Is a 2 tier health service as bad as its made out to be?

chanste

Ok this may show my complete ignorance to the politics of the health system, but given that Mary Harney has just resigned (who I think many perceive to have plugged a private 2-tier health service during her reign) I wanted to ask what is the problem with a 2 tier system?

I mean the obvious answer would be that a rich guy shouldn't be able to "buy" better health care than is given to someone in the public system.

But if that's all there is to it, then I think ethically it is a rather grey area. I mean sometimes I don't think it is simply about what money people have, but also what they value and are willing to spend it on.

Walk through some of the poorest areas of the country and no one will have a problem with people having new cars (even the cheapest which will typically be €15k - €20k), and I know I've met people who've actually wasted shed loads of money on superficial **** while giving out that their health isn't being paid for by someone else.

It seems to me the same problem exists in education. People think that going to private school is a privilege that gives some students better chances than others - every year there are reports giving out about discrepancy between Private schools leading league tables, but I get pissed off because I went to a private school for 6th year; I got a job, a loan, and worked to pay for it, while other people my age at the time were spending all their money on drink and other crap. I invested in education.

So back to health, people have a thing about rich people (for the record I am far from rich myself, indeed I am up to my tits in debt) getting better service, but the way I see it, a couple of grand for health insurance would sort people out and a person doesn't need to be rich to have it, but it's not worth that much to the people who complain, they want to have a holiday and a car and social life and as for health... well someone else can pay for it. At this point I would like to point out that if you value these things more so than health insurance I've no problem with that - but don't whine about not having "The best"... standard will have to do! In fact I don't have health insurance myself, so it's only right that I accept public system for all its flaws if I'm not willing to pay for something better. Frankly I'm grateful for the service I'm given. Someday when I have more money which I can spend on myself I will surely include such insurance because I think its important.

It seems to me that people who have huge sums of money and great health cover will be able to afford for themselves and their families better healthcare than is sustainable by the public system and some people, not only the ones which can't but sometimes simply WON'T pay (perhaps because they don't place so much value in it), for good healthcare will never get as good a service. They are as I understand them the 2 tiers of health service; those who are willing to pay for extra and those that can't or won't (But I think we usually assume it's can't which is simply not true).

Vorsprung

IMO, private healthcare is great for
"routine" illnesses or "elective" procedures. However if my mum was acutely unwell, and I mean seriously down the tubes, I would prefer her to be in the public system.

And just to clarify, I wouldn't quite know where to put cancer care - I'd have put it in with the former group, but I have personal experience of cancer care in the public system and there was little I saw I which I could complain about.

tallaght01

Most public health people will tell you that this is about "voice".

If rich people use a system, they have clout, and people care about them. If important people lie on trollies, then a fuss is made, and things are more likely to change. This is because rich people have "voice".

Poor people don't.

So, when only poor people, or people with very little clout, use a health system, no one gives a flyin mickey if they're waiting on trollies. And nothing changes, as the important people are doing OK.

charlieroot

Let's face it we effectively do have a two tier system when it comes to everything except emergency care.

I don't personally have a problem with it, in fact I think it could work well if carefully managed and regulated. Off the top of my head here area few potential dangers that might arise in a two tier system are as follows:

1) the gap between the two tier has to be carefully regulated. The lower tier should have an absolute minimum standard which does not compromise the health and dignity of the patients it serves. I do believe this to be the case in Ireland on the whole....but there are isolated and extreme counter examples.

2) the lower tier as in Ireland provided for by public funds should not be open to abuse my individuals and companies to profiteer from, this happens at present in my opinion. Consider price paid for private bed in public hospital....I know this for various reasons isn't a fair direct comparison.

3) the flip side is that tier 1 / public services should not act in an anti competitive way preventing entry to private companies into the market - currently happening in Ireland. Compare public v private costs of nursing home care.



While you argue that lots more people could afford health insurance if they prioritised it, I think you're allowing your own background and current age to bias you somewhat. Not everyone is a healthy young individual with no dependents ( to the best of my knowledge anyway . Contrast your situation with a family with two children on the average industrial wage with mortgage etc....

chanste

charlieroot wrote: »

While you argue that lots more people could afford health insurance if they prioritised it, I think you're allowing your own background and current age to bias you somewhat. Not everyone is a healthy young individual with no dependences ( to the best of my knowledge anyway . Contrast your situation with a family with two children on the average industrial wage with mortgage etc....

I take your point. I must admit I am very much focusing on myself and people like me... and thankfully I've no dependencies just yet

kelle

tallaght01 wrote: »

Most public health people will tell you that this is about "voice".

