Will Universal Health Insurance (UHI) make us any healthier? Not unless the promotion of health becomes an integral part of all health service delivery, including those delivered by the GPs and acute hospitals commissioned by insurance companies.
Unfortunately, The Path to Universal Healthcare: White Paper on Universal Health Insurance gets things wrong from the start.
While acknowledging “that the central role of the health service is to improve the health and wellbeing of people in Ireland”, the White Paper proposes separating the tasks of keeping people well and treating patients.
A Health and Wellbeing Fund will be established to provide services that promote health and prevent disease.
Chronic disease management programmes will be “funded as part of a bundled service package” and included in the standard UHI package, which will be delivered by GPs and acute hospitals. This separation of wellness and illness is nonsensical.
Same old problem
The new health system will have the same problem as the old one: too much of the overall health budget spent on treating disease and not enough on health promotion and prevention.
When everyone has UHI, about €9 billion will be spent every year on treatment services. This comprises the €4,303 million now spent by the HSE in acute hospitals; the €2,433 million now spent on medical and GP visit card services; and the more than €2 billion now spent in private hospitals and on GP services by non-medical card holders.
The Minister, Dr James Reilly, has said the overall budget will remain the same, so the Health and Wellbeing Division will have to make do with €234 million to not only promote health and prevent disease, but reverse the ill-health caused by the actions of other sectors.
Health is determined by factors outside the health system. Whether a person is healthy or not depends on educational attainment, income and environment.
There is convincing evidence that people with low incomes have worse health and more disability than those who are better off.
The White Paper notes that the majority of health services are used by a minority of the population. “While medical card holders account for 41 per cent of the population, they account for 60 per cent of all day cases and in-patient bed days.”
A person who leaves school at 16 with no qualifications and who is still unemployed when they are 40 years of age, is about three times more likely to be obese and have chronic health problems, such as diabetes, than a person who gets a qualification and any kind of a job.
Depression is 30 per cent lower in neighbourhoods with ample greenery yet local authorities want to pave everything.
In 2013 the Government published a major policy, Healthy Ireland: A Framework for Improved Health and Wellbeing 2013-2025 (Hi) , which aims to increase the proportion of people who are healthy at all stages of life and reduce health inequalities, using a whole-of-government integrated approach.
The 2014 HSE Service Plan prioritises the "integration of Health and Wellbeing [with] service delivery models and reform programmes to address the rise in chronic disease".
Where is the incentive
to have less?
The White Paper proposes to do the exact opposite. Insurance companies and providers will have no responsibility for overall population health and wellbeing.
They will treat and manage chronic health problems but not prevent them. Where is the incentive to have less? In fact, the more chronic disease there is in the population, the more money will be made by the providers.
The UHI scheme is an opportunity to achieve the goals of Hi but the proposal to separate the tasks of promoting health, preventing disease and treating sick people must change.
It is just not good enough for the standard UHI package to include only patient education and management of chronic disease. Insurance companies approved to provide UHI must share the responsibility of keeping people well.
This has to be a lot more than the offer of an annual health check proposed by James Reilly a few years ago.
Service providers must get involved in outreach work to improve the living and working conditions of the communities they serve.
A proportion of the budget for each “bundled service package” must be s et aside by hospitals and primary care services to promote health and prevent disease.
Otherwise we will be back where we started in 2025 by which time Hi should have achieved its goals and will not unless UHI and Health and Wellbeing are integrated right from the start.
Dr Jacky Jones is a former HSE regional manager of health promotion.
drjackyjones@gmail.com