Universal health insurance is at the core of Fine Gael and Labour's health strategies – but would it work here, writes JOANNE HUNT
FREE GP services for everyone, free healthcare for the under 18s and prescription medicines that don’t cost a penny. This isn’t Nirvana – it’s the Dutch health system.
Fine Gael and Labour have proclaimed themselves enamoured with aspects of the universal health insurance (UHI) scheme that the Netherlands seems to have perfected, so what will it mean if the Irish health system goes Dutch?
Michael Van den Berg of the Dutch Institute of Public Health is author of a performance report commissioned by the Dutch government on its health system.
Published last November, the report found that “the accessibility” of Dutch healthcare is “mostly excellent”, with most users said to be “consistently positive about the services they receive”.
For a health system born back in 2006, it’s high praise.
“Before then, two-thirds of the population had public health insurance,” says Van den Berg. “The rest, those with income above a certain level, had private insurance.”
But in 2006, private health insurance became mandatory for all citizens, he says. “Now, you cannot choose to be uninsured”, though the insurance of those on low incomes is subsidised by the government.
So what does it mean for citizens?
The Netherlands’ health insurers are legally required to provide a standard benefit package.
Costing about €105 a month, it covers everything from medicines to hospitalisation, specialist dental care, maternity care, ambulance services as well as limited physiotherapy, speech therapy and occupational therapy.
While every insured adult must pay the first €155 or so of healthcare costs in a given year, GP visits are free.
“The citizen purchases insurance from the insurer and the insurer then purchases services from GPs and hospitals,” says Van Den Berg.
Physicians practise directly or indirectly under contracts negotiated with private health insurers, and tests in pay-for-performance and quality in primary and hospital care are ongoing.
Most hospitals are private, non-profit organisations and are encouraged to obtain capital via the private market.
Van den Berg says that with about seven big health insurers servicing the Netherlands’ 16 million citizens, the insurance companies play a key role.
While the government regulates the cost of basic services, health insurers are responsible for negotiating with GPs and hospitals on the cost and quality of everything else. “The insurers are essentially responsible for the quality of services,” he says.
With Van den Berg citing OECD figures that the Netherlands has “the lowest out-of-pocket cost with few variances in care”, the Dutch system seems to work.
When told that the cost of a GP visit in Ireland is up to €60, with a further prescription levy charged on the cost of medicine, Van den Berg is incredulous.
“A high cost of primary care is a dangerous situation – those who can’t afford it just won’t go to a GP. It leads to avoidable hospital admissions.”
However, Van den Berg says they are still striving for more data and greater transparency so that citizens can better compare healthcare providers in terms of quality and patient outcomes.
“Insurance companies are mainly competing to limit the prices of insurance policies and the costs of healthcare services,” he says. “The quality of the care is still of limited influence in the purchasing process. We need more data here.”
For Dr Stephen Thomas, a lecturer in the Centre for Health Policy and Management at Trinity College Dublin, while both Labour and Fine Gael have universal health insurance in their sights, their plans for delivery differ.
For Labour, the emphasis is on a public insurance fund, to take care in particular of the less well-off, while Fine Gael’s focus is on private insurance and risk equalisation.
Thomas says “changing the financing side doesn’t solve the issue of capacity in primary care and hospitals”. Increasing the number of GPs, improving access to primary care and greater hospital efficiencies have to happen too.
He says that while Fine Gael’s plan draws heavily on the successful Dutch system, he questions how it will translate here.
“In Holland, you have this competition and that helps drive down prices – but in a small country like Ireland where you haven’t got that many health insurers, then how effective will the competition be at doing that?”
Thomas says the plans of both parties show vision but will require “facing off stakeholders”.
“It’s more a performance system where you are not paid to exist but to do certain kinds of activity. That means a culture shift.”
Francis Ruane, director of the ESRI, says: “It’s probably still very early to say whether the Dutch system is working,” with the Dutch themselves highlighting several areas for improvement.
In terms of the challenge of implementation here, Ruane cautions that while the Dutch changed from a state insurance system to their current model, our “medical card, private health insurance or no health insurance” context means the “background connection between citizens and state insurance is very different”.
But could the Dutch model work here? “The question is really whether the Dutch system of regulated competition would be able to work in a market as small as ours, and also with such a different distribution of population,” says Ruane.
“You learn from what’s done abroad rather than copy it. Any change will need to be incremental rather than disruptive for both the deliverers and the users of care.”
UNIVERSAL HEALTHCARE: WHAT'S ON OFFER?
A system of universal healthcare, free at the point of delivery when needed, will be put in place in the Republic for the first time after the general election if Fine Gael, Labour or Sinn Féin are in government . . . or at least that's what they've promised.
Fine Gael says free GP care for everyone will gradually be introduced under its Dutch-style universal health insurance system and "this will be fully bedded in during the second term of a Fine Gael government". It says free hospital care for all, bringing an end to the two-tier system, would be in place within 10 years.
Labour, on the other hand, says it would have free GP care for all, regardless of means, in place by 2014. It would cost €389 million and be funded from savings elsewhere in the system, including cutting the pay of hospital consultants. The party would establish a system of universal insurance for hospital care by 2016 and says this would cost an extra €371 million a year if hospitals worked at 100 per cent efficiency levels. If not, it could cost up to €7.4 billion.
Under both the Fine Gael and Labour proposals, everyone would take out insurance, with those on lowest incomes having their policies paid by the State. How much those on medium and higher incomes would pay for insurance is not yet clear.
Sinn Féin has promised free universal healthcare too, but says this would be provided by the State from funding raised by taxation rather than through insurance company involvement.
The Green Party also favours universal healthcare but like Fianna Fáil says that universal health insurance is effectively a new form of taxation. The Greens say a single-tier public health system could be achieved within two to three years through restructuring. Fianna Fáil would effectively continue with the current system.
Patients would welcome a system of universal healthcare free at the point of delivery. But can it be done? It should be possible given the experience in other countries, but change takes time and in this instance it will cost money, no matter how you look at it – something that is in scarce supply right now. It may be overly ambitious to expect the next government to provide both free GP and hospital care for all, but if we were well on our way to free primary care for all in five years' time, that would indeed be a historic first step.
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Eithne Donnellan
IN HOLLAND: 'THERE'S NO RIGMAROLE OF RECEIPTS OR CLAIM FORMS'
Irishman Dermot Garry, living in the Netherlands for 25 years, pays €105 a month for standard private health insurance that includes free GP visits, prescription medicine, specialist consultations, hospital stays, dental surgery and orthodontist work.
"It's not cheap, but practically everything is covered, so you've no concerns about unexpected high bills. There's no reason to put off seeing a doctor or specialist.
"The best thing is that it's practically cashless – there are no cash transactions at the doctor, specialist or pharmacy.
"They bill the insurer and the insurer bills you for amounts up to 'own' risk" - about €165 in Garry's case, but GP visits are free. There's no rigmarole of receipts or claim forms.
Insurers declare their prices in November with customers free to switch until January 1st. Insurers can't refuse a customer on health and age grounds. This year, one million Dutch people are reported to have switched insurance provider.
Citizens' health records are stored centrally, so if you switch GP or are in an accident, your medical record is available instantly.
Privacy is a concern for some, so the Dutch Ministry of Health has sent a letter to citizens saying "you're in unless you specifically opt out".