John Bartonargues that removing the automatic entitlement to an over-70s medical card was a bad decision
THE GOVERNMENT'S decision to remove the automatic entitlement to a medical card for the over-70s is a regrettable one.
The Taoiseach, the Minister for Health and the Tánaiste, Mary Coughlan, have said that the scheme was neither sustainable nor affordable because it costs €245 million annually and rising.
Coughlan has indicated that rich people like retired consultant doctors, high court judges, property tycoons, senior civil servants, ministers for state and well-off pensioners can afford to pay for their healthcare. The Minister indicated that giving such individuals medical cards was unfair and inequitable.
The provision of medical cards to the over-70s is, in fact, fair and equitable.
Many academics have written about affordability and sustainability in healthcare financing. The dictionary meaning of sustainable is: "able to be maintained".
Professor of political economy at Princeton University in New Jersey, Uwe Reinhardt, says a distinction needs to be made between economically sustainable and politically sustainable.
The decision to remove medical cards because it is economically unsustainable is extraordinary, because the scheme can clearly be maintained, as proven by the climbdown on the removal of the medical cards, by getting GPs to share the cost burden.
As Reinhardt states: "The debate over healthcare is less a pure macroeconomic issue than an exercise in the political economy of sharing."
Reinhardt refers to the definition of affordability as: "the means for acquiring it without serious inconvenience" and professor of economics at the University of British Columbia in Vancouver, Robert Evans, says the dictionary meaning of afford is: "to be able to bear the cost of".
Is the Government really saying that the taxpayer cannot afford to provide medical cards to all our older members of society?
Have Government politicians and indeed others lost sight of the basic principles of solidarity and equity present in most European healthcare systems, including our own?
In an article in the journal of Health Politics, Policy and Law in 2006, Prof Timothy Stolfus Jost of the University of Washington and other academics from Britain and Holland recently defined healthcare solidarity as a society in which all members have universal access to healthcare regardless of their ability to pay.
A solidarity-based system requires individuals to pay income-related insurance or tax contributions and receive the same healthcare benefits. This is the fairest way of getting the wealthier members of society to pay for healthcare.
High-income individuals in society help to pay for low-income individuals, healthy members for sick members and the young for older individuals.
This basic principle, which is enshrined in the basic laws and traditions of Western European countries and has been supported by decisions of the European Court of Justice, will be undermined by removal of the medical cards from our older members of society, as the sick older individual will have to pay for their healthcare. That is not fair or equitable.
Decent countries are guided by these core principles in health. The Government's decision to remove the automatic entitlement to medical cards to the over-70s has made this country less decent.
What is so wrong with providing healthcare to all "free" at the point of care? For example, several countries have no charges for general practitioner services, unlike Ireland.
In these countries the rich, the poor and not so rich do not pay their GP.
These countries include the UK, Canada, Denmark, Spain, Italy and Holland. The Germans introduced a charge of just €10 for the first visit to a doctor in 2003.
Most of the other countries in Europe have minimal charges called co-pays or co-insurance and they include Sweden, Belgium, Portugal, Finland, Luxembourg and France. Australia and Austria have no direct GP payment for 80 per cent of the population.
Ireland, on the other hand, has large direct GP charges for two-thirds of the population. In health financing terms, direct charges to patients for healthcare are termed user charges.
Robert Evans, in his critique of user charges in healthcare, states in an analogous way that user charges represent a case of the Sheriff of Nottingham stealing from Robin Hood.
By this he means of course that user charges are a means of shifting the burden of financing healthcare onto the user of the healthcare service - many of whom, in Ireland's case, are middle income families - away from all higher income individuals.
The one saving grace for our primary care system has been the medical card. In fact, it has been so successful that Ireland has a primary care system that is one of the most pro-poor in the OECD!
This was found in research performed by the Health Equity Research Group of the OECD in 2004. The medical card is the instrument that in fact makes our primary care system more equitable, not less equitable.
Unfortunately, the same research showed that a medical card made the hospital system more inequitable. Despite that fact, why undermine this instrument of solidarity and equity in primary care by removing it from older people?
So, our Tánaiste should realise that in solidarity-based systems such as that present in Canada, the UK, Denmark or Holland, sick higher income individuals such as high court judges, property developers, medical consultants, civil servants and ministers of state have an entitlement to healthcare based on their need and not on their ability to pay.
Similarly, lower and middle-income individuals have the same right to healthcare as higher income individuals. They, unlike us, have ensured greater solidarity and equity in their health system.
This would be a far better system than having some of our sick, older people pay directly for their healthcare as currently decided by the Government.
• John Barton is a consultant cardiologist at Portiuncula Hospital in Galway, and stood for Fine Gael in Galway East at the last General Election