By Tamara Mathias
(Reuters Health) – British citizens with HIV who live in Spain could face serious healthcare challenges in the event of a no-deal Brexit, potentially risking public health at large, researchers say.
A no-deal Brexit could leave many patients with HIV or other chronic conditions in the lurch after 2020, authors Jean McHale from the University of Birmingham in the UK and Miguel Ramiro Avilés of the University of Alcalá in Spain wrote in AIDS, online September 26.
“We’re not scare-mongering. We’re indicating to patients that there are concerns (and) that it’s really important that there’s clarity,” McHale said in a phone interview.
At present, European Union law guarantees healthcare to British citizens residing in any other member state. Spain is home to nearly one-third of British nationals living in other EU countries. The UK government reimburses Spain for any health care costs, and Spain pays the costs for its nationals in the UK.
Under the withdrawal agreement negotiated between the UK and EU but rejected by the UK Parliament, that reciprocity would have continued. In a no-deal Brexit scenario, British nationals who obtain a residence visa to continue living in Spain will temporarily receive protection from Royal Decree-Law 5/2019, passed by the Spanish government earlier this year. But this guarantees healthcare coverage only for 21 months – through December 2020 – and will require reciprocity from Britain for Spanish nationals in the UK. Without a long-term bilateral agreement, HIV patients could still lose access to treatment, the authors warn.
“The UK and Spain have each taken steps to ensure that people living in each country can continue to access healthcare as they do now until at least 31 December 2020,” a spokesperson of Britain’s Department of Health and Social Care told Reuters Health by email.
“Our priority is to secure the continuation of reciprocal healthcare arrangements so UK and EU nationals have access to medical treatment in the same way they do now… Public health law in Spain protects the right to treatment for any HIV patient and this will be unaffected by the outcome of Brexit.”
The spokesperson also cited the National Health Service (NHS) page for Spain: http://bit.ly/2qvRUGh.
However, Aviles says that the spirit of Spanish law is to protect nationals of low-income countries who will be covered because their home countries do not reimburse their medical costs. He noted that in 2016, UK nationals living in Spain spent GBP 222 million ($288.05 million) on healthcare, while Spanish nationals living in the UK spent GBP 4 million ($5.19 million).
Without reciprocity and reimbursement, the Spanish NHS cannot afford this cost, he said.
For years, the Spanish National Health System has provided free access to drugs that reduce the AIDS virus to undetectable levels, which also prevents transmission to others.
If treatment becomes inaccessible, Brexit poses “not simply a serious problem for the individual patient,” the authors write, but a public health risk.
The UK is scheduled to leave the European Union at the end of October. The possibility of a no-deal Brexit remains high, as Britain’s politicians argue over whether to leave with a deal, exit without a deal or hold another referendum.
Tamara Hervey of the University of Sheffield, UK, who leads a research project on post-Brexit health governance, says this would be the “worst outcome” for patients and public health.
“Unraveling over 40 years of integration needs to be done carefully, with attention to all its facets,” said Hervey, who was not involved in the paper.
“Because ‘health’ is not regarded by the UK government as part of ‘trade’ or ‘security’, which is where the Brexit negotiations are being conceptualized, it is very difficult for the health messages to reach the appropriate governmental levels, or for government to act on them.”
Joaquin Cayon-De las Cuevas, an associate professor of health law at the University of Cantabria in Spain, agrees.
“The public agenda has been mostly focused on political, territorial and commercial issues,” he said.
“As far as I know, there are no particular public health insurance programs that can facilitate treatment access. I am afraid the subscription of a private health insurance will end up being the only absolutely safe guarantee.”
After Brexit, patients will need to buy expensive private insurance or subscribe to the Spanish national health service, but this would not cover medicines administered outside of hospitals, the authors note.
They estimate the average annual cost in Spain to treat HIV is 7,923 euros ($8,680).
The UK government’s “get ready for Brexit” information campaign simply advises travelers to make sure their health needs are covered by insurance, without details on whether such insurance will be accessible, Hervey said.
Outlining a possibility not considered in the paper, she added, “Spain could … unilaterally declare that … it recognizes the provision the UK has made for Spanish nationals in the UK to access treatment as sufficient reciprocation.”
Cayon-De las Cuevas is hopeful that an agreement will be reached.
“My fear is that the political reaction might occur too late, when there has already been damage to patients,” he said.