What our health service will look like under UHI

Maureen Browne looks at the Minister for Health’s vision for a health system under Universal Health Insurance and the unanswered questions about the new proposals.

Health Minister, Dr. James Reilly spelled out what the health system will look like in 2019 under Universal Health Insurance, when he launched the White Paper on UHI earlier this month.

Dr. James Reilly, T.D.
Dr. James Reilly, T.D.

He said everyone will have mandatory insurance with the insurer of their choice and all persons will be entitled to the same package of care.

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Our current two-tier health system will be eliminated and replaced by a single-tier health service, which will merge the public and private systems. Treatment will be on the basis of medical need rather than ability to pay.

A new Healthcare Commissioning Agency will channel state funding for UHI to the insurance companies, while premia from individuals will go straight to the insurance companies.

The basket of services which will be covered under UHI will be determined by the state and will include primary, hospital and acute mental health care. People will be allowed to purchase supplementary insurance packages which will include items not covered in the standard package e.g. more luxurious accommodation. Insurers will not be allowed to sell packages of care that allow faster access to care.

Insurers will be obliged to accept everyone regardless of age or health status and will compete for business on the basis of price and service. Insurers will not be allowed to offer different prices for the same policy based on a person’s gender, state of health or age. However, they will be allowed to charge children lower premia, as happens at present. Premium income will be supplemented by a system of co-payments.

The state will pay for those on medical cards and subsidise the insurance costs of those on lower income. It will also have a key role in regulating the health system, in protecting patient safety and in ensuring that costs are kept under control.

The state will continue to directly fund long term care and other social services

The HSE will have ceased to exist. A new Healthcare Commissioning Agency will channel state funding for UHI to the insurance companies, while premia from individuals will go straight to the insurance companies. The insurers will, in turn, contract for the health services to be provided under UHI. There will be risk equalisation and a fund to manage insurer insolvency. If necessary, insurers’ overheads and profits will be capped.

The organisational reform necessary for UHI will be implemented having full regard to the needs of staff including their existing rights under agreed industrial relations procedures.

The Healthcare Commissioning Agency will also centrally fund certain elements of the services within UHI e.g. ambulance service and Emergency Departments from general taxation and will pay directly for services which are not covered by UHI e.g., long term care.

Public providers of care will be reorganised into autonomous hospitals trusts and community care organisations. Public hospitals will remain publicly owned.

The organisational reform necessary for UHI will be implemented having full regard to the needs of staff including their existing rights under agreed industrial relations procedures. Employment rights will be protected and there will be consultation with staff associations as the reform proceeds.

The Minister said the new system will cost no more than the current system and should not require any higher taxes. He said that since full UHI will not be introduced until 2019, he could not provide precise insurance premia costs. However, it was likely that if UHI was in place now the average premia would be lower than the average private health insurance premia paid in 2014 net of government subsidy. This was €920 per person per year.

Under UHI, tax relief on insurance premia will be ended and the health levy is likely to be continued but subsumed into general taxation. ED charges are also likely to continue to be charged to non medical card holders. Employers can continue to subsidise the cost of health insurance under UHI.

Money Follows the Patient will replace the current block funding of hospitals.

A new Healthcare Pricing Office will set the prices to be used under Money Follows the Patient. A specific price will be attached to each service and over time, this price will be adjusted to reflect best international practice.

New legislation will allow the Minister for Health to control induced demand under UHI should it prove necessary.

The Minister said there would be improved cost management driven by a number of key reforms. These will include new legislation on cost control, the establishment of the Healthcare Pricing Office to help drive down the prices of treatment and the introduction of the new Money Follows the Patient financing system to help ensure that waiting lists are reduced even as costs are also lowered.

New structures and systems will be put in place to improve patient safety and service quality, including the establishment of a new Patient Safety Agency.

While there were no details given on the precise type of UHI which was planned, the press conference was told that the Government had examined a number of UHI systems including those in the Netherlands and Germany.

Dr. Reilly said UHI will be progressed in three phases. Phase 1 will involve an extensive consultation exercise with the public and stakeholders which will last until Wednesday, May 28…Health managers can make individual submissions. A Commission will be established to consult widely and present to the Government a series of costed options on the proposed basket of services for UHI. The Joint Oireachtas Committee on Health will hold hearings on the values which should underpin any such basket and on the costed options presented by the Commission. The Department will invite written observations on the White Paper.

Under the second phase, health reform legislation will be introduced in 2014 and 2015 to replace the HSE with what is called a Purchaser/Provider split. A new Healthcare Commissioning Agency will be created to purchase services for patients from various providers. Existing public providers will be reorganised into new hospital trusts and community organisations with much greater autonomy than at present. The regulatory structure for the health system will be strengthened. Separate legislation to gradually roll out free GP care, starting this year, will be introduced.

In Phase 3, full UHI will be introduced by 2019, underpinned by key legislation.

Read The White Paper on UHI