1 Introduction

European citizenship guarantees freedom of movement within the EU and equal access to social rights for EU citizens.Footnote 1 Yet, post-recession intra-EU flows from Southern to Northern European countries have challenged the overall acceptance of the freedom of movement as inherent to EU citizenship and equal access to welfare. The mobility of young Southern (and Eastern) European workers started to be perceived as a burden by destination countries. In 2013, German, Austrian, Dutch and UK representatives complained to the European Commission that intra-EU migration “burdens the host societies with considerable additional costs, in particular caused by the provision of schooling, health care and adequate accommodation” (Mikl-Leitner et al., 2013). Since then, scholars have addressed the challenges of post-crisis intra-EU mobility to alert against the limitations of freedom of movement as a constitutive element of EU citizenship (Bruzelius et al., 2017; Engbersen et al., 2017; Lafleur & Stanek, 2017) or to nuance both theoretically and empirically the instrumental uses of EU citizenship (Finotelli et al., 2018; Harpaz & Mateos, 2019). Legal restrictions to social rights went along with exclusionary practices towards “unwelcome” EU citizens from Southern and Eastern European Member States (Perna, 2018). Social rights retrenchments within the EU citizenship regime are currently a reality in several EU countries contributing to the growing awareness of EU citizenship as a citizenship with shrinking social rights (Barbulescu & Favell, 2020).

Interestingly, the debate on European citizenship as a source of equal access to welfare has mainly revolved around labour mobility among Southern and Eastern European workers in Northern Europe (Trenz & Triandafyllidou, 2017; Barbulescu, 2017; King et al., 2017). After having been addressed as transit countries for asylum seekers and hotbeds of irregular migration, Southern European countries were rapidly stigmatised as sources of unwanted EU-citizens. By contrast, non-labour motivated mobility of (mostly elderly) EU migrants and its welfare impact have largely been side-lined by the scholarly debate with few exceptions (Thym, 2015; Bruzelius et al., 2017; Finotelli, 2021). In other words, scholars have mainly addressed the question of how the retrenchment of intra-EU mobility rights has affected Southern Europeans en route to Northern Europe rather than the impact of Northern European intra-EU migrants in Southern Europe. But what about the non-labour-motivated mobility from Northern European countries in Southern Europe? To what extent is it perceived as a welfare burden for Southern European countries?

To answer these questions, this chapter analyses the relationship between intra-EU mobility and welfare chauvinism by focusing attention on the mobility of Northern EU citizens in Southern Europe, who are motivated by factors other than labour, and who have traditionally been welcomed in their new countries of residence. In line with the concept of regime proposed in the introduction of this volume, the aim of the chapter is to show how the perception of intra-EU migrants as “welfare scroungers” has contributed to modify the mobility regime of intra-EU citizens through restrictionist legislation changes and local practices, and hence control the freedom of movement and its consequences as a constitutive element of EU citizenship.

To do so, the following pages address the provision of healthcare assistance to intra-EU retirees in Spain, as one of the main categories of non-labour-motivated movement in the EU. The choice of Spain as a reference case is due to its relevance as a destination country for intra-EU retirees from Northern Europe (King et al., 2000; Casado-Díaz, 2006; Gustafson, 2008; Huete et al., 2013). As Finotelli (2021: 609) noted, “The EU is not only a space of freedom of movement, but also of freedom of retirement” in which Spain has the lion’s share with the largest population of non-native Europeans over 65 in Southern Europe (Eurostat, 2016). In addition, the Spanish healthcare sector is a tax-funded healthcare system which provides healthcare on a universal basis. Against this backdrop, analysis of the Spanish case will show that intra-EU retirees as healthcare users in Southern Europe can be perceived as a welfare burdens who challenge the equity of the welfare regime and therefore legitimate restrictions in the access to social rights.

