funding universal health and social care in ireland

Funding Universal Health and Social Care in Ireland:

Charles Normand Edward Kennedy Professor of Health Policy and Management 11 February 2015

Ageing, dying and affordability

Trinity College Dublin, The University of Dublin

Outline of Presentation

• Why is health different?

• Stated objectives in Irish health policy (and what happened)

• What do we mean by universal health care?

• Nothing comes from nothing

• Funding what?

• Ageing and dying

• System capacity and plausibility of UHC

• Dealing with legacy issues

• Towards affordable universal coverage


Why is health different?

• Information issues, monopolies and other market failures

• Fees discourage both useful and less useful use

• The perfect storm – we can pay when we do not need and we need when we cannot pay

• As a society we are not willing to allow access to be determined only by ability to pay.


Stated objectives in Irish health policy (and what happened)

• Access to good quality services

• On basis of need and not ability to pay

• Efficient provision, with access at lowest feasible level of complexity

• No significant changes in entitlements

• Retention of fees despite evidence

• Poorly thought out organisational changes (with new ones under way now)

• Continued support for private insurance and provision.


What do we mean by universal health care?

• Everything that is good value

• Good value generally in terms of being effective and cost-effective

• As a rough guide, everything with cost/QALY below €45,000?

• We should cover all of some things and NOT some of all things

• None of this implies a callous approach or a refusal to support innovation and development.


Nothing comes from nothing


Funding what?

• All cost-effective services

• Efficient provision of care – evidence suggests we could still get 10-15% more from system and an extra 2-3% per year

• Explicitly rationed (or explicit priorities set)

• Carefully considered approach to rare conditions and very high cost (price) services.


Ageing and dying

• Ageing will increase health care costs (but only very slowly and slightly)

• Balance of needs will change substantially

• Dying is much more important than ageing

• Some of recent growth has been giving more to existing older people and not more older people – the weakening of implicit rationing

• Changing demographics bring some gains from more care of older people by older people

• Some interesting new challenges from multi-morbidity and need for more team work and skill mix changes.


System capacity and plausibility of UHC

• People are generally willing to pay more to get more, but not more for the same

• Even those in Ireland with higher levels of entitlement tend to face constraints in access

• UHC as conceived in this paper needs increased capacity and co-ordination of care, especially around primary care and areas of chronic disease management and continuing care.


Dealing with legacy issues

• Private medical insurance – enshrines unequal access but contributes relatively little to funding (around 10% cash but less value)

• Supported and subsidised despite conflict with policy objectives and effects on wider system

• Current model clear evidence of path dependency!

• Difficult to see how community rating can survive as a genuine feature of PHI in Ireland

• It is not useful to have full fee access to GPs, and it makes integrated care hard to develop.


Towards affordable universal coverage

• How universal is a choice, but what kind of universal is a given

• We could have a pretty good universal service for what is currently paid in tax, PHI and out of pocket

• There would be some losers – who currently get better access from PHI

• The often criticised USC provides a possible framework for a single contribution to UHC

• Long term care will be an areas of growing need – some mechanism like Fair Deal is probably best, but covering all aspects of care

• Two tier systems tend to advantage the rich and the very poor and disadvantage the low paid working population.

Thank You for Your Attention

funding universal health and social care in ireland

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