Last week's news that people not subscribing to health insurance before the age of 35 years will have to pay higher annual premiums to take out policies with such as VHI or BUPA should provoke some concerned debate. The proposal, contained in the Government's new Health Insurance (Amendment) Bill, would certainly appear at least to modify the current legal insistence on the principle of community rating in health insurance in this country. This is the provision which ensures that health insurance premiums are the same for all in the community, regardless of such factors as age or gender. In effect, the payments of all who are healthy pay the medical bills of those unfortunate enough to become ill so that each individual premium varies only in accordance with the level of service insured for by the individual.
The primary anxiety will focus on the possibility that this variation of the current state of health insurance will lead to greater variations so that the underpinning principle of fairness to all subscribers will gradually be whittled away until those in most need of health insurance will be those least likely to prove profitable to the insurer and, as a result, those most unlikely to be offered membership in any health insurance scheme. This would effectively remove from health insurance schemes the humanitarian purpose which has informed health insurance in this country since the State set up the Voluntary Health Insurance Board nearly half a century ago. There would be a risk that health insurance could become every bit as commercially driven as the general insurance industry.
It goes almost without saying that where commercial concerns and market forces underpin health care, both health care providers and patients tend to get the worst of all possible worlds. The simplest social model of illness and health care indicates that the people most likely to fall ill are those with the least means to pay for the care they need. This model is most emphatically and tragically demonstrated in the poorest countries of the world where poverty goes hand in hand with high morbidity and mortality of their citizens. It is also seen in slightly more sophisticated terms in the United States, with one of the highest national expenditures on health care in the world and very poor returns in terms of good health, especially among the less privileged citizens in that wealthy nation.
Closer to home, the British National Health Service - once one of the most cost-effective and comprehensive systems of health care in the world - has never recovered from the Thatcher government's ideological attempt to impose "internal" market forces on its delivery of care. Market forces in medicine work only for those individuals wealthy enough to pay for every treatment they need. At the very least, in any humanitarian society, payment for health care must be kept separate from the point of delivery of that care. At its simplest, a person who is too ill to work cannot pay the doctor's or the hospital's bills when there is no income coming in to the house. This is just one of the reasons for requiring a retention of the community rating system in health insurance.
The new Health Insurance Authority, the establishment of which is also proposed in the new Bill, must be enabled by its political founders to insist on the maintenance of the principle and practice of community rating by all health insurance providers in this State.