The Cedar Lounge Revolution

The Big F****** Deal and progressive healthcare proposals in Ireland March 24, 2010

It’s odd, there’s simply been too much to think about this side of the Atlantic for the events in the US to have much traction. And so issues rise and fall and they’re ignored. But… Health Care has passed… and… well, perhaps it’s a disappointment. On one or two, or maybe many more, levels. This isn’t the social democratic millennium. It’s not exactly socialised medicine and there’s no sense that this is an NHS. But… for all that, it does mark a step forward. No giant leap, but some movement. Or as Joe Biden put it, inappositely given the proximity of microphones – but not inaccurately… it is indeed a ‘big fucking deal’. And not least because of the near-hysterical opposition to it, from – in part – people who should have known better. That this opposition manifested itself in racial and homophobic epithets directed at members of Congress on the day of the vote tells us something about the profound divisiveness of US political discourse in this era (although, for all Obama’s goal of bi-partisanship, when was it ever really otherwise).

Whether it’s an opportunity for progressives, to use a broader canvas, is a different question. It certainly shores up a government that has taken some hammering over the past year or so. I’ve been rewatching the West Wing across the last two or three years — small children do that to you, you know, reducing the time, and more importantly the energy, that is available to consume media. Put aside, as best as is possible, the now almost painfully tragic death of John Spencer and the pathos that lends to his role as Leo McGarry and watch Santos cruise, well, not actually cruise, more stumble through a field of missteps to the Presidency and the resonances with Obama are now so great as to be almost prescient (not least when there is talk of how Santos/McGarry could energise the ‘rock the vote’ crowd). Of course Santos was based in part on Obama, but throughout the fictional campaign there is an undertow that ‘no, he can’t make it – it’s too soon’.

And as with any achievement that in itself becomes almost too suffused with its own meaning why is there any surprise that Obama’s ratings have fallen since the Presidential election, albeit not quite as precipitously as they might have, that his stock has diminished, that that initial lustre is now tarnished in some indefinable fashion. It is almost as if it were better that he had won, and then slipped away into obscurity, for the winning was the main thing and all else… a disappointment.

He’s had to make all the little compromises that we on the left knew he would, albeit one could argue that the tone of the US in international affairs is vastly improved (even if the reality, as with Afghanistan, hasn’t changed enormously) and from time to time there have been flashes of a different way of doing things, as with this last weeks spat with Israel over settlements in East Jerusalem. Indeed it becomes clearer and clearer that while progressive, in some respects, Obama was a much more centrist figure, in both personality and policy, than he was painted by either his fiercest opponents or staunchest supporters.

Even the rhetoric of his speech to House Democrats, as noted by John Dickerson on Slate, while tilting away from Republicans didn’t exactly paint the flag red…

“Something inspired you to get involved, and something inspired you to be a Democrat instead of running as a Republican,” he said. “Because somewhere deep in your heart you said to yourself, ‘I believe in an America in which we don’t just look out for ourselves, that we don’t just tell people you’re on your own.’ “

Hmmmm… there’s more than one Republican who could justly say, even thoguh I disagree with the analysis, ‘ah, yes, but… we believe that people are better placed if they make their own provision than if government does it for them…’.

But, there’s a part of me, that despite the disappointment, thinks that on a human level the extension of health care to a further 32 million Americans, despite the lack of a public option, is in and of itself a good thing. That curiously the Republican contradictions in terms of their appallingly hypocritical stances on Medicare have been educative. That while not big government, Obama has – at least – provided an explicatory lesson as to why the state, even in a polity as right of centre economically and socially as much of the US is, has a hugely important role to play.

These are achievements, however difficult to parse (and I liked the headline on this.. ) and partial though they may be. That they are not per se of the left, that they could, in this state, be supported by many on the centre right doesn’t reduce their significance for the US.

Indeed in this state they are supported by the right (and that thought should belie the the notion that we live in anything close to a state with social democratic levels of public provision). This week the issue of the latest Fine Gael healthcare proposals came up. And as SonofStan noted, for a non-socialist party, they’re not without merit (and worth adding that Vincent Brown has found stuff in the New Politics proposals that he likes – kudos to Fine Gael).

A 3-Phase Programme
Reforming the Irish health system will not be easy. The last thing Ireland needs is another ill-conceived experiment like the formation of the Health Service Executive (HSE). In addition, any reform must be undertaken within Fine Gael’s overall budgetary framework. We have, therefore, divided our FairCare programme into three distinct, but over-lapping phases that will allow us to gradually introduce reforms in a way that is both carefully planned and affordable

It continues…

Phase 1: Maximise what we have (Implemented from Year 1)
In the first phase of FairCare, we will change the way hospitals work and, as indicated above, will also significantly strengthen Ireland’s Primary Care system.

