OPINION:The authors of a report calling for a single-tier healthcare system, free at the point of delivery, challenge Mary Harney's rejection of their ideas
WE WELCOME the Minister for Health engaging in the debate over a new system of universal health insurance for Ireland. However, we were surprised at the vehemence of opposition to a coherent model for reform, particularly after the policies of the last six years have failed to bring a fairer health system.
The Minister implies (Opinion and Analysis, April 28th) that health financing is unimportant, or certainly less important than resource allocation. The Minister is mistaken for two reasons.
Firstly, she fails to understand that health financing determines entitlements to care, and hence access to services. By making access to essential care dependent on the payment of user fees and private insurance, the Minister is allowing better entitlements for those who can pay.
Conversely, many who need healthcare are denied it because they cannot afford it. If we are to attain a health system with access related to need, as the Minister says she wants, we must pay attention to how health is financed.
The evidence is clear. Study after study shows user fees are unfair and inefficient. While they deter those who would use services inappropriately, they also deny care to those in genuine need. The case for eliminating user fees is overwhelming.
Secondly, the chosen method of health financing affects how big “the cake” is – how much money you have to allocate across health needs. In contrast to our current system, social-insurance systems involve an earmarking of money to a separate fund, which, as we suggest, should be placed outside government. Such systems are typically more transparent and more accountable, as people know their health contributions are not going to be used for other purposes.
In countries with social-insurance systems, people are willing to contribute more because they can see where their money is going and feel more ownership. Thus, a social insurance system in Ireland can help provide the additional resources necessary to make access to care more equitable. The financing of health is important, because it helps achieve universal access to care and helps raise the money to deliver it.
The Minister is of course right to say no system has unlimited resources, but she is wrong to say our model has not been costed. As economists, it was our pleasure in our earlier reports to review both what it would cost to run a universal health insurance system, and what resources would be required to relieve the existing bottlenecks around capital and human resources. (Such bottlenecks, by the way, have been produced by previous poor decisions around resource allocation and investment.)
We agree fully that the process of resource allocation is of utmost importance. A contracting model for purchasing care (or allocating resources, if you wish) is a key focus of the report. We advocate a provider payment mechanism that creates incentives for efficient and high quality care for those in need. The current approach to paying hospitals relies largely on incremental budgets which do little to boost efficiency.
We accept there will always be rationing in every system. But some forms of rationing are inefficient and unfair. The current system relies on the market to ration care. It does not focus on medical need as differential waiting lists show.
The Minister thinks it is impossible, or at least illegal, to end the two-tier system. This is an interesting exercise in semantics.
A one-tier health system is not synonymous with the abolition of private health insurance. In a universal health system, private insurers can continue to offer supplementary insurance packages. These packages can provide care or services that fall outside the basic benefits package.
The fundamental point is that, in a one-tier system, private insurance does not entitle any patient to “skip the queue” for essential services. Patients are treated based on medical need. We have demonstrated the feasibility of such a system in Ireland. So a one-tier system is possible, legal and surely desirable.
It is a worthy goal for a mature society to deliver universal access to healthcare free at the point of contact. This won’t be achieved overnight: long-standing bottlenecks need to be resolved first. Nevertheless, with careful planning and investment, support from stakeholders and further technical work, it is within our grasp.
The US has shown major improvements can be made to a health system even in the face of fierce opposition. It is now Ireland’s turn.
Steve Thomas and Padhraig Ryan work in the Centre for Health Policy and Management at Trinity College, Dublin, and are two of the authors of the report Effective Foundations for the Financing and Organization of Social Health Insurance in Ireland, available on the Adelaide Hospital Society's website: adelaide.ie.