Universal Health Insurance systems and the
provision of health services for people with
disabilities
A National Disability Authority Working Paper
This working paper was commissioned by the National Disability Authority and
prepared by Gavin Davidson, Berni Kelly and Geraldine Macdonald, School of
Sociology, Social Policy and Social Work, Queen’s University Belfast, and Alison
Martin, Maria Rizzo, Oluwaseye Abogunrin and Louise Lombard, Matrix Evidence,
London. The views and opinions contained in the report are those of the authors
and do not necessarily reflect the views or opinions of the National Disability
Authority.
1
January 2012
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Contents
1.0
Key messages ...................................................................................... 5
2.0
Glossary/definitions ............................................................................ 6
3.0
Introduction ........................................................................................ 8
4.0 What is the issue? ............................................................................. 12
4.1. Brief Overview of Range of Health Care Funding Systems ....................... 12
4.2. Current Health Services Funding System in Ireland ................................... 13
4.3. The planned system of Universal Health Insurance for Ireland ............... 14
4.4. Community and long term care ...................................................................... 15
5.0
Why is it important? ........................................................................ 22
6.0
Methodology ..................................................................................... 24
7.0 Findings .............................................................................................. 25
7.1. Country summaries: Bismarck approach ...................................................... 26
7.2. Country summaries: Beveridge approach ..................................................... 29
7.3. Findings from the literature review ................................................................ 30
8.0
Limitations of the existing research ............................................... 45
9.0
Implications from the research ...................................................... 46
10.0
References ...................................................................................... 48
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List of Tables
Table 1. Long term care funding systems in Netherlands, Germany and Australia.
................................................................................................................................................ 20
Table 2. Type of health insurance in countries identified in the literature review
(adapted from Skinner & Rovere, 2010). ....................................................................... 32
Table 3. Health financing, provider payment and existence of gatekeeper for
countries identified in review, late 2000s (adapted from Wagstaff 2009). ............. 34
Table 4. Community health and social care services covered by Social Health
Insurance and Universal Health Insurance (AARP European Leadership Study,
2006) ...................................................................................................................................... 36
List of Figures
Figure 1. Pyramid of Universal Health Insurance system levels (adapted from
Saltman, 2004, p.17) ........................................................................................................... 11
Figure 2. Inputs for Universal Health Insurance ........................................................... 32
Figure 3. Conceptual framework for the impact of Universal Health Insurance on
people with disabilities ....................................................................................................... 40
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1.0 Key messages

The proposed Universal Health Insurance system, with equal access to health
care for all, based on need and not on the ability to pay, could greatly improve
the provision of health services for people with disabilities in Ireland.

However, benefits are not guaranteed. The introduction of Universal Health
Insurance has been associated with increased health spending and mixed
effects on health outcomes.

People with disabilities have higher level of health needs than the general
population. Any deficiencies with the Universal Health Insurance system
introduced in Ireland could disproportionately disadvantage people with
disabilities.

Key concerns at a systems level in introducing Universal Health Insurance
include the costs, vis-à-vis other models; the extent of coverage and the
regulatory, licensing and risk management of the model.

With regard to the impact on people with disabilities key concerns centre
around equitable access to services, access to insurance and the potential for
excessive supplementary or out-of-pocket payments for the individual.

The potential main benefits of the proposed system (universal coverage and
equal access) could be undermined by the potential limitations (under-funding,
not including the full range of needs/services, barriers to access).

Out-of-pocket payments disproportionately impact on people with disabilities
because of their higher levels of health needs. Strategies to mitigate against
this effect need to be carefully considered.

People with disabilities must be able to negotiate the insurance process and
receive the appropriate services to meet their needs.

It will be important to provide sufficient support and information for people
with disability, and avoid prolonged disputes about eligibility for services.

There must be no incentives for insurers to selectively recruit people with
lower levels of health needs or to impose financial disincentives for people
accessing services.

Comprehensive regulation and monitoring of Universal Health Insurance
services should take into account the specific needs of people with disabilities.

Findings suggest that population health programmes including screening and
preventative health programmes need to be protected through tax-based
financing and provided for outside of an insurance based model.
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2.0 Glossary/definitions
Bismarck and Beveridge systems - One method of distinguishing health care
funding systems is between Bismarck and Beveridge systems (Björnberg et al.,
2009). Bismarck systems, implemented in countries such as France and Germany,
are characterised by the use of a range of Social Health Insurance providers who
are usually independent of the providers of health services. Beveridge systems are
also sometimes referred to as single payer systems, where the payer is usually
the government, such as in Canada and the UK. In these countries, the funding
and service provision tends to be managed, although not necessarily provided,
through one organisation.
Disability – The definition of disability is an evolving and, at times, contested
concept. In the Disability Act 2005 s2 (1) disability is defined as “a substantial
restriction in the capacity of the person to carry on a profession, business or
occupation in the State or to participate in social or cultural life in the State by
reason of an enduring physical, sensory, mental health or intellectual
impairment”. In Article 1 of the United Nations Convention on the Rights of
Persons with Disabilities it is stated that “Persons with disabilities include those
who have long-term physical, mental, intellectual or sensory impairments which in
interaction with various barriers may hinder their full and effective participation
in society on an equal basis with others”. The World Health Organization (2011,
p.5) uses the International Classification of Functioning, Disability and Health
which suggests that “problems with human functioning are categorized in three
interconnected areas: impairments are problems in body function or
alterations in body structure – for example, paralysis or blindness; activity
limitations are difficulties in executing activities – for example, walking or
eating; participation restrictions are problems with involvement in any area of
life – for example, facing discrimination in employment or transportation.
Disability refers to difficulties encountered in any or all three areas of
functioning”.
Public health and government insurance (tax-based) – another label for
Beveridge systems as defined above, which acknowledges that some Beveridge
systems use general taxation to fund health care (e.g., in the UK) and some use a
single national insurance scheme (e.g., in Canada).
Private Health Insurance – along with Bismarck and Beveridge systems of
funding health care the third main system is through private health insurance.
Individuals have to purchase their own insurance which is set by privately
operated companies and based on their estimated risk of needing care (Saltman
et al., 2004).
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Risk equalisation – in systems where there is more than one insurance
provider, people with relatively high needs for care may not be equally
distributed between the insurance providers. A risk equalisation system attempts
to transfer funding between the providers so that people with higher needs are
not penalised.
Single-payer health insurance - refers to systems where there is just one
payer/provider of insurance, usually the government (Goodman et al., 2005).
Single tier health care - refers to a system that provides the same level of
health care to all. People are generally not able to buy additional or faster access
to health care through paying more, although this may be allowed for nonessential services. In two or multi-tier systems only a basic level of health care is
provided for all. People are then able to purchase additional insurance for faster
access to a higher level of service provision (Loewy and Loewy, 2004).
Social Health Insurance – is a method of financing and managing health care in
which a range of insurance providers regulated by the state, use contributions
from individuals, employers and sometimes government to commission health
services. It is a method of pooling risk as contributions are means tested (Saltman
et al., 2004).
Universal Health Insurance – although the terms ‘social health insurance’ and
‘universal health insurance’ are often used interchangeably in the literature Social
Health Insurance does not necessarily provide universal coverage. Universal
Health Insurance is a form of Social Health Insurance that provides universal
coverage.
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3.0 Introduction
In March 2011 the newly elected coalition Government for Ireland announced, in
the Programme for Government, that “This Government will introduce Universal
Health Insurance with equal access to care for all. Under this system there will be
no discrimination between patients on the grounds of income or insurance status.
The two-tier system of unequal access to hospital care will end. The Universal
Health Insurance system will be designed according to the European principle of
social solidarity: access will be according to need and payment will be according
to ability to pay. The principle of social solidarity will underpin all relevant
legislation” (Government for National Recovery, 2011, p.32). It was also
specified that “Insurance with a public or private insurer will be compulsory with
insurance payments related to ability to pay. The State will pay insurance premia
for people on low incomes and subsidise premia for people on middle incomes.
Everyone will have a choice between competing insurers” (p.34).
The Government has used the term Universal Health Insurance and so this will
be the term mainly used in this report, although Social Health Insurance is often
used interchangeably with it in the international literature. However, the two
terms are not entirely synonymous. Social Health Insurance is not necessarily
universal, and so Universal Health Insurance may be understood to be a form of
Social Health Insurance which is compulsory for all. According to Wagstaff (2009)
Social Health Insurance systems provide coverage in exchange for earningsrelated contributions levied largely on formal sector workers; tax financed
systems, by contrast, rely on general government tax (and nontax) revenues.
(Wagstaff, 2009, p 25)
This extremely significant policy development has important implications for the
provision of health services for people with disabilities. It represents an excellent
opportunity to design a system of health insurance, with the involvement of
people with disabilities, which will more fully meet their needs. It also provides
the opportunity to ensure the provision of health services is compliant with
Article 25 of the United Nations Convention on the Rights of Persons with
Disabilities, which the Government is committed to ratifying. Article 25 states
that “persons with disabilities have the right to the enjoyment of the highest
attainable standard of health without discrimination on the basis of disability”. On
the other hand, there is also the risk that the new system could be under-funded,
difficult to access and negotiate, and may not take into account the full range of
needs of people with disabilities. This reinforces the need for the involvement of
people with disabilities, and consideration of the available international research
evidence, throughout the planning and implementation process.
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The World Health Organization and World Bank (2011) have identified that
many people with disabilities still do not have equal access to health care, other
disability related services, education and employment opportunities, and continue
to experience higher levels of exclusion from the activities of everyday life. In
Ireland, the National Disability Authority (NDA) (2005) has previously identified
inequalities in access and use of mainstream health services and highlighted
“the substantial and wide-ranging health impacts of disability. These
include (i) greater risk as a consequence of having a reduced
income due to exclusion from the labour force and being caught in
the ‘benefits trap’, (ii) the additional costs of being disabled, (iii)
increased incidence of other disabling conditions and illnesses, (iv)
lack of access to acute, rehabilitative and population health services,
(v) experience of a range of barriers to accessing care (financial,
physical, organisational, transport, communication, informational
including the inadequate knowledge of health care providers and
attitudinal), (vi) experience of un-coordinated and fragmented
provision, exacerbated by the involvement of multiple health and
social providers and (vii) limited provision due to the focus of
health services being on the individual’s impairment rather than the
health issue or condition” (p.5).
The main aim of this paper is to present an overview of the available evidence on
how Universal Health Insurance may affect the provision of health services for
people with disabilities. The paper appraises and summarises international
evidence; considers and discusses the implications of the research for Irish policy
makers and practitioners and identifies gaps/limitations in the research. The
structure of the report is as follows: the key messages are followed by the
glossary of terms. Section 4 defines the issue and the context, and in Section 5
we discuss why it is important. Section 6 briefly outlines the methodology used
to identify the relevant evidence and the findings are presented in Section 7.
Section 8 sets out the limitations of the research and in Section 9 the implications
from the research are then discussed and applied to the Irish context. Further
details of the methodology and evidence tables of the included studies are
available from the National Disability Authority.
The Government’s current proposal suggests that the current system of multiple
insurance providers will continue. However, Universal Health Insurance can also
be implemented using a single insurance provider. The World Bank (2009) has
acknowledged that there is not yet sufficient evidence to conclude which system
works best and it would appear that this decision is often influenced by a range of
other considerations such as historical, contextual and ideological factors. Both
single and multiple insurer systems have been criticized. Single health insurance
9
systems have been criticized for not using their monopoly powers to manage and
contain costs through promoting the most efficient service providers. Multiple
insurers need risk equalization, which can prove controversial, and also need well
informed service users and robust governance arrangements to ensure quality
standards across providers.
It is also important to consider heath service reform and the introduction of
Universal Health Insurance in particular in the wider societal context. The
introduction of Universal Health Insurance may have the potential to address
some of the wider discrimination and social exclusion issues relevant to people
with disabilities, but there are still significant barriers to address, and change is
needed at all levels in society. Saltman (2004, p.17) used a pyramid to
demonstrate the levels that need to be considered when designing a
universal/social health insurance system:
Examples:
Funding flows, contracts, payment
mechanisms, fee schedules
Associations of sickness funds,
hospitals, physicians
Legislation, regulation, statutory
requirements, monitoring,
Social relationships, solidarity, social
values, cultural expectations, religious/
political/
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Figure 1. Pyramid of Universal Health Insurance system levels
(adapted from Saltman, 2004, p.17)
It may also be useful throughout the process of change to keep in mind some of
the principles that have been proposed for developing health services for people
with disabilities. These may be a useful guide for informing the complex and
difficult decisions that will be needed during the further planning and
implementation of Universal Health Insurance.
In 2005, the NDA provided a more specific set of principles for health services
for people with disabilities, stating that funding should:

