Nat O'Connor: The recently completed (Feb 2012) Steering Group Report On a National Substance Misuse Strategy has taken a public health approach to the issue of alcohol, and it estimates the costs to Irish society of dealing with alcohol abuse to be €3.7 billion. At the same time, the alcohol manufacturing and retail industry provided €2 billion in VAT and excise to the State, as well as 50,000-60,000 direct and indirect jobs.
There’s just no way to reduce the €3.7 billion of social harm and retain the same levels of tax and jobs. One of the recommended societal goals is to reduce alcohol consumption by nearly a quarter (page 7), which would have to significantly affect the alcohol industry.
It's a good case study of a genuine dilemma facing the Government about how to curb the societal harm and economic costs from alcohol abuse while minimising the loss of jobs or tax revenue from the alcohol industry.
Minority reports from both the ABFI and MEAS disagree with the steering groups findings. This suggests that the alcohol industry sees the report's recommendations overall as a financial threat, although it would be unfair to infer from this that the industry is unwilling to deal with the issue of abuse.
Table 7 (page 78) gives the breakdown of the €3.7 billion cost to society:
• €1.2 billion (32%) Costs to healthcare system of alcohol-related illnesses
• €1.2 billion (32%) Alcohol-related crime
• €526 million (14%) Alcohol-related road accidents
• €330 million (9%) Output lost to alcohol-related absence from work
• €197 million (5%) Alcohol-related accidents at work
• €167 million (5%) Alcohol-related suicides
• €110 million (3%) Alcohol-related premature mortality
The economic role of alcohol production and consumption is addressed too (page 71):
• €7.2 billion personal expenditure on beverages
• €2.9 billion turnover in drinks manufacturing, including €1 billion in drinks exports
• The on-trade provides 43,629 full-time job equivalents, and off-licences another 2,850.
• Manufacturing and retail provide €2 billion in VAT and excise.
Alcohol consumption in Ireland (at 11.3 litres per capita) is higher than the OECD average of 9.1 (page 64), but more significantly, Irish adults binge drink more than any other European country, with one quarter of Irish adults binge drinking every week (page 7).
A summary of some of the recommended actions (listed in full on pages 54-62) are as follows:
• Increase the price of alcohol over the medium term to ensure that alcohol becomes less affordable, using excise, including linking excise more closely to alcohol content;
• Minimum pricing per gram of alcohol;
• Increase enforcement of some existing laws, including physical separation of alcohol in mixed retail outlets;
• Develop proposals for an all-island initiative in relation to alcohol issues;
• Allow the HSE to object to the granting of a court certificate for a new licence or renewed licence;
• Introduce a statutory code of practice on the sale of alcohol in the off-licence sector;
• Develop a system to monitor the enforcement of sale, supply, delivery or online advertisement of alcohol to minors, with particular emphasis on age verification;
• Consider the possible need to strengthen the legislative controls on distance sales;
• Establish standards for mandatory server training programmes in the on-trade and off-trade sectors;
• Engage with EU colleagues to explore the feasibility of introducing common restrictions on advertising on a European level.
• Restrict alcohol advertisement generally, including a 9pm watershed for tv and radio, alcohol ads for over-18s cinema screenings only, and prohibition of all outdoor advertising of alcohol;
• Phase out drinks industry sponsorship of sport and other large public events by 2016;
• Introduce appropriate hospital procedures to provide alcohol testing of drivers who are taken to hospital following fatal/injury collisions;
• Monitor and regularly publish the volume of driver alcohol testing by An Garda Síochána;
• Introduce a ‘social responsibility’ levy on the drinks industry;
• Reduce the low-risk weekly guidelines to match the UK levels;
• Develop and implement more detailed clinical guidelines for health professionals relating to the management of at-risk patients;
• Increase information on alcohol products sold in Ireland to include grams of alcohol, calorific content and health warnings;
• A wide range of preventative measures, especially targeted at high risk groups, particular communities, and children and families of those abusing alcohol;
• Encourage the provision of alcohol-free venues for young people, with an emphasis on those most at risk (e.g. Youth cafés, alcohol-free music and dance venues and sports venues);
• Further integration of alcohol strategy with other national addiction and mental health strategies;
• Various clinical guidelines and protocols;
• Improve detoxification services;
• Continue to implement and develop, as appropriate, epidemiological indicators and the associated data collection systems and a research programme to examine the economic, social and health consequences of alcohol and the impact of alcohol policy measures.
