Content: Health systems review. Overview: Essay comparing the health systems in Ireland and the United States of America in terms of equity, efficiency and effectiveness. Please Note - This essay is purely academic and I will not accept legal responsibility for any information, interpretations or options contained herein. - Feel free to utilise, critique, print or reference any of this content :)

1. Health system comparison: Ireland and the United States (2017)
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Definitions
Health care: Efforts made to maintain or restore physical, mental, or emotional well-being especially
by trained and licensed professionals (Merriam-Webster 2017).
Health system: All organizations, people and actions that provide a product or service that is seen or
intended to promote, restore or maintain health.
Introduction
Illness and disease affect us all; although the severity, experience and consequences are different for
everyone. The transition to the “Kingdom of the Sick” as Susan Sontag (2002) calls it can have far
reaching emotional, experiential, productive, and societal consequences. However it is currently
known how to cure the biological causes or at least alleviate symptoms of almost every disease or
condition. These desirable health states are not only achievable but almost universally accepted as a
fundamental human right or entitlement (Kinney 2001). Nevertheless how do we grant people
access to this healthcare in an effective and desirable way is far from black and white and varies
considerably across the globe.
The WHO (2007, p.2) defines a health system as “all organizations, people and actions whose
primary intent is to promote, restore or maintain health”. However health care can become a widely
marketed product within some health systems (e.g. in the USA) and any profit driven health-care
providers fall outside the WHO’s definition of a health system. For this reason I will be defining a
health system as “all organizations, people and actions that provide a product or service that is seen
or intended to promote, restore or maintain health”.
Note that under this definition defence and security providers, family caretakers, providers of
alternative medicine, certain religious institutions, and many charities/NGOs would all be included.
However while all these sources feed into the perceived provision of health and wellbeing within a
population in this report I will only focus on: government provided health services relating to disease
treatment and care for the sick, and private health insurance.
Comparisons will be made between Ireland which has universal health care mainly funded through
taxation and the United States where there is a strong market presence within the health system
and coverage is not considered universal. I will focus on three main factors equity (fair access to
treatment), efficiency (use of resources) and effectiveness (quality of outcomes).
Please Note
- This essay is purely academic and I will not accept legal responsibility for
any information, interpretations or options contained herein.
- Feel free to utilise, critique, print or reference any of this content 

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Overview of systems
Before assessing the outcome of these systems in terms of equity, efficiency and effectiveness I will
first provide an overview of the constituents, structure and services available under each system.
This comparative overview will provide the context and foundation for later assessments.
Funding sources
In Ireland health care is primarily funded by the government taxation (67%), with smaller
contributions coming from private out-of-pocket payments (17%), and private insurance (13%).
In the United States a lower proportion of funds are provided by government taxation (48%) and
private out-of-pocket payments (12%), and much more is provided by private insurance (35%).
Figure 1: Sources of funding for health care systems in different countries in 2013 (OECD 2015)
Public and Private services
In Ireland the “Government, the Minister for Health [currently Simon Harris (Department of Health
n.d.)] and the Department of Health are at the head of the health service” being responsible for the
“development and implementation of policy for the health services” (Citizens Information 2013b).
These services are then run by the Health Service Executive (HSE) through a network of 32 Local
Health Offices across 4 administrative areas as seen in Figure 2 (Citizens Information 2013b). More
recently acute hospitals have been structured into 7 Hospital Groups and Health Care Organisations
into 9 area groups (HSE 2015). Ireland has 52 public hospitals and 21 private hospitals; 17 of the
public hospitals are voluntary meaning that they are run by an organisation other than HSE but are
still non-profit and similarly government funded (Jones 2013, HSE n.d.-a, HSE n.d.-b). Main health
services in Ireland consist of dental practices, GP/family doctors, public hospitals (HSE and
voluntary), private hospitals, pharmacies, and community health care organisations.

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Most public health services (all treatments)
are free in Ireland however some charges
still exist throughout the system. Hospital
stays for public patients cost €80 per night,
capped at €800 for any 12 consecutive
months, for private patients in a public
hospital stays are about €650-€1000 per
night, €100 charge for using accident and
emergency services without a GP referral,
GP visits costing €30 to €65, and there is
the costs of medications (Cullen 2014,
Citizens Information 2017a).
In the United States the president and
government are responsible for Federal
health service policy which is overseen by
The Department of Health and Human
Services (HHS). The HHS is led by the
Secretary [currently Tom Price] and Deputy
Secretary of Health who are both
nominated by the President of the United
States and approved by the United States
Senate (Pear and Kaplan 2017, Rasmussen
2017). As seen in Figure 3 the HHS is a large
and complex body with 11 operating
divisions, and 14 secretary offices.
Each state then has its own health departments that oversee and adapt federal policies to their
areas and local health departments at the county or city level carry out a similar role (McKenzie et al.
2016). Hospitals are divided into non-government non-profit 2845 (59%), investor owned (for profit)
1034 (21%) and state or local government 983 (20%) (AHA 2017). In addition to the main health
services seen in Ireland there are additional private health services in the USA such as urgent care
(doc in a box), minor surgery centers, speciality facilities (x-rays, dialysis), and minute clinics (within
stores) (McKenzie et al. 2016).
Public supports
Within Ireland’s public system individuals with sufficiently low income or certain other conditions
can qualify for the General Medical Services Scheme (GMS) receiving a medical card; and other
services include a GP visit card, the Drug Payment Scheme, and the Long Term Illness Scheme.
Medical cards remove almost all charges associated with health care however there is still a
prescription charge of €2.5 per item for medications (capped at €25 per month per family), a
possibility of charges for hospital stays over 30 days, and dental charges for more than 2 aesthetic
fillings in a calendar year as all emergency dental treatment for relief of pain and sepsis is provided
(Citizens Information 2016a, Citizens Information 2017b).
Figure 2: Ireland's 32 Local Health Offices and 4 Administrative Areas (HSE n.d.-b)

