White paper on universal health insurance

I am a few days late on this but the government White paper on Universal Health Insurance is an important document and worth a thread here. The Irish Times have a summary here.

Addendum:

Some links that might be helpful

The White Paper itself:
http://health.gov.ie/wp-content/uploads/2014/04/White-Paper-Final-version-1-April-2014.pdf

Newspaper articles:

Here is a basic article from the Irish Times giving the details of the white paper:
http://www.irishtimes.com/news/health/universal-health-insurance-what-is-it-all-about-1.1747201

Column by Muiris Houston arguing that it will never be implemented:
http://www.irishtimes.com/news/health/six-reasons-why-the-universal-health-care-plan-is-likely-to-fail-1.1749314

Piece by Billy Kelleher on the cost of universal health insurance:
http://www.irishtimes.com/news/health/universal-health-insurance-will-drive-up-costs-for-many-1.1702639

Irish Independent article on opposition to the proposal:
http://www.independent.ie/lifestyle/health/opposition-grows-to-plan-for-universal-healthcare-30161443.html

Paul Cullen in the Irish Times: Dutch health insurance costing 23.5% of income
http://www.irishtimes.com/news/health/dutch-health-insurance-costing-23-5-of-income-1.1752380

Universal Healthcare: Trick or Treat? (www.irishhealth.com) by Catherine Wilkinson and Declan Brennan:
http://www.irishhealth.com/article.html?id=19208

Article from http://www.thejournal.ie where GPs argue that they were not adequately consulted:
http://www.thejournal.ie/gps-say-they-were-not-adequately-consulted-universal-health-insurance-paper-1394547-Apr2014/

Fianna Fáil opposition:
http://www.thejournal.ie/micheal-martin-fianna-fail-ard-fheis-speech-1376437-Mar2014/

Article from http://www.thejournal.ie on opposition from health workers:
http://www.thejournal.ie/uhi-impact-groups-gps-1395368-Apr2014/

Journal articles:

Briggs, A. (2013). How changes to Irish healthcare financing are affecting universal health coverage. Health Policy, Volume 113, Issue 1 , Pages 45-49.
http://www.healthpolicyjrnl.com/article/S0168-8510(13)00211-X/abstract

McKee et al (2013). Universal Health Coverage: A Quest for All Countries But under Threat in Some.Value in Health (Elsevier Science). Supplement, Vol. 16 Issue s1, pS39-S45.

http://www.sciencedirect.com/science/article/pii/S1098301512041526

Comments

comments

76 thoughts on “White paper on universal health insurance”

  1. Universal Health Care usually starts out with Universal Hospital Care. After the wrinkles are worked out in five years or so it expands to Universal Health care in the form of General Practitioners and Specialists for pregnant women and children 0 to 16 years old, disabled people of all ages and people over 65 years old. After ten years it can be expanded to the 17-64 year olds. That is provided it is operating efficiently and effectively. On the twentieth anniversary it could be expanded to include drugs/dental/vision.

    The French system I know from direct experience works very well. It should be studied in detail from a cost benefit analysis point of view for at least three years and if it is not found suitable to our needs, call the whole thing off.
    Ireland’s medical cost structure is three times that of Poland and much more than Germany. If there is no willingness to deal with the obscene fee structure then there is no point in having the government intercede to rob us blind.
    We do not need another FAS or overstaffed, overpaid quango of any kind.

    Most important is the Health Care Charge to appear on every pay stub every month. Self employed to pay monthly by direct deposit.

  2. The important thing (more important than the health of the people) is that for-profit insurance companies not be cut out of the equation and, indeed, that they have more customers funnelled to them. How else to explain the fact that Ireland (19th in the WHO 2013 rankings) has apparently chosen to emulate the Netherlands (17th in the WHO rankings) rather than France (1st)?

  3. You know you’re in trouble when the first “overarching principle” is a bald-faced lie: “The Irish Government recognises the right of the Irish people to the enjoyment of the highest attainable standard of physical and mental health.”

    The “highest attainable standard” is embodied in the French system. France isn’t mentioned in the document.

  4. A few comments:
    – I can’t see how the government really has the will to transfer the real control of a lot of influential private hospitals into the public sector. If these hospitals no longer have a funding stream of “special” non-state patients, getting prompt treatment in return for private premia, their autonomy will vanish, and I doubt the ability of the government to pull that off. Apart from repeated across-the-board public sector pay cuts in the crisis, the Irish government has little aptitude for sustained confrontation with powerful special interests, particularly over period of around a decade as this would require.
    – Let us approach this from another perspective, which is Ireland’s role as an aircraft carrier for US etc FDI: that means US executives must want to move to Ireland. Are we really going to say to such executives and their families that they can’t have better-than-normal-Irish-standard no-waiting-lists health insurance? Because if so, they wont come.
    – And if zero-waiting-list health insurance continues to exist for such expats, its going to continue to exist for Irish people too. They are married, they have families, etc etc.
    – And if the marginal rate of tax on a €55-125k salary has to rise to pay for this, that will also work very much against the FDI policy, because the marginal tax rate is already high for Googlers and similar.

  5. MH + 1
    I’ve also direct experience of the French health system and, while there is a lot of paperwork, the incentives seem to be in place for all parties to do the right thing from both the patient and provider viewpoint.
    If we in Ireland are spending so much money on health why can’t we benchmark our results against world-class systems in terms of resources and outputs and incentivise (or force) health providers to match best practice in other countries.

  6. Yes, it is unconscionable. Which is why it is equally unconscionable that, apparently, no consideration is being given to a single-payer system in which access to healthcare will truly be universal and at lower cost than the Obamacare-like system that is being proposed (in which insurer profits are sacrosanct).

  7. Er, there’s no chance whatever of there being a system where access to healthcare does not depend in part on ability to pay, even Reilly’s proposals allow for it.

  8. IMHO, there will be ‘UHI’ simply because another ‘tax’ will have to be found.
    In reality we already have a UHI of sorts. All people can still access healthcare, maybe not as much healthcare as they would wish, or as quickly as they would wish.
    What the existing health system cannot afford is the hemorrhage of people from the private health sector, at least some of whom could afford to pay for healthcare, and are now freeloading on the health system.

