An Unhealthy State


Sir, - The recent series by Maev-Ann Wren focused on the apparent schism between private and public services in our health system relative to other European countries. Your Editorial of October 7th suggested that we are showing every sign of following the US model of a two-tier healthcare system.

The general theme is that a republic with a social conscience should get into line with the rest of our European neighbours. This effectively means a compulsory universal health insurance in which those who could afford it would pay their own premiums and those in poorer circumstances would be subsidised by the Irish State, providing equal entitlements for all at the point of service.

Europe has several different systems and all of them are facing the same problem - escalating costs - because better medicine means that life can be prolonged significantly. From an economic viewpoint, although death always wins in the end, the bulk of health spending tends to be in the last six months of peoples' lives. This means all modern health systems provide society with an expensive way of dying, which is not cost-effective in terms of allocation of national resources.

How exactly do our European neighbours fund their different health services and what lessons can be gained from the financial problems they are presently experiencing?

Firstly, there are the so-called single-payer systems. In these, healthcare is paid for and organised by governments at either national or regional level with money from income taxes. This type of system, common to Britain, Scandinavia and some Mediterranean countries, guarantees access to healthcare for everyone. The main problem is that governments set the healthcare budget. If this does not cover costs, waiting-lists appear, care is rationed, and quality of care deteriorates. Secondly, there are the social insurance-based or multiple-payer system, prevalent in Germany, Austria, France, Belgium, the Netherlands, and Luxembourg. In these countries, citizens must pay a premium and join mandatory private, non-profit organisations called sickness funds. Premiums are set by the government.

In all of these countries, sickness fund systems have run large deficits which governments have had to balance with money from general taxation. As a consequence, the theoretical distinction between single-payer systems and sickness-fund systems is practically negligible.

Thirdly, there is the Swiss system, by which health provision is totally based on private insurance. Although premiums differ substantially, the government reduces inequities by handing out subsidies to certain risk groups, paying a percentage of their premiums. Because of recent budgetary problems, these subsidies have been reduced and many Swiss insurance companies are now experimenting with American-style health maintenance organisation (HMO) schemes, encouraging patients to seek out cost-conscious physicians.

Because it is the patient who drives this system, however, cost-cutting will never be achieved at the expense of quality. The problem with both the single-payer and the sickness fund systems is that the young and healthy are paying for the healthcare of the sick and elderly. As the population ages, these systems come under pressure as the numbers needing care increase relative to the numbers paying for it. Private insurance systems are immune to this threat as an individual pays today for his own needs later.

One might expect the poor in Britain to be healthier than the poor in Switzerland, but this is not the case. It appears that in Britain, even after 50 years of equal access under the NHS, health is still very dependent on social class. In Switzerland, however, health does not appear to be related to wealth. This is because there are many other determinants of health, including genetic factors, socio-economic factors, and life-style.

This is why the Irish Government would get much better value for its hard-earned punts by preventing heart disease rather than wasting all that money in coronary care units. In Ireland, we should learn from these problems and introduce a new healthcare system that would combine the best of all the European systems. Firstly, we should differentiate between ordinary health care provision (category 1) and the technologically expensive aspect of medicine involved in the last few months of many patients' lives (category 2). There should be a compulsory, government-regulated single-payer system for Category 2 events and a sickness-type fund system for all the other risks.

Category 2 health insurance would be mandatory and paid for out of income taxes. Category 1 patients could, of course, opt out of the sickness fund system, which could also cover general practice, and take out private insurance for specific health risks. This would mean that access to medical services for extremely ill patients would no longer be related to wealth and would be reserved for those who required it the most. Private patients, of course, would still benefit from having all the other medical services they required, depending only on their premium level and the other demands of the market. - Yours, etc.,

Dr Patrick Treacy, Ballsbridge, Dublin 4.