If rich people use a system, they have clout, and people care about them. If important people lie on trollies, then a fuss is made, and things are more likely to change. This is because rich people have "voice".

Poor people don't.

So, when only poor people, or people with very little clout, use a health system, no one gives a flyin mickey if they're waiting on trollies. And nothing changes, as the important people are doing OK.

That's horrible but so true. Of course a 2 tier system should not exist and everybody should be treated equally, it would be ensured that waiting lists would be hastened if the rich and powerful were on these waiting lists along with the general public - but that's never the case, the rich and powerful will always talk their way to the top of these lists!

Vorsprung is correct about cancer care being the same regardless. My parents were both diagnosed with terminal cancer at the same time, Dad was on the public system Mum was private (just the way it worked out!) and both waited exactly the same length of time to see their Oncologists and started their chemo at the same time. However, Mum's oncologist was much nicer and kinder than Dad's!

Traumadoc

Two tier public health care is good in one way that people who have already paid taxes pay again .

But when 50+% have private health insurance in a country that has "free" health care far all you have to ask why.

I believe the reason fo this is that the public health care is so bad ( including emergency care) that if you can afford it, you get private health insurance.

This incentives the public health care to be even worse.
The worse it is the more people who feel the need to have private health care

In the uk you now have relatively good national health care and as a result the numbers with private insurance is low.

opinion guy

Traumadoc wrote: »

Two tier public health care is good in one way that people who have already paid taxes pay again .

But when 50+% have private health insurance in a country that has "free" health care far all you have to ask why.

I believe the reason fo this is that the public health care is so bad ( including emergency care) that if you can afford it, you get private health insurance.

This incentives the public health care to be even worse.
The worse it is the more people who feel the need to have private health care

This pathetic state of affairs was of course was the FF-PD plan all along

lonestargirl

kelle wrote: »

Vorsprung is correct about cancer care being the same regardless. My parents were both diagnosed with terminal cancer at the same time, Dad was on the public system Mum was private (just the way it worked out!) and both waited exactly the same length of time to see their Oncologists and started their chemo at the same time. However, Mum's oncologist was much nicer and kinder than Dad's!

Once you become a cancer patient the care is pretty similar in the two systems. In fact when I worked in cancer services it was easier to PETs for public patients than for private ones. However where the two-tier system comes into play is in getting that initial diagnosis. Public waiting lists for 'routine' colonoscopies, breast mammograms/ultrasounds etc. are too long in many areas leading to people sometimes being diagnosed with more advanced disease (the Susie Long case typifies this situation).

netaddict

I just put in a salary of 34000 sterling into a tax calculator, this leads to a person paying £3,110.80 in National Insurance (i.e. what you pay for health, dole etc). While in Ireland at a 40000 euro (same at 1 euro = 0.85 sterling) salary one pays €2,935.84 or roughly (£2495.50 equivalent). Now to be fair I think health insurance should be added in and taking quinn health insurance plan B most comm you need to add €728.64 or approximately (3663 euro or 3114 sterling pounds). So in the end for this average person on 40000 euro a year both would pay roughly the same in taxes for a reasonably comparable service.

However overall society is actually worse in ireland as no free GP, not everyone is covered etc.

Waiting times are reasonably well managed, not perfect but would definitely be comparable to those of private in ireland.

However, that individual does lose choice, i.e. cannot force GP into gettin MRI scan etc. But this is not always a bad thing as many investigations I saw when working in Ireland were unnecessary or over the top, leading to poor management of scarce health resources.

The big question is that for this person on 40000 euro a year theirs no real big difference in healthcare but they lose choice. But they were under the NHS system covered as a child and will be when they retire etc i.e. no bed charges etc. So when you say public only versus 2 tiered I have no problem with either, but it is more about what we feel as a society we should put our money into. Do you want to give this person with 40000 euro more choice, or do you want to cover everybody with a specific standard of care.

I know the above argument doesn't cover everything but this is supposed to be a post not and essay, although its starting to come close to it.

RobFowl

There is nothing wrong with the 2 tier system






As long as you are on the top tier.......

JuliusCaesar

The problem with our two-tier system is that it is that: private care better than public care. Now the PDs/FFs knew that - you just have to look at the US.

The reason most of us (clinical people working in the HSE) are against a 2-tier system is that it is fundamentally unethical: either each human life is worth an equal amount or......... who the hell is going to judge which people we should help and which people we should not help?

I've helped some unsavory characters in my time. But it's not up to me to deny them help, thank heavens.

(Also, to declare my interest, a close relative died due to the waiting list.....had she been diagnosed earlier, her Ca would have been caught.)

Big_G

As has been stated above, the main difference between public and private healthcare in this country is waiting.

