Health Policy 120 (2016) 235240

Contents lists available at ScienceDirect

Health Policy
journal homepage: www.elsevier.com/locate/healthpol

From universal health insurance to universal healthcare? The

shifting health policy landscape in Ireland since the economic
crisis
Sara Ann Burke , Charles Normand 1 , Sarah Barry 1 , Steve Thomas 1
Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Ireland

a r t i c l e

i n f o

Article history:
Received 14 April 2015
Received in revised form 30 October 2015
Accepted 2 December 2015
Keywords:
Universal health insurance
Universal healthcare
Ireland
Health system
Health policy implementation
Financial crisis
Equity

a b s t r a c t
Ireland experienced one of the most severe economic crises of any OECD country. In 2011,
a new government came to power amidst unprecedented health budget cuts.
Despite a retrenchment in the ability of health resources to meet growing need, the
government promised a universal, single-tiered health system, with access based solely on
medical need. Key to this was introducing universal free GP care by 2015 and Universal
Health Insurance from 2016 onwards.
Delays in delivering universal access and a new health minister in 2014 resulted in a shift
in language from universal health insurance to universal healthcare. During 2014 and
2015, there was an absence of clarity on what government meant by universal healthcare
and divergence in policy measures from their initial intent of universalism.
Despite the rhetoric of universal healthcare, years of austerity resulted in poorer access
to essential healthcare and little extension of population coverage. The Irish health system
is at a critical juncture in 2015, veering between a potential path to universal healthcare
and a system, overwhelmed by years of austerity, which maintains the status quo.
This papers assesses the gap between policy intent and practice and the difculties in
implementing major health system reform especially while emerging from an economic
crisis.
2015 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
This paper traces the evolution of universalism in Irish
health policy in recent years in order to assess the gap
between policy intent and practice. Ireland has never had a

Open Access for this article is made possible by a collaboration

between Health Policy and The European Observatory on Health Systems
and Policies.
Corresponding author. Tel.: +353 1 8964240.
E-mail addresses: sarabur@gmail.com (S.A. Burke), normandc@tcd.ie
(C. Normand), barrys6@tcd.ie (S. Barry), thomassd@tcd.ie (S. Thomas).
1
Tel.: +353 1 8962201.

system of universal health coverage universal health coverage as dened by the World Health Organization (WHO):
a situation where all people who need health services
(prevention, promotion, treatment, rehabilitation, and
palliative) receive them, without undue nancial hardship [1].
Universal health coverage consists of three dimensions:

i) Breadth: coverage for the entire population.

ii) Scope: coverage of the full spectrum of quality health
services according to need; and

http://dx.doi.org/10.1016/j.healthpol.2015.12.001
0168-8510/ 2015 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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S.A. Burke et al. / Health Policy 120 (2016) 235240

iii) Depth: coverage of the full costs of health services (no

user charges) [1].
In March 2011, a new government was elected in Ireland
soon after the country had entered an international bailout. The two parties that formed the coalition government
in 2011, campaigned for power on a platform of introducing:
a universal single-tiered health service, which guarantees access based on need, not income. . . through
Universal Health Insurance. Universal Primary Care will
remove fees for GP care and will be introduced within
the governments rst term in ofce. [2].
This was the rst time in Irish history, when a government committed to end the two-tier system of access
to healthcare, which gives preferential access to hospital
care to those who have private health insurance [3]. In
Ireland, two-tier refers to the fact that people who can
pay privately or have private health insurance (PHI) can
get a diagnosis quicker and can secure faster hospital treatment, even in public hospitals, because they can afford the
monthly premiums [4]. About 45% of the population have
PHI but it contributes only about 9% of all health spending [5]. Those who cannot afford private health insurance
must often face long waiting lists [6]. Details of the complicated nature of coverage in the Irish health care system
are explained in Fig. 1.
About two fths (37%) of the population have medical
cards under the General Medical Services (GMS) scheme,
which are means tested and allocated on the basis of low
income. These cards enable poorer people to access GP and
hospital care without charge and medicines at a low cost.
In addition, a GP visit (GPV) card is available, which entitles
those without GMS but still on low incomes or at certain
age to GP visits without charge. The rest of the population
have to pay on average D 52.50 for each GP visit and up
to D 144 a month for prescription drugs [7]. They also pay
D 100 for presenting at an Emergency Department without
a GP referral and D 75 per day for public hospital treatment,
capped at D 750 per year [7].
A recent analysis of the Irish health system found
Ireland is the only EU health system that does not
offer universal coverage for primary care. . . Ireland is
an extreme outlier among EU countries when it comes
to user charges. . . A recent assessment of coverage. . .
found that gaps in population and cost coverage
distinguished Ireland from other European countries
[8].