The majority of the analysis is based on a review of the local newspaper articles, official documents and parliamentary memos. The chapter is divided into four parts. The first section provides an overview on retirement migration in Spain as it has been addressed in the literature. The second part addresses the evolution of the public perception on the presence of intra-EU retirees in Spain in particular in regard to their use of healthcare services. The third part analyses the modifications of the legal framework currently regulating access to healthcare provision for EU citizens in Spain while some considerations about the relevance of intra-EU mobility to better understand the welfare-migration nexus are provided in the fourth and concluding part of the chapter.

2 Intra-EU Retirement Migration in Europe and in Spain: An Overview

International retirement migration does not represent a type of mobility aimed at improving individuals’ opportunities by inclusion into welfare (Bommes, 1999; Sciortino & Finotelli, 2015), but rather a type of mobility aimed at improving individual well-being (King et al., 2017). In contrast to other forms of migration, international retirement migration can be seen as the consequence of an excess of resources, rather than of a shortfall of them (King et al., 2000; Warnes et al., 2004). Moreover, international retirees are seen by destination countries as a group of migrants with great economic potential. In the last few years, Southern European countries have implemented measures to attract wealthy Northern European retirees through tax reductions or the construction of senior housing in attractive environments. This, of course, has caused certain discomfort in countries of origin and destination. For instance, the favourable Portuguese taxation regime for non-residents was sharply criticised by the Portuguese public, while the Swedish and the Italian governments scolded their own retirees for searching for tax benefits in countries such as Portugal (Cottone, 2017; Smith, 2020). Nevertheless, the fact that international retirees are intra-EU migrants who take advantage of a favourable institutional environment has certainly diminished the research interest for the welfare challenges represented by this group of migrants. Indeed, international retirement migration has been traditionally explained from the perspective of the tourism-migration nexus. The motivations of residential tourists are mainly related to the search for a warmer climate and a desire to improve their own health conditions (King et al., 2000; Rodríguez, 2001); this has turned international retirement migration into a particularly extended form of lifestyle migration (Benson & O’Reilly, 2009; Janoschka & Haas, 2013). International retirees are considered “active migrants” who search for gratifying experiences abroad, rather than vulnerable migrants at risk of becoming dependent on welfare services such as healthcare and long-term care in their country of residence. In these studies that analyse international retirement migration, tourism rather than the aging process plays the crucial role.

In contrast to tourism, the welfare-migration nexus is a rather under-researched angle in the field of international retirement migration. Scholars have started to analyse how elderly migrants deal with their vulnerability when they enter their “fourth” age (Cela & Fokkema, 2017; Ciobanu et al., 2017). However, very few researchers have studied how this applies to international retirees. Some scholars have analysed how poverty or illness encourage a return to the country of origin (Dwyer & Papadimitriou, 2007), while others have rather focused on transnational practices to solve the contradiction between the obligation to have only one residence for fiscal and legal purposes and flexible forms of individual mobility (Ackers & Dwyer, 2002; Horn et al., 2013). Analyses of the welfare-migration nexus in the case of international retirement migration have mainly used Spain as a reference case due to its long history as destination of intra-EU migrants and the progressive aging of its population of international retirees. As a matter of fact, with respect to the age structure, the share of retirees older than 70 years have increased between 2008 and 2019. This means that more and more of those retirees that were formerly considered residential tourists are bound to become people with an increasing need of healthcare and care services (Finotelli, 2021). Most of the works on the welfare migration nexus focus on British retirees in Spain since they represent the largest and less concentrated group of retirees in Spain. Some researchers have already started to focus on the physical vulnerability of British retirees and possible return strategies (Huete et al., 2013; Giner-Monfort et al., 2016), while a smaller group of researchers has looked at what happens to those who decide to stay in Spain despite worsening health conditions (Ahmed & Hall, 2016; Hall & Hardill, 2016). Yet, most of the currently available works on the welfare-migration nexus focus on the use that retirees make of welfare services and their satisfaction with the Spanish healthcare system (Betty & Cahill, 1999; Legido-Quingley & La Parra, 2007; Coldron & Ackers, 2009; Legido-Quigley et al., 2012; Calzada, 2018). Others have analysed how international retirees rely on affordable private welfare providers such as migrant care workers (Gavanas & Calzada, 2016), charity organisations (Haas, 2013) or transnational practices to obtain social protection (Schriewer & Rodes, 2008; Gehring, 2015). However, there is a persisting research gap about the social and institutional impact of international retirement migration and retirees’ growing welfare dependency in the countries of destination.

