We need the type of health service where access to treatment is determined by clinical need and not ability to pay, writes Dr Fergus O'Ferrall
'Three years to live - because I didn't have private health insurance", ran the headline after Rosie told her heart-rending story to Joe Duffy on Liveline recently. Rosie, aged 40 with two children, is a public patient who had to wait many months for a colonoscopy for bowel cancer.
Patients with private insurance obtain access to diagnosis and treatment much faster than public patients, often with life-saving consequences: Liveline over a number of days had personal stories of the cruel differences between public and private patients.
The tragedy for Rosie and all the other Rosies is that it does not have to be like this in Irish healthcare. Ireland's unique "two-tier" health system can be changed by switching to a different financing system - essentially changing the way we pay for healthcare from a taxation plus private health insurance system to a comprehensive social health insurance system.
Many of the most successful healthcare systems in the European Union are based on social health insurance and they have universal access at the point of need and the capacity to meet the healthcare needs of their citizens.
The Adelaide Hospital Society published a detailed independent research report last November entitled Social Health Insurance: Options for Ireland. The report was prepared by Prof Charles Normand, Dr Stephen Thomas, and Samantha Smith - in the School of Health Policy and Management in Trinity College Dublin - who have international and national expertise in healthcare financial systems.
The report presents clear costed options to end the "two-tier" system. It demonstrates that comprehensive coverage of every citizen is both feasible and desirable in the Irish context.
The study analyses the current dysfunctional financing system whereby the public pay 90 per cent of the cost of the healthcare system (75 per cent through taxation and 15 per cent through out-of-pocket direct payments).
Only 10 per cent is paid through private healthcare insurance and this small element distorts perversely the system to create the disadvantages suffered by so many public patients such as Rosie.
Social health insurance is a mechanism which has the potential to improve both the transparency of the way the health system is financed and also the performance of the system in terms of both equity and efficiency. As a result of the report we now know the cost (at 2004 prices) of giving each citizen free access to their GP, as already available for medical cardholders, and for the first time we know what it would cost to achieve equity in our healthcare system.
The four options in the report in brief are:
r Levelling up access and quality of all services to current private patient care quality for all citizens at a cost of €2.1 billion per annum (the "Rolls Royce" option)
r Extending medical card coverage to all the population and removing some of the barriers to hospital services at a cost of €0.7 billion (The priority to primary care option)
r Extending hospital insurance cover across the population and lowering GP access charges to those without medical cards at a cost of €1.4 billion (The priority to hospital services option)
r Reducing the financial barriers to access to hospitals for the uninsured and lower GP attendance fees at a cost of €380 million. (The "Mini" option)
The proposals in the report are designed not to affect adversely those on relatively low incomes in moving towards a comprehensive social insurance system. The options could be progressively introduced in stages towards the "Rolls Royce" option. Given that citizens already spend €14 billion per annum on their health system and that this increases by over €1 billion paid each year, the additional costs are entirely feasible in an Ireland where far more than these increases are used each year for physical infrastructure. For example, Ireland is the only EU country where most citizens pay fully to visit their GP. We could have free access to primary care for an annual amount less than the cost of extending the M50 motorway. This may help to put our national priorities in perspective.
A key advantage of citizens paying for their healthcare through social insurance rather than through taxation is that it places every citizen on an equal basis as an insured patient: providers of healthcare would have to efficiently and effectively treat patients in order to keep their business. Social insurance would end the "two-tier" system once and for all. Access to treatment would be determined by clinical need and not ability to pay. Social health insurance is based upon social solidarity whereby insurance is paid according to income or wealth and care is provided on the basis of need.
An additional advantage is that social health insurance gives an ear-marked independent, transparent financing system for healthcare in contrast to our heavily political and opaque system with its perverse financial incentives. Under social health insurance, public, not-for- profit and private providers could compete for patients - the money would follow the patient.
Voters who were moved by Rosie's story and her courage in bringing this issue so clearly to the fore can demand of each political party in the general election a clear, well-costed set of proposals to end our "two-tier" health system: it can and must be done. Let's make Rosie's courage a catalyst for change in 2007.