“ensure the level and quality of provision, which meets the requirements of
national and international human rights and equality instruments

be equivalent to that of other health facilities

target health inequalities, reflecting socio- economic need

be dependent on the provision of a quality of service that meets stringent
national standards

deliver value for money

be flexible to address changing need

support innovation

be withdrawn from services which do not provide a nationally agreed quality
of provision

be linked to addressing the needs of the individual

work within an investment framework, considering the costs to the individual,
family, community and wider society of not providing resources to support
the recovery and social inclusion of persons with disabilities

be informed by the impacts of budgetary cuts in the disability sector on the
individual, family and community” (p. 50-51).
It should be noted that while the paper is investigating Universal Health Insurance
systems, there are other types of systems that may generate the same benefits of
universal coverage, such as the National Health Service approach in the UK, but
are funded through general taxation. These systems have in common their
universal coverage and that most of the associated services are provided free at
the point of delivery. This point should be highlighted from the start as the main
benefits of Universal Health Insurance systems may in fact, be due to this
universal coverage and access rather than the insurance system per se.
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4.0 What is the issue?
The central issue is how the introduction of Universal Health Insurance in Ireland
may impact on the provision of health services for people with disabilities. The
World Health Organization and World Bank (2011) reported that the choice of
financing influences the type and level of services that are available and, crucially,
whether people are protected from the financial risks of using the services they
need. They also state that although it is important to ensure access to
appropriate health care for everyone, the current research suggests that people
with disabilities have more health needs and more unmet needs than those
without disability.
In order to provide the background to this issue a brief overview of the range of
different systems used to fund health services will be provided before the current
system in Ireland is presented.
4.1. Brief Overview of Range of Health Care Funding Systems
One method of distinguishing health care funding systems is between Bismarck
and Beveridge systems (Björnberg et al., 2009). Bismarck systems, implemented in
countries such as France and Germany, are characterised by the use of a range of
insurance providers who are usually independent of the providers of health
services. The proposed system for Ireland would fit with this model. Beveridge
systems are also sometimes referred to as single payer systems, where the payer
is usually the government, such as in Canada and the UK. In Beveridge systems,
the funding and service provision tends to be managed, although not necessarily
provided, through one organisation. A third system is based on private health
insurance, as in the US. In reality most countries use a combination of these
different approaches in varying degrees.
O’Ferrall (2009) explains that the key difference between Universal Health
Insurance and private health insurance systems is that, in universal systems,
payment is usually means-tested, everyone is covered and has equal access to
services based on need. In contrast, with private insurance, the individual pays
based on their assessed risk of needing services, and those who cannot afford it
are excluded. O’Ferrall (2009) suggests there are five main advantages to
Universal Health Insurance: it enables a one-tier system of hospital care which is
fairer and more efficient; it facilitates the delivery of GP services free at the point
of delivery for all; it focuses attention on the person using the service rather than
the service provider; it makes service provision transparent and therefore
accountable; and it promotes social solidarity.
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Thomas et al. (2010) identified a range of possible designs within Universal Health
Insurance systems. What they refer to as a ‘pure’ system involves payroll and
income deductions into a dedicated insurance fund. Contributions to the fund
are means tested with people below a certain income not paying at all. The
second variation also involves payroll and income deductions but these are
subsidised from general taxation. A third way uses a ‘mixed bag’ of funding from
a range of taxation, including possible new sources of tax revenue such as carbon
taxes. The final variation they present is for there to be a flat rate for all with
some Government contribution for those on lower incomes.
The World Health Organization (2010) has identified three interrelated problems
that tend to restrict countries that are attempting to move to a universal system
of coverage. The first is the level of resources available for the provision of
health services. This may be an extremely relevant issue in the Irish context. The
second problem is that methods of addressing limited resources, including
additional payments for certain services create disincentives for people on lower
incomes to access services and so undermine the key equal access aim of
universal coverage. The third barrier that the World Health Organization
identified is the inefficient and inequitable use of resources, which further reduces
the amount of effective care that can be provided. Addressing these three issues
- ensuring there is sufficient funding, reducing or ending any supplementary
payment at the point of delivery, and promoting efficiency - are fundamental to
the successful transition to a universal system.
In order to consider the transition to Universal Health Insurance in Ireland the
current system will be outlined, and then what is known about the proposed
system examined.
4.2. Current Health Services Funding System in Ireland
The current system in Ireland uses a range of funding mechanisms: taxation,
(which provides approximately 70% of health funding); fee-per-service payments
(providing approximately 15% of funding); and private insurance coverage (used
by around 50% of people in Ireland, although it accounts for just 10% of
healthcare funding). Approximately 30% of people are eligible for a medical card.
This facilitates free access to health care for certain disadvantaged groups
including many people with disability, although these patients may have
considerably longer waits for care than those with private cover (O’Ferrall,
2009). McDaid et al (2009) report a more detailed breakdown of total health
expenditure by source of funding from 2006: 78% from taxation and other
government income; 12% out of pocket payments; 8% private health insurance;
1% social insurance ; and 1% other private funds. The Department of Health and
Children’s (2010a) report Resource Allocation, Financing and Sustainability in
Health Care: Evidence for the Expert Group on Resource Allocation and
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Financing in the Health Sector (Volume II) estimated direct out of pocket
payments by households to be 10-15% of total expenditure.
There are currently a range of private health insurers in Ireland. The publicly
owned Vhi Healthcare (previously VHI - Voluntary Health Insurance) provides
approximately 80% of private cover. Other providers include Aviva and Quinn
Healthcare. The private insurance market is regulated by the Health Insurance
Authority. Risk equalisation payments have been used between the insurance
providers to ensure that there is no disincentive to insuring people with potential
higher levels of need. However, in recent years, the need for risk equalisation has
led to a series of legal challenges mainly questioning the fairness and legality of
the arrangements. In 2008 the Supreme Court ruled that the current risk
equalisation scheme was unconstitutional and so an interim system has been in
place since then (McDaid et al., 2009). A “strong and reformed system of
community rating and risk equalisation” is part of the new planned system
(Government for National Recovery, 2011, p. 33).
4.3. The planned system of Universal Health Insurance for
Ireland
The Programme for Government in March 2011 outlined the planned steps
towards universal coverage. The first is to remove fees for general practitioner
(GP) care and so introduce universal primary care. The second major objective is
to have a universal insurance system in place by 2016. By enabling access to
hospital care for all, this will provide services equivalent to what only the
privately insured have at present. It is also proposed that the current
responsibilities and roles of the Health Service Executive move to the Minister of
Health and the Department of Health. Although mental health and services for
older people are identified as priorities, there is little detail in the Programme for
Government about how the specific and complex health needs of people with
disabilities will be addressed within the proposed system. However, the first
group to have free access to primary care will be claimants of free drugs under
the Long-Term Illness scheme, followed by those under the High-Tech Drugs
Scheme, which would include many people with disabilities.
There are many details of the planned system that are still unknown, not least
what people are likely to have to pay and exactly what services will be provided.
The specific proposals for people with disabilities, especially those who may be
high- and long-term users of health services, have also not yet be clarified.
Nonetheless the Minister for Health, James Reilly, has added some further
information through press releases and, most recently, in response to questions
in the Dáil. In a press release on 24th March 2011 the Minister stated “I am
acutely aware that, in designing any new payment system, it will be necessary to
build in safeguards for ‘quality’ and to ensure that the payment system does not
14
encourage ‘cherry picking’ of straightforward cases. “Money follows the patient”
will be an important stepping stone to Universal Health Insurance”. On the 13th
April 2011 he provided some idea of the overall timeframe by saying “What I’m
setting out to do is guarantee equal access to healthcare for everybody in our
country as quickly as possible but absolutely within the next 10 years”. In June
the Special Delivery Unit was established to address waiting times.
Since then, in the Dáil, the Minister has provided an update in response to a
series of questions on the introduction of Universal Health Insurance. He stated
that “One should bear in mind it took the Dutch 20 years to achieve their model.
We are learning from their mistakes and what they did right. Therefore, we do
not need to reinvent the wheel. None the less, Ireland is a very different country,
geographically, culturally and in terms of population. We know there are many
variations on the Dutch system that will not work here but that the core of it can
and will. We must ensure we have a properly regulated health insurance market
before we proceed. There are many aspects to be considered. There will be
many full debates as the various parts of the programme are put together so we
can realise what I believe is a worthy aspiration, namely, that everybody in the
country will have access to medical care based on need, not on what they can
afford”.
O’Ferrall (2011), although endorsing most of the Government’s plans, has
suggested that having a number of insurance providers requires a complex risk
equalisation scheme. Because of this, a single payer system should still be
considered. However, this possibility has not featured in any of the statements
from Government. O’Ferrall (2011) also points out that the National Health
Service in the UK was established in a time of economic crisis and so the current
climate should not be viewed as an insurmountable barrier to major reform.
4.4. Community and long term care
The introduction of Universal Health Insurance would seem an ideal opportunity
to consider how the full range of health and social care services are funded to
avoid the creation of perverse incentives. An example of this is when people
access expensive hospital care that is free to them, so they can avoid paying
charges for cheaper community care. It is also an opportunity to ensure the
benefits of a more equitable health system are not undermined by continuing
inequities in social care.
This report, and the proposals for Universal Health Insurance in the Programme
for Government focus on the impact on health services, mainly access to primary
care and hospital care. The arrangements for the full range of community and
social care services that people with disabilities need are not addressed in detail.
The Programme for Government does include some plans for developing care of
15
older people, community care and integrated care, and these other developments
will have implications for people with disabilities. It stated:
“Investment in the supply of more and better care for older people
in the community and in residential settings will be a priority of this
Government. Additional funding will be provided each year for the
care of older people. This funding will go to more residential places,
more home care packages and the delivery of more home help and
other professional community care services.
The Fair Deal system of financing nursing home care will be
reviewed with a view to developing a secure and equitable system
of financing for community and long-term care which supports
older people to stay in their own homes.
The integration of care in all settings is key to efficient health care
delivery, in which the right care is delivered in the right place.
Integration of care will be the responsibility of an Integrated Care
Agency under the aegis of the Minister for Health. This agency will
oversee the flow of centrally tax-funded resources between the
different arms of the system so that there are incentives for care to
occur in the best setting” (Government for National Recovery,
2011, p. 36).
The commitment to integrated care suggests that this issue will be explored, and
so some of the relevant issues are identified here. In order to consider these
issues the alternative ways of funding social care are summarised first. Following
this, we further examine how these arrangements work in practice in a number
of different countries. A number of terms are used to describe these services,
including social care, community care, and long term care.
The Office for Economic Co-operation and Development (OECD, 2011) has
identified three main approaches to funding long term care (LTC):

