Editorials

The Irish Times view on health insurance coverage for key cancer drugs: unwelcome gaps

At a minimum consumers need to be made aware of the difference between the three health insurance players in key areas

VHI: its customers are reimbursed for key cancer drugs, but the two other big players have not yet done so in relation to some newer drugs ( Photograph: iStock)

Thu Jun 1 2023 - 21:30

Almost half the population has some form of health insurance and the concept is now so deeply integrated into the Irish healthcare system that we tend to lose sight of the fact that the companies involved are out to make profits.

This particular chicken has come home to roost in the provision of advanced drugs for the treatment of cancer. Two leading oncologists this week accused two of the three large health insurers, Irish Life and Laya, of “hiding behind” the lengthy process by which the HSE approves new cancer therapies for use in the public system.

The process can take up to two years from when the drugs are approved by the European Medicines Agency (EMA) and is one of the slowest in the EU. The third and largest player in the market – State-owned VHI – does not wait for the HSE and usually reimburses its customers within a couple of months of EMA approval.

The key word here is customers. VHI is an insurance company run on commercial lines, as are the other two players. The obvious question is why Irish Life and Laya’s customers don’t become customers of VHI and avail of its more proactive approach to cancer drugs.

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There is more than one reason but the most obvious is that health insurers don’t cover new customers for pre-existing conditions. This is normal enough in insurance – you can’t insure against an event once it has happened – but in the health insurance market it appears to thwart competition.

Laya and Irish Life can drag their feet on covering new cancer drugs secure in the knowledge that their customers have limited alternatives.

Private health insurers are regulated by the Government through the Health Insurance Authority (HIA) in recognition both of their importance to the healthcare system and the various structural obstacles that militate against full competition. The HIA’s “vision” is for a “well-regulated, competitive health insurance market where consumers are empowered to make informed decisions”. This does not sound like a description of the status quo as it pertains in the area of advanced cancer drugs. At a very minimum the HIA needs to make consumers aware of the difference between the three players in this regard and not leave it to doctors to raise public awareness.

It is not clear if the HIA has the power to go further. Its job is to ensure compliance with the Health Insurance Acts and legislation is a matter for the Government. It might be simpler to accelerate the HSE approval process for these drugs.

The affair also highlights a central issue with the health system. It is biased, particularly in terms of speed of access, in favour of the bettter- off, who can afford private insurance. Sláintecare is designed to create a level playing field, at least in terms of essential treatments, but there is still a long way to go here.

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