At its meeting on November 4, 2025, the Constitutional Court ruled on constitutional case No. 32/2024, reported by Judge Krasimir Vlahov.
The Court rejected the request of a three-member panel of the Third Division of the Supreme Administrative Court, First College, to establish the unconstitutionality of the provisions of Article 55, paragraph 2, items 3b and 3c of the Health Insurance Act (HIA).
Regarding the provision of Article 55, paragraph 2, item 3b of the HIA The court finds that its purpose is to ensure that hospitals have medical specialists by guaranteeing by a law a certain minimum levels of remuneration for their work by law. This objective is of constitutional importance and is aimed at ensuring the realization of the fundamental constitutional rights of citizens, namely the right to health and the right to work. According to the Court, the provision of accessible and high-quality medical care depends on the availability of qualified medical specialists, which in turn requires fair and decent remuneration for their work. The Court also notes that guaranteeing a certain minimum level of remuneration for medical specialists applies equally to all hospital care facilities receiving funds from the NHIF budget under contracts for the purchase of medical care, and in this sense does not affect their equal treatment.
Regarding the provision of Article 55, paragraph 2, item 3c, letter "a" of the Health Insurance Act. The provision provides for the financing of medical personnel in medical establishments that perform medical activities in populated areas in hard-to-reach and/or remote areas or are the only ones performing the relevant activity in the municipality. The court considers that this provision is aimed at protecting the internationally recognized and constitutionally guaranteed right of citizens to accessible medical care, who should not be placed at a disadvantage because of their territorial connection to a particular area which, for reasons beyond their control and capabilities, is not provided with the relevant health infrastructure. The funding provided for in the contested legislation is a measure aimed at ensuring the state's obligation under the Basic Law to protect the health of citizens and provide them with accessible medical care.
The Court notes that economic freedom (Article 19(1) of the Constitution) is not only objectively incapable of ensuring the realization of citizens' right to health, but also, within the meaning of the Constitution, cannot exempt the state from fulfilling its obligation to guarantee this right under conditions of equality for all entitled persons. It is for this reason that the state not only can, but is also obliged under the Constitution to take measures to guarantee accessible medical care to all its citizens when the free market and competition cannot provide it.
The contested law does not place the relevant category of medical establishments to which it applies (those performing medical activities in populated areas in hard-to-reach and/or remote areas or those that are the only ones performing the relevant activity in the municipality) in a more favorable position compared to other medical establishments performing medical activities within the country, as the former and the latter are not in the same or a similar position. In essence, the contested law aims to guarantee the right to accessible medical care for citizens from areas that objectively do not have such care for geographical and infrastructural reasons. Thus, the law not only does not create inequality, but on the contrary, is designed precisely to overcome inequality in access to hospital care for citizens from different regions of the country. The need for the state to take active measures to overcome the geographical and economic inequality of citizens from different parts of the country in terms of their access to medical care also follows from the provision of Article 20 of the Constitution, which obliges the state to create conditions for the balanced development of the different regions of the country.
Regarding the provision of Article 55, paragraph 2, item 3c, letter "b" of the Health Insurance Act, which stipulates that national framework agreements for medical and dental activities must contain a methodology for financing the provision of medical personnel in hospitals under Article 45, para. 2a of the Health Insurance Act, i.e. in priority multi-profile hospital care facilities, the Court notes that it is aimed at achieving a legitimate constitutional objective, such as guaranteeing the right to health of citizens, which is an obligation of the state under the Basic Law. This regulation does not violate the principle of equality, as it treats all hospitals that meet certain criteria in the statutory and substatutory regulations equally, regardless of their ownership. In this regard, the Court notes that the contested provision does not apply to all multi-profile hospitals, but only to those that provide emergency care and treatment of severe and complicated cases in certain areas of medicine.
Eleven constitutional judges participated in the sitting. The decision was adopted by 10 votes, with a dissenting opinion by Judge Sonya Yankulova and an opinion by Judge Sasho Penov.
Link to the full text of the Decision — https://www.constcourt.bg/bg/act-10183