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A political show down on universal healthcare…

Posted in Blog by saraburke on April 19, 2010

So at last, the idea of universal healthcare is gaining public and political momentum in Ireland. Last week the Irish Medical Organisation launched a document on universal healthcare coverage and there was a conference on financing and organising social health insurance in Ireland organised by the Adelaide Hospital Society. So what did the respective bodies have to say and where do our political health leaders stand on these proposals?

For the first time in the history of the State, all opposition parties are in support of universal healthcare, albeit in very different ways. Minister Mary Harney remains utterly opposed to such proposals, Fianna Fail have no official health policy other than ‘government’ (ie Mary Harney’s) policy while the Greens position is utterly contradictory….

Obama’s Whitehouse special advisor on health Dr Ezekiel Emanuel (older brother of Obama’s chief of staff/spin – Rahm Emanuel) opened the day. Dr Emanuel spoke in huge detail about the amount of change that they are introducing in the US healthcare system, about the struggle it has been to introduce that change, what he described as ‘a monumental event of world historical proportions’ – the Emanuels are never ones to under state their position in history!

It was really positive to hear the detail of the changes in healthcare that are happening in the USA , although Dr Emanuel managed to avoid explaining the importance of dropping the public option for insurance coverage, which ultimately may be the reason for failing to bring down insurance and healthcare costs.

But what was most interesting Emanuel’s insight into how politics can bring about significant and positive change on how health services are provided. And if they can do it in the USA, then surely change is possible here.

Each of the three main opposition political parties were asked to respond to the Trinity Social Health Insurance (SHI) and Adelaide Society proposals. Instead they laid out their vision of what type of health system they would introduce if (and when) they are in government.

Enda Kenny, Eamon Gilmore and Caoimhghin O Caolain each spoke for about 15 minutes.

Enda Kenny was much more polished that I had heard him previously on health reform. He has been doing a tour of the country selling their ‘FairCare’ policy. Fine Gael’s FairCare policy is about universal access to all health services with a form of compulsory private health insurance that the government would pay for if you cannot afford.

The Labour party were the first to propose a social health insurance model in 2001 so Eamon Gilmore is very supportive of such a model but their proposals differ from the proposals outlined in Trinity research as they include competition between private providers and a public option. Eamon Gilmore announced that they would be producing an updated version of their 2001 proposals this year.

And Caoimhghin O Caolain while supportive of principle of universal access was advocating Sinn Fein’s policy of a universal, tax funded system where access is based on need, not ability to pay.

What most interesting was the common ground among them, each advocating a universal system of healthcare, despite huge differences in detail of what they would do. But also what was palpable was the upbeat nature of the event, where political and health service change seemed like a possibility.

And then Minister Harney spoke. It was quite striking the shift in energy when Mary Harney’s turn came. She welcomed the opportunity for honest debate and then very quickly dismissed any proposal of social health insurance or universal healthcare.

Her body language was telling as she stood behind the podium with her arms firmly crossed.

She has this persistent line about how it does not matter how the money is raised it is how it is spent that counts. Hence she set up a Resource Allocation Working Group.

Yet one of the key findings from other countries (which was presented by Prof Charles Normand earlier in the day, for which she was not present) where they have social health insurance models is that people there are prepared to pay a bit more for health if they get a better service that is more transparent and where access is universal.

Minister Harney had a wide ranging speech over 5,000 words in length, which she did not read from but covered most of its content during her 30 plus minute input. In it, she made her position on healthcare provision much clearer.

Throughout her speech, Mary Harney kept on talking about how health budgets are limited but throughout the day there was a focus on how best to raise and spend money on health in a resource limited environment.

The Trinity SHI proposals include a range of options, most of which do not involve additional expenditure (eg free primary care for all) which would also make 10% efficiencies. What is most interesting about the social health insurance models is that they ensure quality health services with universal access where efficiencies are possible and incentivised. And payment comes out of an ear marked, social health insurance fund.

The Minister clearly outlined how she believed co-payments are good things, saying ‘I am a big fan of co-payments’ and defended the recent introduction of prescription charges for medical cards holders – despite a raft of international evidence (which I have written about recently) that this inhibits people who need the medication from taking it.

And really Mary Harney failed to address what was a serious concern of all the previous speakers which was our unequal system of care which continues to privilege private patients over public patients within the public hospital system. Or how the current tax funded system could address issues of inequality and transparency.

In the one place in her speech Mary Harney spoke about how the consultants contract ensured that access to outpatients consultant appointments was on the basis of medical need. However, there is not one shred of evidence that this is happening in fact any evidence is to the contrary evident in the unopened letters in Tallaght and recent case highlighted by Ombudsman Emily O’Reilly.

Also the official line is that the new, expensive consultants contract would limit private practice in public hospitals yet it is still far in excess of the 20% that they are contracted to do and many hospitals and consultants have rates way above that. The overall figure was 25% private work in public hospitals for December 2009 and there is little difference between amount of private practice in public hospitals in December 2008 when compared to December 2009.

Most interestingly, the minister said and reemphasised how ‘a pure one-tier health system’ is not on offer. By this she meant there will always be voluntary and private including for-profit healthcare providers. However, nobody speaking at the conference contended this point. But the fundamental point made by all the other speakers was the inequality and unfairness in providing private (often for-profit) care within the public hospital system. Mary Harney’s speech showed quite clearly that she just does not get this or that universal health care and financing through social health insurance are not an option for the current government.

The absence of Fianna Fail and the Greens at the conference was notable. I rang Fianna Fail press office the day after the conference asking for their health spokesperson and their response to the SHI proposals and was told that ‘government policy is Fianna Fail policy’ and to put my query in writing (which I did, so more on this anon).

I spoke to Niall O Brolacháin, the newly appointed Greens spokesperson on health (since Deirdre de Burca’s dramatic resignation), and he said the Greens fully supported ‘universal access to a one tiered health system, funded by social health insurance’. When I pointed out that this was completely contradictory to government health policy he said it maybe inconsistent in the short term but not in the long term!

What was most significant and interesting (and hopeful until the Minister spoke) about the Adelaide Hospital Society conference on health was that it was the beginning of a more public and political debate about what type of health system we want as a people.

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