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

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

Nothing comes from nothing

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

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.

Trinity College Dublin, The University of Dublin

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