2. Tracing universalism in the Irish health policy

process 20112015
The 2011 coalition government was elected with a signicant majority, however its popularity declined as it had
to continue to implement austerity measures introduced
under the 2010 troika bail-out. This included cuts to health
[6]. Until 2011, there was a distinct absence of any intent
of universalism in Irish health policy with only a minimal

focus even on equity. Key policy moments are detailed in

Table 1.
The predominant inuence on health policy choices
from 2009 to 2014 was the prolonged austerity leading to
continuous cuts to staff and budgets alongside an increasing demand for care [6]. In the midst of this, the 2011
Programme for Government committed to a single-tiered
health service through universal GP care and universal
health insurance (UHI) [2].
Future Health, published in 2012, was the governments
roadmap to reform for implementing the Programme for
Government [9]. It reinforced the above commitments,
with major healthcare reforms that will be introduced by
2015, prior to the launch of Universal Health Insurance in
2016 [9].
The Path to Universal Healthcare The White Paper
on Universal Health Insurance, the legislative basis for
the introduction of UHI was published in April 2014
[10]. It proposed a multi-payer model of compulsory private health insurance, with for-prot insurance companies
operating in competition and delayed its implementation
until 2019. However, the new system was also to be a
hybrid model as an unspecied amount of health care was
to remain tax-funded [10]. The promise of universal free
GP care and UHI which would deliver universal access to
hospital care demonstrated the intent and ambition of universalism.
In May 2014, the government parties lost many seats in
local and European elections and the loss of GMS medical
cards related to improved economic conditions and tighter
eligibility rules was cited as the strongest reason for this
[11]. Two months after these poor election results, a cabinet
reshufe resulted in a new health minister, Leo Varadkar.
Speaking on the issue of medical cards in October 2014,
Minister Varadkar said
the more that I have studied the issue of eligibility
for medical cards, the more I have become convinced
that the only solution is universal healthcare. No matter
what means-test you apply, whether nancial or medical, there will always be anomalies and there will always
be people just above the threshold [12].
In January 2015 Minister Varadkar, published his list of
85 priorities, which clearly indicate that the UHI policy is
delayed and possibly abandoned [15]. Included under the
banner of Universal Healthcare (UHC) were:

Make the rst concrete steps to universal healthcare by

extending GP services without fees to the under-6s and
over-70s.
Complete the initial costing analysis [of UHI] and revert
to Government with roadmap.
Implement a package of measures to increase the number
of people with health insurance [13].

The two central planks of universalism in the 2011

Programme for Government were the introduction of universal free GP care by 2015 and universal health insurance
after 2016 [2].

S.A. Burke et al. / Health Policy 120 (2016) 235240

237

Coverage for care in Ireland, 2015

Publicly funded long-term re

Pr

+ assets,

drugs costs up to a max of 144 per month for

63% of pop

Mental health services, largely publicly provided, dicult to access, focus on acute
Homecare available on basis of need but ra

Hospital care without

charge for 37% of pop

ted privately & by family

45% of pop have PHI, mostly covers cost

of private
care
Public hospital care capped at 750 per year for 63% of
pop

Many primary & social care services publicly ra

Primary care is free at the
point of use for 37% of

GP visit cards
cover 5% of
pop including
under 6s &
over 70 year
olds

available privately at a cost

GPs charge @50 per visit,

other primary care services for 63% of pop

SERVICES & ESSENTIAL MEDICINES

Pr
drug charge 2.50
per item, capped at 25 per
family

care subject
some costs not covered

Some universal public health services such as maternal & inf

0%

100%

POPULATION
Fig. 1. Coverage for care in Ireland, 2015.

2.1. Universal free GP care

The Programme for Government stated that universal free GP care would be introduced on a staged basis
within the governments rst term, starting with the
sickest in 2012. However, this approach was stalled by

legislative difculties and key milestones were not met.