Of course, some of these actions, particularly local action and prevention, may require additional financial resources at a time when the Government is still battling a massive deficit. Yet, the economic gains of tackling alcohol-related harm may be a good social investment that will pay dividends in later years.
From an equality perspective, excise increases will disproportionately affect people on low incomes. While there are good arguments in favour of using price to disincentive negative behaviours (i.e. pignovian taxes), this compounds poverty and an already unfair distribution of income. Ideally, we should ensure a minimum adequate income for everyone in Ireland before relying on flat taxes to dissuade people from alcohol abuse. There is also a risk that people with an alcohol addiction and/or related mental health problems will simply spend more of their incomes on alcohol and less on everything else. Therefore education and other action to support people in tackling alcohol addiction will be crucial, and this will require significant investment in healthcare and social support services, not least specialist interventions with the highest risk groups.
Many of the recommendations, particularly the earlier ones, will cost money to the alcohol industry to implement. Not least the call for a ‘social responsibility’ levy on the drinks industry, which could help pay for the required healthcare and social services. So the stage is set for conflict between the long-term health costs and the short-term economic benefits of alcohol to the Irish economy and society.
Showing posts with label healthcare. Show all posts
Showing posts with label healthcare. Show all posts
Friday, 16 March 2012
Monday, 7 February 2011
Guest post by Dale Tussing: Chinese Health Care - Its Rise and Fall and Current Struggles
With healthcare one of the items on the General Election agenda, Professor Dale Tussing takes a look at the Chinese experience.
It is quite a jump, from the health care system of the Republic of Ireland, population just over 4 million, to the health care system of the People’s Republic of China, where just under 4 million people call themselves doctor! With a colleague, I have been investigating the Chinese system lately and have hopes of publishing our research findings someday soon. I will share with readers here some of what I have learned.
Recently an on-line journal called FP: Foreign Policy (Foreignpolicy.com) included China (together with Russia, the USA, and Turkmenistan) as having achieved one of the four worst health care reforms in the world. A system which was once globally admired is now despised. As China’s productivity soared, something bad happened to health care. What happened? I want to answer that question and assess current Chinese efforts to rebuild their health care system.
The Communist Party of China (CPC) came to power through revolution in 1949. They began to build healthcare institutions, often in areas that had never been served by doctors, hospitals, or clinics. That was especially true in rural areas, which held the vast bulk of Chinese population, and which still today accounts for a large majority. In 1958, the commune system established collectivized agriculture, and shortly thereafter China built a system of Cooperative Medical Care (CMC), based in communes. Care was inexpensive, partly because it was rudimentary.
Primary care was provided by paramedics with limited education and training, who became known as the “barefoot doctors”. Care was predominantly traditional Chinese medicine, or TCM, relying on herbal medicine, much of it grown by the barefoot doctors in their own gardens. Participation was universal and compulsory. Under this regime, life expectancy almost doubled (from 35 years to 68) between 1952 and 1982, and infant mortality fell from 200 to 34 per 1000 births.
The World Health Organization, meeting at Alma-Ata in 1978, was inspired by the Chinese rural CMC system to issue a declaration about the possibilities for health care in third-world countries. Ironically, it was in the same year of 1978 that the Chinese leaders began the process of abandoning the system. The “household responsibility system” and markets replaced the communes. The CMC system was ditched. It had been based on the communes, and without major changes would be inconsistent with the new rural economy. Moreover, the CMCs had enemies in the Chinese leadership.
There must have been something special about the year 1978. The radical Chinese shift to privatize their economy occurred in the same year that privatisation began in earnest in Western Europe, Great Britain, and the United States. In the USA, President Jimmy Carter brought in Professor Alfred Kahn, the Cornell economist who introduced privatization in many areas, beginning with deregulation of commercial air service. Professor Kahn died in January of this year. Just two years later, Ronald Reagan, who was to accelerate the process, was elected president. In Britain, Margaret Thatcher became Prime Minister in 1978, and began her campaign to undo nationalization by privatizing large parts of the British economy. In Western Europe, privatization began in several countries in 1978.
In China, the result of privatisation was that the majority of the population lost their health insurance, and almost all medical care began to be sold on an out-of-pocket basis (the process of marketizing medical care was a process that took a long time, not overnight after 1978. Even till this day, many government employees continue to enjoy “free” healthcare). Many people with serious illnesses could not get care, and they became disabled or died. Most barefoot doctors returned to farming, and those who continued as paramedics began to charge fees. China’s primary care system virtually disappeared and has never really been replaced. Most Chinese people seek care from hospital-based specialists.