    We are faced with a situation, where if even the existing inadequate health care provision is to be continued, money will have to be collected for it. Cutbacks have reached their end, albeit leaving those that should have been cut almost untouched.

    The DOF or Dept of Expenditure may make the usual noises, but there is no doubt that they will see the necessity to collect the funds; equally Dr Reilly knows that he has to dress-up the oncoming collection of funds as a additional ‘service’, hence UHI.

  9. @ Otto

    My reference was to “basic” health care. This would include diagnostic tests for conditions that could prove fatal. This is currently, as I understand it, not the situation with regard to waiting lists; a matter of possible life or death. It is this aspect which I find the most unconscionable.

  10. Well then maybe you ought to have thought twice before advocating precisely the sorts if “reforms” (gag, cough) that have led to this sorry state of affairs.

  11. It’s difficult to discuss health care financing without also considering provision and governance. To make the French or British models of financing work we would need to have a major overhaul of the relationship between providers and purchasers and that is not on the horizon at the moment. The medical profession and private hospital providers will continue to fight a rearguard action to prevent the kind of control on costs that is exerted within the French system.

    The UHI model proposed in the White Paper is inefficient, but it’s not like a slightly more efficient model (e.g. having everything controlled through VHI) would deal with the root cause of our problems. Like so much of public life in Ireland we need a much more fundamental conversation about values (thank you MDH) and question why professions like medicine (as with the higher ranks of the PS, the charity sector, the other professions) have become a vehicle to personal enrichment as opposed to a vocation for contributing to the public good.

    Let’s also not lose sight of the fact that health care doesn’t make much of a difference to population health. We are as healthy as the Brits and the French for all the failings of our health system.

  12. @Johnny Foreigner

    You write: “why professions like medicine (as with the higher ranks of the PS, the charity sector, the other professions) have become a vehicle to personal enrichment as opposed to a vocation for contributing to the public good.”

    You really are unbelievable. You never stop insisting that private-sector “reforms” are needed in the public sector, including the introduction of competition and performance incentives and then you profess to be shocked, SHOCKED when the public sector that your ideas have created is no longer governed by a vocational ethos.

  13. @ JF

    You have put your finger on the rather paradoxical situation in which we find ourselves i.e. despite the lack of equity in terms of access to basic health services, the system has, in fact, adapted because no one in real emergency medical need is refused treatment, irrespective of their financial situation, and the treatment is of a very high quality. However, the way in which it is provided is inefficient, un-affordable and is threatened with breakdown because the privately insured sector is contracting and the “state”, i.e. the taxpayer, cannot afford to take up the slack.

    One is forced to the conclusion that that the country lacks a “social conscience” i.e. in the sense that there is no acceptance across the political spectrum of certain minimum standards with regard to state provision in respect of health. In this regard, we are much nearer Boston than Berlin. (This is also true IMHO with regard to the UK where the NHS is a product of a coincidence of circumstances post-war rather than the result of any basic agreement across ideological divides. Harley Street rules OK!).

    This analysis is confirmed by the negative reaction from quarters in Ireland that one would have expected to be enthusiastic supporters of James Reilly, especially when the idea of a universal health service supposedly forms a core policy value of their political movements.

    How the system is to be funded is a secondary issue. What is in question politically is how the political parties view the financial impact of any changes on their core voters. This unique Hibernian character of the debate is almost entirely lost on the participants. Take that on the “charities sector” for example. Paddy, and Patricia, it seems, do not want to pay the taxes necessary to provide the level of services required but are happy to volunteer contributions to charitable organisation which are seen as filling the gap left by the unwillingness of the “state” to pay for them. The circular nature of the argument is not perceived even when it emerges that the arrangement is wide open to abuse.

  14. @ JF

    “The budget is the skeleton of the state, stripped of all misleading ideologies”.

    Rudolf Goldscheid 1917 (courtesy Wikiquote!).

    According to the SBP, ministers are being invited to concentrate their attention on how to save €2 billion as promised in the October budget.

  15. Typically, Dan O’Brien only mentions the spending side in the course of decrying the lack of fiscal rectitude during the 2000s. No mention of the various PD-inspired decreases in taxation rates, which were what really bought Fianna Fail those elections.

  16. I have many questions about UHI.

    Will the premium be a % of wages or a flat euro figure, like current HI?

    Will the premium be per person? So in a 2A 2C family with one worker, there will be four premia? Or like in Germany, where a 1-earner family pays the same premium as a single person, AFAIK.

    As Govt exp on public hosps will decrease a lot, what taxes will be reduced?

  17. ‘It is at once both astonishing and unsurprising that there is so little reference to the fundamental point being made by Dr. Reilly; the fact that it is unconscionable that access to a human right – basic health care – should be based on the capacity to pay rather than need’

    I should think that is because most people know that the real world is a lot more complicated than that. Conflicting value sets can co-exist. Health care is a complex set of services and products, where the consumer has historically little means of discerning quality. The emotional and practical impact of illness also tends to blunt people’s normal critical faculties.

    Teaching hospitals exist to teach as much as to treat. Big Pharma has its hooks into the leading research departments, and engages in large scale regulatory capture, which increasingly distorts the direction of medical science at global level. There are huge technical and financial barriers to entry, which leaves lesser players, and weaker countries, always playing catch-up.

    Ireland ain’t France. It ain’t the Netherlands either. Those are countries with serious wealth and an imperial history. We are a small, indebted player, so the UHI initiative may simply be a vehicle for de facto state withdrawal from direct health care provision on the current model.

    A view may be taken that the domestic system is captured consultants and other vested interests, that the technical challenges of regulating them are too much of a challenge for our domestic institutions, and the political costs of confrontation with them are just too high for our pols. The logic, then, is to let the insurance sector ‘sort it’, but as Ernie implies, profit will continue to be their prime concern. Frying pan, fire etc.

