds were allocated to the building of the non-governmental sector and the first NNOs were founded. The government approved a seminal defining the principles of the integration policy for the Czech Republic.[2] These princip developed in the official Conception for Migrant Integration in the Czech Republic that wa The Conception defines the specific measures in all the areas of integration (i.e., reside citizenship eligibility, migrant political participation, employment and entrepreneurship, and health care insurance, education, minority rights, and preservation of distinct tradit The third stage (2004–present) saw the incorporation of an additional factor into the inte the European Union guidelines that were approved in 2006 as part of an amendment of the 19 Law. This process encouraged a more systematic approach to immigration issues and several documents were passed by the government targeting the most pressing issues identified rece during the previous stages (Dorůžková 2007: 31–32). For instance a large-scale study title the socio-economic status of long-term residency foreigners was initiated, as well as upda Conception for Migrant Integration in the Czech Republic. The updated version of the Conce included a section calling for improvement in areas of failing integration practices (Jelí One of the major areas listed in Czech governmental Resolution #126 of the year 2005 was t of third-country nationals to participate in the Czech public health care system, includin family members and children. In August 2008, the Czech Ministry of Interior assumed back t for coordination of realization of the updated Conception overtaking the role of the Minis and Social Affairs (note: the Ministry of Interior originally handled immigration policies Ministry of Labor and Social Affairs was appointed to take over the responsibility in the synchronize the process of integration policies among NNOs and all appropriate departments Ministry of Education, Youth, and Sports, Ministry of Regional Development, Ministry of Cu of Commerce and Industry, and Ministry of Health. All departments are to abide by the prin called integration mainstreaming, which is a policy approved in the third integration stag each department’s policies, regulations, and measures need to be evaluated in terms of the impact on the integration of foreigners. This goal, however, remains highly underachieved mere lip service paid in order to satisfy the EU’s standards in migrant integration policy migrant exclusion from the state policy of public health care access stands out as a strik integration mainstreaming failure. The integration mainstreaming has been adopted to prop up the harmonization of EU prioriti socio-economic needs. In relation to the domestic interests, one of the roles that migrati by long-term governmental planning is to balance out the Czech demographic structure in te ageing population, due to which the state will inevitably struggle with ensuring a large e working people actively contributing to the national social security system in the near fu 2005). Additionally, since 2000 the Czech government has announced its intention to increa of migrants with higher and/or specialized education. In order to achieve this goal, the p amendments to the current immigration policy especially needs to focus on migrants in acti interest in staying in the Czech Republic. This involves people applying for citizenship a applying for permanent residency and a long-term residence permit (for 12 months and longe from the other EU states have basically the same rights to employment and residency as Cze are not typically included in integration policies, like asylum applicants, whose situatio by the State Integration Program, which complies with the EU provisions and unlike the reg programs it includes state funding for housing. While the state recognizes that the target long-term residency non-EU migrants and has come up with the Four Prioritized Areas of Int them – including (a) Czech language proficiency, (b) economic self-sufficiency, (c) socio- sufficiency, and (d) integration into the mainstream society – it is not making adequate p to achieve them. The following text that analyzes the impact of excluding people that belo vulnerable population groups in the state from the national public health care highlights gaps between theory and practice in Czech migration integration policy that characterizes this area. Having valid health insurance is one of the preconditions of being eligible for a long-ter residency permit. Upon request by the foreign police and associated law enforcement offici foreigner in the Czech Republic is required to present his/her current health care coverag during the stay in the country. This requirement is fulfilled either by obtaining national or commercial health care coverage. In addition, the (emergency) commercial health care co purchased from one of the Czech-Republic-based private companies.