Health Technology Assessment and Health Care Reimbursement in the European Union: Permissive Dissensus and the Limits of Harmonization through the Backdoor.

Member states have consistently limited the European Union’s competences in the area of healthcare reimbursement. Despite these efforts, there has been a slow but steady tendency towards harmonization of a key tool in reimbursement decision-making: health technology assessment (HTA), a multi-disciplinary evaluation of “value for money” of medicines, devices, diagnostics, and interventions, which provides expert advice for reimbursement decisions. This paper examines the origins of this paradoxical appetite for harmonization, as well as of the dissensus that has, at the moment, somewhat stalled further integration in HTA. It finds that the pro-integration neofunctionalist “permissive dissensus” is still present in decision-making on HTA but potentially offset by dissensus or outright opposition from key actors, including member states and the medical device industry. These actors are able to decipher the potential consequences of highly technical issues, such as HTA, for national systems of social protection. Despite that, they have little interest in politicizing the issue, potentially opening the door to integrative policy solutions in the future