  18. As a German I look at this with bewilderment.

    I have exactly the same health care as any asylum seeker, and it is OK.

  19. The Irish system of health provision is based on allocation of budgeted quanta of codified procedures. ‘Allocation’, ‘budgeted’ and ‘codified’ collectively imply masses of administration to try and ensure equal rationing and underprovision across all services and regions (except for mental health and child services which are perpetual cinderella services the latter of which nobody wants to work in).
    The entire system needs to move swiftly to a ‘money follows the patient’ model, but the legions of administrators/’managers’ (many originally nurses or paramedics) who would become redundant or lose leverage in the system will prevent this from happening.
    The worst possible outcome would be for citizens to cooperate with demands for hypothecated premium payments without guaranteed service levels. Our state (like most others) is efficient at raising revenue but far from customer focused.

  20. I saw a reference in an OECD publication that Ireland has a very low utilisation rate of generic (cheap no brand) drugs. This is for drugs paid for by the gov’t. This is typical Irish behaviour. Rich countries look carefully at efficiency, efficacy and cost, but dear old Ireland chooses not to do that.

  21. @
    Mickey
    If you really want pharma FDI, you don’t step on their toes over domestic drug pricing. Retail pharmacy has also been a big stakeholder domestically.

  22. @ All

    This report in the Indo shows how ingrained the “two-tier” system is and the general lack of appreciation of the gross inequity involved.

    http://www.independent.ie/lifestyle/health/opposition-grows-to-plan-for-universal-healthcare-30161443.html

    Until there is a sea change in public sentiment on this, there will be no radical change. Instead, the debate will go down every possible by road and less relevant avenue – which it is already showing every sign of doing – to the bewilderment of most outside observers.

    @ Tony Owens

    The point that you make is, of course, the second vital leg of any reform i.e. control of costs on the principle of the “money follows the patient”. This can only be achieved by creating a market for the services in question. It may be noted that opponents of the proposed system are already citing the failure of the Dutch system to do so. Also striking is the fatalistic assumption that waiting lists are a fact of life when they should be eliminated under any successful reform.

    I invariably think of the Buckley Report in this context because of the inclusion of “hospital consultants” (Chapter 10) as part of the nomenklatura that is so entrenched that it required the country to be nearly bankrupt before anyone admitted to being aware of it.

    http://www.reviewbody.gov.ie/Documents/Report_No_38.pdf

    The explicit link made (Chapter 7) between the salaries of elected representatives and public servants – which is still in place- goes a long way towards explaining how public service costs – including health care – ran out of control.

    Creating a market for health services without a radical re-think of the overall approach is an impossibility.

  23. “As a German I look at this with bewilderment. I have exactly the same health care as any asylum seeker, and it is OK.”

    Ye, that’s right, in a German environment of 40 or more years of development of middle class healthcare, socialised and extended to all, with lots of investment and relatively high taxation of incomes. But Ireland appears to be trying to jump from a long-waiting-list public health provision to a short waiting list situation without putting any more money in, in fact in an environment where the average Irish person pays very little tax on their income, and where the main government party is talking about tax cuts. So the proposal has many doubters…

  24. The point that you make is, of course, the second vital leg of any reform i.e. control of costs on the principle of the “money follows the patient”. This can only be achieved by creating a market for the services in question.
    >>>>
    I really doubt this. Rather, explicit prioritization/rationing, with central decision-makers paying only for high value added services is probably the way to go, the US is a good example of “money follows the patient”, and it’s a costly fiasco.

    >>>>
    While we are on this note, perhaps people noticed recently that the rather stupid rule that consultants changing posts in the health service had to give up their previous salaries and take the “new entrant” drop in wages appears to have been abandoned?
    e.g. “With effect from February 14, 2014, health employers should ensure that where a serving permanent clinical (e.g. non-academic) consultant takes up employment in a new or replacement consultant post, they are to be employed on the salary scale to which they were subject prior to such appointment,” O’Brien wrote to health service managers.” from Irish Medical Times.

  25. @ otto

    The two fundamental principles IMHO are (i) equality of access and (ii) affordability, which Germany and other Continental countries have succeeded in meeting. The first is easier to establish than the second; experience and studies have shown that there is almost an unlimited demand for health care. Costs can only be kept within limits by a market mechanism. How this is organised is another matter. What is certain that fixed salary scales for all involved, irrespective of motivation, workload and output is a recipe for bad value and out of control costs.

    The added factor is that the two-tier system is not confined to the patients. It also extends to the medical profession, hospital doctors in particular. In the latter case, the major category is defined by what those involved are not i.e. Non Consultant Hospital Doctors. This is a direct inheritance of the British – self-regulating – medical system.

    http://en.wikipedia.org/wiki/Associate_Specialist

    Furthermore, consultants employed by the taxpayer have also private practices in associated “private” hospitals, a fact which simply underlines the fudged organisation of health services which is the result of a failure to face up to responsible societal choices since the foundation of the state.

  26. “Costs can only be kept within limits by a market mechanism.”

    And there it is: tendentious ideological bullsh*t presented as pure fact on the same level as a law of nature.

  27. A single payer that can negotiate rates with all suppliers, has an interest in keeping costs down, and has no need to turn a profit is, almost certainly, the only way to keep costs down. The US has “market mechanisms” up the wazoo and maybe you should take a look at how well they succeed at “keeping costs within limits,” DOCM.

    The fact is for-profit enterprises are incompatible with domains where people’s health, lives and livelihoods are at stake. Someone whose life is at risk will pay any price, allowing for infinite profit margins. That is why capitalist health care can only deliver the $300 aspirin and the $10,000 colonoscopy.

  28. @ DOCM

    ‘Costs can only be kept within limits by a market mechanism.’

    Provided that said market is adequately regulated, and that the regulators are not captured. Power and size of market players is critical, so exchanging one set of market manipulators for another is hardly a solution.

  29. @DOCM

    ‘What is certain that fixed salary scales for all involved, irrespective of motivation, workload and output is a recipe for bad value and out of control costs. ‘

    The record also shows that profit incentivisation leads to routine over-treatment, iatrogenic disease, as well as social and ecological problems.

