Pie in the sky for UHI?

Posted in Blog by saraburke on April 11, 2014

See below my column for the Medical Independent from 3 April 2014 where I question whether Minister Reilly’s big idea of Universal Health Insurance will ever actually happen. 

The Programme for Government promised a White Paper on Universal Health Insurance (UHI) “early in the first term”. It has taken more than three years to produce and there is much dissatisfaction within Government on the long-awaited White Paper.

The document itself is comprehensive and provides a good outline of what needs to happen for Minister Reilly’s UHI plan to come to fruition. His version of Universal Health Insurance imagines a “multi-payer model of universal health insurance”, ie it will be compulsory for people to choose insurance coverage from a few competing private health insurance companies and a public option, Vhi.

Critically, the draft White Paper is missing crucial details – what range of services will be covered under the proposed model and how much it will cost both the State and the citizens?

A draft of the document was purposively leaked at the end of February alongside a very stern letter of reprimand from a senior official in the Department of Expenditure and Reform.

The letter shows the extent of opposition to the proposals, citing particular concern over the potential cost of the plan and the absence of alternatives to the model proposed.

The White Paper does not cost the UHI model because the proposals have not got that far. Working out what’s in and what’s not in the ‘basket of services’ is an extremely complex process. The absence of health economists and experts on health insurance in the Department of Health must explain some of the delay and lack of specifics in the White Paper.

The White Paper says that “premium prices in 2019 will ultimately be established in a competitive health insurance market”.

It also says that the UHI model will cost no more when it’s introduced than current health costs. But that’s dependent on bringing down the cost of care in the meantime. Plus, the proposed model is based on the premise that costs will be brought down by competing private insurers, which is not the national or international experience.

Recent Irish health insurance costs, where we have competing private insurers, have doubled since 2007. In Holland, which introduced this model in 2006, there has been huge healthcare inflation, which is now resulting in rationing of care. Internationally, insurance-based models cost more than tax-based models, eg Ireland currently spends below 9 per cent of GDP on health, similar to other tax models, whereas insurance-based systems tend to operate at 10-12 per cent of GDP.

The White Paper states that in deciding on the proposed model, they did an intensive review of multi-payer models but crucially, they ignored countries which have introduced a single insurance payer model such as Thailand, Turkey and Taiwan, which have successfully provided universal access at a lower cost.

The Draft White Paper states: “The introduction of Universal Health Insurance will see the purchasing of primary and hospital care largely devolved to insurers.” International experience shows that in multi for-profit insurance models, the insurers, not the doctors, act as the gatekeeper to healthcare. I don’t think the majority of the population will want insurance companies acting as gatekeepers to their healthcare.

And I suspect most people don’t really understand how UHI will impact upon them.

While Minister Reilly’s drive to provide universal access is admirable, under the proposed model, people who currently have private health insurance will lose out as they won’t be able to skip the queue. It is likely that quite a large proportion of the 45 per cent of the population who still have insurance are core Fine Gael voters who might not like losing this privilege.

All international experience shows that it takes at least 10 years to change to a UHI model. While the White Paper promises its delivery by 2019, it is likely that it will take much longer than that. If one looks at the line-up of opposition to the White Paper even before it was published, it’s hard to see it ever coming into being.

That said, Minister Reilly should be given credit for putting the prospect of a universal health system out there. All of the building blocks being put in place – the new HSE Directorate model, hospital groups, Money Follows the Patient, licensing all healthcare providers, unique health identifiers, free GP care – can all happen without Universal Health Insurance.

Big change does not work in health. A gradual move towards better and universal care that current reforms are trying to achieve, while UHI is delayed due to economics and politics, may not be a bad thing.


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