2.1 The Healthcare “Scrounger” Stereotype

The Spanish healthcare sector provides healthcare on a universal basis and is mainly financed through tax allocations and allocations from general state budgets. No arrangements are made for co-payments for certain services in the Spanish healthcare sector, while the quality of the services provided is still perceived as satisfactory by a large part of the Spanish population (OECD, 2016). That is why the spending cuts enacted during the Great Recession did not affect positive attitudes regarding the public healthcare system among the population (Petmesidou et al., 2014). Yet, the Spanish population’s positive attitude did not prevent growing discomfort among the public towards intra-EU retirees as beneficiaries of the Spanish welfare regime, and particularly its healthcare regime. Healthcare access of international retirees in the previous years had been an object of relatively little attention by scholars and the general public. At the end of 1990s, research conducted in the Province of Alicante, one of the most attractive regions to EU retirees showed that at least the half of the interviewed immigrants, including EU retirees, visited a doctor no more than once a year, while this was not the case of natives who visited their doctor more often (Ferrer Cascales et al., 1997). Such findings were in line with the fact that most EU retirees at the time had not reached their “fourth” age, where healthcare and more general care needs start to appear. However, in the first decade of the new century, new types of healthcare patterns among intra-EU retirees started to emerge. It was, for instance, observed that intra-EU retirees residing in Spain often require more costly treatments in comparison to other categories of migrants as they are more exposed to chronic diseases due to the progressive aging of this group (Fernández Molina, 2005; Pi, 2007). But it is only in concomitance with the Great Recession that the perception of intra-EU retirees as a welfare burden enters into the Spanish public debate. In 2009, a report by the General Council of Nurses questions, for instance, the large number of hip-surgeries and by-pass surgeries in the hospitals of the Costa del Sol received by German and Dutch citizens (Nexotur, 2009). The same report refers to alleged “trickeries” implemented by many EU-retirees to circumvent EU legislation in order to be treated in the Spanish healthcare system, such as for instance a sudden attack related to a pre-existent illness to be attended by a Spanish hospital. According to the President of the Trade Union of Medical Doctors of the Autonomous Community of Valencia, “picaresque” is widespread and “many citizens, foremost Europeans, arrive in Spain not only attracted by sun and beach but also by the ‘good reputation’ of its healthcare professionals” (Martín Plaza, 2009). The stereotype of Spain as “Europe’s retirement home” and as “incomparable surgery paradise” for European tourists arriving in Spain to enjoy sun, sand and high-quality medical treatment turns into a frequent topic in the Spanish public debate. Intra-EU retirees start to be represented as a burden for the Spanish healthcare regime fuelling the perception that healthcare provision for natives could be at stake. The President of the Nurse Council argues that a foreigner older than 65 is a healthcare consumer by default for whom the Spanish healthcare regime is not prepared (Nexotur, 2009). Likewise, the President of the Autonomous Community of Extremadura claims for a healthcare regime “for Spaniards and only for Spaniards” (Martín Plaza, 2009). The debate also involves criticism of Member States “unfairness”. So, it is suggested that the UK Embassy provides information to UK citizens about how get access to the Spanish system giving “practical advice on the procedures to follow to be able to enjoy the Spanish healthcare system as any other taxpayer” (Martínez, 2012) while some media point to the existence of residential developments aimed at host intra-EU retirees during few months while they are “unfairly” treated by a Spanish hospital (García, 2012). Dissonant voices were rare. It is for instance the case of the Economic Head of the Healthcare Service of the Autonomous Community of Murcia who declared that the Government of Community of Murcia analysed the hospital admissions of European patients and the outpatient surgery performed on these patients in recent years and has not detected this problem. In his words: “Despite the myth generated about the supposed mass trips of European retirees to Spanish hospitals to undergo hip surgery, the so-called health tourism has never existed. This is what all administrations and most experts defend. It’s not real; It simply does not exist” (Parra, 2010).

