IN THESE straitened times, the proposal from the Adelaide Hospital Society that current spending on healthcare could be transformed into a health system providing free GP care, free medicines and free acute hospital treatment is guaranteed to attract public attention. In contrast to our two-tier health service and the difficulties faced by the Health Service Executive in winning public confidence since it was set up, the proposal promises greater equity and enhanced efficiency.
Universal health insurance is an idea whose time has come. It forms the basis for the major changes introduced recently by the Obama administration in the United States which, for the first time, will see a basic level of healthcare available to all. It has been Labour Party policy since 2001 and Fine Gael’s more recent Faircare proposals encompass a system of free or affordable health insurance by means of “managed competition” between insurance companies.
A report, prepared by the Centre for Health Policy and Management in Trinity College Dublin for the Adelaide Hospital Society, advocates the development of a social health insurance (SHI) model for the Republic. Drawing on international practice, it proposes four different options to replace general taxation funding with revenue earmarked for health: pure SHI funded by income deductions; subsidised SHI which combines payroll deductions and government funding for those below a certain income threshold; a “mixed bag” model financed through a basket of taxation sources; and a “flat premium plus subsidy” SHI, where all adults pay a fixed premium to insurance companies, with government subsidies available for certain social groups.
The report favours the pure SHI model but acknowledges the subsidised SHI option is less disruptive and more practical. It proposes using the subsidised option as a stepping stone to the pure model over a 15 year period, with the aim of providing guaranteed access to quality care at the lowest cost on an equal basis for all.
Minister for Health Mary Harney has welcomed “open and honest debate on the very complex issue of health financing” but warned against creating false expectations by moving from taxation to levies or insurance as the basis for funding healthcare. “Money should follow the patient’s best health. What matters most is how resources are used, not how resources are raised from the public,” she said.
Many of the Adelaide proposal’s headline attractions are dependent on achieving considerable cost savings. One of these, a proposed 10 per cent cut in the cost of primary care services, appears at odds with the report’s greater emphasis on the gatekeeping role of primary care and its acknowledgment of a current shortage of family doctors.
In the last week both the Irish Medical Organisation and this report have advocated discussion on the merits and drawbacks of different models of universal health insurance. The fulcrum of healthcare is moving from Boston to Berlin: it is time for a structured and vigorous debate about its future financing.