  30. Off topic, but does this remind anyone of anything?

    “Chinese property companies are buying stakes in banks and raising fears that the country’s already stretched developers are trying to cosy up to their lenders.

    Ten Chinese property companies have invested Rmb18.4bn ($3bn) in banks, according to the Financial News, an official newspaper published under the aegis of China’s central bank.

    Some of the developers are heavily indebted, sparking questions about the motivation for these deals, and specifically whether the property companies are hoping to use their links to the banks to obtain preferential financing.”

    http://ftalphaville.ft.com/2014/04/07/1820562/both-a-lender-and-a-borrower-be-china-property-edition/

  31. @ otto: ” … the average Irish person pays very little tax on their income.”

    I would question this. If I am reading my Income Tax return correctly, I am paying 30% (inc. the Social Charge). However, there are a few other ‘charges’ on my income: Household charge; water charge; Residential Property tax; vehicle registration charge; vehicle taxation; and VAT on utilities. Its quite difficult to arrive at a valid aggregated % of income, but it is probably close to 50%.

    However, if you are claiming that our politicians are eager to spend other people’s money, by reckless borrowing, then you indeed have a point. But voters will not support any politician who would advocate a ‘pay-as-you-spend’ budget strategy. I cannot understand why any political party would want to advocate a vote-losing strategy – such as reducing inequities in health-care access and personal taxation. Unless there is something unpleasant behind the scenes – that we are, as yet, unaware of.

    It may just be that the ‘average Irish taxpayer’ actually needs an reduction in their direct income taxes (ie. a nett increase in disposable income) in order to maintain their living standard. If consumer spending, which has fallen significantly, does not start to increase, then revenues from spending taxes will not increase. So, more ‘non-tax’ revenue gathering methods will have to be employed. Nasty carousel.

    The ‘inequity’ in the provision of medical services is mirrored (thus, not unconnected) to ‘inequities’ in our personal taxation system.

    @ DOCM: “Costs can only be kept within limits by a market mechanism.”

    I’d like to experience that sort of market. Market manipulation is a national sport. Its endemic.

  32. @BWSr

    “It may just be that the ‘average Irish taxpayer’ actually needs an reduction in their direct income taxes (ie. a nett increase in disposable income) in order to maintain their living standard. If consumer spending, which has fallen significantly, does not start to increase, then revenues from spending taxes will not increase. So, more ‘non-tax’ revenue gathering methods will have to be employed. Nasty carousel.”

    Funny, I didn’t hear you making that argument about consumer spending when it came time to cut public-sector pay, repeatedly. So €1 billion in tax increases is to be deplored because it would dampen consumer spending. But €1 billion in pay cuts for the PS is to be applauded because, well, just because. Never mind that the latter has less positive effect on the fiscal balance sheet than the former.

  33. @ DOCM

    ‘Costs can only be kept within limits by a market mechanism’

    US healthcare and UK railways would suggest otherwise.
    The market has its place but it is no panacea.

    CH has a market system and insurance premiums rise by 6-8% per annum. Markets also include oligopolies and rampant inefficiency.

  34. @ Ernie Ball

    “A single payer that can negotiate rates with all suppliers, has an interest in keeping costs down, and has no need to turn a profit is, almost certainly, the only way to keep costs down.”

    You, and others, may be confusing my references to a “market mechanism” with “making a profit”. You actually appear to favour, or at least describe, a market mechanism in which the suppliers, of course, would have to make a profit in order to stay in business. The monopolistic power of the single payer would have to be regulated in some fashion.

  35. B Woods Snr:
    Re @ otto: ” … the average Irish person pays very little tax on their income.” I would question this. If I am reading my Income Tax return correctly, I am paying 30% (inc. the Social Charge).

    I think you need to read this post of Ronan Lyons re taxes on income in Ireland (who in fact just says what much research has found)
    http://www.ronanlyons.com/2012/04/10/who-pays-tax-in-ireland-the-little-quiz-revisited/

    Understanding this is vital to understanding Ireland’s current fiscal mess.

    Yes, of course there are other taxes etc. but they dont make up, anything like, the very limited tax on incomes of average Irish people.

  36. @ DOCM

    Wow, one quarter of all posts on this topic are yours – you must be the quite the healthcare expert.

    Costs can only be kept within limits by a market mechanism.

    Now that is what we in the reality based community call an “unsupported political article of faith” and not an argument per se. As several people have pointed out above there are a good many examples where moving from a centrally planned single authority system to some kind of market solution for a vital national service has been a costly disaster. In a small country like Ireland the overhead of market creation and regulation seems infinitely less preferable than a properly funded NHS style system (though the hospitals and consultants will not like it much).

    Also the fact that the Dutch experiment with markets is really not doing well at all can also not just be waved away as if it is of no consequence. Singapore without the dictatorship just did not work. You have nothing to say to this though. No ideas, no facts, no theories, just the same tired old catchphrases of the neoliberal evangelist.

    http://blogs.lse.ac.uk/europpblog/2013/01/30/health-reforms-netherlands-ilaria-mosca/

    Perhaps one of the most unexpected – and unwanted – trends following the reform is the steady growth of health care spending.

    Among rich nations there appears to be no beneficial link between degree of privatization/market creation in healthcare and efficiency of the service.

    http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries

    Of course Cuba does better than Germany. In the real world communist central planning seems to have a considerable edge over market fetishization‎ in the efficiency stakes.

  37. @ EB: What are you getting at? You know as well as I do that banks can create as much money as they like, as often as they like, for whatever programme they like. Its virtually costless – for them. And the leaders of these banks appear to have decided that they intend to continue emitting costless money for the foreseeable future. They have come to realize that creating fiat money is a much more reliable source of funding than relying on dopey taxpayers and in-debt consumers. So, all PS wages, salaries and pensions are in no danger, now or forever. We can all relax.

    So why are we paying taxes to fund an inequitable HS when the actual cost of that service is actually costless? Beats me!