…

Phase 2: Introduce “Money follows the patient” (Year 3)
Under the current system of fixed budgets, each additional patient is effectively a “cost” to the health service. This system provides no incentives for efficiency or productivity. Under MFTP, health providers will be paid for how many patients they treat. Patients will be a source of “income” rather than a “cost”, just as they are in private hospitals today.
MFTP will mean that decision-making is increasingly devolved to the hospitals themselves. Once MFTP is introduced, the National Treatment Purchase Fund will be closed, saving around €100 mn a year. Long term, we expect MFTP to increase efficiency by as much as 10%.

Let’s hold on right there, because this is very similar to… proposals from another party… step forward Labour in their 2007 Election Manifesto – the Fair Society!

The Money Follows the Patient:Towards Universal Health Insurance

The existing two-tier structure in the health services is both unfair and inefficient. It establishes a perverse structure of incentives, particularly for consultants. It leads to resources being allocated bureaucratically to health care providers, rather than ensuring that resources automatically flow to wherever patients are and want to be. Labour believes that a high quality and fair health service requires the introduction of universal health insurance, which would ensure that resources are allocated to meet the needs of patients.

Perhaps Labour should sue. Or perhaps this means that there’s a slight chance this will be implemented in a future coalition government. Or both.

The FG document continues:

Phase 3: “Universal Health Insurance” (Implemented in Year 5)
Once the first and second phases of FairCare have been successfully implemented, Fine Gael will introduce Universal Health Insurance (UHI), a system that is widely used in Europe and in Canada. UHI will only be introduced once waiting lists have been significantly reduced in Phases 1 and 2. In the interim, the current system of voluntary insurance in Ireland will remain in place.

Within its first 30 days in office, a Fine Gael Government will establish a UHI
COMMISSION, which will include representatives from all of the major stakeholders in the health service. Its primary task will be to build a consensus around the practical measures that need to be taken to prepare the health system for UHI. One of the keys to success for any insurance system is strong regulation. The Regulator will be answerable to the Minister and the Oireachtas. Fine Gael proposes to introduce the Dutch model of UHI in Ireland, with mandatory health insurance for everyone, to be chosen from a selection of providers. The Netherlands spends only slightly more than us on health on a per capita basis, but is ranked number 1 in Europe for quality and Number 2 for value for money (Source: European Health Consumer Index 2008).

The Dutch system of UHI has strict community rating and an obligation to cover, which means that insurance companies will not be able to discriminate against anybody on the basis of age, sex, medical history, etc. This will be underpinned by a system of Risk Equalisation, which will compensate insurers for covering higher risk, higher cost patients. The insurance model will also address mental health.

All good stuff… but back to Labour…

In other words, the money follows the patient. We are committed to this objective. Such a system can only be introduced over a period of time and requires significant change to the structure and capacity of the health service in advance of the introduction of full UHI. Accordingly, we propose to develop a UHI system through a series of steps, each of which represents an important reform, in and of itself, improving the quality of service to patients.

We will:
■ Change the way doctors are paid, establishing a stronger link between the work consultants do for public patients and what they get paid.
■ Change the way hospitals are paid to link budgets more closely to work done for patients, and to provide explicitly for activities such as teaching.
■ We will extend free health insurance cover to everyone up to age 16.

Actually, there’s some remarkable crossovers in terms of the text…

Here’s Labour:

Mental Health Services
Mental Health has long been the Cinderella of the health services, under-funded and neglected. There a number of unmet needs, including mental health services for children and services for those suffering from dementia. Meanwhile, the problem of suicide requires urgent attention. Labour supports the concept of ‘recovery-orientated mental health services’.
What Labour will do:
■ In time, we envisage a minimum base line funding for mental health services of 10 per cent of current health spending.
■ Put in place multidisciplinary community mental health teams, reducing the need for inpatient care.
■ Close psychiatric institutions that are inappropriate for their purpose, once
adequate out-patient services are in place. Funds from the sale of such institutions to be ring-fenced for mental health services.

And here is Fine Gael:

Fine Gael will also ensure that resources, arising from the sale of psychiatric institutions and lands, will be ring-fenced to mental health. Psychiatric illness must be treated like any other illness, and resourced accordingly.

