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The Irish ‘health basket’: a basket case?

  • Pricing and reimbursement systems in Europe
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Abstract

The Irish health care system is typically described as complex and inequitable and yet the source of the complexity is difficult to identify. This paper examines and documents the way in which the structure of the Irish system is complicated when compared with other countries. Analysis is conducted in the context of the ‘health basket’ framework. A health basket describes which health care services, and which individuals, are covered by public funding, and to what extent. The Irish health basket is outlined along three dimensions of breadth, depth, and height, and compared with the health baskets of the United Kingdom, Canada, Australia, Sweden and France. Results indicate that it is in the combination of breadth and height that distinguishes the Irish basket from others. The majority of Irish health care services are run on a cost sharing basis; user fees are higher than in other countries particularly in primary care; and the structure of entitlement restrictions are complex. It is difficult to identify other countries in which all these factors operate within one system. In addition, the way in which the Irish health basket is delivered in practice introduces further complexities into the breadth and height of coverage.

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Notes

  1. Denmark, England, France, Germany, Hungary, Italy, Poland, Spain, the Netherlands.

  2. Thus, there are now three sets of income thresholds to determine eligibility for Category I entitlement: for full medical card entitlement; for full medical card entitlement if aged 70+; for GP Visit medical card entitlement.

  3. Exceptions include specific resource flows to GPs for services provided free of charge to all individuals (e.g. GP maternity and infant care services; the Heartwatch programme; the Methadone Treatment Scheme; services provided under the Health Amendment Act (1996) for those who have contracted hepatitis C from the use of human immunoglobulin-anti D/other blood product or transfusion).

  4. This list includes some medicines that are also available over-the-counter (e.g. mineral supplements, pain reliefs etc.). If prescribed, these over-the-counter medicines are eligible for public coverage.

  5. e.g. 100% for oral examination, scaling and polishing; 100% for eye examination and specified spectacles; 50% for contact lenses; 50% for hearing aid [15].

  6. Demand for private health insurance is high in Ireland, covering 50% of the population. Private insurance covers mainly hospital care although private health insurance companies have recently begun to offer primary care benefits, usually with high deductibles [17]. The majority of people with private health insurance have Category II eligibility, but a small proportion of individuals with Category I eligibility (i.e. medical card holders) also hold private health insurance (3–4% of the population).

  7. Specialist hospital doctor.

  8. Tax relief on private health insurance premiums reflects the Government intention to promote the private health insurance market [19] but there has been limited evidence of a strong link between the relief and demand for private health insurance.

  9. As the focus is on comparing the whole basket, investigation of depth is limited to the broad taxonomy of care that disaggregates by primary, secondary, community care etc.

  10. Health baskets have been documented in the literature for the French and UK systems [3].

  11. In Canada, the precise shape of the health basket varies by province. The focus here is on the baseline basket, outlined in the Canada Health Act, that provinces must provide.

  12. Private resources account for 56% of expenditure on prescription medicines [24].

  13. Most GPs opt to bulk bill the government health insurance system, ‘Medicare Australia’, in which case the service is effectively free to the patient. Alternatively, GPs charge the patient a higher amount and the patient can claim an 85% rebate on the schedule fee from Medicare Australia. For out-of-hospital specialist consultations, Medicare Australia reimburses 85% of the schedule fee [25].

  14. Patients pay the full cost for prescribed drugs up to €100, after which the level of subsidy increases to 100%. The annual maximum co-payment is €200 [26].

  15. Eligibility Review Division at the Department of Health and Children, http://www.dohc.ie/about_us/divisions/eligibility.html.

  16. It is important to note that the shape of the Irish health care basket has developed incrementally over time. The history behind the Irish health care system [18, 30] shows that the policy process has been influenced at different stages by a wide range of economic and non-economic factors, as well as by specific institutions and individuals. The bias in funding and attention paid to curative hospital care in the Irish health basket was influenced over time by a number of factors including: prestige of voluntary hospitals as places of learning and sources of private income; successful funding mechanism via the Irish Hospitals Sweepstakes (mid 1930s); strong opposition by Catholic hierarchy and the medical profession to expansion of Government role in primary care.

  17. Further complicated by the use of three separate sets of income thresholds for full medical cards, full medical cards for individuals aged 70+, and GP Visit cards, as noted earlier.

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Acknowledgements

I wish to acknowledge Prof. Charles Normand for his expert advice and help in developing this piece of work. The paper is based on research funded by the Irish Research Council for the Humanities and Social Sciences and by the Adelaide Hospital Society.

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  1. Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Dublin 2, Ireland

    Samantha Smith

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Smith, S. The Irish ‘health basket’: a basket case?. Eur J Health Econ 11, 343–350 (2010). https://doi.org/10.1007/s10198-009-0171-4

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