  38. Cuba health care ……..

    cough, spit

    Has any of ever been to Cuba, and took a ride on a public bus?

  39. sounds like a good idea in theory,why people who smoke over eat refuse exercise drink and generally have crap health should pay the same as those who don’t..
    problem is it becomes a bit of a slippery slope but i totally don’t think/believe anyone who smokes should pay same for health ins. as those who don’t,id include junkies too and dipso’s but lets just leave it at smokers:)
    http://www.cbo.gov/sites/default/files/cbofiles/attachments/45214-ICA_Presentation.pdf

  40. OECD data on health care statistics for Canada and the United States shows that as recently as 1965, the cost of those two systems competed neck-and-neck.

    That year, Canada spent 5.9% of its GDP on health care. The United States spent 5.7%. But around that time, Canada was transitioning to its current single-payer system. Over the next four decades, the growth of health care costs slowed in Canada while it accelerated in the United States. By 2011, Canada was spending 11.2% of its GDP on health care – – and covering everyone. The United States was spending 17.7% of its GDP and leaving 45m uninsured.

    The OECD said health spending accounted for 17.7% of GDP in the United States in 2011, unchanged from 2009 and 2010 but by far the highest share in the OECD, and more than eight percentage points higher than the OECD average of 9.3%. Following the United States were the Netherlands (at 11.9% of GDP), France (11.6%) and Germany (11.3%).

    Ireland was at 8.9% of GDP and 11% of GNP.

    The United States spent $8508 on health per capita in 2011, two-and-a-half times more than the OECD average of 3339 USD (adjusted for purchasing power parity). Following the United States were Norway and Switzerland which spent over $5600 per capita. Americans spent more than twice as much as relatively rich European countries such as France and Sweden.

  41. @Michael Hennigan

    I am sure there is a health economist in the house but I remember two short pieces from the last few years focussing on MRI costs that laid the blame on the inefficiency/fragmentation of the private health care insurance business and general gouging by the medical/pharma industries.

    Looking for a price inelastic product? Something people may die without.

    In Japan, MRIs Cost Less

    Why an MRI costs $1,080 in America and $280 in France

    Anyway, the US is an odd place, the richest nation in the world, they spend 600 billion dollars on their military annually, they can put a nuclear powered robot the size of a car on Mars but they remain 34th placed in infant mortality rates, behind Cuba and a host of other poorer countries.

  42. Shay,
    If Cuba was so good, why was the partner of one of the Colombia 3 bird watchers flown from Havana to Dublin for treatment. If Cuba is so good, how come Jarry goes to the US for his free treatment. I would rather go to Germany than Cuba .

  43. @ MH

    That is, of course, the problem with an inefficient and badly organised system as in Ireland; we are paying effectively the same as three model countries – France, Germany and the Netherlands – and getting a much poorer service. The US cannot be considered as an example of anything other than a deplorable lack of responsibility at a societal level.

    What is intriguing about the Irish situation is the evident confusion at the level of reasoning that assumes that there exists a left right dichotomy in Ireland in the matter. Maybe it would be better if there did!

    Change is definitely coming as the current system is nearing collapse. What it will consist of remains to be seen.

    http://www.independent.ie/irish-news/businessman-denis-obrien-takes-control-of-beacon-hospital-30163314.html

  44. Shay’s

    “Of course Cuba does better than Germany”

    what an unbelievable gross nonsense of a completely ideologically driven

    what should we call it

    clown, idiot, habitual liar, academic sand box dweller.

    If one has ever been to Cuba, and not just to some 5-star or Club med resort, such a sentence is just completely cynical nonsense.

    Ever walked normal streets with normal people there?

    I have been there, when I had to fly from JFK to Paris to Frankfurt to Dresden to (something I forgot) to Valadero ? second largest after Havanna and close to Guantanamo, because I would have to ask for a US state department permit otherwise. (from my dead cold hands you would get such a request, accepting their desire to rule over my liberty)

    And you see how rapid the regular people there age (same life expectancy as Germany ? in your dreams !)

    To get a single pill of Aspirin in a Hotel? Problem.
    Putting 1, 2, 10 $ on the table doesnt solve it.

    Then you have to walk for 15 min to some “pharmacy”, and get 2 pills for whatever negligible price.

    I have in front of me a Walgreens supermarket 500 tablet Aspirin bottle, bought for 2.65$, probably back in 2000 or so, guessing based on the long gone experation date : – )

    Cuban health care , like any other numbers, are just propaganda,

    but people like Shay obviously fall for it

  45. Cuban health care is on a par with Barbados, the only two countries in the Caribbean where it is not mandatory to charter a plane to Miami if you must have a blood transfusion.
    Recently I took a public bus from Juyuy to Termas de Reyes Argentina. It was a 1950s’ diesel, engine cooling going up steep hills was done by the driver throwing gallons of water on the engine. Cuban buses are rickety but the resort buses are made in China and Volvo class complete with air conditioning.

    I would not look down my nose at anything in Cuba, they are “maitre chez nous” which is more than a lot of countries can say.

  46. Just propaganda, Francis? Ordinarily, I’d defer to your superior expertise on the subject of propaganda, but here I cannot. For, apparently the WHO are also among those who “fall for it.” See:

    http://www.who.int/gho/countries/cub.pdf?ua=1
    http://www.who.int/gho/countries/deu.pdf?ua=1

    Then there’s our resident lobbyist with this bit of mendacity: “we are paying effectively the same as three model countries – France, Germany and the Netherlands – and getting a much poorer service.”

    Lessee: France, 11.6% of GDP; Germany, 11.3% of GDP; Netherlands, 11.9% of GDP and Ireland, 8.9% of GDP. Apparently “effectively the same” means “not at all the same but sufficiently close to use in a feeble attempt to establish my talking points, which have nothing to do with evidence but everything to do with ideology.” Only in that sense are they “effectively the same.”

    Meanwhile the very reason that Ireland’s healthcare system is not good value relative to France’s is precisely the overindulgence of DOCM’s favoured free-market, privatised, ideology.