But beyond those ‘similarities’ in a way these proposals present a problem. Because these are not socialist, or even truly social democratic. The structures remain – in part – private. The state is not the provider of insurance, it merely holds the ring. And the Fine Gael document, perhaps to provide ideological cover, is very very open about this.

UHI: The Best Medicine for Ireland’s Failing Health System
There are basically three different models of healthcare right now.

• The Beveridge model (centralised monopoly health service provider financed from taxation: Ireland, UK);
• The Business model (voluntary private insurance: USA); and
• The Bismarck model (mandatory social insurance with tax subsidies;
decentralized and independent health service providers: Germany, France, the Netherlands).
On most international comparison, the Bismarck model has been shown to produce superior results. REFORM, an independent think-tank, has looked at a variety of international case studies. It has concluded that insurance incentives in healthcare are vital because they:
• Achieve greater value.
• Help de-politicise healthcare.
• Provide reasons for individuals and authorities to value long term improvements in health and wellbeing; and
• Define exactly what individuals are covered for, ending postcode lottery and empowering individuals to demand their rights from providers.
For all of these reasons, we propose that Ireland should move from its centralised model of healthcare based on the HSE to a UHI system.

And the role of the State?

Under the Dutch model of UHI, the Government is neither the provider nor the chief funder of healthcare. However, it remains the ultimate guarantor of the system. It will be the Department of Health’s job to ensure that safety and quality were maintained at the highest level throughout the system. In addition, it will be up to the Government to ensure that the system remained truly competitive. More generally, the State will still be responsible for the funding of long term care, mental health, services to improve and protect public health, disease prevention, health research, education and training, etc.

Well, not sure I buy into that. But… I can’t help but think, though, that if the opportunity came to put them into practice the very concept of universality – for me – trumps almost all else. Because that can be worked on and extended. If universal provision in health care is accepted and acceptable, then why not in a range of other social areas? And that is a fundamentally educative moment for a society.

We see in the UK how the titan of the NHS has, despite both frontal and covert attacks, remained in situ across many decades. Once extant it is difficult to remove (although this has happened at the margins in the NHS) service provision. But to shift from where we are to where we want to be, some form of universal system of health provision, would be assisted by a universalisation of health insurance. It would be difficult, one suspects, to strip away that level of provision subsequently. What, after all, would be the alternative on offer? Either a deepening of it, or a fractured system that self-evidently doesn’t function sufficiently well. And the US experience of Medicare provides a telling example, where the Republicans attempted to pitch the Obama healthcare initiative as a threat to it, even to the point of pretending that Medicare wasn’t a Federal programme.

Interesting too that there are aspects which deserve greater detail. For example, what of supplementary elements to health care packages?

In essence, the insured are free to join any insurer and can change their insurer each year. All of the insurers must offer a standard insurance package, mandated by the State, covering all of the essential services and treatments one would normally expect – GP and hospital care, medicines, maternity care, ambulances, etc. It will also include cover for psychiatric illness. The insurance companies compete for business largely on the basis of price and reputation (the package of services covered is determined by the State). The insured will have every incentive to look for the best package available.

The insurers can offer supplemental packages to cover items not in the standard package – non-essential medical treatments such as additional dental treatments and therapies for adults, etc. – but this will not be regulated by the State and customers will have to pay for this supplementary insurance coverage out of their own pockets.

That’s something that I’d certainly want more information about.

I certainly don’t want to sound overly critical about Fine Gael, or indeed Labour. As I say, the suggestions, albeit not social democratic in my understanding of the term, would introduce key elements of a progressive agenda into our health services. They have the merit of actually attempting to put shape and form onto a sector that by any reckoning has been chaotic. Yet there is nothing inevitable that means that any progress would move beyond universal health coverage, that a UHI might not simply stop at that, and that would be up to social democrats and socialists to push for subsequent to its introduction.

Mind you, one could also ask, when it comes down to it why it is that the thoughts of Vincent Brown earlier this month as to a potential way forward are not being adopted by the Labour Party…

We are talking about a society that would impose a single tier, publicly funded, health service (if people wanted private medicine they would be free to pay for it themselves, with no State subsidy). Ditto in education. And a publicly-funded pension scheme for all citizens, with no tax breaks for private pensions.

It could be that simple. But no one will – apparently – grasp the nettle of what is, in truth, fairly mild traditional social democracy. So, two – perhaps two and a quarter – cheers for Fine Gael, and Obama. But…