Tom O'Connor: The Fine Gael political party has recently launched a comprehensive set of proposals aimed at creating a fair health system in Ireland which would also be cost effective and efficient. This has been publicised on billboards all over the country in recent months. The Fine Gael policy document concerned is entitled ‘Fair Care: Fine Gael Proposals to Reform the Health Service and Introduce Universal Health Insurance’. In what follows, this set of proposals is critically evaluated.
Throughout the report, ample evidence is provided for the contention that the Irish health services are essentially broken. The evidence consists of a long litany of failings: in terms of success, Ireland is ranked as low as number 15 across Europe according to the European Health Consumer Index (Fine Gael 2009:8).
The Irish government in 2001 promised that by 2009 a total of 400 Primary Care Health Teams, which are designed to prevent many from having to be in hospital and are configured by a team of health care professionals, would amount to 400 nationwide. The reality is that “there are now only 97 teams in place, only 10 of which are fully functional and only 10 centres have been built to date”(Fine Gael 2009: 10). The report also highlights the shortage of GPs in Ireland: quoting a report from the Adelaide Hospital Society (2004), they show that there are only 52 GPs per 100,000 of the Irish population which is extremely low by international standards. For example, in Austraia, France and Germany, the corresponding figures are 144, 164 and 102 GPs per 100,000 respectively.
The report details how the government’s policy to transfer 1,000 patients occupying private beds in public hospitals into co-located private hospitals has not yet provided a single bed, even though the policy was rolled out in 2005. The current waiting list times for treatment highlighted by the report are quite shocking, despite improvements in recent years:
“Inpatient waiting lists (over 3 months) = 40,000 approx.
Outpatient waiting lists are > 150,000.
Average number of A&E patients on long-term waits on trolleys = 300” (Fine Gael 2009: 10).
More generally, the report paints a picture of a huge demographic time bomb, where, due to the huge rise in the older population by 2030, the already inefficient public health system will be swamped and incapable of delivering unless it is reformed. The report is strongly critical of the government in failing to address the future demographic time bomb in health care. At the moment, the report points out, only 11% of the population is over 65 but this will rise to over 59% in 2021. The government is not addressing this challenge, the report claims, with the government being accused of only ‘tinkering’:
“If Ireland is to meet both of these challenges – severe budgetary pressures now, and a demographic time bomb in the future - we need to substantially change the current model of healthcare. Tinkering with the system at the margins will accomplish nothing”(Fine Gael 2009: 5)
Efficiency and Spending
The report works from a clearly stated position that the Irish health system is hopelessly inefficient and much of the spending within it is wasteful. It suggests that the public health system is uncompetitive and the fact that the public health system is both the purchaser of health services and the provider of the same services serves to make it more inefficient. The report is continuously pushing its arguments in the direction of the separation of these two functions, and calling for more competition within the sector.
Fine Gael Solutions
The Fine Gael proposals in the broad sweep are about increasing the efficiency of health spending and the introduction of universal health insurance over a period of five years. These seem reasonable and fair objectives which concur with the ‘Fair Care’ title of the document. However, on closer inspection, as will be displayed below, they may not be very fair at all and may, to quote the old adage, resemble the ‘wolf in sheep’s clothing’.
In the first two years, the plan is focused on gaining increased productivity and efficiencies through the use of existing resources. These are, however, vague and aspirational and there are no clear plans outlined as to how this will happen. The main hope is that the cost to the state of providing hospital care can be driven down in the early years by treating more patients in the community: “Fine Gael recognises that significant bed capacity in hospitals could also be freed-up if patients facing delayed discharge or requiring rehabilitation could be treated in the Community”(Fine Gael 2009: 2). However, apart from going on state that these will be funded through the introduction of universal healh insurance, they don’t explain how the bed reductions will happen, simply because they don’t explain how primary care and community care will be expanded. The authors of the document seem to realise this shortcoming when they state, immediately after the above statement, that: “We will publish specific proposals on this issue over the next few months to address the current deficits in long-term care and rehabilitation” (Fine Gael 2009: 2). This is clearly unsatisfactory. It casts doubt on the proposals from the outset and the reader is left with the impression that the proposals might be more laden with rhetoric than with real and feasible plans.
However, the Fine Gael policy on the on the introduction of universal health insurance is where the biggest problem arises. At face value, the argument they make that everybody in the country would have health insurance and there would be no two tier service sounds exceptionally fair. It sounds even fairer that all children and old people would be covered, even though these groups would not be in a position to pay.
However, clear dangers emerge from there onwards. The report highlights that there are two ways that universal health insurance can be implemented. The first is the widely used Rhineland model which operates in France and Germany. In this system, taxes are levied on people’s incomes which are dedicated specifically to a health insurance fund. This fund is used to buy health insurance at the cheapest market price from dozens or even hundreds of competing providers across Europe in order to get the cheapest price. Health insurance is then provided for all members of the population, man woman and child. People who are not working, such as children, disabled and older people are covered by the fund. Thus, the two tier service no longer exists because everybody is covered. This is a ‘single tier’ health system. In March this year, a detailed TCD report in conjunction with the Adelaide Hospital Society showed how universal health care, including geriatric care, could be provided in Ireland for as little as 2% of gross pay.
However, Fine Gael rejects this model of health insurance delivery and instead goes for the Dutch model. Realistically, however, this Dutch model is more about making all citizens who are working buy health insurance privately. It involves all citizens being essentially mandated by the government to buy private health insurance, and the 50% of the Irish population who already have insurance could stay with their existing providers if they wished! There is no health fund, even though the Fine Gael commits that the government would cover children and old people separately. This plan is far closer to the USA model of private insurance-based health funding for most of the population. That is why it is entitled ‘managed competition’.
The report castigates the government for not implementing its co-location plans, which suggests that it is in favour of private hospital expansion. This is totally consistent with their plan to roll out private health insurance, which is essentially masquerading as universal health insurance, which in all true cases of its operation involves people paying 5-7% of their gross income in social insurance contributions to cover health care. However, Fine Gael seems to be averse to raising taxes to cover a genuine universal health insurance system. The plan also involves the calculation of cost savings in staff from transferring people in to community health care, and does not talk about increasing bed capacity. The report also recommends a ‘Money Follows the Patient’ (MFTP) scheme for funding hospitals. This is a performance-based system where hospitals will only receive adequate funding if they can show that they are treating more patients.
To conclude, Fine Gael’s policies resemble-market based and neoliberal responses to reforming the Irish health care system. They are not about ‘fairness’, because most people will have to buy health insurance privately. There is no mention about what happens if people can’t afford private health insurance. Instead, this is dressed up as a ‘fair’ universal health insurance system. They are attempting to sell these policies to the population through the promise of free GP care. However, it is not free if people have to purchase health insurance to cover the cost. In many respects, Fine Gael’s policy document, while doing a good job explaining the problems in the health system, is extremely duplicitous and dishonest in the solutions it provides. In this regard, it would be a shame if ordinary people were fooled by their promises.
Tom O’Connor is a lecturer in economics, public policy and health/social care at Cork Institute of Technology.