The general discontent about healthcare access of non-labour motivated migrants from other EU countries seemed to confirm the argument that tax-funded healthcare regimes, such as the Spanish one, are bound to produce “spill over” costs, which could easily turn into a source of potential political conflict over freedom of movement as a contributor to equal access to welfare (Ruhs & Palme, 2018). That is also why EU regulation on healthcare access became a matter of discussion at EU and national level especially after the Great Recession of 2009.

3 Cross-Border Healthcare Provision for EU Citizens

3.1 The European Framework

Healthcare policies are the exclusive competence of Member States. However, a set of norms has been approved in the last decade, with the objective of contributing to “the protection of human health” as a basic right of EU citizens. This has led to a two-track system in the provision of healthcare services for EU citizens. The first track of healthcare assistance for intra-EU migrants is represented by Regulation (EC) No 883/2004 of 29 April 2004 and Regulation (EC) No 987/2009 of 16 September 2009 (hereafter the Regulations) on the coordination of social security systems, while Directive 2011/24/EU (implemented in Spain by Royal Decree 81/2014 of 9 March 2014) on the application of patients’ rights in cross-border healthcare (hereafter the Directive) represents the second track. The subject and the object of the Regulations and the Directive are similar, but their objectives are different: the purpose of the Regulations is to guarantee freedom of movement, while the Directive regulates free provision of services within the EU (Álvarez González, 2018).

To receive unplanned healthcare assistance under the Regulations, EU patients need to be insured in a public insurance system in their country of origin (Finotelli, 2021). Reimbursement under the Regulations is inter-institutional, and patients are not allowed the option to choose treatment from a private healthcare provider. The Regulations not only address access to healthcare in the case of residency in another EU country: in the case of stays shorter than 3 months, EU citizens are required to present a European Healthcare Card and can receive medical treatment only in the case of an accident or sudden illness following travel to the country of stay.

In contrast, unplanned healthcare assistance under the Directive can be provided upon explicit request by the patient without any previous formality. Nevertheless, treatment beneficiaries must pay for their treatment in advance and apply for reimbursement afterwards. In such a case, reimbursement is processed by their national institutions according to the rates established for the same treatment in the country of origin (2011/24/EU, Article 7(4)). However, and in clear contradiction with the Regulations, patients can decide between public and private healthcare providers in the country of destination. Since reimbursement procedures under the Regulations are more advantageous to patients, the Regulations are used as the reference norm for access to unplanned healthcare assistance, except in the case that the patient explicitly requests to be treated under the Directive (Álvarez González, 2018). Finally, neither the Regulations nor the Directive include long-term care and palliative care in the authorised treatments.

As can be seen in Table 13.1, in the case of unplanned healthcare assistance major differences between the Directive and the Regulations regard reimbursement procedures and the possibility to choose private healthcare providers. More similarity can be found for planned assistance since both the Regulations and the Directive formally require previous authorisation from citizens’ corresponding national institutions. In both cases, authorisation can be issued if the treatment is admitted by the national healthcare authority and if the corresponding treatment cannot be provided in a realistic timeframe in the patient’s country of origin.

