The Cedar Lounge Revolution

It really is a puzzle to me how the basic inequities in the health system appear to be a blind-spot amongst our political classes. Over the last decade or so I have had the sense that a lot of the rhetoric about waiting lists and such like merely serve to mask a deeper problem, that being that a health system where access is predicated upon personal income (or rather expenditure). This week we have had a tragic object example of that in the case of Susie Long, who at 41 died from colon cancer, a cancer which took seven months to test whereas patients with health insurance were apparently seen within 3 days (for the Dáil transcript, the response of our leading ’socialist’ and a grim post on same let me guide you to P O’Neill on Irish Election). I have personal experience in my family (indeed in this day and age there are many many who do) of colon cancer, and know all too well how crucial it is that it be identified rapidly in order that it can be dealt with as best as is possible. That someone should have to wait over half a year is incomprehensible to me.

In a letter two days ago in the Irish Times Dr. John Barton of Portiuncula Hospital made a basic core point:

They have failed Susie Long and her family and many other patients. Susie Long could have criticised the medical profession for the delay in diagnosing her condition but she recognised that it was the politicians who created and continue to support the current financing system. Both Susie and her husband had great courage, decency and principle in retaining a core belief that health care should be provided on the basis of need and not on ability to pay.

There is a lot of nonsense talked about in this society - and one key piece is (and I’m probably as guilty as any in this regard) that in social policy we are broadly liberal left. Well, we are, up to a point. The reality is that while there is a ‘public’ system which is free, that system is curtailed by ability to pay. Sure, one will be seen - eventually. But if one has money then one will be seen sooner. That isn’t a small point. That is a crucial one, as the case of Susie Long demonstrates.

And this is something we see in health, in education and other areas. Two systems. One free, but effectively rationed. Another rationed only by pay. Yet… and here is the remarkable aspect of all this, it is the state which underwrites the private sector involvement. In effect we have a state which as Dr. Barton notes, facilitates iniquitous divisions. As he writes:

Prof Eddy Van Doorslaer of the Health Equity Research Group studied 21 OECD countries health systems in 2004, to ascertain which were pro-poor or pro-rich. He found that Ireland had the third most pro-rich system in respect of access to hospital doctors. He went on to determine what factors contributed to this inequity.

Not surprisingly, he found that private health insurance was one of the leading contributors to our system being pro-rich, and therefore inequitable. To his surprise, but not mine, he also found that having a medical card was one of the other major factors creating this inequity. He could not understand why a card which entitled someone to free hospital care created this inequity. Medical cards are an insurance system against the cost of medical care but they do not pay fees to hospital doctors and are therefore a financial disincentive to hospital access.

Two further articles in the Irish Times make interesting points. Firstly there is one from a group of oncologists which provides an apologia for the private and independent health sector.

Much has been written and said about independent and private hospitals changing the health landscape in Ireland. But, regardless of one’s personal opinion, we have to accept that we have changed remarkably as a nation. We travel more, see how other countries operate and have higher standards of living, and we now expect higher standards here. Over 50 per cent of Irish people have private health insurance. The challenge for healthcare providers is to meet their demands, while still providing an excellent service to public patients.

The problem with this thesis is that health simply isn’t analogous to ‘travel’, ’standards of living’ and the expectation of ‘higher standards’. The point that 50 per cent of Irish people have private health insurance is irrelevant to the debate and the existence of that tranche of people is not in itself a justification for private health care. It is arguably the legacy of considerable underfunding in our health service and is - quite frankly - part of the problem. The two goals stated in the final sentence are incompatible for much of healthcare - worth noting too that the VHI was essentially a state insurance scheme writ large. That doesn’t make it any better, but it does rather undermine the ‘private’ thesis above.

Simply put health, as with education, is indivisible. Access to care should not and must not be predicated on personal income. This week I’ve pointed to the Labour Party - seemingly in the process of reconfiguring itself as social democratic. One might say with justification - if only they were. If only this society was. If only our supposed ‘populist’ and ‘centrist’ parties actually saw how inequality of treatment based on income was indefensible…

The consultants continue:

The independent and private health sector will never replace the public hospital system. However, with close collaboration, a symbiosis can exist that can benefit all patients in Ireland, both public and private.