Is the China of today a socialist state? The central government and the CPC still have much control, and public ownership of enterprises is still widespread. But the example of health care shows how misleading appearances can be. Almost all Chinese hospitals are government-owned. But government subsidies were drastically reduced, and by the 1980s had fallen to 5% to 10% of hospital expenses. Hospitals had to rely primarily on their own revenues, and doctors relied on hospitals for their incomes. Doctors began to prescribe drugs, often medically inappropriate ones, in enormous quantities, and hospitals, rather than drug stores, sold them. Half to 60 percent of Chinese medical expenditures became allocated to drugs, as compared with about 10 percent in the USA and about 15 percent globally. Hospitals remained nominally public, but they had become effectively private – with decisions made by administrators and doctors in their own interests. And care became grotesquely distorted.
The fraction of Chinese health expenditures paid out-of-pocket by families is a telling statistic which graphically shows the astonishing twists and turns of Chinese health care in the last generation. That share was a laudable 20% in 1979, but it rose steeply to 32% in just four years, a change of a magnitude few countries have experienced, absent major war. But that was just prologue. Ten years later, in 1993, the proportion stood at 42%. The peak occurred in 2001 with 60 % of health care expenditures coming from individuals. The figure today stands at close to 40 percent. This figure can be misleading. Many Chinese families cannot afford to pay for treatment of major illnesses and injuries. The out-of-pocket share is depressed whenever care is not covered by any third party but patients and their families cannot afford the out-of-pocket payment.
Cutbacks in health care spending were part of general cutbacks in social welfare spending, and indeed in government spending in general, both absolutely and in relation to GDP.
China has attempted to navigate a middle course in recent years, pursuing a health insurance strategy. Leaders created the New Cooperative Medical Care (NCMC) system in 2003. The name harks back to the successful and popular CMC system of the Mao era, but the NCMC is an insurance system, not a health care delivery system. The ambitious new system had a number of flaws, chief of which was perhaps the fact that not enough money had been allocated. That is a problem which persists today, despite significant increases in government subsidies to insurance.
In 2009, Chinese leaders released a massive document, “Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform,” setting out plans for the future development of the health services. It is long and rambling, and hard to summarize, but some points may be noted:
• Health insurance was to be universal by 2010.
• Hospitals could reduce their dependence on drug sales only gradually.
• The government assured that everyone would have access to at least “basic” medical care.
What is basic care? That appears to be an important question, though the expression remains undefined. The document promises not only basic care, but also basic medical security or insurance, covering basic care to treat basic conditions, using “essential” medicines, all of which is backed up with basic public health. Whatever may be the exact meaning, the purpose and effect of assuring basic care is to limit public outlays on health care. And the government does not undertake to pay for even basic care.
The health insurance system is decentralized, with provinces establishing programme details. Thus it’s impossible to say whether the goal of universal coverage was achieved by the end of 2010. But because of inadequate funding, the drive for universal coverage comes at a very high price. Most provinces cover little or no outpatient care. High deductibles must be met annually before coverage kicks in. There are very high co-pays, with patients often paying half of the after-deductible bill. And perhaps worst of all, there are annual per-patient limits on insurance coverage. The result is that, while there very well may be universal coverage, it remains true that tens or hundreds of millions of Chinese would not be able to afford medical care if they became seriously ill or badly injured.
Chinese leaders seem sincere in their desires to ameliorate the terrible consequences of destroying the health security system, and much of the delivery system, in the late 1970s and throughout the 1980s. They are trying to build an insurance-based system consistent with the state capitalist system they have constructed. But the system they have developed is thus far still a mess. There are many economic incentives which will have perverse consequences. For example, insurance coverage of in-patient but not out-patient care will encourage doctors to hospitalize patients unnecessarily, when out-patient care would suffice, in order to make treatment eligible for insurance reimbursement.
The most serious problem, however, the one which is the source of most of the other problems, is under-funding. Chinese medical care expenditures hover around 5% of GDP (about half of European proportions). Until Chinese leaders are ready to increase significantly government funding for medical care, it will be difficult if not impossible to create a medical care system which is adequate, efficient, and fair.