Table 13.1 EU citizens’ access to healthcare
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The approval of the Directive was characterised by a deep tension between the principle to guarantee free healthcare access to EU citizens and the will of Member State to keep control on patients’ freedom of movement. The preparation document of the Spanish Presidency in 2010 declared that the main Presidency objective was “to strike the right balance between the rights of the patients in cross-border healthcare and the responsibilities of the Member States for the organisation and delivery of health services and medical care” (Council of the EU, 2010, p. 2). The declaration was related to the fact that reimbursement and prior authorisation represented a major contentious issue during the approval procedure of the Directive. Against this backdrop, the Spanish Presidency also reminded that the European Court of Justice “has held on to a number of occasions that it is possible for the risk of seriously undermining the financial balance of a social security system to constitute per se an overriding reason in the general interest capable of justifying an obstacle to the freedom to provide services”. This allowed the Presidency to introduce relevant modifications into the second version of the Directive to be presented to the Commission. According to the new version of the document, prior authorisation can be denied for reasons of general interest, such as the general need to maintain oversight over costs, or to guarantee a certain degree of equity in access to high-quality healthcare treatments (Boggero, 2018). In addition, according to the general rule, the Member State competent to grant a prior authorisation according to Regulation 883/2004 (i.e. the Member State of residence) is also the Member State who should reimburse the cost of cross-border healthcare for pensioners. However, if a pensioner is treated in his country of origin (it means where he/she was initially insured), the new Directive proposal establishes that this country would have to provide healthcare at its own expense. In this vein, the new document contradicts the previous version of the Directive which established that the Member State of affiliation was responsible for reimbursing the cost of hospital care provided in another Member State in the case that its social security system would have assumed the costs if the healthcare had been directly provided in its territory (Art. 8.3a). The objective of the modification was to avoid that pensioners with their residence in Spain could go back to their country of origin or original country of affiliation to be treated there while the new country of residence, Spain for instance, had to reimburse the treatment costs. This allowed the Spanish government to block the Directive initiative promoted by Sweden and the United Kingdom who was particularly beneficial for these countries due to their condition of sending countries of pensioners (Martínez de Rituerto & Prats, 2010). At the same time, the approval of the new Directive, and in particular the long-standing debate on the definition of the Member State of affiliation, also allowed the Spanish government to modify the regulation of healthcare provision for EU citizens in Spain.

3.2 The Provision of Cross-Border Healthcare in Spain

The new Regulation of healthcare access of EU citizens in Spain, and in particular of intra-EU retirees, was boosted by the new government ruled by the Partido Popular (2011–2016), elected during the peak of the economic crisis in Spain. The 2012 annual report published by the Spanish Court of Auditors (Tribunal de Cuentas) denounced the “repeated misuse” of the European Healthcare Card. As the Court reported, Spain provided healthcare assistance to EU citizens insured in their home country (and not resident in Spain) who decided to move to Spain with the aim of receiving medical treatment under the Healthcare Card, which was only intended for temporary stays. Instead, these new residents were supposed to use the E-112 form, which, in turn, required the specific approval of the corresponding Autonomous Healthcare Service (as requested by Art. 20, Reg. 833/2004) (Tribunal de Cuentas, p. 143). As the report stated, “the misuse of the Healthcare Card allows them [retirees] to keep privileges in their country without giving up complete and cost-free healthcare in Spain” (ibidem, 142). The publication of the report was supported by the declarations of the then Minister of Health, Ana Mato, who argued that the budget of the Spanish National Health System was assuming the healthcare of people who already have it covered within their country. In particular, according to the ministry, almost 700,000 foreigners have accessed the health card without the right to do so, which has caused an expense of 917 million euros (García, 2012).

As a response to this and other perceived challenges, such as irregular migrants’ access to universal care in Spain, the Spanish government approved Royal Decree n. 16/2012 (hereafter the Decree) on urgent measures regarding healthcare provision in Spain. The Decree did not only exclude irregular migrants from universal healthcare but also introduced other types of restrictions that specifically addressed EU citizens with the aim of preventing potential misuses of the universal healthcare provided in Spain. As the Decree’s preamble stated:

The Court of Auditors has shown that the National Healthcare System, financed through the National Budget Plan, has taken over the healthcare of people who already enjoy comprehensive sickness coverage either through the institutions of their country of origin or through private insurance systems, which is currently eroding its financial capacity and preventing the improvement of services by their managers.

