A two-tier healthcare system

Sir, – Orla Muldoon's article on equalising access to healthcare makes a strong argument for what is already, I believe, a widely agreed goal (Opinion & Analysis, April 22nd). Speaking as a hospital doctor, I have never heard an argument made in favour of unequal access to healthcare. The question is really of how to achieve a large-scale change while ongoing day-to-day needs are met. I suggest that much of the answer lies in her other observations.

One point in which I would quibble with her is that “poverty” equates to public care while the rich use private services. I very frequently encounter patients who make massive sacrifices to pay for health insurance, and they are not at all wealthy. It is simply a matter of priority for them. Most obviously, those covered by the Garda insurance plan, or those in the Army or our prison officers, are not the idle rich. They are indeed, literally, the rank-and-file members of our society.

Her statement that the “poor smoke more, drink more alcohol, eat badly”, whether we wish to admit it or not, reflects choices made by real people. Smoking 20 cigarettes a day, for example, involves burning enough money annually to pay for an average family’s health insurance, and can be as much a cause as an effect of poverty.

To achieve the one-tier care that we all wish to see will require detailed analysis of numbers and data. In broad terms, though, about half of the four million people in the country have health insurance, while half do not. And basic level private insurance, per individual, costs around €500, including children, who get sick less often and so cost less. Thus the two million people lacking health insurance could be covered at a cost of around €1 billion.

This, in context, equates to the Irish health budget for about three weeks.

Perhaps in the terms of the HSE budget, that’s an acceptable sum to implement what is clearly an enormous and system-wide transformation.

It would furthermore implement another proposed change to how healthcare is paid for here. We would immediately realise the long-proposed “money follows the patient” system, that is one where a patient arriving at a hospital is a source of income rather than an institutional cost.

This, at present, is perhaps the crucial difference between how pubic and private patients are perceived by hospitals.

It is, finally, worth noting that the current US president is remarkably unpopular in Ireland, and that perhaps his least popular action has been attempts to dismantle his predecessor’s Affordable Care Act. This worked by the deduction of small amounts of money from individuals who lacked health insurance, from what revenue sources they had, to supplement government payments of their premiums. A similar model in Ireland raising a billion euro annually, through taxes on vices or on any form of income, could do the same. Few in Ireland were ideologically against Obamacare. So should we not implement our own version? Is it time to consider Varadcare? – Yours, etc,


Kinsale, Co Cork.

Sir, – The VHI’s decision to increase the number of criteria for new cancer drugs represents a serious assault on the public health service. Breaking away from the previous arrangements undercuts the HSE in its negotiations with the pharmaceutical industry and potentially could cost the exchequer millions of euro. It is now time to set up a statutory body free from commercial and political influence to regulate the approval and use of new and existing drugs to ensure both value for money and equity of access for our citizens. – Yours, etc,


Consultant Respiratory


Oughterard, Co Galway.

Sir, – I am tired of hearing rants about the two-tier health system in Ireland. I pay more than €4,000 for health insurance for my husband and myself because I have no confidence in the public health service. I have had some health issues and I will not suffer for an appointment when I need care. Is this wrong ?

Should I be castigated for spending hard-earned income on my insurance? If all those citizens who pay tax, PRSI, and on top of that health insurance decided to abandon that insurance, where would the public health services be? It’s nonsense to keep blaming people with insurance for the ills of our health service. – Yours, etc,




Co Dublin.