2 The Irish health care system

Ireland’s health care system is characterised by a complex mixture of public and private delivery and financing and multiple eligibility tiers, which govern access to care. Ireland has the only European health system that does not offer universal coverage of primary care (Thomson et al., Reference Thomson, Busse, Crivelli, van de Ven and Van de Voorde2012). The system is predominantly tax-financed (69%) with out-of-pocket (OOP) payments contributing 15% to overall financing and private health insurance (PHI) contributing 13% in 2014 (Central Statistics Office, 2016). PHI purchases preferential access to hospital care despite its relatively low financing contribution, and approximately one-third of general practitioner (GP) primary care is financed by OOP payment of fees (Wren et al., Reference Wren, Connolly and Cunningham2015). From 2004 to 2012, in a period spanning years of financial crisis in Ireland, there is evidence that the tax-financed share declined, whereas OOP and PHI shares increased (Wren et al., Reference Wren, Connolly and Cunningham2015). Comparison between the financing composition in 2014 and earlier years is not possible, however, due to changes in health accounting methods. High salaries and drug prices contribute to underlying cost pressures in the system (Thomson et al., Reference Thomson, Busse, Crivelli, van de Ven and Van de Voorde2012). Irish current health care expenditure has exceeded the OECD average as a percentage of gross domestic product (GDP) since 2008 and was estimated at 10% of GDP in 2014. Ranking Irish health care expenditure for international comparative purposes is challenging, as GDP is an over-stated measure of national income owing to the repatriated profits of the large multi-national sector and national health care accounts may over-estimate health care expenditure due to the inclusion of funding for social programmes.

Notwithstanding increased health care expenditure, there is evidence of financial barriers to access, unmet need for care and relatively high user charges for primary health care (O’Reilly et al., Reference O’Regan2007; Kringos et al., Reference Kringos, Boerma, Bourgueil, Cartier, Dedeu, Hasvold, Hutchinson, Lember, Oleszczyk, Rotar Pavlic, Svab, Tedeschi, Wilm, Wilson, Windak, Van der Zee and Groenewegen2013). A minority of the population qualifies for medical cards on grounds of low income, or older age and low income combined. Medical cards give access to all forms of care without charge, with the exception of a charge for prescribed medications. A further category of card (GP-visit card), also accessed on age or income grounds, removes the need to pay fees for visits to GPs. The majority of the population must pay OOP fees for GP visits. Irish OOP fees are at the full market rate set by self-employed GPs, which are high compared with co-payments in other countries (Kringos et al., Reference Kringos, Boerma, Bourgueil, Cartier, Dedeu, Hasvold, Hutchinson, Lember, Oleszczyk, Rotar Pavlic, Svab, Tedeschi, Wilm, Wilson, Windak, Van der Zee and Groenewegen2013), and there is evidence that they deter necessary medical visits (O’Reilly et al., Reference O’Regan2007).

In 2015, 46% of the population purchased PHI (MillwardBrown, Reference Mikkers and Ryan2016), which is largely intended to ensure timely access to care, whether in public or private hospitals. Hospital consultants may hold contracts that permit them to conduct private practice in public hospitals, for which they earn private fees on top of their public salaries, and public hospitals also earn additional income from treating private patients. Although a nominally common waiting system was introduced in 2008, privately insured patients’ faster routes of access to initial consultations in consultants’ private rooms and to diagnostic tests, ensure that they gain faster access to public hospital elective care while public patients can experience long waits (Tussing and Wren, Reference Tussing and Wren2006; Department of Health, 2016). Additionally, privately insured or paying patients can access the private hospital sector, which expanded rapidly in the early 2000s supported by Government subsidies (Tussing and Wren, Reference Tussing and Wren2006).