In 2014, government decided to introduce free GP care
on age basis, to under six-year-olds and to over 70-yearolds.
In July 2015, GP visits cards were extended to all under
six year olds and over 70 year olds. Budget 2016 announced

Table 1
Policy measures tracing universalism in Irish health policy 20012015.
Year

Measure

Impact

2001

National health strategy published: Quality

and Fairness A Health System for You. No
focus on universalism.
Medical cards introduced for all over
70-year-olds.
GP visit card (GPV) introduced
Economic crises. 1st emergency budget
October 2008
Two supplementary budgets and health
budget cuts
Ireland enters bailout
Change of government. Programme for
Government commits to Free GP care &
Universal Health Insurance
Future Health published, roadmap for reform
White Paper on Universal Health Insurance
(UHI)
Change in minister after poor local & European
election results & decline in numbers with
medical cards
Small increase in health budget, the 1st
increase in six years
Introduction of Life-Time Community Rating

Led to multiple changes in public health system structures,

rather than impacting on access or quality issues.
From 2002, all over 70-yr-olds entitled to medical cards
(GMS)

2005
2008
2009
2010
2011

2012
2014
2014

2015

Very low uptake, fewer than 150,000 GP visit cards by 2014

Removal of GMS for over-70s. Increased hospital charges.
Increased & new charges, HSE budget & staff cuts. Salary
cuts
Troika in charge. More cuts
Huge programme of health system reform promised, HSE
to be abolished
Plan for reform. Free GP care delayed, UHI by 2016
No clarity on who would be covered for what or cost of UHI
Shift in policy from UHI to universal healthcare (UHC).
Criteria for medical cards loosened. HSE not to be
abolished.
Free GP care for under 6s & over 70s.
Penalties introduced for those who take out PHI over age
35
UHI costings published showing model unaffordable

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S.A. Burke et al. / Health Policy 120 (2016) 235240

in October 2015, pledged to extend free GP care to all under

12 years olds in 2016.
2.2. Universal health insurance
There has been no progress implementing universal
health insurance since the publication of the UHI White
Paper in 2014. In November 2015, long-awaited costings
of the proposed UHI model were published which found
that it would cost between D 666 million and D 2 billion
more than current health spend [5]. The health minister
concluded that this particular model is not viable stating it
was not affordable now nor ever [14].
In the meantime, on 1 May 2015, life-time community rating was introduced, which brought into effect late
entry loadings for those who take out PHI over age 35.
The purpose is to encourage people to purchase PHI at a
younger age with the intent of making the health insurance market more sustainable by spreading the costs of
care across the population. However, there is concern that
in the absence of a UHI plan, life-time community rating
exacerbates existing inequalities by maintaining two-tier
access to hospital care and making it more expensive for
poorer over-35-year-olds to take out health insurance.
3. What has happened with coverage since 2011
Fig. 2 details proxy indicators of coverage for the Irish
health system between 2008 and July 2015. It shows little actual change in the proportion of the population with
GMS medical cards, GP visit cards and private health insurance coverage between 2011 and 2015, despite the intent
of universalism in the proposed reforms.
3.1. Breadth of coverage
In mid-2015, 37% of the population had a medical card
on the basis of their low income, while 63% of the population did not [15]. The numbers of people with GMS medical
cards grew from 1,694,063 million in 2011 to 1,866,223
in August 2013. Since then, there has been a decline, with
1,735,168 people covered in July 2015, however the proportion of the population covered remained static.
Instead of introducing universal free GP care (as
announced in the government program), government
decided in 2014 to introduce free GP care on age basis. By
July 2015, 5% of the population qualied for GP visit cards
[16].
PHI coverage peaked in 2008 at 51.6% of the population
[17] and declined (largely as a result of the crisis) to 45%
in 2014. Numbers with PHI coverage began to increase in
the third quarter of 2014 [17]. An additional 74,000 people
signed up for PHI before May 2015 when life-time community rating was introduced.
3.2. Scope of coverage
Due of the complicated nature of the package of care
in Ireland with differential access to different parts of the
health system (as detailed in Fig. 1), it is very difcult to
monitor the scope of coverage. However, recent waiting