Dale Tussing is Emeritus Professor of Economics at Syracuse University, in Syracuse, New York. His publications on the Irish health care system date back to the early 1980s. Together with Maev-Ann Wren, he was commissioned by the Irish Congress of Trade Unions in 2005 to conduct a broad study of Irish health care policy, to inform Congress's positions on health care. A version of the report was published in 2006 by New Island Press as How Ireland Cares
It is quite a jump, from the health care system of the Republic of Ireland, population just over 4 million, to the health care system of the People’s Republic of China, where just under 4 million people call themselves doctor! With a colleague, I have been investigating the Chinese system lately and have hopes of publishing our research findings someday soon. I will share with readers here some of what I have learned.
Recently an on-line journal called FP: Foreign Policy (Foreignpolicy.com) included China (together with Russia, the USA, and Turkmenistan) as having achieved one of the four worst health care reforms in the world. A system which was once globally admired is now despised. As China’s productivity soared, something bad happened to health care. What happened? I want to answer that question and assess current Chinese efforts to rebuild their health care system.
The Communist Party of China (CPC) came to power through revolution in 1949. They began to build healthcare institutions, often in areas that had never been served by doctors, hospitals, or clinics. That was especially true in rural areas, which held the vast bulk of Chinese population, and which still today accounts for a large majority. In 1958, the commune system established collectivized agriculture, and shortly thereafter China built a system of Cooperative Medical Care (CMC), based in communes. Care was inexpensive, partly because it was rudimentary.
Primary care was provided by paramedics with limited education and training, who became known as the “barefoot doctors”. Care was predominantly traditional Chinese medicine, or TCM, relying on herbal medicine, much of it grown by the barefoot doctors in their own gardens. Participation was universal and compulsory. Under this regime, life expectancy almost doubled (from 35 years to 68) between 1952 and 1982, and infant mortality fell from 200 to 34 per 1000 births.
The World Health Organization, meeting at Alma-Ata in 1978, was inspired by the Chinese rural CMC system to issue a declaration about the possibilities for health care in third-world countries. Ironically, it was in the same year of 1978 that the Chinese leaders began the process of abandoning the system. The “household responsibility system” and markets replaced the communes. The CMC system was ditched. It had been based on the communes, and without major changes would be inconsistent with the new rural economy. Moreover, the CMCs had enemies in the Chinese leadership.
There must have been something special about the year 1978. The radical Chinese shift to privatize their economy occurred in the same year that privatisation began in earnest in Western Europe, Great Britain, and the United States. In the USA, President Jimmy Carter brought in Professor Alfred Kahn, the Cornell economist who introduced privatization in many areas, beginning with deregulation of commercial air service. Professor Kahn died in January of this year. Just two years later, Ronald Reagan, who was to accelerate the process, was elected president. In Britain, Margaret Thatcher became Prime Minister in 1978, and began her campaign to undo nationalization by privatizing large parts of the British economy. In Western Europe, privatization began in several countries in 1978.
In China, the result of privatisation was that the majority of the population lost their health insurance, and almost all medical care began to be sold on an out-of-pocket basis (the process of marketizing medical care was a process that took a long time, not overnight after 1978. Even till this day, many government employees continue to enjoy “free” healthcare). Many people with serious illnesses could not get care, and they became disabled or died. Most barefoot doctors returned to farming, and those who continued as paramedics began to charge fees. China’s primary care system virtually disappeared and has never really been replaced. Most Chinese people seek care from hospital-based specialists.
Is the China of today a socialist state? The central government and the CPC still have much control, and public ownership of enterprises is still widespread. But the example of health care shows how misleading appearances can be. Almost all Chinese hospitals are government-owned. But government subsidies were drastically reduced, and by the 1980s had fallen to 5% to 10% of hospital expenses. Hospitals had to rely primarily on their own revenues, and doctors relied on hospitals for their incomes. Doctors began to prescribe drugs, often medically inappropriate ones, in enormous quantities, and hospitals, rather than drug stores, sold them. Half to 60 percent of Chinese medical expenditures became allocated to drugs, as compared with about 10 percent in the USA and about 15 percent globally. Hospitals remained nominally public, but they had become effectively private – with decisions made by administrators and doctors in their own interests. And care became grotesquely distorted.
