Ageing, Health Services and Health
Insurance: Understanding Patterns and
Influencing Policy
Charles Normand
Edward Kennedy Professor of Health Policy &
Management
University of Dublin
Trinity College
Outline of Presentation
• Funding health services and funding services in
Ireland
• Patterns of use of health services and social care
• Access to and use of health care – age or illness
• Using evidence to influence policy on access to
care
• Universal health insurance, ageing and access to
care
• Challenges.
– ‘Nothing
comes from
nothing!’
Risk Based
Insurance
Households
Government
Income
based
insurance
Flat rate
insurance
Providers
Non-Capital Health Financing in
Ireland
• Its mainly tax
• Insurance is small proportion
overall
• Insurance is for the old, the rich
and the fit.
Non-Capital Health Financing in Ireland
(1980-2010)
Medical card and private health
insurance coverage by age
Age Group
65-69
70-79
Entitlement Status
50-59
60-64
Medical Card Only
Dual Cover
Health Insurance Only
No Additional Cover
Total
24%
5%
52%
19%
100%
31%
9%
51%
10%
100%
32%
17%
42%
10%
100%
All Medical Cards
All Health Insurance
30%
57%
39%
59%
49%
59%
Source TILDA 2011
80+
All 50+
52%
39%
8%
1%
100%
68%
29%
3%
0%
100%
36%
16%
37%
11%
100%
91%
46%
97%
31%
52%
53%
Entitlement Status by Self Rated
Physical Health (50+)
Self Rated
Health
Not Covered Medical Card
Medical
Insurance
Total
Excellent
15
9
22
14
Very Good
29
22
35
28
Good
35
34
31
33
Fair
17
26
10
19
Poor
3
8
2
6
Source TILDA 2011
Service use
• Services are used by sick people
• Services are used near the end of life
• Both of these are correlated with age, but age in
itself is not very important
• More people (but lower proportions) are living with
a chronic illness (or more than one)
• More people (but lower proportions) are living alone
• Use and cost of care is higher for people living
alone.
Percentage who use each
service by age
Age
GP Visit
OP Visit
ED Visit
Hospital
Admission
50-59
81
36
14
11
60-69
89
43
15
13
70-79
95
46
17
17
80+
95
37
15
15
TOTAL
87
40
15
13
Source TILDA 2011
Nights in hospital for those who were
admitted by age
Age
1-4
%
5-9
%
10-14
%
15-19
%
20-29
%
30-39
%
40+
%
50-59
54
25
9
2
5
2
3
60-69
44
27
15
5
5
1
4
70-79
40
25
14
4
8
3
6
80+
35
25
16
3
10
5
6
TOTAL
45
27
12
3
7
3
4
Source TILDA 2011
Percentage of those in POOR
HEALTH who use each service by
age
Age
GP Visit
OP Visit
ED Visit
Hospital
Admission
50-59
94
61
29
23
60-69
96
64
25
24
70-79
98
64
27
27
80+
96
45
22
25
TOTAL
96
61
26
25
Source TILDA 2011
Percentage who use community
and social services by age 50+
Service
50-59
60-69
70-79
80+
Total
PH Nurse
2.2
3.7
11.8
24.9
6.6
OT
0.9
1.3
2.2
3.2
1.5
Chiropody
1.3
2.2
9.8
15.6
4.5
Physio
3.9
5.1
7
6.9
5.2
Home help
0.5
1.3
6.2
19.9
3.5
Meals on W
0.1
0.3
2.4
3.3
0.9
Day care
0.3
0.6
1.6
6.8
1.2
Source TILDA 2011
Access to health care – ageism
or good clinical practice? 1
• Unpublished Canadian data suggest some of each
• There are good reasons for not providing services
where co-morbidity and limited capacity to benefit
make an intervention less useful
• Some evidence that some older people choose not
to have some treatments.
Access to health care – ageism
or good clinical practice? 2
• However access to useful treatment is often not
offered
• Study of dialysis in 80+ showed good outcomes
and better QOL than for younger people – those
who were otherwise well did well, those who had
multiple health problems did badly
• Key issue to shift away from age as criterion for
rationing or setting priorities.
Access to health care – ageism
or good clinical practice? 3
• Unpublished Scottish data suggest access to
potentially life extending treatments continue but
QOL enhancing ones do not neat the end of life (cf
CABG and Cataract)
• Most growth in service demand reflects more use
by older people and not more older people –
growing expectations are more important than
ageing in driving increases in demands for services.
Using evidence to influence
policy on access to care
• Ageing per se is not a large driver of increasing
health care costs, but will lead to significant rises in
needs for community and social care
• Converging life expectancy of men and women is
tending to reduce the growth in costs of care
• Evidence from TILDA shows that older people are a
major resource for caring for older and younger
people
• Evidence from TILDA suggests that use of services
is affected by medical card and insurance status.
Universal health insurance,
ageing and access to care 1
• UHI is a mechanism not a policy – the policy is the
U and how U is the insurance is the question
• UHI can be associated with increases (or
decreases) in efficiency, so can allow more for less
• Overall burden of paying will still fall on households,
but distribution of burden may change
• Defining the benefit package is still the big
challenge
• Diversity and choice may come at the expense of
universalism and equity.
Universal health insurance,
ageing and access to care 2
• Current private insurance redistributes from well to
sick
• Poorer younger insured subsidise older richer ones
• Community rating rules protect many, but also
exclude many – poorer working people could afford
normal health insurance but cannot afford
community rated insurance
• The advantage of UHI is the transparency of
funding, but does not guarantee better access.
Universal health insurance,
ageing and access to care 3
Compared to present system:
• 60% of those over 80 should see better access to
hospital care, and 3% to GP care
• 41% of those 70-79 will see improved access to
hospital care and 9% to GP care
• 43% of those in their 50s will see better access to
hospital care and 70% to GP care.
Challenges
• Making chronic disease management across all
levels of care a reality
• Shifting care closer to users where feasible and to
specialised providers when necessary
• Removing perverse incentives to patients and
providers for wasteful use of services
• Accepting that rationing is inevitable and necessary
and must be done fairly
• Recognising options and choices are complex.
End
Thank you for your attention