While definitions of universality differ, the ‘universal coverage cube’, adapted from a concept developed by Busse et al. (Reference Busse, Schreyögg and Gericke2007) as a framework for the definition of universality, has been adopted by the World Health Organisation (WHO) to monitor its achievement. The cube identifies three dimensions of universality – population coverage, service coverage and cost coverage (WHO, 2010; Kutzin, Reference Kutzin2013). By pooling funds (through taxation, social insurance or some other means), universal systems aim to remove financial barriers to accessing care. The extent of financial protection and universal coverage then depends on the proportion of necessary services that are financed from the fund; the breadth of population coverage; and the extent of the removal of OOP payments required to access necessary health care (Wren and Connolly, Reference Wren and Connolly2016). Using this framework of analysis, it can be seen that the Irish health care system fails to protect the majority of citizens against financial barriers to accessing primary care. Furthermore, the dual system of state-supported private care in public and private hospitals with rationed public hospital care fails to ensure timely access according to need to elective hospital care for those who cannot afford PHI or private fees.

3 Historical and institutional background

The Irish health care system’s characteristics of financial barriers to accessing primary care and inequitable, ‘two-tier’ access to hospital care have survived through a long history of opposition to reform, pre-dating the independent Irish state. Common throughout the period from 1911 to 2011 was a fundamentally libertarian perception of health care as a marketable commodity rather than a right (Wren, Reference Wren2003; Smith and Normand, Reference Skocpol2011). Ten years before Irish independence, in 1911, the Catholic Church and some in the medical profession, with the support of Irish representatives at the UK’s Westminster parliament, successfully opposed extension to Ireland of a medical benefit system funded by social insurance, to provide free GP care and medications, which was introduced in the rest of the United Kingdom (Barrington, Reference Barrington1987).

A key factor in the divergence of policy on health care in Ireland from other developed states was the powerful position of the Catholic Church, espousing a particularly conservative brand of Catholicism, which had become equated to nationalism in the long Irish struggle for independence. Although the independent Irish state came into being in 1922 after a war of independence, there followed a bitter civil war fought over the terms of independence and the political revolution did not herald the changes in state or class structures, which characterise social revolutions (Skocpol, Reference Ryan, Thomas and Normand1979; Breen et al., Reference Breen, Hannan, Rottman and Whelan1990). The independent state retained the state apparatus inherited from the British colonial government, the post-colonial society retained its traditional suspicion of government and the new government had a minimalist concept of its role (Breen et al., Reference Breen, Hannan, Rottman and Whelan1990). The weak State left political space for the Catholic Church to occupy. The Church delivered and controlled much of education and health and social services. Since the 19th century, Ireland had a tradition of Catholic Church-founded and controlled hospitals, funded by charitable endowment, augmented by grants from parliament and from 1930 by a national lottery (Barrington, Reference Barrington1987), and funded in the modern era by taxation and PHI.

Catholic social teaching was suspicious of state activity, shaped the attitudes of Irish politicians and influenced the 1937 Irish Constitution, which gave explicit recognition to the role of the Church (Breen et al., Reference Breen, Hannan, Rottman and Whelan1990). Ireland of this era has been compared with Spain and Portugal in its commitment to maintaining a Catholic, rural society (Crouch, Reference Crouch1993). While after the Second World War Catholic political parties in many European states were either left-wing or prepared to ally themselves with socialists in supporting the development of the welfare state (Whyte, Reference Whyte1980), in Ireland the Catholic Church was fearful of socialism or of reforms that would dilute Catholic control of health care institutions and sexual morality (Wren, Reference Wren2003). The emphasis on sexual morality in the Irish Catholic Church has been interpreted as at least in part the consequence of the famines of the 19th century, which provoked a societal response of celibacy and late marriage to avoid the sub-division of farms (Daly, Reference Daly1981) and exacerbated population decline – from 8.2 million in 1841 to 4.4 million in 1911.