The fraction of Chinese health expenditures paid out-of-pocket by families is a telling statistic which graphically shows the astonishing twists and turns of Chinese health care in the last generation. That share was a laudable 20% in 1979, but it rose steeply to 32% in just four years, a change of a magnitude few countries have experienced, absent major war. But that was just prologue. Ten years later, in 1993, the proportion stood at 42%. The peak occurred in 2001 with 60 % of health care expenditures coming from individuals. The figure today stands at close to 40 percent. This figure can be misleading. Many Chinese families cannot afford to pay for treatment of major illnesses and injuries. The out-of-pocket share is depressed whenever care is not covered by any third party but patients and their families cannot afford the out-of-pocket payment.
Cutbacks in health care spending were part of general cutbacks in social welfare spending, and indeed in government spending in general, both absolutely and in relation to GDP.
China has attempted to navigate a middle course in recent years, pursuing a health insurance strategy. Leaders created the New Cooperative Medical Care (NCMC) system in 2003. The name harks back to the successful and popular CMC system of the Mao era, but the NCMC is an insurance system, not a health care delivery system. The ambitious new system had a number of flaws, chief of which was perhaps the fact that not enough money had been allocated. That is a problem which persists today, despite significant increases in government subsidies to insurance.
In 2009, Chinese leaders released a massive document, “Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform,” setting out plans for the future development of the health services. It is long and rambling, and hard to summarize, but some points may be noted:
• Health insurance was to be universal by 2010.
• Hospitals could reduce their dependence on drug sales only gradually.
• The government assured that everyone would have access to at least “basic” medical care.
What is basic care? That appears to be an important question, though the expression remains undefined. The document promises not only basic care, but also basic medical security or insurance, covering basic care to treat basic conditions, using “essential” medicines, all of which is backed up with basic public health. Whatever may be the exact meaning, the purpose and effect of assuring basic care is to limit public outlays on health care. And the government does not undertake to pay for even basic care.
The health insurance system is decentralized, with provinces establishing programme details. Thus it’s impossible to say whether the goal of universal coverage was achieved by the end of 2010. But because of inadequate funding, the drive for universal coverage comes at a very high price. Most provinces cover little or no outpatient care. High deductibles must be met annually before coverage kicks in. There are very high co-pays, with patients often paying half of the after-deductible bill. And perhaps worst of all, there are annual per-patient limits on insurance coverage. The result is that, while there very well may be universal coverage, it remains true that tens or hundreds of millions of Chinese would not be able to afford medical care if they became seriously ill or badly injured.
Chinese leaders seem sincere in their desires to ameliorate the terrible consequences of destroying the health security system, and much of the delivery system, in the late 1970s and throughout the 1980s. They are trying to build an insurance-based system consistent with the state capitalist system they have constructed. But the system they have developed is thus far still a mess. There are many economic incentives which will have perverse consequences. For example, insurance coverage of in-patient but not out-patient care will encourage doctors to hospitalize patients unnecessarily, when out-patient care would suffice, in order to make treatment eligible for insurance reimbursement.
The most serious problem, however, the one which is the source of most of the other problems, is under-funding. Chinese medical care expenditures hover around 5% of GDP (about half of European proportions). Until Chinese leaders are ready to increase significantly government funding for medical care, it will be difficult if not impossible to create a medical care system which is adequate, efficient, and fair.
Dale Tussing is Emeritus Professor of Economics at Syracuse University, in Syracuse, New York. His publications on the Irish health care system date back to the early 1980s. Together with Maev-Ann Wren, he was commissioned by the Irish Congress of Trade Unions in 2005 to conduct a broad study of Irish health care policy, to inform Congress's positions on health care. A version of the report was published in 2006 by New Island Press as How Ireland Cares
Wednesday, 7 July 2010
Fine Gael health proposals
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).
Primary Care
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.
Hospital Care
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.
Conclusion
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.
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).
Primary Care
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.
Hospital Care
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.
Conclusion
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.
Thursday, 18 March 2010
Another take on healthcare
"There is a startling commonality between the root causes and defects of the ongoing banking crisis and those that continue to gain momentum within our health system. There are lessons to be learned." Read the rest of Professor Ray Kinsella's take on our healthcare system - and what can be done to fix it - here.
Sunday, 14 March 2010
Tallaght Hospital controversy: An apposite quote
An Saoi: I recently came across the following comment from an interview with Dr. Giovanni Berlinguer, professor of Social Medicine and younger brother of the late Enrico.
I think the esteemed professor has covered exactly why the problems occurred - you cannot have a dual health system operating side by side.
“The health sector is a central actor in eliminating health inequities through universal coverage and by initiating collaboration with other sectors to address social determinants.
