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Health a public good?

Posted on March 01, 2014 by Tom Healy

Tom Healy, Director NERI
Tom Healy, Director NERI

Health has been in the news a lot recently. Accident and Emergency under pressure. Budgets running over. Private health insurance costs ever rising. Standards of care concerns to the fore. People worried about whether they will get the treatment they need when they need it and within their means. Health can be an emotional issue. Everyone cares about health because everyone has to face times of ill-health or hospital need at some stage in their lives. There is an unlimited demand for more and better health services while, at the same time, resources are limited.

Societies have choices about how to ration scarce resources towards multiple ends. When it comes to health there is scope for the market to ration resources on the basis of prices. Markets can be efficient but ruthless. Few object to the idea of paying insurance (whether social or private) against health risk. But, if you are getting on in years or have a history of particular health conditions can you afford a huge premium?  As we await further details of the current Government’s plans for ‘universal health insurance’ in the Republic of Ireland we must wonder about the future of our health services. Ireland is not getting any younger. Treatment costs are rising. Promises in the Celtic Tiger years to end waiting lists were not fulfilled. Promises to introduce universal health insurance (whatever it will mean in practice and however it will be funded and by whom) remain to be delivered.

Perhaps now is a time to get back to the most basic of questions:

  • Is health a public good more than it is a private good?
  • Is health a fundamental human right which should depend more on need than capacity to pay?
  • Is it moral that those who can pay should be able to jump the queue when medical resources and personnel are limited?
  • How effective can primary care in the community be to relieve pressure on hospitals and other centres?
  • How much are we prepared to pay for health?
  • Do we want to pay for it individually, collectively or by some mix of both?

Amidst the furore about health in Ireland and other countries we can sometimes overlook basic facts and statistics. Did you know that one out of every three Euro spent on health is either ‘out of pocket’ or from private health insurance contributions.  At 67% total public contributions to health spending in Ireland is out of line with most of the rest of Europe. Whereas, in most European countries, the ratio is 3:1 public to private, in Ireland it is 2:1. In the USA the ratio is approximately 1:1. But, then we like to be a little nearer Boston than Berlin.

The determinants of health are complex. Countries that spend a lot on health are not necessarily more healthy. However, one thing does emerge from research: countries with greater levels of social and economic equality tend to be healthier. Ireland is not known for equality when it comes to health. We don't seem to be able to shake off our two-tier system. Somehow the promise of a universal private insurance model is not convincing on grounds of affordability, equality and effectiveness.

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