A further factor that contributed to the divergence of health policy in Ireland from the European mainstream was the political party system, which developed post independence. The independent state was relatively rural with only 13% of the labour force engaged in industry in 1911 (Kennedy et al., Reference Kennedy, Giblin and McHugh1988); Northern Ireland was more industrial but remained within the United Kingdom, splitting the emerging labour movement (Daly, Reference Daly1981). The Irish case is seen as an exception to the models of party systems that apply across Europe (Mair, Reference Lynch1999). Politics in the independent Irish state has been dominated by two political parties (Fianna Fail and Fine Gael) which, as in the US party system, have their roots in allegiances from a schismatic civil war, and have cross-class appeal (Mair, Reference Lynch1999). Their dominance has prevented the emergence of the reforming, class-based politics, which fostered the growth of welfare states internationally.

As the political party system so too the welfare state in independent Ireland eludes categorisation. While in other European countries Catholic-party strength has been associated with the development of conservative welfare regimes, such as in Germany or Austria (Esping-Andersen, Reference Esping-Andersen1990), Ireland lacked the critical historical accompaniment for their development of an absolutist State. Insofar as Ireland fits into one of the three worlds of welfare capitalism, its means-tested benefit system and modest social transfers suggest it could be placed among liberal welfare regimes (Esping-Andersen, Reference Esping-Andersen1990). However, this would not be the case were equity in and access to health care the criteria for welfare regime categorisation, since Ireland’s healthcare system has little in common with the systems of liberal regime states like Canada and the United Kingdom.

Without a tradition of mainstream social democratic or secular politics, Irish political parties were deferential to Catholic Church leaders until the final decades of the 20th century (Whyte, Reference Whyte1980; Browne, Reference Browne1989; Wren, Reference Wren2003). In France and the United Kingdom in the post-war years, comprehensive health care systems developed funded by social insurance and taxation, respectively, with roots in the occupational health insurance systems, which had developed in the 1920s. However, in Ireland the combination of weak State and powerful Church obstructed reform at a critical juncture. When the UK’s introduction of a comprehensive free national health system (NHS) in 1948 encouraged reform proposals from Irish politicians and government officials, an alliance of Church and doctors prevented introduction of a proposed ‘Mother and Child’ scheme in 1951, which would have offered free primary care to children and free care to mothers before and after birth (Whyte, Reference Whyte1980). In a letter to Government in 1950, Catholic bishops argued against introducing free primary care for children in Ireland on the grounds that the right to provide for the health of children belonged to parents not to the state, which should not ‘deprive 90 per cent of parents of their rights because of 10 per cent necessitous or negligent parents’ (Browne, Reference Browne1989).

Thus, the medical profession, which feared state employment and loss of private fee income, found an ally in the Catholic Church in impeding reform up to the 1950s.

Medical opposition to state health care was also a feature of the reform process in other countries: the establishment of the NHS met medical resistance in the United Kingdom in the 1940s (Foot, Reference Foot1973); in the Canadian province of Saskatchewan in 1962, doctors went on strike in opposition to the introduction of compulsory health insurance (Taylor, Reference Smith and Normand1987). However, while democratic politics prevailed in the United Kingdom and Canada, this was not the case in Ireland.

Paradoxically, within the same decade as the critical ‘Mother and Child’ defeat, the concept of the role of the State fundamentally altered and broadened in 1958 with the introduction of economic planning and opening up to foreign investment in response to economic stagnation and mass outward migration (Breen et al., Reference Breen, Hannan, Rottman and Whelan1990). Furthermore, influenced by progressive social thinking in the wider church, which in the 1960s had come to view health care as a human right (Catholic Church, 1963), the Catholic Church in Ireland became an advocate of health care reform from the 1970s (while continuing to seek to control sexual morality and applying Catholic ethics in hospitals under its control). The medical profession, however, remained opposed to reforms that would remove private fee income, with hospital consultants preventing the introduction of free hospital care by threatening to strike in 1973 (Wren, Reference Wren2003). In an echo of 1951, the government was unwilling to use State power to face down opposition to reform.

