Photo credit: Department of Health

Let’s face it: Voters are to blame for the health mess

Last week, I was wondering: How can it be that health spending in Ireland has increased by well over 50% in real terms, since the turn of the millennium, while the number of acute hospital beds remains the same?

To answer that question, it’s worth thinking about the only time in my lifetime where a healthcare policy decision seriously imperilled the survival of a Government, and provoked such public anger that it required an immediate U-Turn.

Pause for a moment, and see if you can remember it yourself.

If it escapes you, then the answer is that the only time a health policy decision provoked full scale public warfare was when the Fianna Fáil-Green Government, faced with an economic collapse and pressure to make cuts, decided to means test the medical card for people over the age of 75.

The proposal was not to take the medical card from the poor, but from the wealthy. One can of course argue about the definition of “wealthy” that may have been used, but the public’s position was clear: If you want to save money, then millionaire pensioners are off limits.

The decision was, of course, reversed. There then followed other cuts, mostly to general health spending, but nobody cared, really, about those.

And in the intervening years, where has the additional money in health gone? Not to beds, is the answer.

But we have, of course, provided free GP care to children under five. And we have, of course, just recently agreed to provide free contraception to all women under 25. And we have, of course, made treatments and drugs free for a range of long term illnesses, regardless of the financial circumstances or age of the person being treated.

All of these things may be worthy, or they may be foolish. But at each juncture, the politicians have divined that given a choice between more hospital capacity for the population at large, and targeted freebies for particular voter groups, the electorate will take the freebies every time.

Most of us, after all, are entirely unaffected by hospital overcrowding. We may be appalled by it, theoretically, but 600 people waiting on trollies leaves about 4.9999 million people who are not waiting on trollies. It’s not dissimilar to the housing problem, which is of course very bad for those who cannot afford a home, but not bad in the round for the majority of people whose own home is accordingly increasing in value. We might express the desire to see it solved, but he urgency to solve the problem doesn’t really exist for most voters.

It’s worth thinking about who the health service exists to serve. In a fully private system, like that in the United States, not everybody has access to treatment. This is the major negative. The major positive, if you can get treatment, is that you are the customer. This is why American hospitals tend to be bigger, nicer, more spacious, more well-appointed places than Irish hospitals: You’re not just getting treatment, you’re getting the customer experience. It’s not a great system, especially if you lack health insurance, but it is a system driven by customer need, and a degree of competition. It is also why they offer more, and more advanced, treatments: Try as you might, and you’ll never find an American Family on American Television trying to raise money to have their child sent to Europe for lifesaving rare treatments.

In the Irish health service, the objective is not customer satisfaction. The objective – at least from the people put in charge of running the health service, our politicians – is votes. But you do not need to be satisfied with a health service, if the objective is to win your vote. You simply need to be minimally dis-satisfied, so that your vote can be bought some other way. This is one reason why elections are never held in January, at the peak of hospital over-crowding season.

What’s more, the objective in such a system is not necessarily the outcome in a particular case, but the best overall statistical performance.

In other words, an individual case is much less important to a politician than the overall statistics. Yes, you might have had a very bad experience, but that doesn’t matter particularly if a politician can say that 1,000 additional nurses were hired, or cancer survival rates increased overall by half a percentage point. The point of the health service, when it is run by Government, is not the best outcome in an individual case, but minimal public dissatisfaction with the health service as a whole. Yes, you might have had a bad experience, but the important thing overall is that the voter in general is happy enough with their lot.

And so, resources go not into providing the best service, but into winning the most votes. We end up spending money subsidising healthcare for healthy children, rather than putting in more beds for flu-ridden pensioners. We buy the contraceptive pill for college aged women, rather than putting nicer seats into accident and emergency waiting rooms.

And because this system is so deeply engrained, most of us cannot imagine any other. Reform of the system is impossible, because reform would necessarily mean taking goodies from those who don’t really need them, and investing that money in those who do. But the needy are a minority, and those with the goodies are a majority. Politicians will never improve the health service if it costs them votes to do it.

And it will.

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