The objective of the Decree was to prevent the erosion of the National Healthcare System’s financial capacity. For the first time, the Decree described how inactive EU citizens had to prove their insurance situation, and specified which rights and duties were associated with it. Its main objective was to guarantee that a Social Security Card would only be issued to intra-EU retirees who were formally registered as residents of Spain in order “to revise a situation that was described as being ‘like paradise’ for inactive EU residents” (Finotelli, 2021, p. 614). According to the new procedure introduced by the Decree, inactive EU residents have to explicitly apply for their Spanish Social Security Card at the corresponding office of the Spanish Social Security System. To do this, they have to prove that they are insured in their home country by presenting an S1 certificate, issued by the Social Security Office in their home country. In addition, they have to demonstrate that they are registered with the Spanish municipal registry (Padrón Municipal), and are in possession of a Foreign Residence Card (NIE). The latter is issued by the local Foreigners’ Office, where applicants for the Social Insurance Card have to provide documentary evidence that there is no risk of them becoming “a burden on the Spanish state during their period of residence” (Art. 7.1.). Once registered in the National Security System, healthcare assistance to EU citizens is provided on the basis of the principle of non-discrimination with Spanish citizens. Clearly, the new procedure represented a substantial change compared to the past.

The goal of the new national legislation (including the procedure for obtaining an NIE) was to prevent EU citizens without full residency in Spain from repeatedly receiving medical assistance from the Spanish healthcare system beyond the assistance provided in the case of emergency situations with the European Healthcare Card. By introducing the requirement of municipal registration, the reform was also intended to correct the practice among most intra-EU retirees, who did not enrol in the municipal registry. This had made it difficult for local authorities to plan the service provision of their population. Before this, there were reports that some municipal registry offices had tried to tackle this problem on their own. For instance, for a certain period of time, municipal officials in a well-known town on the Costa del Sol refused to register EU residents in the municipal registry if they had not presented their Foreign Residence Card to prove that they had been residing in Spain for at least 3 months (Finotelli, 2021). Strikingly, this was not applied to non-EU citizens, who could register with their passport alone. This “bad” practice, which has been now corrected by the National Statistical Office, only provides anecdotal evidence about administration routines at the local level. Nevertheless, it cannot be excluded that the intention of the officials involved was to reduce the number of people eligible for healthcare insurance in the region (Finotelli, 2021). The above-mentioned episode also suggests that traditionally “welcome” migrants, such as economically inactive, supposedly wealthy European retirees, might not be exempt from discretionary implementation practices at the local level to prevent any alleged misuse of Spanish healthcare services.

Overall, analysis shows that the set of “norms and practices” (Jenson, 2007) constituting the EU citizenship regime also experienced changes in Spain after 2009. According to the general public, the Decree put an end to the era of welcoming “legions of European pensioners eager for sun, sea … and hospital beds” (García, 2012). In more general terms, the Spanish case showed that interaction between intra-EU residents and universal healthcare regimes could trigger a restrictive turn in the European citizenship regime, where the alleged welfare burden represented by EU citizens, and their observation as potential welfare scroungers by the state, could be contrasted by legislation changes and possibly negative implementation practices. Yet, the main objective of limiting financial erosion was only partially achieved as the next section will show.