Ireland underwent rapid economic and social change in the final three decades of the 20th century: industrialisation raised national income – more people were employed in industry than agriculture for the first time in 1969 (Daly, Reference Daly1981); access to education improved; EEC membership in 1973 increased awareness of other social models. By the late 1970s, the former ageing and decline in population had been reversed and the Irish had the youngest average age in Europe. Irish Gross National Product per capita, estimated at 60% of the UK’s in 1913 (Kennedy et al., Reference Kennedy, Giblin and McHugh1988), converged to the EU 15 average in the early 2000s (FitzGerald, Reference Fitzgerald2006). Yet, notwithstanding the rapid economic and social change, the nature of Irish politics remained inimical to fundamental reform in health care. In a further parallel with the United States, where patronage-oriented politics impeded the development of a welfare state (Skocpol, Reference Skocpol2008), clientelist politics in Ireland, where the voting system elevates local concerns over national (Garvin, Reference Garvin1999), did not promote the emergence of a universalist agenda in health care.

With increased national income, government expenditure in general and on health increased in the 1970s and 1980s, although a fiscal crisis in the late 1980s provoked cutbacks to health care expenditure. Nonetheless, in response to campaigning by the trade union movement, free hospital care became nominally universal from 1991 (Wren, Reference Wren2003). However, ‘two-tier’ access was further institutionalised with the retention of public hospital consultants’ rights to earn private fee income in public hospitals and work simultaneously in public and private hospitals, combined with the growth of PHI in response to the cutbacks in public care (Wren, Reference Wren2003). The focus of government reform attempts on reducing financial barriers to hospital care, while failing to address such barriers to primary care, resulted in the development of a particularly hospital-centric model of care and under-developed primary and community care (Ruane, Reference Rosenau and Lako2010; Thomson et al., Reference Thomson, Busse, Crivelli, van de Ven and Van de Voorde2012).

Ireland’s economic transformation was based on market solutions (Breen et al., Reference Breen, Hannan, Rottman and Whelan1990), and openness to market solutions in health care increased with the participation in coalition governments of the influential, albeit small, Progressive Democrat party. Founded in 1985, the party advocated reduced taxation, deregulation and privatisation, inspired by the agenda of Reagan and Thatcher (Wren, Reference Wren2003). Government tax subsidies from the early 2000s promoted the growth of for-profit, private hospitals (Tussing and Wren, Reference Tussing and Wren2006). Opening the formerly state-provided PHI industry to competition promoted the growth of tax-subsidised for-profit, PHI (Wren, Reference Wren2003; Tussing and Wren, Reference Tussing and Wren2006). The combination of insurance-funded and fee-for-service reimbursed private medicine with rationed and hospital-centric, public health care has given rise to a complex system of perverse incentives that mitigate against equitable delivery of care prioritising medical need (Tussing and Wren, Reference Tussing and Wren2006). Although there has been a significant recent movement to support for health system reform within the medical profession (Irish Medical Organisation, 2010), the growth of PHI gives almost half the population preferential access to hospital care, which has created a potential large voting bloc in favour of the status quo.

The first Irish Government to re-espouse the aim of the Mother and Child scheme of 1951 of removing fees for GP care for children was the Government elected in 2011 – 60 years later (Wren and Connolly, Reference Wren and Connolly2016). It is hard to overstate the historic nature of the 2011–2016 Programme for Government, which committed to a health care system ‘designed according to the European principle of social solidarity: access will be according to need and payment will be according to ability to pay’ (Department of the Taoiseach, 2011: 31). The programme proposed to end two-tier access to hospital care and introduce GP care free at the point of use for all in a system financed by UHI. This 2011–2016 Government achieved an extension of free GP care to children aged under 6 and people aged 70 and over, whereas the successor Government elected in 2016 has committed to extending free GP care to young people up to the age of 18 (Department of the Taoiseach, 2016).

