It comes down to values in the end.
"Cherish your commitment to solidarity and equity. Cherish your universal coverage and relatively low costs. You may not realise how good your systems really are."
This advice was given to Europeans by an American academic, Prof Bradford Kirkman-Liff, at the end of a gloomy review of the failings of the US health system. He was not talking about Ireland.
The Irish healthcare system is not distinguished by solidarity, equity and universal coverage. Five of the seven states in States of Health - Canada, France, Germany, the UK and Denmark - can claim those attributes. The remaining two - the US and New Zealand - have inequities, which are comparable to our own in the case of New Zealand, and on a more exotic scale in the US.
Some states fund healthcare from taxation, as in Ireland, the UK, New Zealand and Denmark; a system which the Government's overdue health strategy is expected to favour retaining. Others like France and Germany fund through mandatory health insurance, proposed by the Opposition parties. Both systems can deliver equitable, comprehensive healthcare but in neither is it a foregone conclusion.
While no healthcare system is perfect, some perform very much better than others. It is possible to have no or negligible waiting lists, equitable access and a higher life expectancy than in Ireland. Canada, France and Germany have achieved all three. In Denmark, life expectancy is disappointing. In the UK, waiting lists are greater than in continental Europe reflecting lower health spending. Most European states offer free or reimbursed GP care and equitable access to hospitals.
The healthcare a society develops reflects its values. In the US, the provision of healthcare is not seen as society's obligation but as a voluntary consumer purchase. In Germany, in contrast, Bismarck established compulsory health insurance after the emperor's charter declared that social welfare for the poor was essential for national survival in a hostile world. Even enlightened self-interest among the better-off therefore dictated that they had an interest in the health of the entire society. From those roots has grown the concept of social solidarity.
The British believed in social solidarity when they established the NHS after the unifying experience of the second World War. Ireland's two-tier healthcare system reveals values that are closer to Boston than Berlin (or Paris or Copenhagen or Ottawa or London).
Ireland shares with many states the problems of an acute shortage of nurses, increasingly expensive medical technology, an ageing population and pressure on hospital services. Ireland differs in its two-tier system of access and care, long waiting lists for the bottom tier, shortage of doctors reflecting a medical hierarchy and training system which sends many abroad, absence of preventive medicine and high levels of cancer and heart disease resulting in a lower than average life expectancy.
The difference in Irish values is reflected in the remark by Dr David McCutcheon, Ontario's assistant deputy minister for health services and former chief executive of Tallaght Hospital, that public and private waiting lists for treatment "would not be tolerated in Canada".
Good quality healthcare does not come cheap. Citizens of some states have shown a greater willingness to spend on healthcare which may be related to how they contribute to it. Governments in the UK and Ireland have favoured funding healthcare from general taxation which makes it easier for them to control health spending. Both are now low tax, low spend states.
In Ireland last year, Government current spending was just 30 per cent of GNP (25 per cent of GDP), by far the lowest in the EU. It was 39 per cent of GDP in the UK. In 1999, Germany spent 48 per cent of GDP, France 52 per cent and Denmark 54 per cent. In the UK, there is a growing realisation that if healthcare spending is to rise, people must be convinced to pay for it. The British health secretary, Alan Milburn, has publicly supported the introduction of an earmarked health tax linked to better services.
In France and Germany, where health spending is funded automatically from employer and employee social insurance contributions, it has risen with wages and growing numbers at work. In recent years growing unemployment, a reduced share of wages in the economy and re-unification in Germany provoked funding crises. France has introduced a health levy on all personal income and Germany has sought to contain health costs. An Irish government which intends to deliver equitable high quality health care will have to convince the electorate to pay for it. An earmarked tax linked to services or mandatory insurance would ring-fence a flow of income exclusively for health, which might make the pain of paying for health more politically acceptable.
When the Government finally publishes its health strategy, now promised in November, the battle lines will be drawn for a pre-election debate about the relative merits of funding healthcare by taxation or social insurance and about the appropriate level of health funding.
Proponents of tax-funding like the Government will have to explain how their system can deliver equity. The Danes achieve it: with free GP care, no private beds in public hospitals and a minute private hospital sector. Even the Danish Medical Association opposes the growth of private medicine. To end the Irish two-tier system, the Government would have to offer free GP care and end the discrimination in waiting times and care between public and private patients. This would require changes in how Irish doctors are employed and remunerated.
As Prof Thomas Rathwell argued when reviewing the Canadian debate about extending private health insurance, if a two-tier system were not to emerge, "drawing on the Irish experience, the conditions to avoid are the designation of private beds in public hospitals and permitting specialists to have both a public and private practice".
Proponents of mandatory insurance like Labour and Fine Gael will have the even greater challenge of explaining this new concept. Mandatory insurance systems can provide equitable access and should not be confused with the inequitable voluntary private insurance system in the US, which leaves many uninsured and cedes control of healthcare to for-profit insurance companies.
Models vary from the Canadian system in which general taxation funds non-profit insurance plans controlled by provincial government and the German and French systems in which social insurance contributions go into employment-related sickness funds which purchase healthcare (rather like being insured through your credit union or trade union).
Labour's latest policy document proposes a mandatory insurance system in which the state pays or subsidises insurance premiums for up to 60 per cent of the population while the remainder continue to pay their premiums. Labour proposes to maintain state control of healthcare by regulating the coverage provided by insurers, to guarantee everyone free GP care and equitable access to hospital care.
The States of Health series illustrated many options for reform. If we are to reform, we must first decide what values we espouse as a society. Do we perceive healthcare as a consumer purchase or do we believe in social solidarity - that as a community we will no longer stand by while our neighbours suffer needless ill-health and premature death?