[3] Which one of the two cares is accessible to a migrant solely depends on his/her residential and employment stat participate in public health care only if he/she is a resident of another EU country, or i already obtained permanent residency. The other criterion of eligibility for national insu employed by a Czech employer. In all other cases migrants have to purchase commercial cove that equal rights to access public heath care are applied only to Czech and EU residents a members. Third-country nationals who are not employed by a Czech company or institution ca country legally only if they become clients of one of the private health insurance compani currently represented by six main players who monopolize the Czech field of private health PVZP a.s., Uniqa a.s., ERGO a.s., Slavia a.s., Axa Assistance a.s., and Maxima a.s. In pra are left with only this choice are all third-country nationals who are self-employed, entr study in Czech or attend Czech-based schools. Most importantly, this group includes all fa often come to the country under the “Family Reunification Act” and are dependent on one br the family. Typically these are wives and children of current or former guest workers, tea scientists, or small business owners. The majority of them come from Vietnam (as the Vietn the largest network of self-employed foreigners in the country), Ukraine, Russia, Moldavia China, Kazakhstan, Belorussia, and the United States.[4] A selection of foreign countries bilateral agreements thanks to which residents from these countries fall under a special g program covering their health care. These include quite numerous migrants from Bosnia and Serbia, Croatia, and other former Yugoslavian countries whose residents form rather minisc in the Czech Republic, also Japan, Israel, or Turkey. While statistical data on the number depending on commercial health insurance coverage are scarce and inconsistent, the figures ČR (the largest national and commercial health insurance company in the country) in 2007 a Statistical Office in 2008 were 100,000 – 130,000 people. The most recent figure stated by collective in the Analysis of Commercial Health Insurance for Foreigners written for the C Migrants’ Rights is 100,000 people (Hnilicová et al. 2012: 6). While the requirement of mandatory commercial health insurance can be met by the purchase coverage neither of them is conducive to the larger governmental goal of creating viable l for migrants interested in permanent residency and/or migrants with higher and/or speciali nor are they meeting any of the Four Prioritized Areas of Integration. Instead of promotin self-sufficiency they turn dependent family members into an economic burden on those famil are legally employed or discourage them from participating in the benefits of the Family R Act altogether, especially if a family is presented with no choice but to shell out dozens Czech crowns to buy basic health insurance for two or more children. Instead of creating a of belonging, the current immigrant health care provision divides Czech society into segme and EU citizens enjoy first class citizenship, employed third-country migrants are second unemployed family members are third class citizens. The first type of commercial insurance complex health coverage that is currently provided only by the PVZP company (a commercial main national health insurance company VZP ČR). This insurance is costly and can be afford percentage of migrants. For example, a 36-year old Russian mother interviewed for this stu Prague with her husband six years ago from Kazakhstan and who was pays 38,000 CZK every tw six-year-old son to ensure he has complex health care coverage. From her first marriage sh old son for whom the family can afford to pay only emergency health care coverage that is CZK for two years: “When my older son came down with a viral infection the other month,” t shared, “the doctor told him that there was nothing he could do for him (unless he paid fo of pocket). Luckily I came down with the virus first and have better health coverage, so I antibiotics and finished treating my strep throat during our summer vacation back in Kazak can buy antibiotics over the counter.” She smiles: “It is very easy to buy antibiotics in Union. People bring dozens of boxes with drugs with them here.” Not everyone can afford to buy complex health coverage for all members of their family. Ra a personal choice, people are often left with no other option but to buy just emergency he coverage and when they are hospitalized with cases of chronic disease complications they a leave large debts with the hospitals. In recent years the total annual debt made by the in the costs of health care as well as by commercial insurance companies’ refusal to compensa for their health service despite initial approval to go ahead with the treatment,[5] amoun 44 million CZK) of all cost of migrant health care on average (e.g., 10.4% in 2007, 7.9% i 2009, and 6.9% in 2010).[6] A part of this amount is legally mandated treatment of patient infectious diseases, such as TB and STDs.[7] The commercial insurance companies have the r any client and typically they do not insure (or only partly) a person with a severe chroni somebody suffering from a condition that is likely to progress. Thus a refusal on the basi conditions is a common practice and a source of producing a pool of so-called “uninsurable who are often children, single parents, or persons who suddenly lost their job. Once migra cannot afford to purchase health insurance for one or more of their children or they are d commercial company, they are faced with the complicated decision either to stay and risk t of their child/children or leave the country – whether to relocate the entire family or sp members. Another precarious type of situation in which migrant parents can find themselves have a prematurely born child or the child is born with defect. The social and economic im discriminatory policy is illustrated by the narrative recorded by Ukrainian parents: “Our son was born prematurely by several weeks. He had to be placed in an incubator in one