The election of a Government committed to such a fundamental reform was the culmination of a decade of development of evidence and policy in favour of reform. Evidence supporting movement from payment at the point of use to pre-payment (financed by tax or insurance) was presented by an expert advisory group appointed by Government (Brick et al., Reference Brick, Nolan, O’Reilly and Smith2010; Ruane, Reference Rosenau and Lako2010). A case for social insurance funding of a UHC system in Ireland was proposed in a series of studies (Thomas et al., Reference Thomas, Normand and Smith2006, Reference Thomas, Ryan and Normand2008, Reference Thomas, Normand and Smith2010). Policy documents published by the two opposition parties who entered government together in 2011 proposed reforms to introduce insurance-financed, UHC. The larger party in Government, Fine Gael, evolved a policy proposing a UHI model financed via competing private insurers based on the 2006 reforms in the Netherlands (Fine Gael, 2009). The smaller Labour Party proposed a UHI model in which hospital care would be financed via multiple, largely public insurers and primary care would be financed by social insurance, with the primary care reform preceding the hospital reform (The Labour Party, Reference Taylor2011). The 2011 Programme for Government was a compromise between these two policies, and its interpretation caused discord in Government (Dail Debates, 2012; Loughlin, Reference Leahy2016a).

After a century in which health care reform attempts by a weak State were defeated by Church and doctors, followed by the evolution of a stronger State promoting market-based solutions to the development of health care, there had emerged for the first time a comprehensive Government health care reform programme, explicitly based on the European value of social solidarity. Yet within the Government there remained tensions between supporters of the market-based model favoured by Fine Gael and the more social democratic model favoured by the Labour Party.

4 Reform proposals: towards universality?

The historic nature of the commitment to universality in the 2011 reform proposals is underlined by the continued support for the objective of universality of the all-party parliamentary committee established in 2016 (Houses of the Oireachtas Committee on the Future of Healthcare, 2017). This section therefore discusses in greater detail the reforms proposed in 2011 and abandoned in 2015 due to cost concerns at a time when Ireland was struggling to emerge from fiscal crisis. Under an elaboration of the proposals in a 2014 White Paper, UHI would finance aspects of primary and hospital care, whereas programmes such as long-term and community care for older people would remain tax- and OOP-financed (Department of Health, 2014). Every member of the population would be insured for the same package of health care services, with individuals purchasing insurance for this standard package from one of a number of competing health insurers. Financial support would be available to ensure affordability by directly paying or subsidising from taxation the cost of insurance premia for people on lower incomes.

The multi-payer competing insurer model outlined in the White Paper was, to a large extent, based on the model favoured by Fine Gael of health insurance in the Netherlands, where PHI became mandatory for all in 2006. However, the applicability of this model to Ireland was questioned even as the policy gained political support. Ryan et al. (Reference Ruane2009), for example, noted that a successful shift to a Dutch financing system could result in a more equitable health care system but questioned whether the Irish health system has the requisite capacity. The Dutch model is predicated on achieving meaningful competition with insurers selectively contracting with health care providers. Such selective contracting is relatively rare in the Netherlands (Bal and Zuiderent-Jerak, Reference Bal and Zuiderent-Jerak2011) and even more of a challenge in Ireland due to lower population density and few major hospitals outside urban centres (Mikkers and Ryan, Reference Mathauer and Nicolle2014).

The 2014 White Paper provided little detail on the potential cost implications of the proposed reforms, although it suggested that spending by the state on health care under a single-tier UHI system should not exceed spending under the two-tier system, which it replaced. The White Paper proposed a number of cost control measures and propounded that multiple competing payers would encourage insurers to reduce their costs and premiums to attract more customers (Department of Health, 2014). However, the available evidence does not readily support the assertion that competing insurers lead to a reduction in costs (Lu and Hsiao, Reference Loughlin2003; Hsiao et al., Reference Hsiao, Knight, Kappel and Done2011; Mathauer and Nicolle, Reference Mair2011). While the rationale for competition is increased efficiency, the level of competition is often limited so that the anticipated effect is not observed in practice (Mathauer and Nicolle, Reference Mair2011; Thomson et al., Reference Thomson, Foubister and Mossialos2013). Evidence from the Netherlands suggests that following attempts to control health care costs by encouraging price competition between insurers, while insurers were successful in reducing their operating costs, these costs amounted to only 7% of insurers’ expenses (Rosenau and Lako, Reference Prosser2008).

