Orla Muldoon: Everybody loses with a two-tier health system

We are at a crossroads. It is time to interrogate Ireland’s two-tier healthcare system and its consequences. A system that divides us in terms of healthcare provision will also divide the nation. There are costs in terms of social cohesion, harmony and, paradoxically, health.

At its heart, the two-tier system works on the idea that those who get better healthcare “earned it”. Even if this is true, which is highly debatable, offering differential healthcare to those who have and have not got health insurance is a questionable practice.

So the announcement by VHI Healthcare that it will now offer a range of treatments to those with health insurance, treatments that are not available to those reliant on the HSE for healthcare, is a clarion call. It is time to wake up to the cost of the two-tier system that has been facilitated for years in Ireland.

Poverty, or low income, has always damaged health. There have been a range of government reports completed in the UK since the now famous Whitehall Studies. Serious government reports such as the Black Report and the Marmot Review demonstrate that poverty and low income lead to a shorter life expectancy and greater ill health over the course of the lifespan.

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It would seem these effects predate modern medicine. Historical analysis of gravestones and graveyards in UK, US and Australian cemeteries indicates that lower socioeconomic status significantly shortened the lifespan.

Health behaviours

In modern times, these differences can be and routinely are lined up with the difference in health behaviours of those in low-income groups. The poor smoke more, drink more alcohol, eat badly, leading them to an early grave. In fact, it can be very early indeed.

An analysis of infant deaths in the Southern Health Board area published in 2000 indicated that almost half of infant mortality in the health board area occurred in the 7 per cent of electoral districts designated as disadvantaged.

So whilst there may be some truth in the idea that health practices and behaviours differ according to income group, there is also clear evidence that those from low-income groups have a greater chance of experiencing adversity in childhood, experience a wider range of stressors and have poorer educational opportunities. In this way we can see that being born into a low-income household brings cumulative risk.

This cumulative risk presents a problem for those of us who want to live in a just society. In times gone by, there was a view that hard work and application to the task would allow people to move out of poverty. Sadly, times have changed.

There is some evidence that ill health can trigger downward social mobility; however, moving up through the pecking order of income groups is a lesser-spotted phenomenon. In fact, there is now strong evidence across EU studies that upward social mobility is the exception, not the rule.

If we want to maintain social harmony in Ireland, now is a good time to pause for thought

And herein lies the problem. Much of the reasoning that we use to justify differences in opportunities, be they in terms of health or educational resources, hangs on the erroneous belief that we live in a society where people reap just rewards. As social mobility has become increasingly difficult, we now live in a society where monetary rewards are not directly linked to effort or deservingness.

With little physical effort, wealth can be accrued by using earned or inherited wealth on the stock market, and can be further accrued by tax avoidance, for example. And we know that the corrupt and the narcissistic, rather than the deserving, can be found at the top of many organisations.

Fabric of society

This brings us to the final, and important, issue. Though poverty and low incomes damage the health of the poor, income gaps damage the rich and poor alike. Disparities in access to health and educational resources affect the fabric of society profoundly.

Imagine two people whose spouses were recently diagnosed with cancer. One has health insurance, the other doesn’t. One is relieved that his spouse has access to treatment, the other is distressed and railing against the injustice of the world. These people meet and realise their lives are playing out differently.

The former feels awkward and even embarrassed by their access to better healthcare, the latter is incredulous and even indignant. The former realises the risks for those outside the health insurance net and so fears falling down the social ladder.

There is a justified personal concern, as well as one for those s/he holds dear. This person is motivated to protect their own and their family’s position and resources as best they can. The latter may agitate for change or believe the system is corrupt and therefore its disruption is justifiable. The latter will also be angry that those who are better resourced care so little for their plight. They will interpret that group’s unwillingness to help as callous. In short, our sense of ourselves, others and our social world is derived from this system.

If we want to maintain social harmony in Ireland, now is a good time to pause for thought. Our two-tier health system is evolving as a divisive force. It undermines us all.

Orla Muldoon is professor of psychology at the University of Limerick