hospitals. We wanted to sign a contract with the PVZP health insurance company to cover hi The company refused and told us they were not in a position to pick up the cost of his pro health care. The hospital bill grew by each day our son was in the Prague hospital amounti of 1,386,000 Czech crowns. We paid all we could but are in no position to cover this expen help to several non-governmental and humanitarian organizations. Some of them had no advic lady eventually told us to apply for long-term residency for our son for humanitarian reas months of stress and fear of having to move out of the country and being persecuted we obt hospital, however, has just sued our son for the unpaid expenses …. “ Besides the threat of being refused coverage because of pre-existing conditions, commercia including the complex type – does not cover relatively frequent health conditions with whi can lead an active life provided that they have access to quality health care. These inclu with insulin treatment or hemodialysis to name the more frequent ones, but also HIV and AI (unless contracted or discovered in the country – then the treatment is mandated and cover The standard list of covered procedures typically excluded therapies in any kind of specia institute or sanatorium, which means that institutional therapeutic programs for people wi substance abuse problems are exclusively marked off for Czech and EU citizens only. The co health care packages include some psychotherapeutic treatment but only when provided by re The burden of complying with the requirement of commercial health care is further deepened that most agreements between the company and a client are signed at least for one but more two years, which means paying at least 26,000 crowns for one family member for only emerge coverage (for the duration of two years). The insurance companies require the payment of t at once upon signing the contract. The network of doctors contracting with the six commerc companies is very small and migrants are thus limited in their choices and forced to seek a suitable doctor ahead of time, in fact, as a kind of preventive measure in case of possi illness. This creates an environment open to corruption on behalf of the relatively few do foreigners.” A Russian-speaking entrepreneur from Kazakhstan shared her personal experienc “When I was pregnant and needed to enroll with a doctor for prenatal care, the man who was me by friends, because he was Russian, worked in Motol hospital. He smiled and said that h on for 1,000 CZK paid in cash to him for each visit on top of my health coverage. He said know that he had a large clientele and did not take everybody!” When asked whether she agreed to pay the Motol obstetrician the regular extra “fee,” she r “Yes, at the beginning I paid this money. A couple of visits. Then I needed to travel back and I needed a medical certificate that I was all right to travel. I was seven months preg to make sure I was okay to do it. I called him to make an appointment. He told me that I d to come in at all, that his nurse would give me the certificate upon payment … of the 1,00 decided to change doctors. I found a Czech doctor who spoke Russian. He had his clinic out but that was ok. He did not ask for any extra “fees” but our agreement was that he was the the baby and his private clinic was going to be paid $1,000 for the birth. It was part of made (Note: The interviewed mother had relatively luxurious PVZP health coverage where her $2,000 for a special pregnancy program on top of the regular PVZP fees). When I was close needed to travel abroad for a holiday. To speed up the due date he painted this black scen can happen during vaginal birth and I got so scared that I agreed to have a …. what do you section.” Two of her friends had a similar experience with paying their gynecologists this “personal case a Czech female doctor in Prague 5 charged 500 CZK that went directly to her pocket an Czech female gynecologist in Prague 1 asked for 600 CZK each visit without providing her R from Kazakhstan with any receipt. The growing numbers of similar narratives illustrate the economic negative consequences of excluding a group of people from the public health care the profit of commercial insurance companies grows by astronomic figures (for instance, in collected 56 million CZK more in insurance premiums than in the previous year[8]; the tota from selling commercial insurance grew between the years 2008 and 2011 from approximately CZK to 450 billion CZK), the growth of the extent of the coverage reflects a disproportion change (the costs that the PVZP insurance company had to pay annually grew only from 6% to collected sum between the years 2008 and 2011) (Hnilicová et al. 2012: 29–37). More import policy clearly produces a social and economic hierarchy of higher and lower class foreigne EU migrants as worthy of stress-free participation in national health care while using non a source of income and support for the national health care system while barring them from This is carried out in a publicly open way when the 2010 Annual Report of the PVZP company of the Board of Directors stating that the 2010 “historically most successful” monetary ga “insuring foreigners”.[9] A portion of the PVZP income is periodically allocated back to p pool of the VZP ČR’s capital. The discriminatory policy of the requirement to purchase com insurance is in direct conflict with the previously mentioned principle of integration mai approved by the Czech government during the third integration stage. It was no later than updated Conception for Migrant Integration in the Czech Republic identified the inability the national public health care system as one of the principle obstacles in the process of integration of third-country nationals.