Although the 2011 Programme for Government committed that the UHI system should be designed to remain outside the remit of EU competition law (Department of the Taoiseach, 2011), as is the case in many European systems of statutory social insurance (Prosser, Reference Pierson and Skocpol2010), subsequent unpublished legal advice to the Minister for Health concluded that competition law would continue to apply to private health insurers within the UHI system (Lynch, Reference Lu and Hsiao2014). If competition law would apply, this would reduce the control government would have over factors such as pricing, cost control and insurers’ margins (Wren and Connolly, Reference Wren and Connolly2016). The distinction in ensuring that a system is outside the scope of EU competition law is that it should be designed according to principles of social solidarity with equal access to services irrespective of the ability to pay (Prosser, Reference Pierson and Skocpol2010).

In November 2015, a report was published detailing the potential cost implications of the proposed model (Wren et al., Reference Wren, Connolly and Cunningham2015). Due to a lack of detail about the proposed reform, the analysis adopted assumptions about aspects of the model including what basket of services would be financed by UHI and the additional costs associated with financing health care through multiple, competing insurers under EU competition law (Wren et al., Reference Wren, Connolly and Cunningham2016). The analysis estimated that the proposed model of UHI would increase health care expenditure in Ireland by between 3.5 and 10.7% per annum (Wren et al., Reference Wren, Connolly and Cunningham2015). While some financing reforms may merely shift financing from one source to another – for example, from OOP fees to public financing via social insurance or taxation – this analysis found that there would be additional health care expenditures, as well as shifts in the sources of financing. The major contribution to additional costs was projected to arise from private insurers’ margins on expenditures financed by PHI, which were formerly financed by taxation or OOP. A further source of additional expenditures would arise from the expansion of services required to address unmet need under the current system (Wren et al., Reference Wren, Connolly and Cunningham2015).

Following publication of the costing analysis, the Minister for Health announced that ‘the high costs for the particular model of health insurance … are not acceptable, either now or any time in the future’(Department of Health, 2015). Subsequently, this model of UHI disappeared from the political agenda. The rejection of the model on cost grounds alone curtailed debate on any offsetting merits that the model might have, on other deficiencies in its design or on adaptations that might reduce the costs or address other deficiencies. For example, while the proposed model of UHI envisaged full coverage of the population, the extent of services to be included was unclear, as was the extent to which OOP charges would remain (Wren and Connolly, Reference Wren and Connolly2016). In addition, the White Paper model stated that insurers would be free to engage in selective contracting with health care providers, which would allow insurers to offer different types of UHI policies, offering a greater or lesser choice of health care providers, and with differing levels of unreimbursed excess (Department of Health, 2014), but provided no detail about how this aspect of the model would be reconciled with provision of equal access based on need rather than ability to pay.

The 2016 election made clear that in Ireland, as in other European countries, austerity measures during the fiscal crisis had reduced support for established political parties and increased support for smaller left-wing parties and independents. Although the Taoiseach (Prime Minister) was re-elected to head the incoming 2016 Government, the minority government of Fine Gael and independents requires support or abstention from opposition deputies to pass any legislation, which has increased the power of the legislature relative to the Government (Loughlin, Reference Loughlin2016b). Reflecting this shift in power, an all-party parliamentary committee (Committee on the Future of Healthcare) was established with the aim of achieving a single long-term vision for health care and the direction of health policy in Ireland. The Committee’s final report, published in May 2017, recommended the introduction of universal GP and primary care, ending private practice in public hospitals, reducing or removing OOP fees and substantially increasing public health care expenditure and capacity in a tax-funded system (Houses of the Oireachtas Committee on the Future of Healthcare, 2017). Despite its cross-party membership, the adoption of its recommendations by Government is not a foregone conclusion. The major political parties achieved the report’s amendment to include a proposal for an independent analysis of any ‘adverse and unintended consequences’ arising from the removal of private practice in public hospitals (Houses of the Oireachtas Committee on the Future of Healthcare, 2017; Leahy, 2017). Earlier, a proposal to remove tax subsidies for PHI was opposed by government ministers and voted down in the Committee (O’Connor and O’Regan, Reference O’Connell, Rasanathan and Chopra2017).