  47. Speaking of health I’m reminded of Marx’s comment on the Irish Famine – ‘it killed a lot of people – but it killed poor devils only – the [upper echelons] were left largely unscathed ….( more or less)

    fyi
    PolyluxMarx: An Illustrated Workbook for Studying Marx’s Capital

    by Valeria Bruschi, Antonella Muzzupappa, Sabine Nuss, Anne Stecklner and Ingo Stützle; translated by Alexander Locascio

    Reading Capital can be a daunting endeavor and most readers need guidance when tackling this complex work. PolyluxMarx provides such guidance. Developed by scholars and political activists associated with the Rosa Luxemburg Stiftung (Foundation), one of the leading political education institutions in Germany, this book has been field tested with groups studying Marx’s masterpiece over several years. It consists of a large set of PowerPoint presentations, combined with detailed annotations and suggestions for ways to discuss the material. Each page illustrates a central argument from Capital, provides helpful introductory texts, and supplies notes on methodology and teaching tips. PolyluxMarx is an ingeniously devised illustrated workbook that will help readers grasp the key arguments of Capital. It will prove invaluable to the curious reader of all ages, as well as to students, teachers, workers, activists, and study groups.

    http://monthlyreview.org/press/books/cl4406/

    Reckon they musta read it in Cuba!

    Key analysts at the BAu of the BBHS are investigating the rumour that DOCM has a ‘healthy conscience’; thus far, empirical evidence has yet to be found tbc.

    Blind Biddy is now in London after enjoying a storming weekend at Thomond Park on the wild side; she is obviously missed in Kharkov at this time but is being kept informed of the developing situation by Paddy Khukov & The Irish Brigade.

  48. @John Gallaher
    Your reasoning is coloured by your time in the USA.
    If you talk to public policy people about the affordability of pensions, health care and related issues they look at longevity as a major cost increaser.

    Smoking and drinking killed off my father’s generation between 55 and 75 years of age. Women to a lesser extent died of obesity related diseases before 80. Alcohol and tobacco are highly taxed so that takes care of the end of life medical expenses, foregone pensions is a pure bonus.

    I was talking to a Dublin woman yesterday whose father retired from a Gov’t owned corporation job at fifty seven and lived to 93. His pension income was indexed to the wage increases of the work force he retired from. Never smoked, drank very little. In Ontario Canada, women teachers are increasingly receiving pensions for longer than the time they worked.
    Something will have to done about all the people not abusing their health before the country goes bankrupt
    Universal Health Insurance prolongs life, MRIs and CT Scans are detecting serious problems earlier leading to expensive treatments some of which continue for over twenty years. In the bad old days the diagnosis was delayed and the patients went to an early grave.

  49. @Mickey Hickey the link may be of interest to Liam,its quite recent and relevant.
    “Presentation on Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget”

    you seem convinced that prolonging life is a good thing,for everyone ?
    any chance of universal car ins. as now if you get a DWI your premium goes up yet if you collapse in a heap stoned/high or fall downstairs drunk no change:)

    Canada- just google Dr Brian Day or Cambie Surgery Centre.

    Cuba-the numbers are unreliable,just announced today they eliminating 100,000 jobs in health care.Bit info on the system lots ‘noise’ around their numbers.
    http://www.nejm.org/doi/full/10.1056/NEJMp1215226
    http://www.aljazeera.com/indepth/features/2012/06/201265115527622647.html

  50. @DOCM

    GNP fetishism is nothing but a ploy for taking the taxation of multinationals off the table.

    GDP is taxable in Ireland. Therefore, GDP is the appropriate denominator.

    QED

  51. Let’s leave Cuba out of it. We are not going to have a Cuban style system in Ireland, But we could have an NHS or one of the more European style systems with relatively short waiting lists, but seems very unlikely without a substantial increase in income tax.

  52. @otto

    For sure Cuba is sui generis but it is still useful as a counterexample to anyone who blathers on about market efficiency and the dangers of central planning. We could learn much from them, especially on the preventative side.

    The NHS is closer to home and probably a better model for us but whatever we do a complex and artificial market “solution” has to be avoided.

    @Francis/@Tullmacadoo

    Against your anecdotes the international health data is powerless.

  53. If the French system of healthcare is regarded as effective and acceptable on a cost/benefit basis – are staffing and drug costs in line with ours – consultants, doctors, various specialists, nurses, auxiliaries – uses of generic drugs etc.?

  54. @ Vinny

    The short answer is no!

    http://about-france.com/health-care.htm

    The stated cost of a visit to a GP in 2012 was €23! (It was unchanged in early 2013). This is as good an indicator as any of the general level of remuneration within the system. Essentially, one has ready access to a GP or a specialist. (With regard to the latter, there is none of this archaic nonsense relating to consultant and non-consultant services prevalent here).

    One of the general claims made with regard to the proposed reform in Ireland is that it would not cost more than the present system. This is a highly credible claim, especially given the exaggerated income expectations within the overall health service stemming from the runaway salaries agreed during the Celtic Tiger era and the failure to reduce staffing post the abolition of the health boards, and assuming that excessive costs are removed through the planned on-going re-organisation.

    Incidentally, waiting for laboratory tests, or lacking the capacity to have them carried out over a weekend, would be unheard of in France where the system is a regulated mixture of public (hospital) and privately owned facilities.

    http://fr.wikipedia.org/wiki/Laboratoire_de_biologie_m%C3%A9dicale

  55. @ vinny

    By the way, I just noted this typically French comment at the end of the first link above.

    “France / USA

    People in France, who have lived with their national health service system for all or most of their lives, and know first hand how well it works, have been very perplexed by the passions aroused in the United States by President Obama’s health care reform. Even the most conservative forces in French life support the national health service and have difficulty understanding why some people in the USA imagine that an obligatory health insurance scheme for all could be a bad thing.”

    Indeed!

  56. @DOCM

    Yes, that’s right, there have been no changes in pay in the health sector since the Celtic Tiger years…

    Is everything you write misleading?