universal coverage within a single programme;

mixed systems; and

means-tested safety-net schemes.
The OECD (2011, pp. 215-228) provides a summary for each system, as follows:
Universal coverage within a single programme
Several countries provide LTC coverage through a single system, which provides
publicly-funded nursing and personal care to everyone who is eligible because of
their need for care. In Nordic countries, social long-term care insurance is
16
separate from health systems, but in other countries, such as Belgium, LTC is
included as part of healthcare. Some systems limit LTC to the elderly, such as
Japan or Korea. Others, such as the Netherlands or Germany, make LTC
available for everyone assessed as needing care regardless of age.
People receiving LTC are required to make co-payments or to pay user charges
or up-front deductibles even in universal coverage systems. However, those
earning below a certain income are partly or fully exempt from payment,
resulting, effectively, in a comprehensive collective coverage of LTC costs.
There are three main sub-models for LTC within a single programme:
1. tax-based models (e.g., Nordic countries), which use taxes to provide
universal long-term care services as part of welfare and health-care services
for the entire population
2. public long-term care insurance models (e.g., Germany, Japan, Korea, the
Netherlands, and Luxembourg), providing comprehensive coverage of services
from stand-alone, dedicated social insurance. The funding channels for LTC
are different from those for health care, are mandatory for all or most of the
population, and are mainly financed from payroll contributions, supported by
general taxation and
3. personal care and nursing care through the health system (e.g., Belgium), with
most LTC provided by nurses within a medical structure of care
Mixed systems
Under mixed systems, LTC coverage is provided through a mix of different
universal programmes and benefits, either provided universally or means-tested.
Many of the countries in this group do not have a comprehensive single
programme for LTC, but offer a range of LTC benefits, programmes, or
entitlements for different groups or settings. One form of mixed system, such as
in Ireland, Australia and France, benefits are given to everyone who is assessed as
needing care, but the amount they receive depends on their income In some
cases, additional benefits such as nursing care are covered by the health system
or local government.
Means-tested safety net schemes
Under means-tested schemes, LTC services and benefits are publicly funded for
people who have less than a certain threshold of income and assets. Care is then
prioritised for those with the greatest need. The criteria to determine eligibility
for services varies from country to country, and there may be a gap between
LTC eligibility and other social assistance available. This system is seen in the US,
with Medicaid funding most LTC services.
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The current system in Ireland is a mixed system using a wide range of service
providers for social care services. Some of these are free, based on need and
some are charged for, based on means testing. The historical development of
services and the wide range of providers have created both geographical
variations in the level of services available and inequities in paying for care.
Single programme universal systems, in contrast to the mixed system in Ireland,
are better at ensuring equitable access to care based on need rather than income.
However, there is variation in the extent of out-of-pocket costs. Systems that
separate out health and social care budgets tend to reduce the use of the more
expensive health services, but this separation, if not managed well, may impact on
continuity of care.
In 2002 the Department of Social and Family Affairs commissioned a report that
suggested that the social insurance model would be appropriate for funding longterm care in Ireland. It argued that:

“Social insurance would provide a stable and lasting framework for long-term
care provision. It would also raise public awareness of long-term care issues.
This could help to encourage further private provision to supplement the
basic social insurance benefits. In particular, it would facilitate a partnership
scheme.

Social insurance would eliminate means-testing for those whose contributions
qualify them for benefits, but social assistance benefits would still be required
for those who do not make contributions.

The public may be more willing to pay additional social insurance
contributions than higher taxes to fund long-term care.

Social insurance contribution income is affected by the economic cycle.
Hence, it may be necessary to supplement the social insurance fund from
general tax revenues or borrowing during an economic downturn.

We conclude that social insurance financing for long-term care would provide
a reasonable “fit” in the Irish context. Moreover, the strong entitlement to
benefit that social insurance financing would confer, along with earmarking of
the contributions made to pay for the benefit, would, we believe, engender
good public support.

