Consultant oncologist John Crownadvocates universal health insurance - a reform that should be supported by both left and right
The inadequacies of our healthcare system are always illustrated most poignantly by individual cases such as that of Susie Long. In separate commentaries written before her recent death, leading consultants explain what they say needs to be done.
The debate about the Irish health system has been a generally ill-informed discourse, laced with bureaucratic wishful thinking on the one hand, and medical self-interest on the other.
Truly informed students of health economics (poorly represented among our ad-hoc health commentariat and even less well in government) will have found the results of the recent Euro Consumer Health Index striking, if predictable.
Ireland ranked 16th out of 29 nations surveyed across a set of consumer parameters, but in the area of waiting lists, the index that matters most to patients, we ranked dead last.
In this regard, there is currently no cancer type for which the timing of radiotherapy in Dublin is currently meeting international guidelines.
Again, unsurprisingly to those who study these things, our neighbour on the bottom of this index was Britain's National Health Service, which has a funding model very similar to that which applies in Ireland - ie hospitals get an amount of money determined by central budgeters, regardless of how many patients use their services.
Strikingly, every one of the top five countries - Austria, Germany, Switzerland, France, the Netherlands - finance their hospitals through a single-tier, social insurance-based "money follows the patient", or Bismarckian model.
How do we fix it? 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.
First, infinity. The demand for healthcare is high, but it can be contained at the level that society decides is reasonable, a decision which is helped by citizens perceiving the connection between healthcare and spending.
While only the most heartless would advocate care by individual ability to pay, there is a cast-iron argument in favour of linking it to collective ability to pay, ie social insurance.
One area where there does appear to be infinite demand is administration (see the 10,000 per cent increase in the number of top-grade Health Service Executive bureaucratic jobs under the Minister, Mary Harney).
What of the truly hilarious belief that only government can deliver healthcare in a disinterested fashion? The common good becomes a mantra to justify rationing, of which waiting lists are the most obvious manifestation.
Life-saving cancer drugs are routinely denied to British cancer sufferers, drugs which are routinely available here. Britain in fact ranked close to bottom for drug availability in the Euro consumer survey, yet in one of those Kafkaesque Irish civil service moments, Sir Humphrey's Irish acolytes have now decided to emulate that system.
In considering the third article of bureaucratic faith, the allegedly negative consequences of spending money on healthcare, there is much to learn from a study of the failures and successes of the American system.
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.
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.
Not since the Ribbentrop- Molotov pact of 1939, which carved Poland between the Nazis and Soviets, have the right and left found such common ground as has occurred in the current health reform process. Nostalgic misty-eyed 1970s socialists see an opportunity for one last stand for state control. They love the concentration of power over the public system in the hands of the bureaucrats, reducing the reactionary doctors to technical status.
Small-government conservatives, who see public healthcare as a huge wasteful behemoth that drains their tax money for the benefit of others, will also be delighted that it will now be contained by the fixed budgets of the HSE.
A true reform, and not the patch job currently in offer, based on universal insurance and single-tier care (similar to Germany, Austria or Canada) deserves support from right and left.
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.
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.
John Crown is consultant medical oncologist and professor in Dublin City University and University College Dublin. He holds an MBA in health management.