Ireland could probably afford Universal Healthcare

If we wanted it, Ireland could probably afford a system of Universal Healthcare but we would need to develop a consensus on what we should include in the package and what would not be covered, Prof. Charles Normand, Edward Kennedy Professor of Health Policy and Management at Trinity College, Dublin, told the HMI Dublin Mid Leinster Forum held in the Dublin Dental Hospital. Maureen Browne reports.

Charles Normand
Professor Charles Normand

If we wanted it, Ireland could probably afford a system of Universal Healthcare but we would need to develop a consensus on what we should include in the package and what would not be covered, Prof. Charles Normand, Edward Kennedy Professor of Health Policy and Management at Trinity College, Dublin, told the HMI Dublin Mid Leinster Forum held in the Dublin Dental Hospital.

In a wide ranging presentation he said the Government supported and subsidised the present health insurance system despite its being in conflict with government policy objectives, contributing relatively little to funding and volume of service, enshrining unequal access and having generally harmful effects on the operation of the wider system.

Universal healthcare would inevitably have to be some kind of rationing – what should be included would be all services that were good value for money. That meant that we needed to exclude any services that did not meet this criterion. If something was in the package it should be genuinely available. In South Korea, they introduced universal healthcare, but only paid 50 per cent of the cost of all care for all people, so the poorer who couldn’t afford the other 50 per cent got nothing and only the rich were covered – in effect the poor subsidised richer people.

Private health insurance was supported and subsidised despite being in conflict with policy objectives and having a generally harmful effects on the wider system.

There had been a lot of debate about equity in healthcare, but this ignored the question that we should only be interested in equity for things that were useful. If we were trying to designate certain treatments as being appropriate, then we needed to find the mechanisms to pay for these.

Conceptually we could approach it by broadening the current approach to approving what drugs should be made available. At present, as a rough guide, we automatically approved all drugs with a cost/QALY below €45,000. However, Fair Deal had a cost/QALY of perhaps €65,000 to €70,000. This suggested that appropriate thresholds would be a little higher than the €45,000 we had at present. After all we did not refuse people nursing home care.

“Rationing does not imply a callous approach (indeed it is less callous than if we ration badly) nor does it imply a refusal to support innovation and development. The problem with explicit rationing is that if it is done well it is extremely complicated. For example, everyone will say cosmetic surgery could be excluded but what about people who are badly disfigured as a result of a street attack or a mugger.

We could have a pretty good universal service now with what is currently paid in tax, private health insurance and out of pocket and a bit of appropriate saying ‘no’ would help reduce waiting times and waiting lists.

“There will always be problems around the edges and with the rare, the bizarre conditions and the unlucky people who have diseases with very poor prospects and ones that are very expensive to manage.”

Prof. Normand said Irish health policy objectives were about access to good quality services.   Essentially access to care should be on the basis of need and not on ability to pay, with efficient provision, and access at the lowest feasible level of complexity.

“But what has happened over the last 12 or 13 years. The only significant changes in entitlement have been to reduce them. A higher proportion of healthcare costs are coming out of people’s pockets. There have been retention of fees in the system despite the fact that they do not do a good job in terms of rationing and there have been poorly thought out organisational changes, with new poorly thought out change underway now.”

He said we had a curious situation in Ireland in terms of private health insurance, which enshrined unequal access but contributed relatively little to funding – a little over 10 per cent cash but much less value. It was supported and subsidised despite being in conflict with policy objectives and having a generally harmful effects on the wider system. Given the huge number of possible policies and the focus of many on low risk customers, community rating was now effectively dead – lifetime community rating was not community rating.

He said that UHC as conceived in his presentation needed increased capacity and co-ordination of care, especially around primary care and areas of chronic disease management and continuing care. “ We could have a pretty good universal service now with what is currently paid in tax, private health insurance and out of pocket and a bit of appropriate saying ‘no’ would help reduce waiting times and waiting lists. There would be some losers in universal coverage – those who currently get better access from PHI. The two tier system tends to advantage the rich and the very poor and disadvantage the low paid working population.

“Money should go from householders to providers with the least harm in terms of putting a burden on the wrong people and not spending money on administration when you could spend it on services.

“On plausible growth estimates we are getting richer more quickly than the growth of needs – we can afford UHC but the question is really if we want it. . . We might be looking at another 5 or 8 per cent to give us access to something like Canada. It will also require some contribution from those older people getting long term care. We can expect 1 – 2 per cent of our growing need to be funded from efficiency gains. If we got UHC organised then 1.5 – 2 per cent increase in funding per year would be needed.

“The often criticised USC provides a possible framework for a single contribution to UHC. Long term care will be an area of growing need – some mechanism like Fair Deal is probably best but one which would cover all aspects of care.

“The pure effects of aging will increase health care costs by 1 per cent plus per year. Ageing is not a big problem for the acute system, but it is likely to be a big problem with a large number of people with social care needs. Men are living longer; the proportion of older couples is increasing and to an extent they can look after each other. Men’s life expectancy is increasing about 2.5 years and women’s by 1.6 years per decade. This makes a big difference. Old people are generally looked after by old people and to a large extent they are now looking after the young. The real problem comes from dying – that is when costs increase most. The older you die, the cheaper it is, as there are less additional costs in dying – the cost reduces by about a third between the ages of 65 and 85.”

Prof. Normand criticised those who argued that providing free GP care for those under six was paying for people who did not need services at the expense of those who did need services. Unless GP care was cheaper than hospitals people would not use services efficiently. Widening free GP care was an important first step.

“Can we do it – we have to start somewhere and the simplest way of expanding the system beyond the under 6s may be to raise the income thresholds.”