5 Applying lessons from the past to the search for a new policy direction

For the first time since the foundation of the independent Irish state, there appears to be a strong political commitment to achieving UHC in Ireland, although the path to achieving universality is still a topic of debate. While identifying a path to universality for Ireland is beyond the scope of this paper, the history of defeated reforms in Ireland offers lessons for progressing to a UHC system. These lessons can be broadly categorised under the headings of the challenge of addressing potential opposition to reform from stakeholders such as medical professionals and the privately insured, and the related challenges of achieving clarity on the definition of UHC for Ireland, broad support for its achievement and a feasible and efficacious approach to reform.

The history of Irish reform attempts suggest that challenges to implementation that may arise include stakeholder opposition. Although the Catholic Church no longer opposes reforms to achieve universality in Irish health care, it retains hospital ownership and may veto procedures in its facilities that are deemed to conflict with Catholic ethics (Wren, Reference Wren2003). In 2017, church-state controversy again emerged in the politics of Irish health care as, following resignations by senior clinicians, the government was forced to review its acquiescence to Church ownership of a new maternity hospital to be financed by state capital investment (O’Connor, Reference O’Connor2017).

While the Church may no longer challenge reform, stakeholder opposition to attempts to achieve universality may arise from provider and societal attachment to a private market in health care. The history of reforms in the United Kingdom and Canada suggests that successful reform may require strong political leadership and a willingness to withstand medical opposition (Foot, Reference Foot1973; Taylor, Reference Smith and Normand1987). While there appears to be a political commitment to UHC in Ireland, that commitment will require the will to overcome potential opposition from sections of the medical profession, who were so potent in the defeat of reforms in the 1950s and 1970s. Although the introduction of free GP care for children aged under 6 years in 2015 was opposed by some GP organisations (Goodey, Reference Goodey2015), with primary care capacity a concern, this did not prevent the introduction of this reform. However, the parliamentary committee appeared influenced by this stakeholder perspective in its 2017 final report, describing GP capacity as ‘exhausted’.

Addressing two-tier access to the public hospital system would require revision of the historically challenging hospital consultants’ contract of employment. Hospital consultants are paid by salary for their public commitment and receive fees for treatment of private patients. Similarly, GPs are paid by capitation for medical card holders’ care and receive fees from private patients for each visit. Such mixed systems of payment create perverse incentives (Tussing and Wren, Reference Tussing and Wren2006) and, to ensure equitable treatment, should be reformed so that providers are paid by the same method for all patients. Yet, the 2014 White Paper was mute on the design of provider payment systems, a testament perhaps to a path dependency that has evolved in the politics of Irish health care, with policymakers reluctant to confront the medical profession due to their opposition to previous reform attempts. The parliamentary committee’s report recognises that changes will be required in the consultants’ contract to effect the removal of private practice from public hospitals (Houses of the Oireachtas Committee on the Future of Healthcare, 2017).

Although recent evidence suggests that members of the general population are in favour of UHC in Ireland, with 52% identifying UHC as their top ‘ingredient for happiness’ (Amarach Research, 2015: 23), there remains a strong commitment to PHI exemplified by the over 40% of the population who continued to purchase private insurance during the recent economic downturn (MillwardBrown, Reference Mikkers and Ryan2016). While there has been no published polling to determine whether attitudes to UHC vary by insurance status, polling has found that the majority of the insured do not want to queue for treatment (O’Regan, Reference O’Connor and O’Regan2014). The privately insured are disproportionately middle class as are voters for the Fine Gael party, which led opposition in the parliamentary committee to removing tax relief for PHI (Gallagher and Marsh, Reference Gallagher and Marsh2016; MillwardBrown, Reference Mikkers and Ryan2016). Although higher-income insured would benefit from universal primary care, to win the support of the privately insured, a universal system would need to guarantee acceptable waits for hospital care.

