An Unhealthy State: What then is to be done? Maev-Ann Wren looks at the options for the health service in the final part of her series
The Irish die younger than the average European. We experience more ill-health. When we are sick, only those of us with money can be confident of receiving anything approaching acceptable treatment.
A society which tolerates this state of affairs is a sick society - literally and metaphorically, yet we are manifestly unhappy with our healthcare system. In opinion polls, large majorities repeatedly say that healthcare matters more than any other issue. How then should our system be reformed to deliver acceptable care for all?
The greatest failing in Irish healthcare is the inaccessibility of primary care. Families on very low incomes must pay €40 for every visit to a GP and spend up to €70 a month on prescribed medication. An individual who earns over €138 a week and a family of four on over €250 will not qualify for medical cards and must pay for care.
International experts have advised the Department of Health that accessible primary care is "axiomatic to a modern health system" and there exists "a strong case for free primary healthcare".
Documents released under Freedom of Information reveal that the panel of advisers on the 2001 Health Strategy recommended that "the establishment of health as a fundamental human right" should be "a key starting point for the strategy" from which "full access to quality health services" would follow.
They argued that Ireland should have a health status which was at least equal to the EU average, given its level of wealth and education, and observed that Irish political debate tended to over-emphasise the issue of hospital waiting lists and failed to understand the potential impact of the primary care system on referrals for hospital services. They noted that investing in health could have an economic payoff.
There was no reference to rights in the Government's strategy. These arguments from Prof Richard Alderslade of the WHO, Dr Judith Kurland of the US Department of Health and Human Services and Dr Charlotte Dargie of the University of Cambridge had fallen on stony ground. A departmental strategy working group, which initially stated its support for "the thrust of a rights-based approach", nonetheless rejected it, because it would allow the courts a role in deciding on health needs.
The strategy contained no proposal to change the 30-year-old legislation, which states that free care under the medical card system should be restricted to those for whom medical bills would cause "undue hardship". Extending medical card eligibility then became one of the first political casualties of economic slowdown.
More than 50 years ago, Noel Browne resigned as Minister for Health when his government colleagues failed to support him against church and medical opposition to his mother-and-child scheme, which included plans for free primary care for children. No Government has since attempted to offer universal free primary care.
Eligibility for free hospital services was, however, progressively extended to the whole population, with the result that our healthcare system is now biased towards costly hospital care. The absence of free access to primary care makes Ireland highly unusual in modern Europe, where states fund access to free primary and hospital care either from general taxation or by means of social insurance.
Primary care in Ireland has remained an underfunded service, supplied by self-employed general practitioners, who set up wherever they wish and frequently work in isolation. The Government's 2001 strategy proposed substantial investment in primary care teams and premises but made no commitment to improved access. Yet an informal working group established by the Department of Health had initially proposed a free primary care system, to be funded by universal health insurance, an approach advocated by the Labour Party.
In the general election a year ago, the electorate was offered a clear choice between two different approaches to reform of the healthcare system. The Government proposed to fund its €13 billion Health Strategy, leave the two-tier system of hospital access essentially unreformed and pin its promises of better public patient care on investing sufficiently to banish scarcity. It offered extended medical card eligibility at some undefined time in the future.
Now that the Government has reneged on its promise to fund the strategy, the poverty of its proposals for reform are laid bare and the alternative approach, proposed most coherently by Labour and with less clarity by Fine Gael, deserves renewed examination.
Labour would have introduced universal health insurance. Everyone would have been insured for a defined package of medical care. Some would continue to pay their full premiums, some would receive State assistance towards paying their premiums, the poorest would have their premiums paid fully by the State. If anyone who could afford to pay a premium did not do so, the State would recoup the cost from their income tax.
It would be a compulsory insurance system, comparable to the system of funding healthcare in France and Germany. Distinctions between public and private patients would disappear because hospitals and doctors would receive the same sums for whomever they treated.
One of the strongest arguments for considering an insurance-funded system for Ireland is that it would provide an earmarked tax for health.
If health required additional funding - as it does and will - then at least society would be clear that funds raised for health would go to health. Since a premium would be paid for each individual, rises in population should create an increased fund for healthcare. And in an insurance system, there are defined and costed benefits, so that premiums should bear a direct relationship to the cost of providing services.
Insurance systems vary hugely. Labour and Fine Gael would have channelled healthcare spending through the VHI and other competing insurance companies, who would purchase care for patients from either publicly or privately run hospitals and from GPs.
Some critics feared the dominance of healthcare by a profit-driven insurance industry as in the US. However, Labour was crucially determined to ensure that the VHI would continue to be run as a not-for-profit company.
Neither party posited the alternative possibility of channelling premiums through a State-run insurance agency, analogous to the approach taken in Canada. They may have been under the misconception that since the EU requires competition in the market for voluntary insurance, there must also be competition in a compulsory insurance system. In fact such compulsory statutory systems are immune from EU competition requirements.
Labour envisaged a system in which "the money would follow the patient" so that hospitals which treated more patients would receive more revenues. As we witness the absurdity of the State's most successful hospitals being forced to reduce the care they offer, this has especial appeal.
Moving to an insurance-based system would involve a seismic shift in how healthcare is funded and delivered.
An alternative path to equity could, however, be achieved in the existing tax-funded system by introducing free primary care in which the state would pay GPs by salary, capitation, fees or a mixture of methods; and by banning private practice in public hospitals and investing in public care so that the majority would opt to take up their statutory right to treatment as public patients in one-tier public hospitals by salaried consultants.
This would be similar to the system in Britain or Denmark, much more mainstream internationally than the existing Irish system.
The VHI would revert to insuring a much smaller proportion of the population for elective care in the small number of private hospitals.
Provided the State invested sufficiently in the public system, the nascent private hospital industry would lose its appeal, but if the State did not invest sufficiently, patients and doctors could take flight into the private system and the schism in care would deepen.
The alternative compulsory insurance system avoids this risk because it creates a system in which all must participate. Private hospitals contract to treat patients within the State system.
Either route could achieve an equitable, accessible healthcare system. Neither is currently contemplated by this Government, yet without reform, healthcare will stay in permanent crisis.
It is clear what reform must achieve and what must be avoided. Reform must achieve equitable access. It must avoid permitting the mutation of healthcare into a private, for-profit industry. The Labour Party proponents of compulsory insurance have, by and large, thought through how to avoid this and would receive support from the EU in designing an insurance system, which is not driven by profit.
It is the Government parties who are sleepwalking their way towards a for-profit health industry with their apparent willingness to allow the sale of the VHI to the highest bidder, their support for for-profit hospitals and their use of State funds for the treatment of public patients in the private sector while they cut back on treatments in public hospitals.
The Germans realised in the 1880s that a strong state required a healthy population and established a system of compulsory health insurance. It took Ireland until the 1960s to recognise the importance of universally accessible education.
The time is overdue to wake up to the need for universally accessible healthcare.
Maev-Ann Wren is author of Unhealthy State - Anatomy of a Sick Society, published this week (New Island, €17.99)