Medicine contributed a lot during the 20th century to the benefit of mankind, but the benefits were not equally distributed. There is an old saying: "Medicine is the science that enables the rich to be cured, and says to the poor how they could be cured if they were rich".
Today, the abolition of universal health systems has happened in some countries and it is beginning to happen in others. This trend must be reversed if we are to ensure that poor and marginalised populations have access to the health system.
Universal coverage is important to health, to human rights, but also to social cohesion and stability. Social cohesion is greater when there is not a division in society between those who suffer and those who do not.”
I think the esteemed professor has covered exactly why the problems occurred - you cannot have a dual health system operating side by side.
“The health sector is a central actor in eliminating health inequities through universal coverage and by initiating collaboration with other sectors to address social determinants.
Medicine contributed a lot during the 20th century to the benefit of mankind, but the benefits were not equally distributed. There is an old saying: "Medicine is the science that enables the rich to be cured, and says to the poor how they could be cured if they were rich".
Today, the abolition of universal health systems has happened in some countries and it is beginning to happen in others. This trend must be reversed if we are to ensure that poor and marginalised populations have access to the health system.
Universal coverage is important to health, to human rights, but also to social cohesion and stability. Social cohesion is greater when there is not a division in society between those who suffer and those who do not.”
Tuesday, 19 January 2010
Is recession bad for your health?
Over on Irish Economy, Brendan Walsh links to this report from The Lancet.
Tuesday, 24 November 2009
Privatisation costs
"Privatising healthcare is a costly business. Increasing privatisation in Ireland has coincided with an increase in health spending of, on average, 8.8 per cent per annum between 2000 and 2006 – the second-highest rate of increase in theiv thirty OECD countries, after Korea".
You can read the rest of Gerry Burke's editorial in the Irish Medical Times here.
You can read the rest of Gerry Burke's editorial in the Irish Medical Times here.
Thursday, 5 November 2009
'There is a better way than cuts'
Slí Eile: In the interest of balance and with due regard for many economists, it is necessary to point out that not all economists believe that we must cut our way out of the Great Irish Recession. Dissent comes from Professor Ray Kinsella, reported from the annual Céifin conference in yesterday's Irish Times as follows:
Tomorrow, Friday 6th November, is an opportunity to begin a fight-back. But, we also need a solid intellectual counter-position backed by detailed analysis and facts and not just slogans. The ICTU Ten point plan is a good start.
"Ray Kinsella, professor of banking and financial services at UCD, said he rejected the idea that cuts were the way forward in healthcare. “It’s certainly leading to extraordinary incidents of psychosocial stress,” he said. Many people taking their own lives in recent times had no record of psychiatric illness but they were desperate and could find no way out.He said he wanted to challenge the orthodoxy that cuts were the only solution: “There is a better way than cuts.” Prof Kinsella said we were unable to get out of this crisis because our existing political framework was obsolete and incapable of reform; our banking system was “malign”; and we could not build a new economic order on a failed political paralysis."
While one may not concur with every pronouncement by the said Professor, the Award for Honest Straight Talking must be given. With the battle lines clearly drawn - OECD economists prescribe cuts in social welfare for the unemployed, old and sick in Ireland and reductions in the minimum wage - unions, community organisations and parties of the left must stand together to defend the poor, the low-paid and those excluded from decision-making.Tomorrow, Friday 6th November, is an opportunity to begin a fight-back. But, we also need a solid intellectual counter-position backed by detailed analysis and facts and not just slogans. The ICTU Ten point plan is a good start.
Monday, 3 August 2009
Sara Burke on McCarthy cuts ... and some alternatives
Health policy analyst Sara Burke - who's post for PE on the health cuts proposed in the Bord Snip Nua report is available here - has an excellent op-ed piece in today's Irish Times.
She concludes that:
There are ways to stop waste and inefficiencies and to generate new money without hitting patient care. These are political choices that just have not been chosen. Unfortunately McCarthy’s shopping list of health cuts does not bring us much closer to them.
Read the full article here.
She concludes that:
There are ways to stop waste and inefficiencies and to generate new money without hitting patient care. These are political choices that just have not been chosen. Unfortunately McCarthy’s shopping list of health cuts does not bring us much closer to them.
Read the full article here.
Friday, 17 July 2009
An Bord Snip - An attack on the health of the nation
Sara Burke: The Bord Snip Nua report has the potential to undermine the health of the Irish people and specifically those who already have the poorest health.