Therefore this is an unequal system. This goes to the very heart of the freedom vs equality debate. The more freedom you have (in this case the choice to wait less by accessing private healthcare) the less equality there is because, and here's the kicker, people aren't equal. Equality is a man made construct. The more you artificially enforce equality, the more you limit certain peoples choices.

The only problem I see here is if the private healthcare is cannibalising public infrastructure to provide it's services, thereby limiting access of public patients. This seemed to be the case before.

The choice is here, do we want to continue to have the freedom to choose, or do we limit freedom and make the system more equal?

In my opinion, the only fair system is an equal system. The system as it stands is unfair to both the private patient and the public patient. In many respects the provision of care in public hospitals is superior to private hospitals and vice versa. Therefore it is unfair to those who do not have the ability to access private care due to their inability to pay because it limits their choice, and unfair to those who can because they pay for services that are available for significantly less.

Notice I haven't mentioned cost as a significant difference. I am open to correction, but I don't think there is significant difference in the cost of provision of treatment in the public and private systems (private may be slightly higher). This is a major annoying issue for me. Some patients have a sense of entitlement without realising that healthcare costs money, a lot of money. They may not pay for it, but someone has to.

The best solution is to make the system fair. To make the system fair is to make it equal. To make it equal means to give everyone the same access regardless of their ability to pay. You can do this effectively in a number of ways but the best way is probably through a universal social insurance. Privately provided and administered so the government cant touch it like they have the PRSI. Everyone has to pay, the amount is based on your ability to pay. But I stress that everyone should pay, even if it is a token amount. This attaches a certain value to the scheme, and limits its abuse. Therefore an amount is paid annually for the insurance and an amount is paid each time healthcare is accessed in a co-pay system. The insurance would then obviously have to be community rated to spread the risk of the old and infirm to the young and healthy.

To further limit choice and the cost of the insurance, preventive medicine may be used in a similar way to Cuba in that yearly checks should be employed. If you exercise your right to choose, your premium goes up.

The beauty of the system is it privatises the administration of the health system which is currently bloated and ineffective.

CathyMoran

In defence of the private system there are some hospitals that are truely private (not just the private section of public hospitals) so while the consultants may indeed be the same the hospitals are different but there is a huge prohibitive premium on these places. As the private sector gets more expensive there is going to be more pressure on the public sector as people can not afford to go to these places.

There are some people who are unfortunate enough to get ill from a young age and neither the private or public sector caters to these people's needs - preventative healtcare is all well and good but it can only do so much.

Plebian

Big_G wrote: »

In my opinion, the only fair system is an equal system. The system as it stands is unfair to both the private patient and the public patient. In many respects the provision of care in public hospitals is superior to private hospitals and vice versa. Therefore it is unfair to those who do not have the ability to access private care due to their inability to pay because it limits their choice, and unfair to those who can because they pay for services that are available for significantly less.

Notice I haven't mentioned cost as a significant difference. I am open to correction, but I don't think there is significant difference in the cost of provision of treatment in the public and private systems (private may be slightly higher). This is a major annoying issue for me. Some patients have a sense of entitlement without realising that healthcare costs money, a lot of money. They may not pay for it, but someone has to.

Just to focus on the cost issue of this, and your post, might introduce more clarity beyond just the moral question.

If we look at decades of peer-reviewed studies comparing public non-profit, and private for-profit provision of healthcare (mostly in the US, but recent studies elsewhere concur), they show quite clearly that a public good like healthcare is more efficiently (i.e cheaper for the same or better outcomes) provided through public non-profit means and ideally through a "single-payer" model.

See the article below on the high cost in the US ( see link and quote below* ). There are many other meta-analyses of years of studies showing the same, and many of these corporations are over here now, -- not suprising given Harney's health privatisation policies.

What I find most interesting about these studies, is how for-profit hospitals, and paying for healthcare through an insurance market, is actually much more bureaucratic (higher administration costs) than public healthcare.

If you look at country statistics on per-person costs of healthcare (see oecd statistics available online in xls sheets), you'll find much higher per-person costs in the American system than say Canada, the UK, or France.


Regarding quality, the profit-motive can introduce some unusual and contraindicitive outcomes...and it is hard to regulate against this. One example is how American for-profit hospitals were sued for unnecessarily doing risky (and profitable) heart operations on patients suffering from angina, when cheaper medication would have been safer and have a better outcome.