One of the lessons of the history of reform is that previous attempts to deliver UHC have been undermined by reform designs, which contained inherent contradictions due to lack of clarity about the definition of universality. The 1991 introduction of universal eligibility for public hospital care, for instance, was undermined by the terms of employment of public hospital consultants who might admit private fee-paying patients, and the 2014 White Paper simultaneously professed to propose a system that would deliver access according to need with payment according to ability to pay, while proposing that insurers might levy differing levels of unreimbursed excess in UHI policies. Such contradictions can be interpreted as reflecting an underlying unresolved conflict in values in Irish society. This conflict arises between belief in a free market in health care (and implicitly health care as a commodity), which was defended historically by organised medicine and now extends to political defence of health care purchase by competing private insurers, and the opposing universalist belief in social solidarity and health care as a right, which motivated trade unionists in 1991 and the expression of support for the social solidarity principle in health care in the 2011 Programme for Government. Ambiguity persists in the Committee on the Future of Healthcare’s recent discussion of UHC, which it defines as providing a wide range of health and social care services ‘on the basis of clinical need’ while elsewhere qualifying that its vision ‘is a universal health system accessible to all on the basis of need, free at the point of delivery (or at the lowest possible cost)’ (Houses of the Oireachtas Committee on the Future of Healthcare, 2017: 58–59). However, influenced by the WHO’s universal coverage cube, the parliamentary committee’s proposals focus on alleviating the effects on access of patient cost-sharing, whereas the focus of the 2011–2016 Government’s reforms on the financing mechanism obscured the necessity to develop policy in such other areas. The challenge remains to achieve a Government platform with a consensus definition of universality and approach to its achievement. Reaching such a consensus and avoiding internally contradictory approaches to achieving UHC are internationally recognised as challenging policy goals (Kutzin, Reference Kutzin2012; O’Connell et al., 2014).

Further lessons from the history of reform relate to the efficacy and feasibility of reform proposals. Caution is required in translating reform designs from different cultures and systems. Only after its adoption did it become apparent that the UHI proposal based on the 2006 reforms in the Netherlands would likely contend with mounting costs and that its model of hospital competition was ill-designed for the relatively low density and dispersed Irish population. More recently, the parliamentary committee’s support for a traditional NHS model with complete separation of the public and private systems could exacerbate the dual nature of the system, where almost half the population has PHI. To retain a large, parallel private system would also risk attracting away staff from the public system, whereas integrating public and private delivery systems in a universal system could offer a route to addressing capacity constraints at least in part by pooling capacity.

The abandonment of the 2011 UHI proposals on cost grounds supports developing an ex ante analysis of the cost of a proposed reform and evidence of benefits for additional costs at an early stage in its design. Demonstrating the affordability of UHC following recent cutbacks is likely to be critical to the success of any proposed reform. Mechanisms to control costs should include reform of provider payment systems to favour capitation and salary and limit fee payments. If an alternative system envisages a role for private insurers, it should be outside the scope of EU competition law giving Irish Government latitude to control insurers’ margins and other costs (Wren and Connolly, Reference Wren and Connolly2016), which requires a design according to social solidarity principles (Prosser, Reference Pierson and Skocpol2010). The evolving requirements of EU law pose a particular challenge for a member country like Ireland coming late to the design of a major health care reform, a challenge not encountered by many European neighbour states, whose health systems predate the establishment of the EEC and the EU. For a late-starter country such as Ireland, health reform design must reconcile not only national imperatives but also the requirements of EU law.