4 Intra-EU Mobility: Between Welfare Restrictions and New Market Opportunities

The decision to more accurately define the category of people who have access to the Social Security Card was closely linked to concerns about the financial capacity of the Spanish Healthcare system. Restrictions helped to reduce negative reporting on this category of migrants in the media (Finotelli & Sebastián Izquierdo, 2019). However, it does not seem that these restrictions, regardless of their harshness, have done anything to contribute to reducing the amount of Spain’s bill. The reasons for this lie partly in the unchanged mechanism of the intra-European reimbursement regime. According to EU regulation, the reimbursement amount for treatment provided during occasional stays (such as tourism) is always based on actual expenditure, while reimbursement for treatment provided to residents can also be calculated on the basis of a fixed amount per calendar year (Spanish Government, 2016). Spain, together with the United Kingdom, Portugal, Sweden, Ireland, Cyprus, Norway, Finland, and the Netherlands, implements reimbursement on the basis of fixed amounts, which in the case of Spain is 250 euros per month (Congreso de los Diputados, 2016). To assess the amount of what other Member States owe to Spain, the fixed amount (cuota global) is multiplied by the number of foreign inactive residents (mostly pensioners) residing in the country during a given year (Tribunal de Cuentas, 2012, 177).

The report of the Court of Auditors highlighted the existence of a remarkable gap between Spain’s expenditure for the healthcare assistance of EU citizens and the amounts that Member States reimbursed Spain for this purpose (Tribunal de Cuentas, 2012). In fact, other EU countries, led by the UK, owed Spain a total sum of about 450 million euros. The Court of Auditors argued that cumbersome reimbursement mechanisms and timeframes as well as a lack of transparency in the available accounting data were the reasons for such a large amount of money. In addition, the Court claimed that the fixed amount of 250 euros calculated for Spain is below the European average and is not sufficient to cover the actual expenses of the Spanish Social Security System for EU residents, particularly British nationals. Such an unfavourable balance between invoices based on fixed amounts and actual expenditures did not change after the reform of 2012. As information from the Spanish government shows, in 2015 Spain billed around 467 million euros for fixed-amount charges as well as 168 million euros of actual expenses for medical treatment to citizens of other EU Member States, half of them British citizens (see Table 13.2). In turn, Spain owed only 46 million euros to other European countries for their healthcare assistance to Spanish citizens abroad (Spanish Government, 2016).

Table 13.2 Billing amounts for healthcare assistance provided by Spain according to standardised rates and real amount of expenses (2015)
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Taking into account that fixed amounts are always related to inactive residents in Spain, the data described above reveal that the majority of Spain’s credit with other countries encompass healthcare expenses for inactive EU citizens who reside in Spain but do not work there, such as EU retirees. One political party, the centre-right Ciudadanos, drafted a (non-legislative) motion in 2016 to discuss this financial issue in the Spanish parliament. However, the Spanish government has shown little interest to date in tackling this issue. As one deputy from Ciudadanos argued in an interview, the Spanish government might not be interested in publicly raising the debate of compensation funds “because the income provided by tourism activities de facto offsets the costs generated by EU residents using the Spanish public healthcare system” (Finotelli, 2021, p. 616). In fact, in 2018 more than 82 million tourists visited Spain; most of them originating from other European countries (INE, 2018), while 14.6% of the Spanish GDP and 14.7% of employment came from tourism (WTTC, 2019). Moreover, the relevance of residential tourism for the construction and service sector has been widely acknowledged by scholars (Analistas Económicos, 1997; Llopis Vañó, 2017).

