Prescription for failure
Universal Health Insurance has, from the outset, been the centrepiece of Fine Gael’s, and the Coalition’s health strategy, going back to the Programme for Government in 2011.
A system of Universal Health Insurance will be introduced by 2016, with the legislative and organisational groundwork for the system complete within this Government’s term of office
Health Minister James Reilly has invested much effort and political capital in the concept and the Department of Health has undertaken a huge volume of preparatory work. It is now clear, however, that this transition will not take place in the lifetime of this Government. It is difficult not to feel some sympathy for Dr Reilly.
Earlier this week, the Government launched — or rather relaunched — its UHI White Paper, to a chorus of political rhetoric that this would be the end of this, and the beginning of that — the usual stuff. Except that it won’t be: It has been acknowledged that UHI is not now scheduled to begin before 2019. In other words, if it happens at all, it will be the responsibility of a different administration, which may have very different ideas on how best to fund, and deliver, the nation’s healthcare.
There are a wide range of UHI models across Europe and other developed countries. A common feature of mandatory schemes, such is that set out in the White Paper, is that each adult is required to purchase insurance from a ‘standard basket’ of health services. Those who are unemployed or on low incomes are subsidised through a national fund on a means- tested basis.
Essentially, the health system under UHI is funded by the exchequer, by insurance and by co-payments other than for specified services such as, for example, A&E and ambulance services, which will continue to be funded by (you’ve guessed it) a levy. The overall aim is a less fragmented funding model and a more egalitarian approach to healthcare. Over and above what will be provided in the ‘standard basket’, individuals may take out supplemental health insurance for additional services. These will be risk-rated and so will be more expensive for older consumers.
The White Paper has only conditional Government approval. It is overshadowed by the reality that it will not be introduced for at least five years — and that’s a lifetime. That’s not all.
There are major uncertainties embedded within the White Paper as it stands. The most important of these, and the most divisive, is the lack of details on the projected cost of introducing UHI compared with the present level of Government funding. Dr Reilly sees costs as something to be estimated over the next year. The Department of Public Expenditures takes a very different view. It is reportedly concerned at proceeding with a seismic change in the healthcare funding model without having more precise information on costs.
There is also an insistence on cost-containment along any trajectory towards UHI, including benchmarking such costs against current levels of expenditure. This has to be seen in the wider context of what has been happening in the last three years. Government health funding has been subject to arbitrary, brutal, and counterproductive cuts that have greatly damaged health status and the stability of public service provision.
Government knows — even if it won’t admit it — that these cuts will have to be reversed and they also know that, in the ‘open prison’ of Ireland’s post-Troika surveillance, this funding will not easily secure approval of those who really determine such matters. The so-called health ‘overspend’, compared with government budgets in the last three years, has been a disingenuous fiction and one that has increased risk and strains right across the public system. So the whole issue of costs of UHI is fraught with all kinds of anomalies. There is no unity of vision or purpose across the cabinet table.
There are other gaps in the White Paper, not least what will be included — detailed proposals for what will be in the ‘standard basket’. This is crucial, as it drives a whole range of issues. The White Paper argues that the ‘standard basket’ will be determined on the basis of consultation. But the Government could easily have drawn on schemes in other European countries as an indicative proposal for what it intends putting in the basket. This uncertainty is, almost certainly, driven by the cost implications; a fear that the political bargaining will push Government to expand the basket and therefore the costs.
There are deeper reasons which may help explain why UHI has now been effectively deferred. There are lessons to be learned.
The first relates to the timing of the UHI reform and the satellite reforms clustered around its implementation. The Coalition came to power at a time of unprecedented fiscal stress. Most new governments succumb to the temptation to reform everything in sight. It’s a very great mistake.
The unprecedented scale of fiscal adjustment being imposed on the economy should have told the Government that this was not a time of systemic reform. It was a time to encourage and to support and to incentivise staff already working in an extraordinary stressful environment.
There is a time for ‘strategies’. There is also a time to work with what is in place and also to say to staff “Thank you for all you’re doing. We really need help to get through this crisis. How can we help you?”
This didn’t happen. It’s hard to know if the failure here — and it is a failure of Government not an individual — arises from ambition, or vanity, or insensitivity to what’s happening in wards and clinics where people come to work early and leave late.
But what compounded this failure to read the signs of the times and what they meant for the delivery of healthcare is the manner in which medical and nursing manpower — from nurses, the transmission belt for change, to consultants who deliver and oversee care and medical training — were systematically disrespected at every level. The new graduates of our medical and nursing training schools are producing the highest quality staff — for export only. Hospitals were — and continue to be — put in impossible conditions. Government completely misread the timing of these reforms and the kind of medical manpower environment — basically trust — that was needed to make them work.
A UHI system has to be built on the private health insurance (PHI) market that is in place. It requires a competitive market in which all insurers operate on a level playing field. Ireland has never had a competitive PHI market. What it has is a set of arrangements that are discriminatory, in breach of European Court of Justice instructions and which is so unaffordable and so unstable that well over 200,000 customers have been forced out of the market. UHI is all about serving the interest of the consumer and empowering the consumer. Ireland’s PHI market is primarily driven by the Government’s agenda.
The costs which have contributed to the unaffordability crisis are substantially driven by the Government itself: In 2013/2014, Government policies imposed a burden in excess of €300m on the market. Basically, the foundation for the kind of insurance which could support a robust UHI model are simply not in place.
But there are also developments in the wider economy that impact on health, including mental health, that is left pushed to the outside of a policy calculus on UHI. A notable example is the exponential increase in housing repossession now under way and which will inevitably and inexorably impose the most severe levels of mental stress, and worse, on the health of tens of thousands of householders.
The Government knows this to be the case — the figures cited in the Dáil recently by Séamus Healy TD are truly shocking. TDs have repeatedly referred to the causes of this crisis and what needs to be done. Mainstream politics is in denial.
It is, at best, cynical to hail the UHI as a breakthrough in the delivery of healthcare while the public system and the PHI market are in disarray and policies are being enforced in the field of the residential housing market that cut the ground from underneath the healthcare of the nation.
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