As the dust settles following the publication of the White Paper on Universal Health Insurance (UHI), the chances of Dr James Reilly’s vision of our future health service being implemented are not good. Despite the Minister’s laudable egalitarian motive, here are some reasons why UHI will likely be stillborn following the five-year gestation period outlined by the Minister for Health:
1. The UHI model championed by the Minister for Health is largely based on a Dutch model. It took almost a decade from initial discussion before the radical overhaul necessary for change of this magnitude was ready to be implemented in the Netherlands. Even then it took another five to six years before teething problems were adequately dealt with and the system settled into level flight. And although now the system is on course to achieve savings, the Dutch government saw significant increases in the cost of UHI in the years following its introduction.
2. In order for Dr Reilly’s radical change to succeed, the fundamental building blocks of a functioning health service would have to be already be in place. The Dutch spent decades building up a highly functioning primary care sector based on significant investment in general practice. In the Netherlands some 10 per cent of the health budget is spent on general practice – in the Republic just 2.3 per cent goes to the sector. In addition, the Minister for Health has presided over a cumulatively savage series of cuts to the medical card system – including a stripping away of general practice infrastructure — with the effect that what was one of the better functioning aspects of our public health system is now on its knees. This means it is in no position to provide the stability needed to support the seismic shocks the introduction of UHI will bring to the health system as a whole.
3. A project of this magnitude needs a specific budget for change. To expect a successful implementation of UHI without such a budget is naive. Speaking at a healthcare conference this week, the director general of the Health Service Executive, Tony O’ Brien, pointed out the HSE had no budget for change, in contrast to the newly-created Irish Water which has €150 million allocated for this purpose. Although presumably not said as a criticism of government, it is a stark reminder from the man responsible for implementing future change in the health service that his line Minister has not secured any change funding for such a challenging project.
4. The UHI paper refers to a particular “basket of services” which insurers must supply as a minimum package to everyone. But it doesn’t give sufficient detail on what specific services these might be. Will citizens be entitled to access community occupational therapy and speech therapy services under UHI? Will the plan cover any medication costs or will this involve another scheme encompassing additional payments from already hard-pressed patients? The Dutch experience is not in the Minister’s favour: the minimum basket of services in the Netherlands has itself been “minimised” over time.
5. There is already a significant divergence in government over the cost of UHI. The Minister referred to a premium cost of under €1,000; the Department of Public Enterprise estimated an annual UHI charge of €1,600 per person. This is against a background of inexorable increases in the cost of private health insurance over a number of years which show no sign of slowing down. A middle-class consumer making a judgment on the future personal cost of healthcare is unlikely to conclude that either figure is realistic.
6. It is difficult to see Government backbenchers (and perhaps some Ministers) selling UHI on voters’ doorsteps in the run -up to the next general election. Standards in the present health system will fall further as funding continues to drop; the cost of private health insurance will have increased; and the first faltering steps towards change will further decrease public confidence. Meanwhile, a savvy Opposition will pursue many of the principles behind UHI under the banner of universal health care but with an alternative funding model.
The Minister must be given credit for having a vision for our health service and for facilitating public consultation and encouraging debate on universal health insurance. However, a broader realpolitik suggests his plans for a universal health insurance model will never be implemented.
Dr Muiris Houston is The Irish Times health analyst