Tuesday, 24 November 2015
Universal Health Insurance
I welcome the Minister to the House and thank him for coming in here to respond to my query on the plans or otherwise for universal health care insurance. I am sure he has responded to this matter in the Dáil and, if not, I am sure he will do so over the next couple of days. Of course, he has taken some media queries on the subject but it is useful that we avail of this opportunity for a brief exchange of views in the Upper House and I thank him for bringing some realism to the debate.
Everybody wishes that a magic wand could somehow be waved by a Minister and the Government in order that we would be in a position to put in place a perfect health care system and a perfect system for funding such care. Unfortunately, that is easier said than done. As long as I have been a Member of this House and the other House, the provision and payment or subsidising of health care has always been on the agenda. The matter has never been fully addressed and certainly not fully responded to.
It could be said, that over the course of the term of one Government or even two, it is possibly not easy to put in place a long-term system of health care delivery and funding. Therefore, we must think about what should happen beyond the lifetime of one, two or three Governments but start from a position of certainty.
Having had lengthy discussions here and elsewhere about Canadian, Dutch, Australian and every sort of model of health care provision, perhaps our new starting point must be to improve the current system, its funding, structures and delivery of service. Everybody concedes that once people access the health service in this country, notwithstanding the enormous challenges it is faced with, a very good service is delivered to the vast majority of citizens. The problem appears to be access and bed provision among other matters.
We must first address the improvement of the current system.Reinventing the wheel is fine. It has been tried by many Ministers and many Governments but it does not seem to have worked. If the Minister has brought the first phase of thinking on a universal health insurance to a conclusion, at least we know what is the new starting point. If I was lucky enough to hold the Taoiseach's position, I would say the same. He outlined last week that other possible methodologies of funding universal health care will be examined by the Government and the ESRI. No matter what report is produced, it will find that such a scheme will be very expensive. The days of expecting an insurance premium of €300 or €400 per person to cover universal health provision are long gone. The Minister was correct in pointing out last week that the concept of asking people to pay €2,000 or €2,500 for what would possibly be a basic cover package was not acceptable or politically expedient. I am interested to hear where the Minister thinks we should move next.
Everybody cheers about the concept of universal health insurance and the concept of universal health care itself but it must be funded. We are at a stage where we have to be realistic. The Minister and his colleagues in government are fortunate to be in a position where nobody expects miracles. Everybody must be realistic enough to know that health care is hugely expensive and there is no easy funding mechanism. We should look at all the options and everything should be on the table. However, at this stage, there is no point in tying ourselves into a universal health care insurance model as originally construed five or six years ago because, clearly, it does not appear to add up. I recall having discussions with the former Tánaiste and Minister for Health, Mary Harney, on the matter at a time when the political party of which I was a member was strongly advocating the Dutch health model and she strongly advised me of her dialogue with the Dutch health department and Ministers who were trying to move away from the scheme. I was always uneasy that we were going to introduce what we thought was the perfect system from a country which was already losing faith in that particular funding mechanism.
We have a blank sheet to work with to see how the present system can be funded better, administered better and work better. The glass is half full. On the whole, the people in the service do a very good job. A huge amount of work is done in the health service. We rightly hear of the hard cases, the people on the trolleys and the waiting lists. We must rid the system of those trolleys and waiting lists but I appreciate it is not easy.
I look forward to the Minister's initial observations on the future funding models and, perhaps, his broader plans. We cannot afford to be fixated on the concept of universal health insurance. It has been examined and people bought into it in good faith. It is not a sin to admit it was an impossible target to achieve and to look at other models both of a care provision and a care funding scenario.
I thank Senator Bradford for raising this issue and for giving me an opportunity to address the Seanad on this matter. I spoke on it in the Dáil last week.The Government is committed to a major programme of health reform, the aim of which is to implement universal health care in Ireland. This means timely access for everyone to effective, quality, affordable health services.
In April 2014, the White Paper on Universal Health Insurancewas published. It proposed a competitive, multi-payer model of compulsory universal health insurance as the means to achieve universal health care. Following its publication, the Department of Health initiated a major costing project, involving the ESRI, the Health Insurance Authority and others, to examine the cost implications of a change to the model of UHI proposed in the White Paper. This initial costing project has now been completed and the underlying reports by the ESRI and KPMG, on behalf of the Health Insurance Authority, were published last week.
The analysis finds that the introduction of the White Paper model of UHI is likely to increase health care expenditure, with additional costs arising as a result of addressing unmet need for health care and the high transactional costs of operating in an insured environment.The high Exchequer subsidies and individual premiums that would be required to fund this model are not acceptable either now and nor would they be at any time in the future. The reports essentially support the Government decision not to rush the implementation of universal health insurance in advance of this costing exercise. It is also clear that there is a need for further research and cost modelling on the best means to achieve universal health care. I have decided, therefore, that the next phases in the costing exercise will include a deeper exploration of meeting the cost of unmet need for health care and a more detailed comparative analysis of relative costs and benefits of alternative funding models, both single and multi-payer.
