Julie Miller
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You had to be there. I know the saying is cliché, but when the Academy for International Health Studies convened in Dublin,
Ireland, last month, the value of the event was something that had to be experienced to be appreciated. I had the honor of
joining 40 executive delegates for a week to observe the Irish healthcare system. (See MHE's comrades pictured below.)
On the positive side, everyone in Ireland has access to the public healthcare system, and spending is just 7.2% of GDP. The
poorest and those over age 70 typically pay nothing. Nursing ratios are high, and drugs are quite affordable and available.
What's not so good is that the public hospitals are filled to the gills: It's not unusual to see six patients sharing one
hospital room. Patients have affordable out-of-pocket costs thanks to the mostly tax-funded system, but timely access can
be a challenge. At the public hospital our group toured, the emergency department actually had visiting hours posted on the
wall because patients were expected to be there a long time. Another odd detail was that the hospital, although only 10 years
old, didn't have air conditioning, and the windows only opened a few inches.
More than half the Irish pay into the private system, which basically allows them better access. There's a growing network
of private hospitals, and many believe co-locating private hospitals on public hospital campuses will open up more beds and
reduce wait times. As it is, the public system already contracts out to the private system when wait times become excessive
for patients. There's a fervent debate over the co-location proposal right now, and the country's top hospital leaders discussed the idea
with our delegation and what it means for Ireland. We also heard a nitty-gritty policy overview from the Minister of Health
and Children, the Honorable Mary Harney.
On the study mission, I also learned the United States does not have a monopoly on perverse incentives. Ireland's hospitals
are crowded, but there's not much incentive for them to change that. Clinicians—who are unionized—enjoy job security and a
great deal of autonomy. New doctors graduate medical school with no debt and many go on to work for an average income of about
$470,000. There's little quality measurement, but health authorities are beginning to address it, just as we are in the United
States.
What Ireland—dubbed the Celtic Tiger in recent years—has going for it now is a young demographic and economic growth. The
inevitable slowing of the economy and aging of the population hasn't hit the radar yet, but it's possible Ireland will be
able to learn something from the United States by then.