This argument makes no sense whatsoever in a heath care environment like the RoI. The bottom line is that at every point the person with private health insurance will get better care and treatment than the person depending on the public service. The consultants argue:

Pragmatism and not ideology should determine the relationship between public and private hospitals,

It is very important that we take a partnership approach between the independent private sector and the public sector to maximise the use of resources. It is essential that ideological considerations are not placed ahead of pragmatic practical approaches that are in the best interest of patients.

But the point is that in the current structure health care is ideological. The nonsense of co-location, an ideological programme if ever there was one, the rationing of health care and so forth make it intrinsically ideological. And maximisation of resources - while a laudable aim - still results in negative impacts and outcomes on those unable to access them.

Pragmatism. Pragmatism suggests a different way.

In a further article in the Irish Times Consultant oncologist John Crown seems to get it, at least mostly.

We must first overcome the prevailing orthodoxy in health economics, a fundamentalist theology with a trinity of assumptions, namely: that the demand for healthcare is infinite; that only government can run healthcare fairly; and that spending on health, unlike spending on clothes, holidays or Volkswagens, is bad for an economy. All of these assumptions are false.

He asks:

So what is happening here? If the current Harney reforms are implemented, the system will be replaced by a rigidly apartheid two-tier system. The poor, whom the right regard as uninsured parasites, will rely on fixed-budget and highly rationed care. Those who can afford it (including virtually all politicians, health bureaucrats and commentators) will use an insurance-based parallel private system.

And he also argues,

We can reasonably, if somewhat quixotically, strive for a zero social welfare society, one where safety nets, while provided, are not actually needed, due to full employment and private pension investment.

We cannot strive for a zero healthcare economy. People, including those who lead careful responsible lives, will usually through no fault of their own develop illnesses, the cost of which is beyond any reasonable self-pay provision.

The problem with the US model?

The failures are obvious. The US, shamefully and alone among western countries, does not guarantee healthcare universally.

The great majority of Americans do, however, have access - via generally affordable insurance - to an incomparable level of care. There are no waiting lists, the system is expensive and Americans pay the highest percentage of GDP of any western country on healthcare.

Which is very true, but… if one is outside the net, and KCRW’s Left Right and Centre and the Slate Podcasts have been discussing health care recently in some detail due to the SCHIPS issue which has now become something of a wedge for universal health insurance there (and which I have a post which I’ll put up soon)… one is in deep deep trouble [a small aside. Commercial health insurance provided by companies was backed by US industry and commerce because of the 'threat' of socialised medicine and from that what was perceived as the threat of communism and socialism. From that came some of the partial nature of the US system, but lest we get too complacent we effectively face a very very similar problem].

He argues that universal health insurance is a best of both worlds situation, one which appeals to both left and right.

The left should love the total equity of access, with the poorest person in the land seeing the same doctors in the same offices and hospitals as does the Taoiseach. They should worship a system where care is delivered on need and not on ability to pay.

The right should love a system which at the stroke of a pen cuts taxes (replacing them with something much more efficient - a non-progressive health insurance contribution), fires thousands of bureaucrats and links hospital funding to activity and efficiency, a system where the patient on the waiting list represents lost revenue, not an inactivity bonus.

Perhaps…but perhaps that too is idealistic. There seems to me to be considerable force behind the status quo. Personally I can’t see why a universal health insurance system couldn’t be part and parcel of taxation. But if the outcome is the same and the user is not discriminated against, then I can live with that. And at least it is a recognition that there is a fundamental discrimination at the heart of this.
But sometimes I get the impression, and I’m far from paranoid about these things, that when it comes down to it those not covered or those who suffer serious negative impacts to their health and longevity are seen as unfortunate collateral damage in the headlong thrust towards ‘markets’, and this in a context where free markets cannot exist in any meaningful fashion.