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How access to health services differs if you've private insurance or are 'in the twilight zone'

Ireland’s two-tiered system contributes to the type of service patients receive, even from public providers, a new report has found.

IRELAND’S TWO-TIERED health system contributes to disparities in the type of healthcare patients receive, even from public providers, according to a new study.

Health Inequalities in Europe: Setting the Stage for Progressive Policy Action examines healthcare services and access in the 28 EU member states.

The report notes that the importance of private health insurance markets varies across Europe, stating that in countries such as Ireland private health insurance duplicates public coverage but provides differential treatment.

Just under half of people in Ireland (45.4%) had private health insurance in 2015. In France, by comparison, almost everybody has private health insurance, so it does not have the same discriminatory impact when it comes to accessing vital services.

ins Source: Health Inequalities in Europe

“Such insurance is so common in Ireland that the health system is commonly referred to as ‘two-tiered’: people with voluntary health insurance enjoy favourable conditions, e.g. obtaining faster access to diagnostics and hospital treatments, even from public providers, thereby giving rise to health inequalities,” the report states.

The research also found that the recession had a particularly adverse effect on people who earn marginally too much to receive a medical card but are unable to afford health insurance, referring to them as being “in the twilight zone”.

Universal health insurance 

The study confirms that Ireland remains unique in the EU as the only western European country not to have universal health coverage of primary care.

The 2017 Sláintecare report, compiled by the Oireachtas Committee on the Future of Healthcare, called for the guaranteed expansion of health funding by between €380-465 million per year, for expanded entitlements and capacity to delivery universal healthcare.

Ireland is also unusual in a western European context in the proportion of health funding that derives from out-of-pocket payments or voluntary health insurance. The researchers note that out-of-pocket payments often stop people seeking preventative and necessary healthcare which can often result in more serious conditions and more expense at a later point.

“The old saying ‘health is wealth’ seems to ring particularly true for Ireland,” Shana Cohen, Director of TASC, which co-published the report, said.

What this report makes very clear is that people with private health insurance in Ireland have a much better chance of getting the health services they need, and getting them quickly. So, where you are in the job market would seem to have a significant impact on your wellbeing and health outcomes.

Cohen said universal health insurance needs to be introduced “as a matter of urgency”.

‘Twilight zone’ 

The research also looks at the impact of the global financial crisis on the Irish health service, which “simultaneously faced substantial budget cuts and higher demand for its services”.

In a country with no universal coverage for primary care, the use of Medical Cards — providing such basic health services for eligible individuals—illustrates these reforms. In 2009, eligibility criteria—based on means-tested income by age groups — were designed to limit access to Medical Cards.

“Nonetheless, the number of people holding such a Card has increased by over 40 percent from 2007 to 2016.

“Despite these expenditure cuts and higher demand, the Irish health system temporarily managed to be ‘doing more with less’ from 2008 to 2012, primarily due to investments predating the crisis,” the reports notes.

shutterstock_589302497 File photo of a patient in a hospital bed. Source: Shutterstock/Thaiview

It adds that this trend reversed in 2013, “when the breadth and depth of coverage had to be reduced in view of the limited resources” and subsequent changes to medical card-eligibility “worked for the economically most disadvantaged”.

However, individuals who the report refers to as being “in the twilight zone” – marginally above the threshold that entitles them to social support measures – fared worse.

Compared with other western European countries, there is a high level of disparity between high and low-income earners: 21.5%. Just 1.1% of people in the top 20% of income earners have unmet medical care needs, while 4.2% of people in the bottom 20% said they have unmet medical care needs.

However, the researchers note that individuals with very low incomes would be more likely to have a medical card and therefore more likely to be able to access primary care at little or no cost.

Life expectancy

Ireland has a life expectancy of 81.5 years – one of the highest in the EU. Across all countries and both genders, life expectancy has improved between 2008 and 2016. In Ireland, for example, such increase has also translated into more healthy years of living — by 3.8 and 4.7 years for men and women, respectively.

However, this is not the case for all European countries. Among others, the corresponding ‘healthy years of living’ statistics in Denmark decreased from 62.4 years to 60.3 years and from 60.8 years to 60.3 years for men and women (separate to life expectancy) — potentially a reflection of increasing challenges in terms of excessive alcohol consumption and rising obesity, as well as in care for chronic conditions.

The full report, published by TASC, the Think-tank for Action on Social Change, and FEPS, the Foundation for European Progressive Studies, can be read here.

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Órla Ryan

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