For instance if you're a patient at the largest for-profit dialysis chain in America, you're 19% more likely to end up dying than if you went to a non-profit chain. If you're at the second-largest for-profit chain, you're 24% more likely to die. These disturbing results were released in a new study in the Health Services Research journal. ( http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2010.01219.x/abstract )


But regarding the morality side of things, I think mlk said it best,

"Off all the forms of inequality, injustice in health care is the most shocking and inhumane."
Martin Luther King

*
The high costs of for-profit care
http://www.cmaj.ca/cgi/content/full/170/12/1814

"Why does investor ownership increase costs? Investor-owned hospitals are profit maximizers, not cost minimizers. Strategies that bolster profitability often worsen efficiency and drive up costs.

[...]

High administrative costs and lower quality have also characterized for-profit HMOs,15 now the dominant private insurers in the United States. Such plans take 19% for overhead, versus 13% in non-profit plans, 3% in the US Medicare program and 1% in Canadian medicare.16,17 Strikingly, contracting with private HMOs has substantially increased US Medicare costs. For the past decade, Medicare has paid HMO premiums for seniors choosing to enroll in such private plans. According to official estimates, the HMOs have recruited healthy seniors who, had they not switched to an HMO, would have cost Medicare little — about $2 billion less annually than the HMOs' premiums.17 Private plans that were unable to recruit healthy people dropped out of their Medicare contracts, disrupting care for millions of seniors. Washington's response? Sweeten the pot for Medicare HMOs by including $46 billion to raise HMO payments as part of the recently enacted Medicare prescription drug bill.18

Why do for-profit firms that offer inferior products at inflated prices survive in the market? Several prerequisites for the competitive free market described in textbooks are absent in health care.19,20...."

Mucco

Plebian wrote: »

The high costs of for-profit care
http://www.cmaj.ca/cgi/content/full/170/12/1814

Thanks for the reference.

The WHO puts the goals of a health system as
- health
- responsiveness
- fair financing

A two tier system probably fails in all three. Health should not be dependent on income. Health systems should respond to the patient, not the money, and fair financing would suggest at least proportionate payment - Private Health Insurance (PHI) is regressive.

It's clear that most people take out PHI in Ireland to jump queues as very often they are getting the same treatment from the same doctor in the same hospital. It's been estimated that the public system subsidises the private system by ~60%, which doesn't seem equitable.
It's interesting to note, that as the doctors get paid per service from PHI as opposed to on a salary basis in the public system, there's a perverse incentive for them to push people to PHI by, for example, maintaining large waiting lists.

The two tier system also seems very inefficient. IE, we're not getting the maximum output for the amount of money we put in. Assessing output in health is very difficult, but having people on trollies is a clear indicator that things aren't working. Ireland also performs relatively poorly in the numbers of preventable deaths. This is despite investing the OECD average in health (as % GDP).

(Edit) Just found this on the OECD site, it backs up my point nicely:

opinion guy

So with election looming, which party will introduce a one-tier system ?

Big_G

Plebian wrote: »

Just to focus on the cost issue of this, and your post, might introduce more clarity beyond just the moral question.

If we look at decades of peer-reviewed studies comparing public non-profit, and private for-profit provision of healthcare (mostly in the US, but recent studies elsewhere concur), they show quite clearly that a public good like healthcare is more efficiently (i.e cheaper for the same or better outcomes) provided through public non-profit means and ideally through a "single-payer" model.

See the article below on the high cost in the US ( see link and quote below* ). There are many other meta-analyses of years of studies showing the same, and many of these corporations are over here now, -- not suprising given Harney's health privatisation policies.

What I find most interesting about these studies, is how for-profit hospitals, and paying for healthcare through an insurance market, is actually much more bureaucratic (higher administration costs) than public healthcare.

If you look at country statistics on per-person costs of healthcare (see oecd statistics available online in xls sheets), you'll find much higher per-person costs in the American system than say Canada, the UK, or France.


Regarding quality, the profit-motive can introduce some unusual and contraindicitive outcomes...and it is hard to regulate against this. One example is how American for-profit hospitals were sued for unnecessarily doing risky (and profitable) heart operations on patients suffering from angina, when cheaper medication would have been safer and have a better outcome.

For instance if you're a patient at the largest for-profit dialysis chain in America, you're 19% more likely to end up dying than if you went to a non-profit chain. If you're at the second-largest for-profit chain, you're 24% more likely to die. These disturbing results were released in a new study in the Health Services Research journal. ( http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2010.01219.x/abstract )


But regarding the morality side of things, I think mlk said it best,

"Off all the forms of inequality, injustice in health care is the most shocking and inhumane."
Martin Luther King

*
The high costs of for-profit care
http://www.cmaj.ca/cgi/content/full/170/12/1814

So by the evidence suggested here, the best system based on cost and outcome would be a not-for-profit system, privately run. This makes sense.