[10] The governmental resolution in which this iden was made also appointed the Czech Ministry of Health to formulate recommendations for a le change that would allow children and youth under 18 and self-employed migrants who are hol term residency visa to participate in the public health care system. The data for the reco were to be gathered in collaboration with the Institute of Health Policy and Economy found second integration stage in 2000. However, the Institute was closed down by the decision o of Health’s leadership (lead by David Rath at the time) and up to this date the criteria o eligibility to enroll in the Czech national health system remain the same. In June 2014 a group of deputies of the Czech Republic lead by Jaroslav Krákora submitted new amendment to the existing law of mandatory commercial insurance (Krákora et al. 2014) controversial and adamantly resisted by the Consortium of Migrants Assisting Organizations Republic and other institutions. While it calls for commercial insurance companies’ accept clients to be obligatory, the opponents state that this obligation can be easily avoided b high premiums that migrants will simply not be able to pay. The opponents are further conc proposal to extend the ability of insurance companies to define exceptional cases in which right to refuse to compensate health-related costs and to establish a minimum annual insur by migrants to be 25,000 CZK per person (Čižinský 2014). This, they rightfully claim, may catastrophes for migrant families with multiple children and lower income. At the time of article, the jury is out on whether or not the bill will pass. The development can be foll page of the Consortium of Migrants Assisting Organizations in the Czech Republic specially campaign for equality in migrant health care: www.zdravotnipojitenimigrantu.cz. All in all of the medical health care system for migrants coming to the Czech Republic from non-EU co as a point in the social science call for the need to deconstruct market-based medicine by assumptions about international heath care, risks, choices, and responsibilities that unde insurance industry. Only through such a process can we determine how the inefficiencies an of market economy-based medical care are created and reproduced. With the increasing numbe worldwide and within the EU region every year, the need to evaluate how old and new social disparities in quality health care access are enacted becomes essential. Daniela Pěničková, researcher at Multicultural Center Prague; lecturer at the School of Hu Social Sciences at Anglo-American University in Prague. [1] Czech Statistical Office. 2013. Foreigners in the Czech Republic 26–63. [2] The document is titled Zásady koncepce integrace cizinců na území České republiky/ Pri Conception for Migrant Integration in the Czech Republic. [3] This law amendment was passed by the Czech government in 2009 and clearly reflects Cze insurance companies’ self-interest in gaining a monopoly in the sector of selling commerci health care coverage equaling travel health care coverage. The argument given for passing that foreigners often buy travel insurance abroad from unreliable or fake companies and in and need to use the insurance no or limited expenses are covered for Czech hospitals. [4] Czech Statistical Office. 2010. Foreigners in the Czech Republic 32–35. [5] Hnilicová, Helena and Karolína Dobiášová. 2009. “Zpráva o stavu zdraví a zdravotní péč ČR“, p. 14-16, www.zdravotnípojistenimigrantu.cz. [6] Czech Statistical Office. 2008-2001. Foreigners in the Czech Republic (Chapter 6). [7] The Act about Public Health Protection #205 and #258/2000. [8] Annual Report of PVZP a.s. 2010. Commercial Activities, p. 8. [9] Annual Report of PVZP a.s. 2010. Commercial Activities, p. 8. [10] Resolution of the Government of the Czech Republic # 126/2006. Zdroje Baršová, Andrea and Pavel Barša. 2005. Přistěhovalectví a liberální stát. Imigrační a inte USA, západní Evropě a Česku. Brno: Masarykova Univerzita v Brně Čižinský, Pavel. 2014. Připomínky k poslaneckému návrhu Zákon o soukromém zdravotním pojiš – Sněmovní tisk 243. Praha, [online]. Available at: http://migraceonline.cz/cz/e-knihovna/ predlozili-navrh-zakona-o-zdravotnim-pojisteni-migrantu-nahravaji-tak-komercnim-pojistovna Dorůžková, Lucie. 2007. Vzdělávání dětí cizinců na základních školách v České republice (d Praha: Katedra veřejné a sociální politiky FSV UK. Jelínková, Marie. 2006. Koncepce integračních politik (diplomová práce). Praha: Katedra ve politiky FSV UK. Hnilicová, Helena et al. 2012. “Analýza komerčního zdravotního pojištění cizinců.” [online www.zdravotnipojistenimigrantu.cz Hnilicová, Helena and Karolína Dobiášová. 2009. “Zpráva o stavu zdraví a zdravotní péči pr Pp. 14-16 [online]. Available at: www.zdravotnípojistenimigrantu.cz Horáková, Milada. 2005. Proměny trhu práce v České republice po roce 1989 se zřetelem na p Praha: Výzkumný ústav práce a sociálních věcí. Krákora, Jaroslav et al. 2014. Zákon o soukromém zdravotním pojištění cizinců na území Čes a o změně zákona č. 326/1999 Sb., o pobytu cizinců na území České republiky a o změně někt Praha: Sněmovní tisk 243/0, část č. 1/4 [online]. Available at: http://www.psp.cz/sqw/text O=7&CT=243&CT1=0 Daniela Pěničková [ URL "LM-296.html "]