list data for access to initial outpatient specialist appointment and hospital treatment show more people waiting
over three, six and twelve months for treatment in summer 2015 than there were in 2011 indicating a decline in
scope [18].
3.3. Depth of coverage
Earlier research showed that the depth of coverage in
Ireland narrowed with increasing numbers of user charges,
even for those on medical cards between 2009 and 2014
[19]. For example, there was no charge for prescription
drugs for GMS until 2010 when a 50 cent charge per item
was introduced, this rose to D 2.50 per item in 2013.
This research demonstrated a steady transfer of out-ofpocket payments from the State onto people between 2009
and 2014 [19]. By 2014, Irish people were paying D 599 million more for drug and hospital charges than they were in
2007 [20]. Many of these increased costs for people were
introduced pre-2011, some were introduced post-2011, for
example the cost of drugs for non-medical card holders rose
from D 120 per month to D 144 per month during the this
period.
The D 599 million gure is an understatement as many
out-of-pocket expenses are not caught by ofcial data such
as private spending on homecare or allied health professionals. These services are often not available to those
without medical cards and if they are, have such long waiting lists that people pay privately for them if they can.
4. Discussion
While there has been an intent of universalism in ofcial government policy since 2011, the data presented here
show little progress made on increasing the breadth, with
decreasing depth and scope of coverage of coverage evident through increased user charges and numbers waiting
for hospital diagnosis and treatment. The exception is the
extension of free GP care to the youngest and oldest citizens in mid-2015 and a small increase in private health
insurance in 2014/5.
This failure to progress towards universalism can be
explained by the unrelenting pressure on the health system as a result of budget cuts since 2009 and by the lack of
clarity on the exact form of universalism espoused and the
mechanisms to achieve it [6,7].
The White Paper on UHI was notable in its absence of
detail, with no clarity on the range of services to be covered
and critically no detail on what it would cost the individual
or the State [10]. This inevitably delayed implementation
and nally led to its abandonment.
Universal free GP care has become free GP care for
younger and older people. Despite previous commitments
to free GP care for all by 2015, Varadkar has stated
that there are different ways to cover adults who are
not already covered for free access to primary care. . .
refunding some of their health care costs through social
insurance. . . could be examined [21]. This is different to
universal free GP care at the point of delivery. The health
ministers statement implies many adults will continue to

S.A. Burke et al. / Health Policy 120 (2016) 235240

239

Proporon of the populaon with medical cards, GP Visit cards & private health insurance
60%

50%

40%

30%

20%

10%

0%

2008

2009

2010
% of GPVs

2011

2012

% of pop med cards

2013

2014

Jul-15

% with PHI

Fig. 2. Proportion of the population with medical cards, GP visit cards & private health insurance.

pay for GP care. Universal free GP care was not achieved

by 2015 as committed to in 2011.
The lack of clarity on the mechanism and route to
achieve UHI also meant that it failed to gain public or political support. The growing evidence from Holland (on which
the initial Irish model of UHI was based) of increased costs
and rationing caused public and political concern, while
the Irish Department of Public Expenditure and Reform
expressed specic opposition to it citing the cost implications for the exchequer and the public of the UHI model
proposed [22]. By the time the White Paper on UHI was
published, other newly-introduced government charges
and taxes for water and property meant that politicians
were very reluctant to impose further new taxes/insurance
costs onto people, especially when the specic cost of the
scheme were still not known, but predicted to be high. By
November 2015, governments proposed model of UHI was
abandoned as it was going to cost up to 11% more than
current expenditure [5,14].
It is interesting to observe the changing stance on
universalism emerging from this analysis. There was no
commitment to introducing universal health insurance in
Varadkars priorities in January 2015, instead universal
healthcare was prioritized. The new minister consistently
uses the language of universal healthcare and rarely mentions UHI. However, apart from the plans for free GP care,
there is little clarity on the steps to universal healthcare
nor precisely what it entails.
While the policy commitments in 2011, 2012 and 2014
clearly specied an intent of universalism, this dissipated
in 2015. Writing in July 2015 the health minister stated

my denition of universal healthcare is wider access to

safer and higher quality healthcare for more people
[21]. Universalism by its very denition means involving all. Speaking to medical specialists in October 2015,
Minister Varadkar redened his take on universal healthcare by which I mean access to affordable healthcare for
everyone in a timely manner [21]. Apparently, the health
minister has a changing denition of universal healthcare
and one which differs from the WHO denition mentioned
above.
5. Conclusion
For four years there was no purposeful action towards
universal healthcare which was then followed by diverging
policy measures, most evident in government introducing
life-time community rating and rejection of their own UHI
model in November 2015.
A general election has to be held in Ireland by April
2016. The real issue for Irish citizens is whether government health policies have resulted in improved access to
services and quality care for everybody. The analysis presented here indicates not.
Ireland is at a critical juncture, veering between a potential path to universal healthcare and a system overwhelmed
by seven years of austerity, which continues to maintain
the status quo and a historical bias towards a two-tier
unequal system of care. Although it is too soon to tell
which direction Irish health policy takes, this research
demonstrates the signicant gap between the intent of
policy and what actually happened. It also clearly shows

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S.A. Burke et al. / Health Policy 120 (2016) 235240

the deciencies of introducing major health system reform

without clear objectives, costings and implementation
mechanisms.
Acknowledgements
This paper is part of an Irish Health Research
Board funded project, grant no HRA-2014-HSR-499. More
https://medicine.tcd.ie/health-systems-research/.
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