Another health-care 'reform'

OVERHAULS of health-care programmes always rock society and even if most citizens do not fully comprehend the substance of various “reform” proposals they do tune carefully to what public officials say when they talk about something as important as health care.

OVERHAULS of health-care programmes always rock society and even if most citizens do not fully comprehend the substance of various “reform” proposals they do tune carefully to what public officials say when they talk about something as important as health care.

Prime Minister Robert Fico surely had the country’s two private health insurers, Dôvera and Union, listening carefully on July 25 when he announced that his cabinet is determined to pursue only a single, state-owned health insurer and that the two private firms will be forced from the Slovak market in one way or another. But Fico added that “we do not have the money in the state budget to purchase the insurers” and spoke quite openly about the possibility of expropriation, saying this would be in the “clear public interest”.

Expropriation in the public interest is rather tricky because it always rocks the trust of the private sector in the stability of a country’s business environment. Fico argued that health insurers are not allowed to generate profits in 26 of 29 European countries and that 16 countries in Europe have a single health insurer, calling his goal a “clear European path”.

Of course the “European nature” of any path depends on its application to real life and it can easily happen that no matter how well meant the direction is it could lead into a murky forest of state monopoly. One of the hurdles that Fico will have to jump as he goes down this path is that a ban on distribution of profits earned by private health insurers enacted during his first term in office was ruled unconstitutional.

It is still unclear how Fico will actually choose to reach his goal: with a purchase of the two private insurers or through expropriation, and also how the group of Slovaks who hold health insurance contracts with Dôvera and Union will be administratively managed.

“Purchase is a legal instrument under the condition that the buyer has money,” Rudolf Zajac, health minister in the government of Mikuláš Dzurinda from 2002-2006, told the Sme daily. Zajac routinely made it to the list of the least popular politicians during his years in office, while one of his predecessors called the health minister’s post a “combination of the electric chair and scuttle butt”

Fico conceded that the government does not have the money to purchase the assets of the private insurers and he knows that the country has no other choice but to further reduce the public deficit. He is also the top official in a society where a persistent lack of funds for health care has been the anthem for the past 20 years, with some critics saying the real tune is linked with ineffective management of the funds that do actually flow to the system.

Fico also sits as the head of a country where hundreds of nurses wearing black T-shirts filled the streets in front of parliament on July 24, rallying against a preliminary injunction from the Constitutional Court which suspended a law that increased their minimum monthly salaries to at least €640. The previous government tailored this law and 141 MPs, including those from Fico’s Smer party, passed the legislation. And last December more than 1,200 doctors left their jobs in state-run hospitals after refusing to withdraw resignation notices they submitted in September demanding pay hikes, leading the state to squeeze out some more cash to get the doctors to return.

Though all these developments clearly highlight the crisis in health care in Slovakia even to citizens who do not think very deeply about its root causes, what people often focus on is only the tip of the iceberg. Slovaks who lived under communism for decades are still struggling to grasp the concept that free health care does not actually mean that no one has to pay the bill.

Even if by some miraculous twist Fico is able to strike an agreement with the private health insurers and avoid expropriation, further steps are critically needed to make sure that funding for health care is used more effectively, for example by the hospitals. If this does not happen, then the newest overhaul can just be added to the long list of changes to the system that have been unfinished, failed or ineffective. One of the problems with the current system is that past overhauls have not been fully completed or even been given time to start working – new proposals have come with every change in the government since 1991. Nearly all these changes treated just the symptoms, while failing to deal with the underlying causes of the system’s malaise.

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