Interestingly, Spain’s attractiveness as a tourist destination may not only represent a reasonable explanation for the government’s inertia in discussing the compensation system but also promoted strategies aimed at attracting patient mobility in the Spanish private healthcare sector (Finotelli, 2021). In fact, the approval of the European Directive in 2011 and its ratification in Spain in 2014 has opened a window of opportunity to the private healthcare sector to attract European patients into Spanish private hospitals. Since its approval, the Directive was never intended to be understood as an instrument to encourage EU citizens to receive treatment outside their Member State of affiliation. This notwithstanding, the General Secretary of the Union of European Private Hospitals (UEHP) welcomed the Directive as an important step to foster intra-EU mobility in the private healthcare sector (iSanidad, 2018). Likewise, the Spanish private healthcare sector immediately saw the Directive as a great chance to boost the travel of EU private patients to Spain by turning the country into nothing less than the worldwide standard for the international healthcare market. To achieve such an objective, the Spanish Federation of Private Clinics created in 2013 Spaincares, a private-public collaboration with major Spanish hotel chains and with the support of the Spanish Ministry of Tourism, which became operational in 2014. As the organisation’s managers noted, the initiative did not focus on European patients already living in Spain, since this category of patients usually chooses the national (public) healthcare system for treatment (Finotelli, 2021). The Spanish private healthcare sector was instead interested in those patients who would explicitly move to Spain to receive the same treatment that they could not receive within a reasonable period in their home country. The “recruitment” of cross-border patients had nothing to do with the alleged misuse of the public healthcare system by EU temporary residents or tourists. As the general director of the Office of the High Commissioner for La Marca España, Francisco Rabena, explained, “These are not people who come to be treated in the Social Security system, to increase the queues, to get the emergency infrastructure overcrowded, or to increase the trouble in finding a bed. They are foreigners who come to Spain with their private health insurance, to private hospitals, with private professionals” (Márquez, 2018). Shifting the system of reference from the public to the private healthcare sector had clearly changed the perception of European citizenship and the therewith attached social rights. In something less than a decade, the public perception of intra-EU retirees as “healthcare scroungers” that burdened the public healthcare regime had been quickly substituted by the representation of the welcome European cross-border patient with beneficial effects for the private healthcare sector.

5 Conclusion

The debate on intra-EU mobility and welfare in Europe has shown how concepts of “undeservingness”, “scrounging”, “unfairness” or “welfare-transit” were not only used to describe bogus asylum seekers or irregular migrants en route to Europe but could be easily transposed to describe “unwelcome” intra-EU migrants from Southern and Eastern Europe. Yet, analysis of the Spanish case in this article shows that the restrictionist turn was not limited to South-North labour-motivated mobility but can be easily extended to the intra-EU non-labour motivated mobility in Southern Europe. This has been for instance the case of the restrictions to public healthcare for EU citizens which were introduced in Spain after the Great Recession of 2009. As Finotelli (2021, p. 615) argued in a previous study “Paraphrasing Maurizio Ferrera (2016), it can be argued that the Spanish central government has tried to reintroduce a ‘modicum’ of state autonomy on intra-EU mobility by applying ‘more severely’ the principle that EU citizens may reside in another Member State for a period longer than 3 months if they have sufficient resources for themselves and their families.” Yet, such a restrictive turn was followed by the decision of the Spanish government together with the private healthcare sector to promote Spain as a healthcare tourism destination under the umbrella offered by the Directive on cross-border patients’ mobility. Against this backdrop, the Spanish case shows that different approaches can be taken when the logics of the EU citizenship regime intersect with logics other than the “protection” of the public healthcare sector such as accumulation logics embedded in the economic and the tourist sector. So, the importance of Spain as a tourist destination has prevented to revise the reimbursement procedure for healthcare treatment provided in Spain to intra-EU retirees. Likewise, the approval of the Directive has promoted widespread euphoria to attract cross-border patients possibly keen to receive medical treatment in the Spanish private sector. Even though the objective to turn Spain into a medical destination par excellence has not been achieved to date (Finotelli, 2021), analysis of the Spanish case shows that the European citizenship regime as embedded in a complex interplay of regulations and practices where important imperatives other than that of guaranteeing equal access to healthcare play a role. The purpose to guarantee fair access to the public healthcare sector to EU citizens and natives was balanced by the will to promote the access of EU citizens to the private sector showing how the context of reference, in this case the public or the private healthcare system, can make a difference on how EU citizens are observed (and acted upon) within the same EU citizenship regime.