However, we would not consider it appropriate that the level of long-term
care benefits provided should vary as between social insurance and social
assistance beneficiaries, as this could imply the provision of different standards
of care as between the two groups” (p.16).
Three countries will be now explored in more depth. The Netherlands and
Germany are examined because they currently have long term care statutory
18
insurance schemes. Australia is also included, for two main reasons: its current
system is similar to Ireland’s; and it has just concluded a major review of this
issue, which has recommended a National Disability Insurance Scheme. This may
provide a useful model for Ireland. Table 1 summaries the three countries’
systems (based on the OECD, 2011 report) and the issues in each country are
discussed.
19
Table 1. Long term care funding systems in Netherlands, Germany and Australia.
Country
Eligibility
for
coverage
Netherlands
Universal
programme
within a
single
system
Germany
Universal
programme
within a
single
system
Universal
Australia
Coverage
Programme(s)
programmes name
Source of
funding
LTC
Public LTC
insurance social
insurance
Exceptional Contributions
Medical Expenses and additional
Act
tax
The Algemene contributions
Wet Bijzondere
Ziektekosten
(AWBZ)
Public LTC
Long-term care
Tax,
insurance –
insurance
premiums,
social Pflegeversicherung
financing
insurance
from Lander
budgets
Multiple
Home and
Tax:
programmes: Community Care
60% federal,
income(HACC)
40% local,
related
Residential care
state and
benefits
by ACATs (aged
territorial
care assessment governments
teams)
for HACC
Tax based
20
Public
Types of
LTC
Target
benefits
spend,
population
provided
% of
GDP
All
Cash and
3.5
in-kind,
home and
institutional
care
All
Older
people
Cash and
in-kind,
home and
institutional
care
In-kind,
home and
institutional
care
0.9
0.8
Some further details of these countries’ systems are provided in Section 7.
Across all three countries, demographic, political and economic change has
affected the development of the systems. In the Netherlands, Glendinning and
Moran (2009) reported that the “social insurance scheme has...faced growing
financial pressures. Insurance contributions and additional charges for services
have been increased. The social insurance scheme no longer funds domestic help;
this is now the responsibility of local municipalities, thus risking fragmentation
between practical help and personal and nursing care. The responsibilities of
families for supporting sick and disabled relatives have also been spelt out.
Changes in assessment practices and in methods of calculating payments to
providers for individually tailored service packages have also been made, in
further attempts to increase sustainability” (p. 2).
They also report that Germany has had to undertake “the first major structural
reforms of its long-term care insurance scheme since the scheme’s introduction
in 1994. A growing gap between the capped insurance benefits and the actual
costs of care, and deficits in the insurance funds themselves, together led to
increases in levels of both contributions and benefits in 2008. Measures to
support family carers have also been strengthened. Further increases in benefit
levels are planned; however, the insurance scheme is likely to be in deficit again
by 2015” (p. 2).
In Australia, the response to rising costs over the last decade has been to try to
move responsibility for funding long-term residential care increasingly to
individual service users. Charges for other community care services have also
increased. However, the Productivity Commission (Australian Government,
2011, p. 2) has recently completed a review of the funding of long term care and
recommended the introduction of a National Disability Insurance Scheme. It
argued that “most families and individuals cannot adequately prepare for the risk
and financial impact of significant disability. The costs of lifetime care can be so
substantial that the risks and costs need to be pooled” (p. 2). It therefore
recommended that “There should be a new national scheme — the National
Disability Insurance Scheme (NDIS) — that provides insurance cover for all
Australians in the event of significant disability... The scheme should involve a
common set of eligibility criteria, entitlements to individually tailored supports
based on the same assessment process, certainty of funding based on need,
genuine choice over how their needs were met (including choice of provider)...
Services would be provided by non-government organisations, disability service
organisations, state and territory disability service providers, individuals and
mainstream businesses. Increased funding, choice and certainty are the key
features of the recommended scheme.”
21
The current systems in the Netherlands and Germany, and the proposed system
in Australia, may therefore be useful to consider when planning how social care
should be funded in Ireland.
The rest of this report returns to the focus on the provision of health services
for people with disabilities. However, it is important to emphasise that the
funding arrangements across all aspects of care need to be considered if a truly
equitable system that does not discriminate against people on the basis of
disability is to be created.
5.0 Why is it important?
The introduction of Universal Health Insurance in Ireland is of high importance
because all aspects of the new funding system have the potential to impact
positively or negatively on access to and provision of health services for people
with disabilities. The different aspects of the funding system include the inputs to
the system, the processes and the outcomes.
Inputs include the level of funding allocated, the purchaser/provider split, the
necessary legislation, and the decisions about what services to provide and to
whom. The processes include the administrative arrangements for ensuring
coverage through the different providers, how needs will be assessed, how
services will be provided, the level of service user involvement, and support for
negotiating the system. The outcomes include health outcomes as well as
satisfaction, social inclusion, choice and control. These themes will be explored
further in the findings, but the general issues for why this development is so
important are considered here.
Internationally, the World Health Organization and World Bank (2011) have
highlighted the increasing evidence which suggests that, as a group, people with
disabilities experience poorer levels of health than the general population. They
also report that:
“Social deprivation was a major contributor to these health
inequalities, and people with mental health problems and learning
disabilities were at a high risk of poverty. The lack of health
promotion, service access, and equal treatment were also cited as
significant barriers. Disabled people identified fear and mistrust,
limited access to general practice lists, difficulty negotiating
appointment systems, inaccessible information, poor
communication, and diagnostic overshadowing. Service providers
22
identified issues such as fear, ignorance, and inadequate training” (p.
61).
It is therefore argued that changes to policy and legislation designed to ensure
equal access to health care have to address a range of issues relating to
accessibility, affordability, availability and quality. They also highlight that people
with disabilities can have particular problems negotiating the administration of
health insurance. These include higher rates of difficulty with obtaining the
appropriate exemptions and/or special rate; completing insurance forms; getting
the relevant information about insurance and entitlements; and receiving
reimbursement.
In Ireland, the Report of the Expert Group on Resource Allocation and Financing
in the Health Sector concluded in 2010 that:
“reform of the present system is necessary on the grounds that it is
not equitable and that it does not encourage appropriate
behaviours. The Group took the view that such reform could take
place either through a Social Health Insurance system or by the
development of the mainly tax-funded system currently in place.
What matters crucially is the effectiveness of the system which is
put in place and not whether it is financed by taxation or social
insurance. The Group identified the main characteristics of a quality
health-care financing system as:

equity and fairness, i.e. those who can afford to pay more, should pay
more;

transparency, i.e. everyone should be able to understand the system and
know what they are entitled to receive;

promotion of good attitudes to care, e.g. encourage patients to be
registered with a GP, and to seek help when needed (requiring prepayment for at least some services);

consistency with policy objectives (e.g. promotion of integrated care);

sustainability (e.g. promotion of treatment of chronic disease within the
community).
In relation to the financing of the health-care system, the Group found that the
current financing system lacks transparency, gives rise to serious
inequities in access to care, and results in numerous anomalies in
terms of incentives for users of care” (Department of Health and
Children, 2010b, pp. x-xi).
23
O’Ferrall (2009) also emphasised the importance of getting the design and funding
of the new system right because, if the revenue generated is insufficient, it would
require supplementation from general taxation and/ supplementary payments for
services. This would reintroduce the inequalities of the current arrangements.
In his press release on 24th March 2011 the Minister of Health asserted just how
important this change will be:
“As the new Minister for Health, my primary goal is to radically
reform the health system so as to guarantee equal access to
healthcare for everybody in our country. It is my firm view that this
can only be achieved through a single-tier system. One that gives
access based on need - not on ability to pay. Hence, commitment to
introduce Universal Health Insurance for the whole population of
Ireland. The introduction of Universal Health Insurance will be the
most profound reform of our health system since the foundation of
the State”.
6.0 Methodology
We have carried out a Rapid Evidence Assessment (REA) for this review. REAs
provide more thorough syntheses than narrative reviews, and are valuable where
a robust synthesis of evidence is required, but the time or resources for a full
systematic review are not available. The reviewers develop and then specify
search strategies in collaboration with clients and other key stakeholders. The
details of the search strategies, keywords used, the inclusion and exclusion
criteria, and a flow chart of the process are all provided in Appendix 1. As part of
the REA each study is briefly quality assessed using standardised instruments.
We searched a number of databases to identify a range of different studies of
relevance to this review:

Medical databases: Cochrane Library, Embase, Medline, PsycInfo

Social science databases: Campbell Library, SocIndex, Web of Science

Economics databases: CRD (NHS EED), EconLit
We also searched a number of websites for additional relevant reports or
documents. These included:

AARP (American Association of Retired Persons) http://www.aarp.org/
24

Australian Government Productivity Commission http://www.pc.gov.au

Center for Intergenerational Studies http://cis.ier.hit-u.ac.jp/

European Health Management Association http://www.ehma.org

National Disability Authority http://www.nda.ie/

Organisation for Economic Co-operation and Development (OECD)
http://www.oecd.org

Public Health Agency of Canada http://www.phac-aspc.gc.ca

The Commonwealth Fund http://www.commonwealthfund.org

the European Centre for Social Welfare Policy and Research
http://www.euro.centre.org/

