Healthcare injustice can no longer be ignored


Our health service is bad even for those who thought insurance could shield them from squalor and neglect, writes FINTAN O'TOOLE

FOR THE last two decades, there has been an unspoken assumption about the health service in Ireland. It is that the middle classes could buy their way out of the consequences of a dysfunctional system. People have screamed and roared and wept and moaned about their own experiences of squalor and neglect. But in a typically Irish reaction, they dealt with the failures of the system not by demanding change, but by quietly withdrawing from it. Evasion is the first resort of our culture. For all those who could afford it, it was the strategy of choice. But, like all our other evasions, it is now catching up with us.

Any discussion about health policy in Ireland inevitably includes the statement that 50 per cent of people have private insurance. But there are two significant realities buried in this endlessly repeated fact.

The first is the appalling inefficiency of this private spending. Private insurance is paid by half the population, but contributes only about 10 per cent of the total cost of healthcare in Ireland. (Seventy-five per cent comes from taxation and 15 per cent from out-of-pocket payments such as GP fees.) That 10 per cent, however, skews the entire system, creating a two-tier health service that is as unmanageable as it is unjust.

The second buried reality is the reason why so many people who are supposedly entitled to public healthcare choose to take out private cover. The demand for private health insurance in Ireland is not primarily driven by people looking for added benefits or luxurious facilities. It is driven by fear. As the Health Insurance Authority noted on the basis of consumer research, “the important determinants of demand for private health insurance in Ireland are the existence of waiting lists for elective treatment in the public hospital system and perceptions among the public of better care being available for private patients”.

Most people who buy health insurance do so because they’re scared. And those fears are perfectly rational. It is probably not true, in general, that private patients get better treatment than public patients who are actually in the system. (Most public patients, when they actually get into a hospital, are happy with the care they receive.) But what is unquestionably the case is that health insurance buys you timely access to that care. Mary Harney’s own expert group on health funding acknowledged, almost as a matter of course, that “individuals who can afford private health insurance gain access to some hospital services faster than those with equivalent health needs but who do not have insurance”.

We know, for example, that if your doctor thinks you need a colonoscopy, you will get one almost immediately if you have private insurance. But if you’re in the wrong 50 per cent of the population, you will join a queue behind at least 1,000 others.

So this is the basic truth about private health insurance in Ireland: fear drives a system that sucks a huge amount of money out of the pockets of ordinary citizens but that contributes only marginally to the overall cost of providing the health service.

Even when times were good, it should have been obvious that this is, in both senses, a frightful way to run a system that is a key benchmark of a civilised society. Apart from the basic obscenity of valuing people’s lives through what the Americans elegantly call a “wallet biopsy”, it creates an insanely complicated system.

There are, for example, four different categories of patients: medical card holders, who are entitled (in theory at least) to fully free services from GPs and in public hospitals; “dual cover” patients who have both a medical card and private health insurance; “non-covered” patients who have neither a medical card nor private health insurance; and patients with private health insurance only. How could such a system not require a vast bureaucracy to run it and how could it not lead to inefficiencies?

As with so much else, however, this vicious and absurd system was tolerated so long as the middle classes could afford to manoeuvre their way around it. But the illusion that middle class people could actually benefit from systematic inequality was just another Celtic Tiger con job. What was actually happening was that middle class people were being conned into paying twice – through taxes and private insurance – for an inadequate, inefficient and unfair system.

A system that depends on people paying again for services they have already paid for through taxation is inherently unsustainable. It is now unravelling. No amount of insurance can buy you out of an overcrowded AE. And the cost of fattening up the VHI for privatisation is simply too high for most people to pay.

The truth is coming home: the rotten injustice of our health system is bad even for those who thought they could avoid it. A fair, one-tier system of social health insurance is not just less shameful and better for the poor. It is also more rational, more efficient and better for everyone.

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