The attitude of the Department of Health to the publication of the White Paper on private health insurance was in marked contrast to the approach taken to last week's Green Paper on abortion. The Department shied away from any direct association with the Green Paper, handing it over to the Government Information Service for a low-key release.
By contrast, an outside public relations firm was drafted in to oversee the White Paper's release. Two of the Department's top civil servants, and an actuarial consultant involved in preparing the document, provided a "technical briefing" on its recommendations.
In addition, the Minister for Health, Mr Cowen, first took questions from the media and later met the interest groups to sell the official line on the document. Yet the White Paper, which seeks to transform the commercial status of VHI with a £50 million injection of State money, may well present the Government with as big a political headache as the abortion Green Paper.
Two in every five members of the population are covered by private health insurance. The vast majority, 1.46 million people, has membership of the State-owned VHI, with the remainder having signed up to BUPA Ireland, which entered the market in 1997. Those figures illustrate how many people have a stake in the proposed changes.
The White Paper is as much a document on the future of the VHI as it is one which deals with the overall private health insurance market. Mr Cowen is in effect attempting to square a circle by encouraging greater competition while simultaneously protecting the VHI from that competition.
The recommendations in the White Paper which alter the private health insurance market are long overdue. Competition, forced on a reluctant Department of Health by the European Commission at the start of this decade, has existed in a limited form in the Irish market for over two years.
The Minister acknowledged the "potential conflict of interest" in his role as shareholder in the VHI and regulator of the overall private health insurance market. The establishment of an independent regulator has been promised since the 1994 Health Insurance Act. Now the White Paper proposes to address the problem by setting up a Health Insurance Authority.
Mr Cowen's approach will see the VHI transformed from a statutory board into a commercial semi-state company. The Government has said it will then "pursue, as a matter of urgency, the question of outside investment, in order to enhance the position and prospects of the VHI".
This is shorthand for privatisation of the VHI, which is likely to happen after legislative changes introduced over the next 11/2 years. The carrot of an employee share ownership plan as part of this sale was waved before VHI employees.
Mr Cowen must now submit these proposals to the European Commission. His officials are confident the £50 million investment in the VHI will be approved despite the objections of BUPA Ireland that it is in effect an anti-competitive State subsidy.
In a wise move, the Department of Health has kept the Commission advised of the proposals it intended including in the White Paper. The Minister is confident of approval from Brussels, although that may come only with a stipulation that the Government sells off the VHI in its entirety.
BUPA Ireland has been making noises about a potential legal challenge to the £50 million investment. However, the real focus of its attention is expected to be seeking to change the risk equalisation scheme proposed in the White Paper.
Under the scheme, BUPA would be obliged to "write a cheque" for several million pounds to its main competitor, VHI, to ensure each was exposed to a similar level of patient profiles. The Department of Health will now commission a feasibility study to assess how to introduce a risk equalisation scheme.
An industry source said last night that the framing of the risk equalisation scheme would be the determining factor in introducing further competition. He estimated that the market here "has the capacity to sustain four or five private health insurance companies".
The Government needs a competitive private health insurance market to keep costs from spiralling out of control in both the public and private sections of the healthcare market. Without competition in the private insurance market, the theory goes, premiums would increase and younger people in large numbers would turn away from the VHI and other insurers.
The resulting pressure on the public system would be simply too great for it too bear. Such a situation developed in Australia in the 1980s, which explains the Minister's emphasis on maintaining the private-public mix in the Irish health system.
However, he still has to address the perception, often confirmed in practice, that those with VHI or BUPA membership can obtain speedier access to treatment than those relying on the public system.
Ironically, it is 10 years almost to the day since the publication of the Report of the Commission on Health Funding. The commission, chaired by Dr Miriam Hederman O'Brien, proposed "a core publicly-funded service for the whole population". It also recommended that "priority of admission should be determined solely by medical need and not by the public or private status of the patient".
The Labour Party is critical of the Government's approach in the White Paper. Its spokeswoman on health, Ms Liz McManus, says "we have an underfunded, two-tier health service". She favours a universal health insurance system which would deliver equality of access and quality care.
Until 1997, the VHI had a monopoly on the sale of private health insurance. The company, and the marketplace in which it operates, is set for radical transformation.
Customers will notice a difference - an increased product range being one early development. However, premiums are still likely to increase, with rises in medical inflation continuing to outstrip the general cost of living.