A prescription for our ailing two-tier health system

Eóin Ó Murchú explores the roadmap to universal healthcare in Ireland


If you don’t know where you’re going, no road will take you there, or so goes the saying. In 1947 Noel Browne, Trinity graduate of medicine, was scuppered in his attempts as Minister for Health in implementing the Mother and Child Scheme, offering free healthcare to women and children up to the age of 16. This was taking place in the context of a broader construction of welfare statism in post-war Europe. Nye Bevan was already implementing his nationalisation of British hospitals in the NHS Act. The Catholic Church however, was resolute in its resistance to the introduction of socialised medicine or “communist interference”. The Irish medical profession, as it did in Britain, also played its part in hampering attempts to establish a national health care system. More money was to be made if citizens were individual customers than if the sole purchaser of healthcare was the state.

Ireland’s system from 1947 is still broadly recognisable today. In its modern form it is colloquially referred to as the two-tier system. An underfunded and understaffed service is provided for those that cannot afford private health insurance and hospitals creak under the financial pressure. In primary care, the effects of the two-tiered system can be seen in the long waiting times public patients must, literally, suffer.

A prescription for Éire

In Ireland, 25% of the population are not covered for healthcare. Those who qualify for a medical card are subject to substandard treatment and torturous waiting times. Mark Murphy is a GP and public health lecturer in RCSI. “I think the issue of differential access to secondary care, through the intertwined public and private mix is the most important issue to tackle in the Irish health services. As a GP, I find the system barbaric. One person gets seen or operated on in 1 to 3 weeks. For the next person, it takes 12 months, with definite harms to their health. It’s cruel, inhumane and not a system I wish to work in, hence my desire to change it.”

Murphy also recalled the case one of his patients, who was referred for sciatica, a nerve pain that radiates from the back down the leg. If he had private insurance then he could have been seen within a few days. However, he now suffers from a permanent paralysis and limp in his leg because he wasn’t able to see an orthopaedic or neurosurgeon surgeon in time. The pain this caused is compounded by the stress a disability can put on a person’s ability to survive. The cost of this exacerbated condition will also far outweigh the costs involved were he to have seen a consultant in a timely manner. Dr. Murphy summarises: “As a result of the delays in the public system he now has chronic pain, a permanent weakness and is unable to work. Quite frankly it is inhumane that Ireland stands over a system which is so unfair and inequitable.”

The Dutch road

The Netherlands’ health system is often seen to be a potential model for Ireland. It is a regulated, subsidised marketplace of competing private insurance plans. However, a 2011 article in the New England Journal of Medicine highlights the flaws of the Dutch system. It describes how the attempt to create quasi-market competition “produced high administrative costs and complexity.” Universal cover wasn’t totally achieved either, where some citizens would miss premium payments and consequently dropped from their coverage plan. And the branding of health care as a commodity, to be traded, advertised, and customised “didn’t improve customer satisfaction and choice”. This is reinforced with polls finding that 65% of those insured had low or very low levels of trust in private plans.

Finally, contrary to free-market belief, the introduction of markets brought with it heavy doses of bureaucracy. The reality is that fragmented, multi-payer systems invariably require expensive administrative apparatuses. Health policy journalist and physician, Adam Gaffney, outlines that genuine universal health care must include the following four features: universal coverage, the elimination of financial impediments to care, comprehensive coverage, and access for all economic or demographic groups. This is difficult in systems with upper and lower tiers of coverage and in which a risk averse mentality encourages excluding certain individuals and treatments. Ultimately, health cannot be seen as a typical marketplace. It is not a bazaar one visits voluntarily but out of necessity, and often desperation. Medical information is given by patients at their most vulnerable. It is unsettling to think that this information could be weighed, analysed, and exploited by private insurers for the sake of profit.

An alternative

Speaking to Trinity News, Vijoleta Gordeljevic, a global health consultant and writer for the Huffington Post, discussed the various ways states can offer their citizens equitable healthcare. On the costs of changing to a single payer system, Gordeljevic describes how the “economies of scale allow for massive savings. This is due to the fact that you have a large pool of people paying into a system and exerting immense bargaining power over Big Pharma.”

The benefits of a single-system are manifold too: “Improved patient satisfaction is seen as quality of care is extended to all and out-of-pocket expenditure is reduced. This is possible through cost-sharing and a progressive taxation regime. For many years the British NHS has proven that this can go hand in hand with high quality care and happy health professionals.”

Gordeljevic remains unpersuaded by the arguments offered by pro-market advocates, such as greater choice for patients and hospitals becoming more cost-conscious. “Most of the arguments encountered are based on weak evidence or bad ideology. Costs can be controlled without extensive pricing, and patient satisfaction can be improved with proper investment. There is a push to turn patients into customers, however healthcare is not an ordinary product. Health care is a human right and letting the free-market decide who gets it and at what price is violating that human right.”

Besides winning the argument, Gordeljevic believes there is more to the fight for universal healthcare: “I am convinced activism is essential. We cannot expect only health professionals to fight as health concerns all of us. I would say creating the political will for change is the most important factor. Financial costs will always be used as obstacle, but even developing countries are making great leaps forward in increasing coverage of their citizens.”

The contradiction of healthcare under market conditions becomes apparent when you view the discontents of that system. By prioritising profit over the supply of just and equitable care, we participate in a system that perpetuates inequality. This should be concerning for all healthcare professionals who take seriously the notion of patient-centred care.

In the words of Aneurin Bevin, founder of the NHS: “Society becomes more wholesome, more sincere, and spiritually healthier if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows have access, when ill, to the best that medical skill can provide.”

It is this mantra that resonates with the Hippocratic Oath stronger than pitting patients and providers against each other in a rat-race for care and resources.