Proposing a cut in social welfare rates of 5% shows no understanding of the day to day realities of living on €200 a week. Already the vast majority of the 1.2 million social welfare recipients have received a 2% cut in their annual income when their Christmas bonus was taken away from them in the April budget.
Over 90,000 households who receive rent supplement have also received a further cut through the changes introduced in the October and April budgets which mean they have to contribute about €11 more per week, this is in effect an 8% cut. Basic social welfare rates are already below the poverty line of €228 per week.
Does this government really want to push more people on social welfare further and deeper into poverty and poor health? It is well established that the most important contributory factors to poor health are one's income, housing, education and work opportunities. Cutting social welfare rates will not just impact on people's day to day lives and pockets, but also on their health.
The proposals for the health sector are also an attack on the public health service which has been built up over the last ten years. McCarthy et al outline €1.2 billion in cuts in the health area.
The three biggest contributory factors to achieving this massive sum are:
1. Reducing HSE staff in by 6,000 (€300 million) plus additional efficiencies in the HSE (€90 million)
2. Opening up contracts with GPs, opticians, pharmacists and dentists to tender and presumably negotiating better deals for those covered by medical cards (€370 million)
3. Revising down income eligibility for medical cards (€100 million) and introducing a range of new co-payments or increasing extra payments which will hit the pockets of patients (e.g. €5 charge for a prescription for all medical card holders (€70 m); making the 70% of the population who pay for their own drugs pay €125 a month not €100 a month as is currently the care (€37 m); increasing admission charges to A&E from €100 to €125 (€6)).
These measures, if introduced, will hit the people who depend on the public health services the most - the sick, the disabled, the young, the old, the poor.
Cutting 6,000 staff from the HSE is bound to impact upon patient care. The HSE by its own estimations is already trying to cut about 3,000 staff, so what impact will 6,000 fewer staff have on front line services?
The report does suggest that these job losses be achieved in the administration and support areas. However, finding 6,000 of such posts is hardly possible. We are already seeing ward closures, difficulties in getting home care packages, longer waits for some treatments: cuts such as these will only exacerbate pressure on a health system already under pressure.
There is no doubt that there is waste in the system, and the report clearly states that without union co-operation such measures must be introduced with 'compulsory redeployment and if necessary, redundancy'. Given the stand off already in place between HSE management and the unions on a previously announced redundancy programme and paid leave, achieving such cuts in staff will inevitably result in industrial relations turmoil, unless a very different strategy is embarked upon.
Similarly, the report is very critical of deals done with the unions and professional bodies which have hampered so-called 'reform' to date. Both the minister and the HSE management have an enormous capacity to alienate every group they are seeking to 'reform'. Achieving better use of public money and new contracts with professionals is essential if the delivery of health and social care is to be sustainable but, once again, the track record in achieving this to date is non-existent. Remember the consultants' contract deal that was heralded by the minister, which took five years to agree and is a very bad deal for the public purse?
Revising the income guidelines downwards for medical cards and introducing charges on prescriptions for medical card holders is a sure way of hitting the people who need, and are entitled to, these services most.
We know from research carried out by the ESRI that the medical card is an effective pro-poor measure. We know from an international body of evidence that introducing charges for health care and services dissuades people who need those services from accessing and utilising them. We also know that cutting essential health and social care services now can be more costly, both economically and health-wise, in the long term.
Many of the measures detailed in the health section of An Bord Snip may save money in the short term, but are sure to cost more in the not too distant future.
On a more positive note, there are some good ideas on the health section. Getting rid of senior managers and administrators that were duplicated rather than rationalised when the HSE was established is welcome, but nothing new. Reducing the staff in the Dept. of Health by 10% a year for three years also seems to make sense. Restricting the National Treatment Purchase Fund to private facilities is a step in the right direction (however, if I were on An Bord Snip I would shift that €100 million into the public health system). Eliminating all bonuses to HSE managers is also welcome, but again nothing new in that idea. Unfortunately, none of these measures add up to a significant amount of savings.
Other political and economic choices could be made in the health area which could save hundreds of millions of euros, without hitting those who need and are entitled to quality public health services, e.g. more use of generic drugs, revisiting the consultants' contract, spending all public money on public health services, really targeting waste in the system identified in a myriad of reports already out there.
More on this anon....