The introduction of universal health care represents the most fundamental change in our health service in the history of the State. We have already introduced the first phases, with GP care without fees or a means test for the youngest and oldest in our society. The latter came into effect during summer. It is vital that before deciding on which funding model to adopt, key building blocks are put in place to provide a solid foundation for universal health care. I have already signalled my commitment to pushing ahead with these key important reforms.
The reforms include putting in place sufficient capacity to satisfy unmet demand in terms of specialists, critical care beds and other infrastructure because a system without adequate capacity will always result in waiting lists and rationing, no matter how it is structured. We need to strengthen primary and social care, which includes the further phased extension of GP care without fees and the improved management of chronic disease. We need to put in place reformed structures to replace the HSE, including hospital groups and community health care organisations. These are now established on an administrative basis, although we still have to appoint all the boards of the hospital groups and put them on a statutory footing. We need to implement financial reforms, including a more efficient activity-based funding model. Some people prefer to term this "money following the patient". The conversion year for the model is 2016. We also need to implement the Healthy Ireland programme and drive forward new patient safety measures. This will reduce the cost of health care in the long term and improve public health.
As well as representing major milestones on the road to universal health care, these are important initiatives in their own right with the potential to drive performance improvement and deliver significant benefits in terms of timely access to high quality health care for all the people of Ireland.
I thank the Minister for his reply. The five points on which he is trying to make progress are a significant part of his contribution this afternoon and I wish him well on advancing those necessary improvements. We could end up being fixated on the concept of what we frame as universal health care and universal health insurance to fund it. In Britain, for example, there is what is supposed to be universal health care, also known as the NHS. It is probably not working as well as it did 20 or 30 years ago. The majority of citizens in this country, by way of the GMS medical card-public health care system, had a degree of universal health care. Tags, titles and framework names about our health service is not really where we must go. We must go into the provision of those five priorities identified by the Minister and others. We must concentrate on them. My question concerned universal health insurance, notwithstanding the view that I and many other people share that it may well be financially unaffordable.
When will the Minister get the next range of reports on the matter? Will he then be in a position to indicate whether an entirely new funding model is required? We cannot keep kicking the can down the road. The citizen is demanding a health service. How we frame it or the title we give it are not particularly important. When does the Minister expect the next range of apparent funding mechanisms to be brought forward? It would be better if we could concede the old concept is simply not going to happen and move onto new ideas and approaches.
The Senator raised a few points. He touched on some of the issues, including whether to have a Dutch, Canadian or, as he mentioned, British model. Whatever we do, we need to have an Irish model because everyone's model of health care is different. Whatever we do will have to suit our circumstances and needs and have regard to the point from which we are coming, which is crucial to all of this.I certainly hope to know the outcome of the research on the cost of meeting unmet demand in the health service next year. I do not have a date for the funding model, but I still hope to have it next year. That does not mean, however, that we will go ahead with it. As I mentioned, we have to make sure there is adequate capacity in the health service, that we strengthen primary and social care provision and put in place the reform structures and financial reforms needed before we change the funding model. Otherwise no funding model will work. It will take more than five years to do these things, which means that I do not anticipate the next Government, if my party leads it, being able to change the funding model for health care substantially.
It is also important that we face up to a few things to which we may not want to face up. Any system of universal health care, no matter where it is in place, whether it be the NHS in Britain, the Dutch system or the Canadian system, involves some rationing. Universal health care systems involve waiting lists in some form, telling people they have to wait because there is somebody with higher priority ahead of them or that they cannot receive some drug or treatment because it is not considered to be cost effective. That is why in every democratic country in the world there is, to some extent, a two-tier system. We allow people to spend their own money on health care if they want to. Even in Britain, where access to health care is very good, 10% or 15% of the population have private health insurance policies with BUPA in order that they can skip queues, choose a consultant or access treatments that are not considered to be cost-effective for the general population. We need to be honest about this in the debate.
Compulsory health insurance schemes can work and do in other countries, for example, in Holland. However, they are expensive. I am not sure having a system of compulsory health insurance would be right for Ireland. What would we do if people refused to pay? Would we fine them or tax them as happens in America if they do not take out insurance under Obamacare? Would we jail them? If they continued to refuse and turned up looking for treatment, would we then refuse them? I do not think we would that in Ireland which is different from other countries. In European countries compulsory health insurance systems have tended to build up over time. Usually an employer pays for insurance for an employee at first and then people subsequently pay for themselves. We do not have that tradition in Ireland and I do not think it would be right for us for these various reasons.
No matter with what funding model we end up in the long term, we first need to address the four major deficit areas. We need to make sure there is enough capacity; strengthen primary and social care provision; put in place reformed structures and achieve financial changes which are also important.