A discussion at the Royal College of Surgeons heard a wide range of opinions on Government plans for universal health insurance versus other models, writes GENEVIEVE CARBERY
THE RECESSION could create the right climate needed to introduce universal health insurance by forcing efficiencies and making vested interests less resistant to pay cuts, the Pfizer/Irish Times Health Forum at the Royal College of Surgeons heard last week.
The discussion, chaired by Irish Timesassistant editor Fintan O'Toole, was on the topic of universal healthcare, a type of which has been promised in the programme for government as universal health insurance.
The panellists were Dr Steve Thomas, health-policy analyst at Trinity College Dublin; Prof Sean Tierney, former president of the Irish Medical Organisation and consultant vascular surgeon at Tallaght hospital; Oliver O’Connor, healthcare business consultant and special adviser to former minister for health Mary Harney; and Dónal Clancy, general manager at Quinn Healthcare.
Universal health insurance systems tend to be more expensive because they deliver more services, said Thomas. However, the downturn could be a “complete windfall” for reforming prices, because expectations have changed, efficiencies are being forced on the health system and stakeholders who in the past would have put up resistance to pay cuts were probably going to have to “roll with it”.
The savings needed could now occur because vested interests had been “softened up” by the recession and would be swayed by the vision of universal healthcare, he said.
However, Oliver O’Connor said if such efficiencies and salary cuts were needed to bring in universal health insurance, it would be much more difficult to achieve.
It would be a “huge challenge” to get the consultant and GP salaries down, and this should not be made a condition of success of the universal health insurance.
“You can’t assume people will give up what they are currently on,” he said.
The efficiency savings in hospitals would also be difficult to achieve, and progress is slow, he said. The first priority of any savings made in the health system would be to pay off the Government deficit, he added.
The Minister for Health, James Reilly, is not necessarily wrong in his aims to introduce a universal health insurance system, but “some realism is needed”, said O’Connor.
Dónal Clancy said the Government needs to first decide the goal of the new system rather than how to fund it.
“If we start by saying where we will get the money, it is the wrong place to start,” he said. “We need to say everyone is entitled to equitable access at this standard, and if we want to achieve it then we need to work out how we are going to do that.”
Competition is vital to any new system, both between insurers funding the system and between healthcare providers, he said.
A centralised procurement system and monopoly insurer would mean that people would pay far more than necessary, said Clancy.
Ireland needs to come up with its own particular solution but also needs to look at what has worked in other markets with regulated competition, he said.
One of the keys to a workable universal health insurance system is good regulation and good risk equalisation, said Thomas.
“You don’t want private insurance to compete by picking out cheap people, you want them to compete by driving down prices,” he said.
O’Connor said general taxation could create a clearer and more effective universal healthcare system than universal health insurance.
He said insurance sounds a lot like general taxation (everyone contributing according to means, compulsory and collected through payroll). However, taxation would be progressive and moving away from that would bring a degree of unfairness.
O’Connor argued that a central fund that looks at the integration of hospital primary and long-term care can bring the types of efficiency needed in hospital care.
Tierney raised concerns about whether a market as small as Ireland could sustain competing insurers. He said insurers in the Dutch insurance scheme, serving a population of more than 16 million, had merged to leave just three or four companies competing. Tierney said a central monolith system would not work either, and Ireland would need to come up with its own solution.
Fintan Hourihan, chief executive of the Irish Dental Association, told the forum he was “very sceptical” about the assumption of efficiency predicated on competition and people actually competing for business.
A strong payment system that would deliver integrated care, reward people for prevention, quality and efficiency gains was needed, said Dr Fergus O’Ferrall, Adelaide lecturer in health policy at Trinity College.
Free GP and secondary care at the point of need was “entirely feasible” within our current wealth if we want to deliver it, he said.
Primary care should be a key goal of universal healthcare, so that people would spend as little time in hospital as possible, said Tierney.
If this new system were introduced it would be the “single largest challenge to Irish governance that we have faced up to”, said Fintan O’Toole.
This was “not simply a question about healthcare but about democracy and how our system functions to serve citizens”. Such a system could not function without a vision and something that goes beyond people’s immediate needs and earnings, he said.
