Reilly’s UHI model the worst possible option for Ireland
This Government’s promise to be “the first in the history of the State that is committed to developing a universal, single-tiered health service which guarantees access to medical care on need, not income”, is the most vital health reform in Irish history.
The Programme for Government promised UHI by 2016. The recently published White Paper on Universal Health Insurance outlines the plans to achieve UHI by 2019.
Under the model proposed, the vast majority of health and social care will remain tax-funded so what is proposed is a very Irish – hybrid – model of universal health insurance.
The multi-payer model will mean that private, for-profit insurance companies will compete with each other and a public VHI to pay for aspects of healthcare – primarily GP and hospital care.
The rest will be tax-funded, and it remains unclear what will happen to the healthcare aspects that the majority of us currently pay for out of our own pockets, such as drugs and allied health professionals.
In other countries with UHI, drug costs are completely paid for or largely subsidised. The White Paper specifies that the “inclusion of pharmaceuticals (subject to co-payments) . . . will be considered”.
It is envisaged that those with medical cards will have their drugs largely paid for. But will people dependent on medication really want to pay for their health insurance and still have to pay up to €144 a month for their drugs?
What about public community and primary care services that are currently only available to people with medical cards?
Will these become universal, free at the point of delivery, for the whole population?
The success of the UHI model proposed is dependent on bringing down the cost of care. Yet internationally, insurance-based models cost more than tax-based ones. In Ireland, overall health costs have been brought down during the economic crisis, largely due to the reduction in staff numbers, cuts to pay and fees to health professionals and better deals with drug companies.
However, critically, the cost of hospital care in Ireland remains very high. The UHI model proposed is also dependent on the competition between insurance companies bringing down the cost.
This has not been the experience in other countries with this type of system. For example, there have been substantial increases in the cost of health insurance in Holland since a multi-payer model was introduced in 2006.
The USA is the most extreme example where private for-profit insurance companies compete and, not coincidentally, it has the highest cost of healthcare of all OECD countries.
In America, more than 17pc of national income is spent on health, while in Holland it is nearly 12pc, in Germany and Switzerland (both with insurance schemes), it is more than 11pc.
In all other OECD countries including Ireland, it is less than 10pc. In order to avoid health insurers rationing or gate-keeping care as happens in Holland and the USA, the White Paper proposes ‘the most explicit approach possible when legislating for the standard UHI package of services.’
This will require very heavy regulation.
But even with regulation, insurance companies tend to be extremely agile at gaming the system for their own benefit.
If previous form on Irish financial regulation is anything to go by, this seems an unwise approach.
The UHI model proposed in the White Paper is the wrong one for Ireland. Interestingly, Minister for Health Dr James Reilly prevented the group – that he set up to advise him on the matter – from considering other options such as a single-payer or taxed-based models.
These have proved internationally to be more equitable, affordable and sustainable.
The timeframe of the White Paper is completely unrealistic because the detail is not worked out. It will not be delivered by 2019.
Perhaps this was the intention of the mandarins in Hawkins House who drafted the White Paper.
And maybe that’s ok, as long as too much damage is not done on the way.
Maybe this absence of detail and unachievable timeframe is a good thing. The White Paper is calling for a ‘national conversation’ on what type of health and social-care system we want and how it should be funded.
This gives us the space to work out for the first time, the best model of health and social care for Ireland, a model that would deliver on the Programme for Government commitment where everyone would have access to a universal, single-tiered system, based on need, not ability to pay.
Now, wouldn’t that be a great legacy for James Reilly.
This column appeared in the Irish Independent on 15 April 2014