Sara Burke is the author of Irish Apartheid: Healthcare Inequality in Ireland, which has just been published by New Island. www.saraburke.com
Proposing a cut in social welfare rates of 5% shows no understanding of the day to day realities of living on €200 a week. Already the vast majority of the 1.2 million social welfare recipients have received a 2% cut in their annual income when their Christmas bonus was taken away from them in the April budget.
Over 90,000 households who receive rent supplement have also received a further cut through the changes introduced in the October and April budgets which mean they have to contribute about €11 more per week, this is in effect an 8% cut. Basic social welfare rates are already below the poverty line of €228 per week.
Does this government really want to push more people on social welfare further and deeper into poverty and poor health? It is well established that the most important contributory factors to poor health are one's income, housing, education and work opportunities. Cutting social welfare rates will not just impact on people's day to day lives and pockets, but also on their health.
The proposals for the health sector are also an attack on the public health service which has been built up over the last ten years. McCarthy et al outline €1.2 billion in cuts in the health area.
The three biggest contributory factors to achieving this massive sum are:
1. Reducing HSE staff in by 6,000 (€300 million) plus additional efficiencies in the HSE (€90 million)
2. Opening up contracts with GPs, opticians, pharmacists and dentists to tender and presumably negotiating better deals for those covered by medical cards (€370 million)
3. Revising down income eligibility for medical cards (€100 million) and introducing a range of new co-payments or increasing extra payments which will hit the pockets of patients (e.g. €5 charge for a prescription for all medical card holders (€70 m); making the 70% of the population who pay for their own drugs pay €125 a month not €100 a month as is currently the care (€37 m); increasing admission charges to A&E from €100 to €125 (€6)).
These measures, if introduced, will hit the people who depend on the public health services the most - the sick, the disabled, the young, the old, the poor.
Cutting 6,000 staff from the HSE is bound to impact upon patient care. The HSE by its own estimations is already trying to cut about 3,000 staff, so what impact will 6,000 fewer staff have on front line services?
The report does suggest that these job losses be achieved in the administration and support areas. However, finding 6,000 of such posts is hardly possible. We are already seeing ward closures, difficulties in getting home care packages, longer waits for some treatments: cuts such as these will only exacerbate pressure on a health system already under pressure.
There is no doubt that there is waste in the system, and the report clearly states that without union co-operation such measures must be introduced with 'compulsory redeployment and if necessary, redundancy'. Given the stand off already in place between HSE management and the unions on a previously announced redundancy programme and paid leave, achieving such cuts in staff will inevitably result in industrial relations turmoil, unless a very different strategy is embarked upon.
Similarly, the report is very critical of deals done with the unions and professional bodies which have hampered so-called 'reform' to date. Both the minister and the HSE management have an enormous capacity to alienate every group they are seeking to 'reform'. Achieving better use of public money and new contracts with professionals is essential if the delivery of health and social care is to be sustainable but, once again, the track record in achieving this to date is non-existent. Remember the consultants' contract deal that was heralded by the minister, which took five years to agree and is a very bad deal for the public purse?
Revising the income guidelines downwards for medical cards and introducing charges on prescriptions for medical card holders is a sure way of hitting the people who need, and are entitled to, these services most.
We know from research carried out by the ESRI that the medical card is an effective pro-poor measure. We know from an international body of evidence that introducing charges for health care and services dissuades people who need those services from accessing and utilising them. We also know that cutting essential health and social care services now can be more costly, both economically and health-wise, in the long term.
Many of the measures detailed in the health section of An Bord Snip may save money in the short term, but are sure to cost more in the not too distant future.
On a more positive note, there are some good ideas on the health section. Getting rid of senior managers and administrators that were duplicated rather than rationalised when the HSE was established is welcome, but nothing new. Reducing the staff in the Dept. of Health by 10% a year for three years also seems to make sense. Restricting the National Treatment Purchase Fund to private facilities is a step in the right direction (however, if I were on An Bord Snip I would shift that €100 million into the public health system). Eliminating all bonuses to HSE managers is also welcome, but again nothing new in that idea. Unfortunately, none of these measures add up to a significant amount of savings.
Other political and economic choices could be made in the health area which could save hundreds of millions of euros, without hitting those who need and are entitled to quality public health services, e.g. more use of generic drugs, revisiting the consultants' contract, spending all public money on public health services, really targeting waste in the system identified in a myriad of reports already out there.
More on this anon....
Sara Burke is the author of Irish Apartheid: Healthcare Inequality in Ireland, which has just been published by New Island. www.saraburke.com
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