  57. If this ridiculous system is introduced, do we assume that all customers of Brown Thomas will be required to shop in Penny’s ? Will patients be required to consult specialists geographically ? If so those living in the West of Ireland might as well apply for euthanasia as early as possible.. Whilst a massive overhaul of the health service is undoubtedly overdue, UHI would not appear to be the way to go. Totally separating Private and Public services makes much
    more sense. In that way those wishing to spend their own money on their health, rather than in the pub, would be free to do so. If private patients were denied access to public hospitals ,the State could concentrate on providing a better service for those unable to afford it. Compulsion never has worked and never will.

  58. @JG
    Dr Brian Day is another Brit come to Canada to save the Canadians from what he believes is a fate worse than death, the British NHS.
    The truth of the matter is that any political party that even remotely hints that it is not 110% behind the one payer health care system becomes toast in the next election.
    It is actually a thirteen member system since it is administered by ten provinces two territories and a separate high risk unit for armed forces and some gov’t employees (e.g. diplomat in Afghanistan). As in France the Doctors and Specialists are independent contractors. The hospitals are largely non-profits except for some highly specialised units such as knee surgery. The difference is that in Canada you swipe in your health card and the doctor gets paid by the relevant Gov’t agency. In France you pay the Doctor/Specialist/Hospital directly and use the receipt to be reimbursed by the Gov’t agency.
    The French make a big deal out of the fact that each individual pays for service. In their eyes it is not a (dreaded in the US) socialised service. A lot of people believe that the fact that the patient pays for service results in the service provider being more responsive to the patient. I myself and members of my family noted this difference between Germany, Canada where the transaction is paperless as opposed to Ireland/France where cash is exchanged. Mikel bi dey dances attenshun on you in Ireland and France. France of course has a co-pay so you get back 70 to 85% of the cost.
    I have never received bad medical care even in places like Senegal and Bangla Desh. Once in Chile I asked the Swiss hotel owner for advice and he told me to avoid the public hospital because a Swiss friend of his had died on the operating table when the public hospital ran out of bottled oxygen. An example of a two tier system where one is abysmal and the other is world class.

  59. @MH,Brian’s case will finally be heard in Sept.Quite familiar with the “Ohip” card used have one,prefer my Blue Cross Blue Shield!
    If and regrettably it’s become a big IF you can afford it,the medical care in the US, is the best in the world used by many,many high net worth Canadians amongst others.No one is bleeding to death on the streets or dying off diseases,NY and the burbs have fantastic world class medical facilities.Thankfully I’ve not had to receive much if any medical care as I look after my health,exercise daily,eat moderately and don’t drink or smoke,it’s called personal responsibility.But shur just send me the bill for those smokers,junkies and alcho’s Darwin had it all wrong then…..

    http://blogs.vancouversun.com/2014/03/10/dr-brian-day-vs-the-bc-government-and-anti-privatization-foes-legal-case-twists-turns/

  60. @ All

    Everybody seems to believe, that whatever he has now, is the best… me too : – )

    And I think in the normal case, for the upper 75% it makes very little difference between us.

    What might give my contribution some worth, is, that I was in 4 different situations.

    a) For the first 25 years in the “private insurance” in Germany, then
    b) A few years in the public, then
    c) In the US for the first years in a very generous company sponsored plan, then
    d) In a less generous US plan

    before going back to Germany and having the choice between the private, at that time actually about 30% cheaper and the normal public plan, I did choose, and certainly do not regret. In fact we have a universal health care system since 130 years, 1885 started by Bismarck, but technically it is a 2-tier system, with the private insurance folks often resulting in 1.8x, 2.3 x payments to the doctor, maybe occasionally somewhat longer waiting time for a specialist, in practice I say, it doesn’t matter.

    I say the differences between various doctors in the same plans are larger than between plans.

    The first dentist in the US was the best I ever had, precise, low waiting times, and sound during operations, a mirror to watch the work, IF you wanted it, pictures taken before and after teeth cleaning. The second one was the worst, 2 times trying to fill a lost gold inlay with Hg Amalgam, without asking permission or discussion of options, which would have lead to phantom feelings.

    The first dentist back in Germany actually tried to remove all inlays and renew them, whether needed or not, and the second was again precise, to the point, doing what is necessary. He has now 4 other dentists working for him in a flourishing business.

    I could repeat the same impression for general physicians, but it would take even more space.

    The main difference I see is,

    What happens if things do not go according to simple standard plan in life, longer unemployment, and self employment?

    In Germany your premiums go down accordingly with income, 2x 7.2% and you are never kicked out. And the added advantage of non-existing paperwork. You cannot fall through the cracks, no matter what.

    @ Joseph
    Social Security payments are also compulsory. And a public option covering the vast majority guarantees good service in health, with schools and universities, where we also abandoned the tuition fees again, last year.

    From my view, a country gets in trouble, when the public services are neglected, when the upper 10 – 20 % are abandoning them in favor of private solutions.

    We are in this together, and we share a common destiny, and this leads to social cohesion.

    To the oxygen bottle thing mentioned, I also remember, when a colleague in Poughkeepsie, NY, yelled at our manager “Their nearly killed my baby” when he was demanding an immediate transfer from the “good, private” health care in the US back to the evil socialized medicine in Germany, and demanded a new job assignment done within 3 working days. There are good and bad doctors and hospitals everywhere, and most of the time most patients cannot really judge the quality of a doctor beyond him being nice.

    The Swedes are also experimenting intensively with privately run hospitals, we to a lesser degree too; this is not excluded with a majority public insurance system, not at all!

    Sooo, these are my reasons, why I like the German public system best, with having experienced 4 different plans in 2 different places extensively

    Shay, (Cuba)

    My words were a little harsh, because if you haven’t been to Cuba, and have to just rely on their paper form, you have to believe their 77 years. And you are right; the one Aspirin anecdote alone would count for very little.

    But this was in the second largest City Santiago de Cuba, and I was first searching by myself for a pharmacy, and where I then got the 2 pills, was a “pharmacy” in name only. A lot of people had bad teeth, and were visibly aging faster, at least in comparison to upstate New York and Germany.