The International Network Health Policy & Reform http://hpm.org/

The International Social Security Association http://www.issa.int

The Swiss Confederation http://www.thinkswiss.org/

The World Health Organization http://www.who.int/
Summaries of all studies identified from the databases were imported into a
database, duplicate studies removed, and then those studies that were directly
relevant to the topic were shortlisted for more detailed examination of their full
texts. Additional reports from the ‘grey literature’ website searches were also
screened and those determined to be relevant were also assessed in detail.
Relevant data from each study were summarised into structured tables, which
are presented in Appendix 2. Each included study was also assessed for overall
methodological quality and for relevance to this review, and given a high, mid or
low quality score. The details of the quality assessment criteria are reported in
Appendix 1. The limitations of the existing research are considered in Section
9.0. In general, the available evidence is limited, and the literature on this subject
often focuses more on the political and ethical issues involved rather than on
developing an empirical evidence base to better inform policy and service
delivery.
7.0 Findings
The literature searches focused on the following countries that have Universal
Health Insurance systems similar to that proposed for Ireland: France, Germany,
Netherlands and Switzerland. Australia and Canada were also included as
comparisons because developments in these countries are also of relevance to
the accompanying state of evidence papers on supported decision making and
25
personal budgets. We kept the searches focused on countries of particular
interest, but did not exclude studies that related to other OECD countries if they
met the other inclusion criteria.
The first section of the findings provides overview data on the health funding
arrangements in the identified countries. Each country summary starts with a
summary from the Commonwealth Fund (2010) International Profiles of
Healthcare Systems report, and then any especially pertinent aspects of the
funding system are highlighted.
7.1. Country summaries: Bismarck approach
Netherlands
“Health care in the Netherlands is regulated publicly and delivered privately, in a
system of “managed competition.” All residents are required to purchase a
standard health insurance package from a private insurer, covering physician and
hospital care and pharmaceuticals. Wage-related contributions are pooled in a
central fund and redistributed to the insurers according to a sophisticated riskadjustment formula. Insurers also charge their own community-rated premiums.
Limited cost-sharing applies to secondary care. Most people purchase
complementary private insurance for services not covered by the standard
benefit package, such as adult dental care and physiotherapy. Long term care is
covered through a separate statutory insurance program [similar to that
proposed for Australia]. GPs operate mostly in small practices with gate-keeping
responsibilities for a registered panel of patients. They are generally selfemployed and paid through both fixed capitation rates and fee-for-service. Most
specialists are hospital-based, self-employed, and paid on a capped fee-for-service
basis that integrates the specialist honorarium costs and the hospital treatment
costs. Hospitals are mostly private and non-profit. One major current initiative is
the introduction of bundled payments for the care of chronic conditions in order
to promote disease management and integrated care” (Commonwealth Fund,
2010, p. 2).
The current system in the Netherlands has been promoted as a potential model
for Universal Health Insurance in Ireland. An example of good practice in the
Dutch system is the website run by the Dutch Government, which provides data
on all the available insurers, service user satisfaction data, and performance
indicators for service providers (van de Ven and Schut, 2008). The Euro Health
Consumer Index, which compares the service user ‘friendliness’ of 33 health care
systems, placed the Netherlands first in 2009 (Björnberg et al., 2009). An
important factor leading to this high rating may be that the Netherlands has one
of the best and most structured arrangements for service user involvement at the
policy and planning level. Practice at the individual level also emphasises the
central role of the service user.
26
However, some concerns have also been identified about the Dutch model.
Vaillancourt Rosenau and Lako (2008) suggested that it may not be very effective
at controlling costs, as premiums are rising and insurance companies are
reporting large losses. The NDA (2010, p. 53) has also identified that the
managed competition between insurance providers does not necessarily increase
competition and choice. The Dutch reforms may not have helped people to
compare companies and move easily between them, and the system of managed
competition may in fact have led to a less competitive market. In considering the
application of the Dutch system to the Irish context, Borowitz et al. (2011, p. 25)
have also urged caution, stating that, although the proposed system in Ireland
seems more equitable, it is still not clear whether it will improve efficiency. The
Dutch model, which was theoretically likely to improve efficiency, has struggled
to show such improvements in practice. Expenditure has increased rapidly in the
Netherlands because of a loss of central control over prices and quantity of
health care provided. Competition has failed to make providers more efficient.
The challenge for Ireland is to make the new system work well. Unless this
happens, Borowitz et al. believe the reforms will lead to equitable access to an
inefficient system.
France
“France has a social insurance system financed by employer–employee payroll
taxes and central taxes. Statutory insurance covers all residents for hospital and
ambulatory care, prescription drugs, and, to a lesser extent, dental and
optometry care. Cost-sharing requirements apply to all publicly covered services,
although these are waived for patients with any of 30 chronic diseases.
Additionally, roughly nine of 10 residents have complementary private insurance
that covers most cost-sharing charges under the public system; they either obtain
this insurance themselves (usually through employment) or, if they have low
income, have it provided by the government. Roughly two-thirds of hospital beds
are public or non-profit, and physicians in these hospitals are salaried; the
remaining third are for-profit, with physicians paid fee-for-service. Ambulatory
care is provided mostly by self-employed physicians paid fee-for-service. Since
2004, registration with primary care physicians who act as gatekeepers has been
encouraged through higher co-payments for self-referrals, and roughly 90 percent
of the population is now registered. A further primary care reform has been the
2009 introduction of pay-for-performance, with GPs able to earn up to €5,000
for achieving quality targets on prevention, chronic disease management, and
drug prescriptions” (Commonwealth Fund, 2010, p. 1).
The NDA (2003) reported that, under the French Social Health Insurance
system, people with disabilities are treated within the general health services.
These include a range of prevention, early detection, diagnosis, treatment and
rehabilitation services.
27
Germany
“Most German residents receive statutory coverage through one of 180
competing non-governmental social insurers (or “sickness funds”). The statutory
system is financed through employer and employee contributions, which, since
2009, are pooled into a central fund and redistributed among the sickness funds
according to a sophisticated risk adjustment formula. Sickness funds offer a
uniform benefit package covering most medical care, including physician and
hospital services, prescription drugs, and dental care. The components of this
benefit package are determined by the Federal Joint Committee along with
representatives from payer and provider organizations. Self-employed, high
income and civil-service residents may opt for private insurance as an alternative
to the statutory insurance system, and roughly 10 percent of the population does
so. Complementary private insurance is also purchased to cover amenities and
cost-sharing charges under the statutory system, particularly for dental care.
Ambulatory doctors mostly operate in solo practices and are paid fee-for-service
with varying degrees of bundling. Gate-keeping is optional but is incentivized
through cost-sharing arrangements, and often by sickness funds. Roughly half of
hospitals are publicly owned and half privately owned. Hospital doctors are
generally salaried and are not allowed to treat outpatients except in certain
circumstances. For several chronic conditions, a set of disease management
programs guided by national evidence-based recommendations has been
introduced; these are implemented by sickness funds through contracts with
providers” (Commonwealth Fund, 2010, p. 2).
A unique aspect of the insurance system in Germany is that higher-income
households have the option to opt out of the Universal Health Insurance system
and buy private cover. In 2009, ten percent chose to opt out (Schoen et al.,
2010).
Switzerland
"Switzerland operates a regulated private insurance market, with individuals
mandated to purchase a minimum insurance package from among competing nonprofit insurers. Premiums are collected by insurers and then redistributed based
upon a risk-adjustment formula. The basic benefit package includes hospital and
physician care and prescription drugs. The 26 cantons (similar to U.S. states) have
responsibility for planning the health services within their borders and subsidizing
hospitals, nursing homes, and home care organizations. Residents generally have
free choice of a GP and access without a referral to specialists (unless enrolled
with a gate-keeping managed care plan). Some managed care plans operate
capitation models, where physicians or physician groups are paid on a capitation
basis; otherwise, ambulatory physicians are paid on a fee-for-service schedule
negotiated between insurers and providers or their organizations at the canton
level. Hospital-based physicians are paid a mix of salary (by mandatory insurance
28
policies) and fee-for-service (by supplemental insurance policies). Hospitals are
for the most part publicly owned or publicly subsidized. Recent reforms have
established a single set of regulations for both public and private hospitals”
(Commonwealth Fund, 2010, p. 4).
Switzerland is often characterised as having very high quality and also very
expensive health services. In addition to the compulsory insurance there is also a
compulsory sickness, old-age and disability insurance. Despite this, out-of-pocket
spending is still relatively high, and includes contributions to the costs of longterm care (Commonwealth Fund, 2010).
7.2. Country summaries: Beveridge approach
Australia
“Australia achieves universal coverage through Medicare, a tax-funded public
insurance program that covers most medical care, including physician and hospital
services and prescription drugs. Most health services are financed and regulated
by the federal government, although the states and territories have responsibility
for public hospital care. Besides Medicare, roughly half of Australians receive
additional coverage through private insurance, which the government subsidizes
and which covers such services as dental care and private hospitals. Most doctors
operate in private practice and are paid on a fee-for-service basis, and GPs act as
gatekeepers to specialized care. Roughly two-thirds of hospital beds are in public
hospitals and the rest in private, although private patients can be treated in public
hospitals. Physicians in public hospitals either earn a salary and can receive
additional fees for seeing private patients, or are in private practice and receive
hourly compensation for treating public patients. Current policy goals include
developing a new management structure for public hospitals around local area
networks, increasing the federal government’s contribution to public hospitals,
introducing performance reporting, and strengthening primary care”
(Commonwealth Fund, 2010, p. 1).
As discussed in Section 4, there have been problems with the Australian system
of long term care funding for people with disabilities. The Australian
Government’s Productivity Commission has recently undertaken an inquiry into a
National Disability Long-term Care and Support Scheme. This was in response to
the finding that disability services were “underfunded, unfair, fragmented, and
inefficient, and gives people with a disability little choice and no certainty of
access to appropriate supports” (Australian Government, 2011, p. 2). The
proposed solution in Australia is a new National Disability Insurance Scheme that
would provide: disability insurance cover for all; fund long-term high quality care
and support; provide accessible information and address stigma; promote quality
standards and best practice; assess needs to determine individual support
29
packages; and would encourage the development of innovative approaches to
support.
Canada
“All citizens receive health coverage through Medicare, yet there is no single
Canadian health system—rather, each province is responsible for delivering care
within its borders according to a broad set of principles laid out in the Canada
Health Act and in accordance with any intergovernmental funding agreements.
Medically necessary hospital and physician services are fully covered across
provinces, although there are variations in prescription drug coverage. Roughly
two-thirds of Canadians have private insurance, but private coverage for services
covered under Medicare is not allowed; instead, private insurance covers such
services as dental care, prescription drugs, and home care. Medicare is financed
through general taxation, much of which is distributed by the federal government
to the provinces via transfer payments; responsibility for financing and delivering
health care is therefore split between the two levels of government. Most
doctors operate in private practices and are paid on a fee-for-service basis,
although an increasing number of providers receive alternative forms of funding
and are moving toward more integrated models of care. Ownership of hospitals
varies across jurisdictions in Canada; in general, they are almost all not-for-profit
and are owned by religious orders, universities, governments, municipalities, or
municipal corporations. Hospital-based doctors are generally paid fee-for-service.
Recent policy focuses on areas including improving waiting times, strengthening
primary care, and broadening the adoption of health information technology”
(Commonwealth Fund, 2010, p. 1).
7.3. Findings from the literature review
We found few research reports on Universal Health Insurance internationally.
The studies that were identified tended to be either highly focused on people
with a particular long term disease or disability, or were general comparisons of
different countries. This means that it is difficult to be sure about the likely
impact of Universal Health Insurance on access to services and the quality of care
for people with disabilities in Ireland.
We identified just 16 studies from the review of the international literature that
have been included in the literature review section of this report. These are
summarised below, in three main sections:

inputs – the structure of healthcare under Universal Health Insurance;

processes – implementation of Universal Health Insurance by healthcare
organisations or staff; and
30

