The sacred cow of health

In recent times we have seen the two main political parties trading blows on the state health scheme and its future sustainability. Both profess their belief in this sacred cow and deny they would ever dream of denying "free health" to Maltese citizens. Crushed under the weight of the precarious state of public finances, however, the Nationalist government wants to reform the system while still proclaiming its universality. It is as ridiculous an objective as any promises that free health would be "guaranteed".

Let's start with some facts. Malta's total spending on health as a proportion of Gross Domestic Product (8.8 per cent) matches the likes of Italy (8.4 per cent) and the United Kingdom (7.6 per cent) while its government expenditure on health as a percentage of GDP (six per cent) again compares well with that of our richer EU partners (Italy's 6.3 per cent, for example) and that of the United States (6.1 per cent).

When the Labour governments of Mr Mintoff decided that universal healthcare was a basic human right and that it should be free, it was in effect setting up an open bar that one could use as often as one wanted - no questions asked. Naturally, what followed was predictable in that the waste and excesses of the system are now forcing the government to limit coverage and entitlements.

It will not take long for the system to degrade to the point where it is barely a shadow of its former self. I believe it will eventually degrade to the point that we truly will have a two-tiered healthcare system. One for those few fortunate enough to be able to make use of and pay for private healthcare while the rest of us are stuck with a Soviet Gosplan system.

What's needed to fix our system is a new window through which to look at healthcare. This means that we should not be biased in favour of the status quo. Approaching the future of healthcare based on the premise that effective healthcare can only be provided on a non-profit basis is absurd.

If we want to fix our healthcare system there are certain paradigms we must embrace. We need to recognise that user fees are a good thing in that they serve to remind those making use of the system that it has some value. It's always easier to spend other people's money than it is to spend your own. Ask any politician.

It is a total myth that effective, high-quality healthcare can only be provided through a not-for-profit vehicle. We need to recognise that for-profit healthcare can be just as effective as non-profit healthcare. The defenders of the status quo want to frighten you with dire warnings that bean-counters will make those life and death medical decisions about your health instead of doctors. It's a specious argument that won't survive the light of day under close scrutiny. In fact, having a few bean-counters looking out for the bottom line can be helpful in eliminating waste, of which we currently have a lot. Strictly speaking, if a private company can deliver a high-quality procedure at a lower cost than a not for profit organisation why not make use of it? The money that's saved could go into acquiring more diagnostic equipment such as MRIs or CT scanners.

Until we are ready to put everything on the table when we examine how to fix our system we'll never fix it.

Despite the bleating by vested interests, there is no compelling reason why the best of public and private care can't be combined to everyone's benefit. But in Malta a politician only has to utter the words "private" or "two-tier" in conjunction with health care to unleash a wail of protest. You only have to mention healthcare reform and people's hair lights on fire. Which is a shame because meaningful changes could result in a better, more efficient healthcare system.

We have an inherent mistrust of anyone seeking to make a profit and this is particularly true in the field of healthcare. Never mind that privately-owned and publicly-funded healthcare components such as clinics, labs, and even physicians have always been part of our national healthcare system.

But as soon as a government spokesman makes some off-the-cuff statement about healthcare reform, his opponents predict the end of state medical care is nigh.

To hear them, you'd think the government is out to privatise medical care solely to make an elite group of businessmen rich while leaving Maltese families at risk of losing everything they have in order to pay the doctor bills. It also conjures up an unfortunate image of affluent patients sipping Chardonnay while the poor masses are forced to empty their own bedpans.

So, what can we do? I believe that everyone who makes use of the system should actually pay into it through direct payment or through source deductions from their paycheque. Some physicians could even bill an additional amount to what is covered through the state healthcare programme. It could be some token amount, never more than about Lm1 per visit.

The government could make private medical insurance a tax deductible expense. Alternatively, it could come up with a sliding tax credit for the purchase of health insurance. Or the government could even advance a credit inversely proportional to the taxpayer's income and pay it in cash if the credit amount exceeds the person's tax liability. This would encourage people who often lack the means to obtain affordable health insurance to enter the insurance market.

One other idea would be to give families vouchers with a value tailored to the average medical spend of the family and then allow them to apply unspent balances to private health-related benefits, such as insuring long-term care services. This type of solution would be quite cost-effective when contracted early in adult life, with beneficial effects in the future.

Persons in higher tax brackets who ought to be able to pay insurance premiums but choose not to would be penalised for going without health insurance in the expectation that the state will subsidise the cost of their healthcare.

We also need legislation to create a framework where the self-employed and small businesses can enrol in collective health schemes. Under such plans, members would be offered various coverage choices. These schemes could be self-funded (possibly bolstered by stop loss insurance to protect against catastrophic claims), insured or based on a mix of both.

The task ahead would be far less painful - for the government, the government-in-waiting and the whole of Malta - if a bipartisan national commission on health were to carefully lay out in advance exactly what reforms could be implemented to ensure a viable national health system.