An Irish solution to a universal problem!

There are many versions of Universal Health Insurance and what pass for UHI systems so it makes sense to design an Irish solution to a universal problem, but it is vital that we get it right this time, writes Denis Doherty.

Denis Doherty
Denis Doherty

Healthcare systems everywhere are struggling to cope with growing needs and escalating costs. Our government recently published a paper titled “The Path to Universal Healthcare – White Paper on Universal Health Insurance”. It is short on specifics where a number of key issues are concerned.

Universal Healthcare and Universal Health Insurance are not interdependent. One of the best examples of universal healthcare is the NHS in Britain. Since 1948, the entire population has been entitled to a high quality service that is free at the point of use, is paid for from general taxation and is inexpensive relative to other healthcare systems.

The inefficiency of the current system here is put forward as one of the justifications for the proposed changes. It is undeniable that the current system is inefficient due, in large part, to the fact that our hospitals network is not fit for purpose. We probably have sufficient beds but many of them are in the wrong places and some of our hospitals lack the facilities and equipment to deliver a modern service.

The example given in the White Paper of what patients will have to pay for – satellite television – is unlikely to become the battleground on which insurers will compete!

In 1968 the Fitzgerald Report set out what changes were needed and in 2003 the Hanley Report contained important recommendations on what needed to be done as well as offering sound advice on future medical manpower provision. The electoral implications of what needs to be done have meant that there has never been a government willing or able to deal with the inefficiencies attributable to a hospitals network that is not fit for purpose.

The cynic in me favours the suggestion that the new hospital groups, which will in time become trusts, is the latest means of nudging an often noisy political can down the road! The preliminary paper to the White Paper, published in 2013, refers to a commissioned report that concluded ‘independent hospitals, operating as legal entities responsible for their own governance and finance, have had some success in England but not in New Zealand or Scotland”. The trusts in England consist of state owned hospitals that are almost totally funded from general taxation.

Here we have a variety of hospital types. There are public hospitals, voluntary hospitals, public voluntary hospitals and private hospitals.

Will the option of taking out private insurance to avoid the uncertainty of meeting difficult to predict costs be available and if so will that not perpetuate the two-tier system?

The white paper acknowledges that consultations are only now about to commence with the private hospitals. It is not stated how the voluntary hospitals view the planned changes. The architecture of the HSE was based on three pillars, one of which was hospital services. It soon became apparent that the separation of hospital services from other health services was undesirable and changes were made. What has changed in the meantime that will avoid fragmentation of services this time?

The White Paper avoids being specific on the likely cost of the new system. The nearest we get to that is a sentence in the Minister’s Foreword which states ‘I am determined that total spending by the State on healthcare in Ireland under the single tier UHI system should not exceed its total spending under the two-tier system it replaces’. That statement is open to a number of interpretations, all of them worrying. The reductions in State spending in recent years have been drastic and it seems that the health budget for this year is going to be exceeded. Fewer people are contributing to the private insurance spend due to the fall off in the numbers insured. Indications that the insurance costs of medical cardholders will be met by the State and that some others may qualify for a State subsidy suggests that those who currently hold private insurance – 45% of the population – may be the only ones who will have to pay full premiums. Then there is matter of the transaction costs in an insurance-based system. In some systems the costs are exorbitant and require significant investment in IT systems.

In the new scheme access will be based on need rather than ability to pay. Everyone will be entitled to be accepted by the insurer of their choice and to switch insurers annually. How then will insurers compete for business? The example given in the White Paper of what patients will have to pay for – satellite television – is unlikely to become the battleground on which insurers will compete!

It has not yet been decided what will be included in the core package. At least some of what will not be included will be provided by the State but not necessarily free of charge. Will the option of taking out private insurance to avoid the uncertainty of meeting difficult to predict costs be available and if so will that not perpetuate the two-tier system?

The White Paper envisages between 90% and 95% of illness being treated in primary care settings. That will require a significant further investment in infrastructure and a reversal of the cuts in general practice that have been severe in recent years.

There are many versions of Universal Health Insurance and what pass for universal healthcare systems so it makes sense to design an Irish solution to a universal problem, but it is vital that we get it right this time. The commitment in the White Paper that ‘the Irish Government will take the most explicit approach possible when legislating for the UHI package of services’ will, if honoured, be worthwhile provided it is extended to include a statutory basis for the other important preventive, treatment, care and support services.