outcomes – the impact of Universal Health Insurance on people with
disabilities.
This way of organising the findings is based on Donabedian’s (2005) structureprocess-outcome framework for identifying and understanding all the factors
involved in health systems. He argued that whilst outcomes “remain the ultimate
validators of effectiveness and quality” (Donabedian, 2005, p.694) they do not
provide much information about how they have been achieved and in some areas,
such as attitudes and satisfaction, outcomes can be difficult to define and
measure. He therefore argued that two other complementary approaches
should be considered – examining the process of care and the structures or
inputs employed. Evaluation of the inputs or structures involves consideration of
“the settings in which [the process of care] takes place and the instrumentalities
of which it is the product…It is concerned with such things as the adequacy of
facilities and equipment, the qualification of medical staff and their organization;
the administrative structure and operations of programs and institutions
providing care; fiscal organization and the like” (p.695). The key point is that
consideration of all three areas is necessary to provide a complete evaluation of
the quality of an intervention. The framework was summarised by Yen and Lo
(2004): “Structure refers to the manner in which the organization is managed and
staffed, process refers to how care is delivered and outcome is the result or
effect of the care rendered” (p.75).
The symbols after the author/s name indicate the assessed quality: [++] for high;
[+] for mid; and [-] for low). More details of the quality assessments are included
in section 11, and more details of the 16 studies are reported in the evidence
tables in section 12.
7.3.1. Inputs – the structure of healthcare under Universal Health
Insurance
POLICY AND
NATIONAL
BACKGROUND TO
IMPLEMENTATION OF
UNIVERSAL HEALTH
UNIVERSAL HEALTH
INSURANCE
INSURANCE
31
Policy on Universal Health
Regulation, licensing, monitoring
Insurance and funding of health
and risk management
and social care
Assessing individual’s ability to pay
Economic circumstances that
may have led to Universal
Health Insurance
Models for providing Universal
Health Insurance internationally
Population circumstances that
may have contributed to the
need for Universal Health
Insurance
Figure 2. Inputs for Universal Health Insurance
Four research studies reported on national level issues around Universal Health
Insurance although we also identified three reports with useful data on funding of
Universal Health Insurance compared with alternative systems or services
covered by such funding. These are summarised in Tables 2, 3 and 4, below.
Skinner and Rovere (2010) ranked 28 OECD countries according to the degree
to which they rely on a pluralistic public-private social insurance approach to
achieving Universal Health Insurance coverage for their population. The five
countries ranking highest for proportion of total health expenditure from Social
Health Insurance were the Czech Republic, France, Netherlands, Luxembourg
and Germany. Data on sources of funding for healthcare for the countries
included in our review are presented in Table 2.
Table 2. Type of health insurance in countries identified in the
literature review (adapted from Skinner & Rovere, 2010).
Country
Predominant
type of
health
insurance
% of total
health care
expenditure
from SHI,
2007
% of total
health care
expenditure
from PHG,
2007
% of total
health care
expenditure
from PHI,
2007
32
% of total
health care
expenditure
out of
pocket, 2007
Country
Predominant
type of
health
insurance
SHI
SHI
SHI
SHI
PHG
PHG
PHG
PHG
% of total
health care
expenditure
from SHI,
2007
73.1
67.7
70.4
42.9
0
1.4
0.1
9.1
% of total
health care
expenditure
from PHG,
2007
5.2
9.0
5.0
16.2
67.5
68.9
76.2
70.7
% of total
health care
expenditure
from PHI,
2007
13.1
9.3
5.7
9.2
7.8
12.6
1.0
4.9
% of total
health care
expenditure
out of
pocket, 2007
7.1
13.3
5.5
30.7
18.0
14.7
20.1
14.3
France
Germany
Netherlands
Switzerland
Australia
Canada
Italy
New
Zealand
Norway
UK
US
PHG
PHG
PHI
12.0
0
12.7
72.1
82.0
32.8
0
1.0
34.6
15.1
11.7
12.3
SHI = social health insurance; PHG = public health and government insurance (tax-based); PHI = private
health insurance
Wagstaff and Morena Serra (2008) found in a study of 28 Eastern European and
Central Asian countries over the period 1990-2004 found that social health
insurance led to greater levels of health expenditure and lower national
employment than in countries with tax-financed systems. In a study covering
OECD countries 1960-2006, Wagstaff (2009) similarly found higher levels of
spending and lower national employment associated with social health insurance
models. This study also looked at the association between preventable early
deaths and a social health insurance model. One cause of preventable early death,
breast cancer, was found to be higher in social health insurance countries - this
was statistically significant at the 10% but not at the 5% level. The author
hypothesised that countries with social health insurance may invest less in public
health screening and health promotion programmes. This is consistent with
findings for Colombia by Arbalaez et al (2004) that the introduction of social
health insurance led to fragmentation of responsibility and discontinuities in
prevention and treatment of tuberculosis.
This suggests the importance of insuring that population health programmes
including prevention and screening are safeguarded in the promised move in
Ireland to a health insurance model.
Wagstaff concluded that adopting Social Health Insurance rather than tax
financing may be associated with increases in health spending per person by 3 to
4% and reductions in total employment by up to 6%. As part of his study, he
33
summarised the type of funding for primary and secondary care providers
according to type of health insurance. These data are presented in table 3.
Table 3. Health financing, provider payment and existence of
gatekeeper for countries identified in review, late 2000s (adapted from
Wagstaff 2009).
Country
France
Germany
Netherlands
Switzerland
Australia
Predominant Payment
type of health for
insurance
primary
care
providers
SHI
Capitation +
fee for
service
SHI
Capitation
SHI
Capitation
SHI
Fee for
service
PHG
Fee for
service
Canada
PHG
Italy
PHG
New Zealand PHG
Norway
PHG
UK
PHG
Fee for
service
Capitation +
fee for
service
Capitation +
fee for
service
Salary,
capitation +
fee for
service
Capitation +
fee for
service +
allowances
Payment for
secondary
care
providers
Gatekeeper
role?
Global budget
No
DRG episode
DRG episode
Global budget
+ daily rate
DRG episode
+ fee for
service
(Outpatients)
Global budget
No
Yes
No
DRG episode
Yes
Global budget
Yes
DRG episode
Yes
DRG episode
Yes
Yes
Yes
DRG episode= diagnosis related group: each inpatient admission is coded to the condition or procedure
that was the reason for admission and payment based on a tariff for each DRG.
34
The AARP European Leadership Study on long term care (AARP 2006)
summarised how health and long-term care services are funded in France,
Norway, the Netherlands and the UK. These are presented in Table 4. The
report found that contributory social insurance was the preferred method to
finance long term care in Germany, Luxembourg, the Netherlands, Japan and
Korea. Funding is universal, based on employer/individual insurance contributions
with a dedicated financing source (which is the insurance payments in contrast to
general revenue systems which are based on general taxation). Scandinavian
countries including Norway use a social democratic model, funded by general
taxation, and run via municipal programmes. Coverage is universal but varying
degrees of cost sharing are required, so these systems are ‘budgeted’, and can
lead to informal rationing of care. In contrast, the UK, US, Australia and New
Zealand rely on means-tested programmes which only cover people with income
and assets below a threshold, and are financed through general taxation.
35
Table 4. Community health and social care services covered by Social
Health Insurance and Universal Health Insurance (AARP European
Leadership Study, 2006)
Country
Eligibility Nursing
Home
home care nursing
covered?
covered?
Norway
Universal
coverage
Netherlands Universal
coverage
Personal
care
covered?
Home
help
covered?
Substantial
no
no
co-payment;
pay 75-80%
of public
pension
Means
Nominal co- Means
tested
payment
tested; pay
up to
€150 per
week
Means
yes
variable
tested
usually
means
tested
Means
tested; pay
up to
€3000 per
month
variable
UK
Universal
France
Hybrid
Means
tested
no
US
Means
tested
Short term:
Partially
funded
under
Medicare;
Long term:
Means
tested
under
Medicaid
Means
tested
under
Medicaid
Means
tested; pay
up to
€3000 per
month
variable
Means
tested; pay
up to €150
per week
variable
Financial
support for
family
caregivers?
Public
pension
credit; paid
leave; respite
care
Paid leave;
respite care
Public
pension
credit;
caregiver
assessment;
respite care
Public
pension
credit
Variable
respite care
Koch et al. (2010) surveyed people with a disability in eight countries with
different healthcare financing systems. They included Germany, France and the
36
Netherlands as countries with Universal Health Insurance. Public or statutory
insurance alone was the most prevalent form of health care insurance in
Germany (78% of respondents funded their healthcare in this way). A
combination of public statutory and private insurance was the most common
form in the Netherlands (used by 81% of respondents). Private insurance alone
was the most common form in France (used by 89% of respondents). The
percentage of people with disabilities who required intensive medical care, for
illness, injury or disability did not vary greatly regardless of type of health care
financing system: i.e. one in five of all respondents from these three countries had
required intensive medical care for illness, injury or disability. This was slightly
fewer than people in Australia (25%) or the UK (27%), but similar to those in
Canada (19%), New Zealand (22%) and the US (23%) (Koch et al. 2010 [+]).
Costs of Universal Health Insurance
Cuellar et al. (2000[+]) summarised the long term care insurance aspect of
Universal Health Insurance in Germany, which was introduced in place of a
means-tested system in 1994 and is administered by sickness funds. The premium
is fixed at 1.7% of salary or pension, with employers and pension funds paying half
the cost and the insured person paying the other half. Eligibility for services is
based on functional status and is established in federal law.
A total of 1.2 million people received ambulatory care in 1998, of whom 50% had
substantial disability, 38% severe disability and 11% very severe. Half a million
people had institutional care, of whom 37% had substantial disability, 41% severe
and 22% very severe. Cash or service payments for home or institutional care
increased with severity of disability, ranging from €200 per month for home care
for people with substantial disability to €1,400 per month for institutional care
for the very severely disabled. Up to €1,650 was also available for people who
qualified for institutional care and met hardship criteria.
Three quarters of those eligible received home care and three-quarters of those
preferred cash payments (such as for family caregiving) rather than services. Care
costs are covered in nursing homes but not room or board in Universal Health
Insurance payments and residents have to pay any excess charges themselves.
Younger disabled people who are cared for in specialised institutions are covered
mainly by social assistance.
They concluded (pp. 22-23) that there were a number of lessons from the use of
a separate long-term care form of Universal Health Insurance: “First, it is not a
law of nature that new social programs, especially non-means-tested ones for
long term care, must cost far more than originally estimated. The German longterm care insurance program has an enrolment fairly close to what was originally
projected, and spending has been lower than anticipated. Second, the political
37
success of the program can be tied to some of its design characteristics. Most
importantly, the German reform plan provided substantial fiscal relief to the
regional and municipal governmental units that funded long-term care. Since
there was no maintenance-of-effort requirement, the Länder were enthusiastic
proponents of the new long-term care program. In addition, the German
insurance program established an entitlement to a specific set of benefits that
people could understand and believed they would receive if they met the
eligibility criteria. Thus, the population was able to see, in a very concrete way,
what benefits they would receive for their new contributions. The program offset
the limited range of services that could be covered as an entitlement by providing
a cash alternative, which can be used for any purpose and thus has maximum
flexibility. Third, in the face of large increases in provider capacity, assuring quality
of care has been a challenge. The program must balance the need for quality
assurance against the costs of extensive quality monitoring, both on the part of
agencies and on the part of providers who must meet the requirements and
collect the data. In addition, efforts to improve quality will most likely lead to
higher prices. This may push more people to the cash option, where quality is
barely monitored at all. Fourth, Germany’s strong insistence on a uniform
national program has meant that there is very little variation in services across
geographic areas or across individuals in the same disability category. This also
has resulted in a fairly rigid program that does not flexibly tailor benefit levels to
individual needs or take into account local needs and desires. Fifth, establishing
boundaries between acute and long-term care is difficult because individuals have
a combination of acute and long-term care needs. Maintaining a separate funding
stream for long-term care protects those funds against being swallowed up by the
much larger and more powerful acute care system but creates problems of cost
shifting and coordination. Sixth, Germany also illustrates the classic conflict