    Very limited statistics, from the people I met in a resort and in a private “pension”, wild guess would be some 5-7 years shorter than official.

    And there are ways you can play with those life expectancy statistics, the USSR did false reporting, the Indian data seem to have Madoff disease as well (the data are too smooth) and the “international statistics” are what the national institutions do report.

    Greece is another example of an official “universal, free” system, which seems to work a lot more with fakelaki.

    And to top it off, I believe that the Eastern European countries are actually underreporting their “life expectancy at birth” by about 3-4 years, by the way these numbers are generated from actuary’s tables. I could go into detail.

    We had Air raid Siren alarm at 3 pm, and they still test the systems every half a year, and it still gives me a shiver, because that was the “nuclear strike ongoing”, when I grew up. And then you had to be real fast.

    And the Cuban strategy in general is right to focus on cheaper prevention, universal minimum.

  61. Some links that might be helpful

    The White Paper itself:
    http://health.gov.ie/wp-content/uploads/2014/04/White-Paper-Final-version-1-April-2014.pdf

    Newspaper articles:

    Here is a basic article from the Irish Times giving the details of the white paper:
    http://www.irishtimes.com/news/health/universal-health-insurance-what-is-it-all-about-1.1747201

    Column by Muiris Houston arguing that it will never be implemented:
    http://www.irishtimes.com/news/health/six-reasons-why-the-universal-health-care-plan-is-likely-to-fail-1.1749314

    Piece by Billy Kelleher on the cost of universal health insurance:
    http://www.irishtimes.com/news/health/universal-health-insurance-will-drive-up-costs-for-many-1.1702639

    Irish Independent article on opposition to the proposal:
    http://www.independent.ie/lifestyle/health/opposition-grows-to-plan-for-universal-healthcare-30161443.html

    Paul Cullen in the Irish Times: Dutch health insurance costing 23.5% of income
    http://www.irishtimes.com/news/health/dutch-health-insurance-costing-23-5-of-income-1.1752380

    Universal Healthcare: Trick or Treat? (www.irishhealth.com) by Catherine Wilkinson and Declan Brennan:
    http://www.irishhealth.com/article.html?id=19208

    Article from http://www.thejournal.ie where GPs argue that they were not adequately consulted:
    http://www.thejournal.ie/gps-say-they-were-not-adequately-consulted-universal-health-insurance-paper-1394547-Apr2014/

    Fianna Fáil opposition:
    http://www.thejournal.ie/micheal-martin-fianna-fail-ard-fheis-speech-1376437-Mar2014/

    Article from http://www.thejournal.ie on opposition from health workers:
    http://www.thejournal.ie/uhi-impact-groups-gps-1395368-Apr2014/

    Journal articles:

    Briggs, A. (2013). How changes to Irish healthcare financing are affecting universal health coverage. Health Policy, Volume 113, Issue 1 , Pages 45-49.
    http://www.healthpolicyjrnl.com/article/S0168-8510(13)00211-X/abstract
    (attached)

    McKee et al (2013). Universal Health Coverage: A Quest for All Countries But under Threat in Some.Value in Health (Elsevier Science). Supplement, Vol. 16 Issue s1, pS39-S45.
    http://web.a.ebscohost.com.elib.tcd.ie/ehost/detail?sid=6aced132-50e1-479c-b1ff-8f1bfeac58e8%40sessionmgr4002&vid=1&hid=4101&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&AN=84766864

  62. @francis
    What surprised me about the German system is that a couple where the one working as a lecturer in a Frankfurt university has a better plan than her husband who is an economist with a Frankfurt development bank.

  63. Singing the praise of Dr. med. dent. Hartmann in Klotzsche / Dresden

    (since most the times everybody is complaining about everything)

    First time there, over ten years ago, discussing prior experiences in the US and some weirdo German dentist.

    Fast, precise work. One x-ray, one inlay renewed. Everything fixed for the next 2 years. Nice chit chat.

    You make an appointment over lunch time, 10 min away from the factory.
    Scheduled for 1 hour, 0.5 hrs reserve for potential difficulties, before the next global tele conference.

    You come on time, some local council politician, with a private insurance, is late by 30 min and does not like to be requeued for that, and politely rebuffed, with the argument that other, more disciplined folks deserve to be treated on time. How do you feel as some ordinary “public insurance” guy, being treated on time. before him? Good!

    The first time I was not treated by himself, but by some new young lady doctor, after asking my permission, hmm.

    Second time, she has some difficulties at a hard spot. It felt like half an hour, for me, was probably just 5 minutes. Apparently afraid to apply too much force. Good.

    Calls in the experienced owner, he asks for permission that a 3rd, new doctor comes in to look at it, and learns, explains to me, why it is difficult, and a little here, and a little there adjustment, solves the mechanical problem in < 5 minutes

    Third time, another of those old inlay falls out, I suggest, that taking the x-ray before putting the inlay back in (because the x-ray doesn’t go through the metal, you have to be an semiconductor development engineer to think about such ideas in such a moment), to search for potential cracks, junior doctors calls owner, says fabulous idea, good learning from a patient.

    In a few years, the then experienced junior doctors, he fielded, will be very good dentists opening their own practice somewhere else, with plenty of experience in practice and how to operate such a store by themselves.
    This guy is surely making good dollars, providing very good service for folks like me, in “german socialized” medicine.

    From whatever angle I look at it, internationally experienced customer, tax payer, MBA, german guy looking after social cohesion,

    Just really good.

    Who of you gets any better, where? For what price?

  64. @francis
    Coverage as in my insurance does not cover this that or the other thing but her insurance does. It seems that there is spousal insurance and things that are not covered for one spouse can be claimed on the other spouse’s insurance if it is covered. In the case I am familiar with the wife has the much better insurance in that her husband submits claims to his wife’s insurance frequently but she never submits claims on his insurance.
    They recently went through a rough period where he broke bones with serious complications.

  65. @francis
    I should also add that her insurance gave him access to top class specialists in Heidelberg which his insurance did not.
    Their daughter is an Osteopathic Surgeon and advises them on who are the better specialists available.

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