between equity and efficiency. Germany’s cash payments can be justified on an
equity basis in that they make family caregivers better off. On moral grounds,
policymakers want to reward informal caregivers for their sacrifices. But from an
efficiency perspective, long-term care funds are spending a great deal of money to
accomplish relatively little behavioral change. Extensive informal care is being
provided, now as before. For people receiving the cash benefit, it is not clear that
much has changed in the way they receive care, although some observers think
that it is too early to tell”.
(Cuellar et al. 2000[+]).
Extent of coverage
The AARP European Leadership study (2006[+]) compared the coverage of
community health and social care in Norway and the Netherlands, where there is
universal coverage, with the UK, France and the US, which have generally meanstested access to these services. Private long term care insurance was rarely
38
available in any country. Even in Norway and the Netherlands, most home-based
services such as home nursing, home help and personal care are either not
funded or are means-tested.
The proportion of the population aged 65 years and older who received home
care was similar for the five countries, regardless of whether or not they had
universal coverage: 2.4 to 6.6% of older people in all five countries had nursing
home care; 2.7 to 5% had residential care or assisted living; and 10 to 20% had
home care.
Universal Health Insurance also made no substantial difference to whether older
people received consumer directed home care. Formal services were received by
elderly people in Norway, the Netherlands, the UK and the US, and a cash
alternative was available in the Netherlands, the UK, France and the US. In
general, relatives, but not spouses, could be hired to offer care. Funding options
for family caregivers varied by country but Universal Health Insurance made no
consistent impact on the type of funding. Paid leave was only available in the two
countries with Universal Health Insurance (Norway and the Netherlands);
however public pension credits were available in Norway, the UK and France;
and respite care was available in Norway, the Netherlands, the UK, and some US
states.
Some problems associated with the use of Universal Health Insurance for long
term care were identified by Cuellar et al. (2000[+]) in Germany. As funding for
long term care is separate from acute care funding, there has been some cost
shifting, which has meant that the goal to favour rehabilitation services instead of
long-term care has not been met. The programme was designed to encourage
competition between providers, but this has not happened as planned, although
the number of providers has increased.
Chiang et al. (2011[++]) summarised the services that were available in 29
developed countries for people with low vision. Data was summarised by region,
making it difficult to determine whether service provision was different for
countries with or without Social Health Insurance. Only seven of 22 countries
with data reported that vision services were fully funded by the government, with
a further 14 countries offering fee-based services that were subsidised at a
national (3 countries) or local level (11 countries). Adults and children with
disabilities were the group most likely to have difficulties accessing services in
nine of the 29 countries, more than ethnic minorities (7 countries), refugees (6
countries), older people (6 countries) and people on low income (8 countries).
7.3.2. Processes – the implementation of Universal Health Insurance
We identified no studies that reported on implementation of Universal Health
Insurance by individual staff within an organisation. We identified only one study
39
that reported on the implementation of Universal Health Insurance at a service
level.
LOCAL IMPLEMENTATION
OUTCOMES
OF UNIVERSAL HEALTH
INSURANCE
Infrastructure to implement
Impact
Impact on Impact
policy
on
providers
on
country
of health
people
and
and social
with a
payers
care
disability
Services covered by Universal
Health Insurance
Costs and funding of Universal
Health Insurance
Costs and funding of services not
covered by Universal Health
Insurance
Providers of services covered by
Universal Health Insurance
Figure 3. Conceptual framework for the impact of Universal Health
Insurance on people with disabilities
Implementation by organisations
Although we found no studies that directly reported on how healthcare
organisations had implemented Universal Health Insurance, one study did report
on what services might be available at a national level.
Hurst et al. (2007[++]) surveyed the opinions of general physicians in the UK,
Switzerland, Norway and Italy, on availability of healthcare resources and
rationing of care. All four countries have universal health coverage, but this is
financed in different ways. Overall, 87.7% of respondents felt that resources were
sometimes not available for patients. In general, respondents from countries with
lower insurance coverage reported greater scarcity of resources. There were no
overall trends in the respondents’ answers regarding which countries reported
40
most or least rationing or scarcity of resources for end of life care, dialysis,
stroke rehabilitation, nursing home care or mental health services. However,
some patterns about specific services were identified. Overall, dialysis was the
service least likely to be restricted, and nursing home care the most likely to be
scarce.
Physicians in Switzerland were least likely to report scarcity for end of life care,
dialysis, stroke rehabilitation and nursing home care, but were more likely than
physicians in the UK and Italy to report scarce mental health services. Physicians
from Italy reported most scarcity of end of life care, dialysis, and stroke
rehabilitation; but least scarcity of mental health services. Almost half of
physicians in Switzerland (45%) thought that people with mental incapacity were
more likely to be denied treatment than those without incapacity, similar to
respondents from the UK (39%) and Italy (44%) but lower than those from
Norway (61%). One-third of Swiss physicians (30%) thought people requiring
chronic care were likely to be denied treatment, similar to the UK (32%) but less
than Norway or Italy (both 47%).
7.3.3. Outcomes – the impact of Universal Health Insurance on people
with disability
We identified 12 studies that reported on outcomes for people with disability in
countries with Universal Health Insurance. The outcomes reported related to
access to services, access to and choice about insurance, and costs of care.
Access to services
People with disability have greater need of healthcare than those without
disability. We found conflicting evidence about whether Universal Health
Insurance can facilitate access to services.
Glazier et al. (2009[++]) calculated the likelihood that people in Canada, a
country with universal coverage of tax-funded health care, would need a visit to
their GP or a specialist in a two-year study period. Compared with people who
rated their health as very good or excellent, people who rated their health as
poor or fair, or who had two or more chronic conditions, were significantly
more likely to have visited the GP or a specialist. However, people with a
disability or with depression were no more likely than people with excellent or
very good health to make GP or specialist visits. The authors concluded that
universal (tax-funded) health insurance appeared to be successful in achieving
equity of access to GPs.
In contrast, Gulley et al. (2008[+]) compared healthcare experiences of adults
with and without disability in the US, a country without Universal Health
Insurance or Social Health Insurance, and Canada, which has universal coverage.
Access to health care for people in Canada was similar to that of people with the
41
same level of disability in the US who had health insurance. People with severe or
non-severe disability in Canada were significantly more likely than those without
disability to have unmet health care needs, to have needed medication that they
could not afford, to be less satisfied with the care they received, and to view the
quality of their care as fair or poor. People with severe disability in Canada were
more likely than those with non-severe disability to have unmet health care needs
(32.5% of severely disabled compared with 23% of non-severely disabled), or to
be unable to afford medication (22% of severely disabled compared with 10% of
non-severely disabled). However, people without insurance in the US had
significantly worse access to all aspects of health care than those with insurance,
or people in Canada.
A third study also concluded that Universal Health Insurance might not reduce
the link between disability and poverty. Holly et al. (2003[++]), calculated
inequality in access to healthcare for people with disability in Switzerland, a
country with Universal Health Insurance plus supplementary insurance. Inequality
was assessed in terms of comparative mortality, illness and disability. Men and
women were more likely to have a disability if they had manual professions rather
than non-manual; were of low income rather than high income; and, for men but
not women, had only completed compulsory education rather than higher
education. This suggests that there is an association between poverty or low
educational attainment and disability. However, this study could not establish
whether disability is a cause of poverty and low education, or whether poverty
leads to disability.
The basic Universal Health Insurance package in Switzerland differs from that of
other countries by including some services such as complementary medicine
given by doctors, and by not covering some services including dental care, invitro fertilisation for infertility, heart-lung transplantation, some types of
psychotherapy, or home help within maternity services. Supplemental insurance
mainly covers inpatient care and gives patients the opportunity to choose their
doctor. Individuals with a low income may decide to purchase basic insurance
with a low premium. However, these cheaper packages may require the
individual to contribute a higher initial payment for each claim, and may therefore
deter insured people from seeking all the care they perhaps need. The authors
reported an almost complete lack of evidence on equity of access to health care
among the very old, 80% of whom have some form of disability.
Access to insurance
Universal Health Insurance is often introduced with an aim of increasing
competition among insurers. For this to be effective, people need to be able and
motivated to switch from more expensive insurers or those offering less
42
comprehensive coverage to those offering lower premiums or broader coverage.
Two studies investigated access to insurance for people with disabilities.
The two studies reported on the proportion of people who switched insurers
under Universal Health Insurance in the Netherlands. Both studies found no
significant difference in actual switching rates for people with or without
disabilities. However, people with a disability who felt that their health was poor
were anxious about whether new insurers might accept them, and may therefore
feel inhibited about seeking better deals. It is unclear from the evidence whether
the similar rates of switching insurer’s means that these fears are not justified.
De Jong et al. (2008[++]) found that people with chronic illness or disability were
less likely than the general population to switch insurer. The proportion
switching was 14% of the chronically ill compared with 20% of the general
population, although this difference was not statistically significant. People with a
disability were as likely as the general population to switch if they felt their health
was good, but were significantly less likely than the general population to switch if
they felt their health was bad (p < 0.0001).
Reitsma-van Rooijen et al. (2011 [++]) compared rates of switching health
insurers among the general population and people with chronic illness in the
Netherlands in 2007 to 2009. There was no significant difference in the
proportion of either group who switched insurer, with 5% to 6% changing in
2007, 4% in both groups in 2008 and 2% to 3% in 2009. However, the general
population were significantly less likely than those with chronic illness to think
that it was impossible for them to switch insurers; to fear that new insurers
would not accept them for cover; or to worry that they might have
administrative problems if they changed insurer.
In countries where SHI schemes compete with each other for enrolees, usually
under a risk-adjusted capitation system (as currently in the Czech Republic,
Germany, the Netherlands, the Slovak republic and Switzerland), there is the
added worry of risk-selection, so that depending on the risk-adjustment formula
some groups will prove less profitable and may be avoided by insurers and
therefore underserved (van de Ven et al. 2003, van de Ven et al 2007)." (p. 10)
It is likely that people with a disability or chronic illness would be most at risk of
falling between cracks in the system.
It would be interesting to explore further how well risk-adjustment formulas
treat pre-existing conditions disability. While risk equalisation for customers
drawn from different age bands may be fairly straightforward, more sophisticated
risk equalisation formulas may be required to address differences in the
43
proportion of people with disabilities or with pre-existing conditions between the
customer bases of competing insurers.
Lack of clarity and certainty for customers with disabilities may also follow from
any perception by insurance companies that they are less desirable customers
(even if the risk equalisation formula fully balances the risks across all insurers).
People with disabilities need the security that they will be covered for medical
treatment as required, rather than having to negotiate their coverage with the
insurance company before arranging for their treatment.
Supplementary or out-of-pocket payments
People with health care insurance may have to pay money out of pocket for a
range of different reasons. These may include:

standard deductibles (e.g. people pay the first €100 of any claim)

shortfalls between reimbursement and what it costs the individual (e.g. Vhi
pays €150 for a visit to a Consultant, and some Consultants may charge
more)

areas of expenditure that are excluded (nursing home non-care costs in
Germany; GP services in Ireland)
Two studies reported on supplementary payments that people with disability are
required to make in countries with Universal Health Insurance (Koch et al.,
2010[+]; Dewey et al., 2004[+]). Although both studies found substantial out-ofpocket costs could be required, no consistent association was seen with type of
healthcare funding. This means that there is no good reason to think that these
costs will necessarily increase when Universal Health Insurance is introduced in
Ireland. A third study found no increased likelihood that people with a disability
in France would take out additional insurance to cover out-of-pocket costs,
compared with the general population. However, this may be because they could
not afford the cost of the additional insurance, rather than not needing it.
Koch et al. (2010[+]) summarised the views of people with disabilities in eight
countries on their healthcare system and how much out of pocket costs they
have to pay. Overall, people in those countries where out of pocket expenses are
lower are more satisfied with their health care systems. Most people in the UK
(63%) had no such expenses in the past 12 months, and 36% thought only minor
changes were needed to the system. At the other extreme, 30% of people in the
US and 25% of those in Germany thought their health care systems needed to be
completely rebuilt, and only 9% (US) and 8% (Germany) paid no out of pocket
expenses. Satisfaction scores were high in the Netherlands and France, where
41% of people in both countries thought only minor changes were needed,
44
although twice as many people in the Netherlands (33%) had no expenses,
compared with those in France (17%).
There was little association between the type of financing of health care and how
many people with disabilities had out of pocket expenses. Most people in France
had only private insurance (89%) but 42% paid more than $1,000 in the last year
in additional expenses and only 17% made no extra payments. Most people in the
UK (83%) had only publicly funded health care, with few paying extra and only 9%
paying more than $1,000 per year in out of pocket expenses. However, 63% of
people in New Zealand and 78% in Germany also had just publicly funded care,
yet only 10% in New Zealand and 8% in Germany paid nothing, and 13%
(Germany) to 15% (New Zealand) paid over $1,000 per year.
Dewey et al. (2004[+]) calculated out of pocket costs incurred by people in the
first year after a stroke in Australia, a country with Universal Health Insurance.
Almost all patients incurred some out of pocket costs, averaging A$1,100 for the
first year, but ranging up to A$32,411. The greatest average cost was for respite
care (A$2,394 in the first year), but other costs included prescription fees,
private therapy, aids and equipment, home modifications, personal transport
costs and community rehabilitation centre fees.
One method to protect patients from excessive out-of-pocket costs is for them
to take out complementary health insurance to cover such costs. Saliba et al.
(2007[++]) surveyed people with a disability in France and found that they were
no more or less likely to consider purchasing complementary health insurance
than the general population. However, the French health care system exempts
co-payments for 30 serious diseases, so people with one or more of these
conditions may have less need for additional insurance to cover out of pocket
expenses.
8.0 Limitations of the existing research
We identified very few studies that directly addressed the likely impact of the
introduction of Universal Health Insurance on people with disability in Ireland or
other countries. Although several reports summarised the healthcare systems in
countries with Universal Health Insurance, we found only 16 studies from the
literature review that were relevant to the topic.
The studies we identified were of two main types. A number of general reports
compared healthcare and health insurance broadly across several countries.
These studies provide useful comparisons but tended to be too general, with too
45
many variables to allow any conclusions to be drawn about the likely impact of
any one factor on access to or quality of care offered to people with disability.
The other type of study provided very focused data on the experiences of care
for people with a specific type of chronic disease or disability in one or more
country with Universal Health Insurance. These studies provide a snapshot of
what healthcare might be like for these groups, but are difficult to generalise to
the wider population and those with different types of disability in the Irish
context.
9.0 Implications from the research
There is clear international evidence that people with disabilities have higher level
of health needs than the general population and experience higher levels of
poverty and social exclusion (World Health Organization and World Bank, 2011;
Gulley et al., 2008). This means that any deficiencies with the Universal Health
Insurance system introduced in Ireland could disproportionately disadvantage
people with disabilities. There is also international evidence that people with
disabilities are more likely to experience difficulties in accessing health services
(Chiang et al., 2011) and so issues of access need to be addressed. Wagstaff
notes criticisms of social health insurance systems for their lack of coverage
among certain groups due to long establishment processes, systematic variations
in benefits packages and variation of care across subpopulations. (Wagstaff, 2009,
p 2) These are issues of critical importance to people with disabilities.
The argument that a Universal Health Insurance system promotes value for
money and quality of care by facilitating people to move easily between providers
and so encouraging competition does not seem to be supported by clear
evidence in the research literature. Wagstaff’s (2009) analysis of OECD countries
found that the introduction of Universal Health Insurance was associated with an
increased health spending per person, decreased employment rates and could
have a negative effect on other measures of health.
In Germany there has not been the anticipated level of competition (Cuellar et
al., 2000). In the Netherlands the research does not suggest any difference in
general between rates of switching for people with and without disabilities.
However, people with disabilities who are experiencing health problems are
significantly less likely to switch insurer (De Jong et al., 2008) and are more likely
to be anxious about the possibility of needing to switch (Reitsma-van Rooijen et
al., 2011).
46
Universal Health Insurance also necessitates risk equalisation and, as the
difficulties already encountered in Ireland demonstrate, this can be a complex and
controversial process. Unless there is an effective risk equalisation system in
place there is the risk that insurance providers will discourage people with
disabilities from having their cover with them or, in other words, an incentive to
‘cherry pick’.
The evidence is not clear on whether a specific compulsory insurance for
disability and long-term care would help promote and ring-fence funding for
health services for people with disabilities, or add further complexity to the
system. Even with this system, in Germany funding has still shifted from
rehabilitation services to acute care (Cuellar et al., 2000)
In the absence of sufficient funding being generated through Universal Health
Insurance, there are concerns that part of the shortfall would be made up by
people have to make out-of-pocket expenses. This would disproportionately
affect people with disabilities. Research by Koch et al. (2010) and Dewey et al.
(2004) suggests that this is a concern regardless of the funding system. The main
issue may be more about getting the right level of funding, rather than whether
this is obtained through Universal Health Insurance, a specific compulsory
disability insurance, or taxation. A related concern from the Swiss system is the
possibility of insurers imposing financial penalties on people making a claim. This
would definitely create a disincentive to access services and so have a great
impact of those with higher health needs.
The changes to the system in Ireland also offer the opportunity to explore other
related possibilities such as the offering of cash alternatives to services, as in
Netherlands and Germany for example. The introduction of personal budgets in
the Programme for Government will facilitate this, but there may be wider
applications. Providing financial incentives for people with disabilities to engage in
education, training and employment would also seem a positive development to
explore.
The literature therefore offers few solutions to the question of what service
provision will be like for people with disabilities when Universal Health Insurance
is introduced in Ireland. However, it has identified a number of concerns that
have been raised in multiple countries with Universal Health Insurance, including:

how to ensure adequate funding of health and social services under the new
funding system – an issue particularly challenging in times of economic crisis;

how to ensure that people with disabilities have equitable access to all the
services they need;

how to promote efficiency in healthcare service provision;
47

how to avoid “cherry-picking” by health insurers so that people with
disabilities are able to access affordable and comprehensive insurance
packages;

how to minimise the need for supplementary or out-of-pocket payments at
the point of care which would disproportionately affect high users of services;
and

how best to regulate health insurers and promote fair competition between
insurers and between healthcare providers.
The introduction of a new system of Universal Health Insurance offers the
opportunity to thoroughly evaluate the impact of this development on the
provision of health services for people with disabilities. It will be important that a
comprehensive monitoring system is introduced to ensure that any negative
impact on people with disabilities is immediately identified and addressed.
10.0 References
10.1. Included studies
AARP Public Policy Institute, 2006. European experiences with long-term care:
France, the Netherlands, Norway and the United Kingdom. Available at:
http://www.pascenter.org/publications/publication_home.php?id=542 [Accessed
September 8, 2011].
Chiang, P.P.-C. et al., 2011. A global survey of low vision service provision.
Ophthalmic Epidemiology, 18(3), pp.109-121.
Cuellar, A.E. & Wiener, J.M., 2000. Can social insurance for long-term care work?
The experience of Germany. Health Affairs, 19(3), pp.8 -25.
Dewey, H.M. et al., 2004. “Out of pocket” costs to stroke patients during the
first year after stroke - results from the North East Melbourne Stroke Incidence
Study. Journal of Clinical Neuroscience: Official Journal of the Neurosurgical
Society of Australasia, 11(2), pp.134-137.
Glazier, R.H. et al., 2009. Universal Health Insurance and equity in primary care
and specialist office visits: a population-based study. Annals of Family Medicine,
7(5), pp.396-405.
Gulley, S.P. & Altman, B.M., 2008. Disability in two health care systems: access,
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