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Secretary
Deputy Secretary
Chief of Staff
Office of the Secretary
Office of the Assistant
Secretary for
Administration (ASA)
Office of the Assistant
Secretary for Financial
Resources (ASFR)
Office of the Assistant
Secretary for
Health (OASH)
Office of the Assistant
Secretary for
Legislation (ASL)
Office of the Assistant
Secretary for Planning
and Evaluation (ASPE)
Office of the Assistant
Secretary for
Preparedness and
Response (ASPR)
Office of the Assistant
Secretary for Public
Affairs (ASPA)
Office for Civil Rights
(OCR)
Departmental Appeals
Board (DAB)
Office of the General
Counsel (OGC)
Office of Global Affairs
(OGA)
Office of Inspector
General (OIG)
Office of Medicare
Hearing and Appeals
(OMHA)
Office of the National
Coordinator for Health
Information Technology
(ONC)
Operating Divisions
Administration for
Children and Families
(ACF)
Administration for
Community Living (ACL)
Agency for Healthcare
Research and Quality
(AHRQ)
Agency for Toxic
Substances and Disease
Registry (ATSDR)
Centers for Disease
Control and Prevention
(CDC)
Centers for Medicare
and Medicaid Services
(CMS)
Food and Drug
Administration (FDA)
Helath Resources and
Services Administration
(HRSA)
Indian Health Service
(IHS)
National Institutes of
Health (NIH)
Substance Abuse and
Mental Helath Services
Administration
(SAMHSA)
The Executive
Secretariat (ES)
Office of Health Reform
(OHR)
Office of
Intergovernmental and
External Affairs (IEA)
Free GP visit cards are provided to people over 70 years of age
and those with an income just above the GMS threshold. The
Drug Payment Scheme is available to everyone normally
resident in Ireland (lived there at least a year or intend to) and
it caps prescription charges at €144 per calendar month
(Citizens Information 2016b). The Long Term Illness Scheme
provides free medication if someone has one of the 16
eligible diseases including epilepsy, cystic fibrosis, and
multiple sclerosis (Citizens Information 2015b).
In the USA there is Medicare and Head Start programmes and
the more recently Medicaid and CHIP (which were formed
under the Affordable Care Act of 2010).
Medicare is for those aged 65 years or older, certain younger
people with disabilities, and people with End-Stage Renal
Disease and consists of various plans involving Part A (Hospital
Insurance), Part B (Medical Insurance), Part C (Medicare
Advantage Plans) and Part D (prescription drug coverage)
(Medicare.gov n.d.). The Head Start Programmes provide
some health care services in conjunction with learning and
support for children up to 5 years old from very low income
families (Office of Head Start 2016).
Medicaid is government health insurance aimed at those with
low income and entitles enrolees to some mandatory health
care services under federal law (e.g. inpatient hospital
services, outpatient services, physician services) and coverage
of other optional services (e.g. eyeglasses, prescription drugs,
dental services) is chosen be each state (Medicaid.gov n.d.-b).
States can also choose whether to charge premiums to
Medicaid enrolees or not (Medicaid.gov n.d.-a).
The Children's Health Insurance Program (CHIP) provides
health coverage to uninsured children whose families earn
just above the Medicaid threshold, and like Medicaid its
benefits vary by state, but all states provide immunizations
and well-baby/well-child care at no cost (Benefits.gov n.d.).
Private insurance
In Ireland private health insurance is voluntary and provided
by GloHealth (not taking new customers since 22 February
2017), HSF Health Plan, Irish Life Health, Laya Healthcare and
VHI Healthcare (Citizens Information 2016c, GloHealth 2017).
There are also restricted membership schemes dealing with
insurance for particular groups of employees including Gardaí,
prison officers and ESB staff (Citizens Information 2016c).
Figure 3:
Organisational
Chart of the HHS
(HHS 2017)

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In Ireland there is a duplicate system meaning that all basic care is provided under the public system
and private patients can be seen in the public system with faster access but the same care (OECD
2016). However private hospitals in Ireland are free to charge their own rates and these costs may
be covered under some health insurance plans (Citizens Information 2017a).
All health insurance in Ireland is also regulated through open enrolment (anyone can get insured),
lifetime cover (beneficiary remains covered as long as they pay premiums), community rating (same
cost for a given service, regardless of age, sex or health status), lifetime community rating (those
who join when over 34 years old pay an extra 2% loading for each year over 34), fixed waiting time
for insurance activation, coverage for pre-existing conditions from more than 5 years ago, and
maximum treatment waiting period of 2 years for all contracts since 2015 and most earlier ones
(Citizens Information 2016c).
In the USA health insurance plays a much larger role than in Ireland since the majority of medical
payments are either out-of-pocket payments or are covered by insurance. As mentioned earlier
government insurance schemes (medicaid, medicare, CHIP, Head Start) exist but vary considerably
across states in relation to the costs and services covered. Otherwise government involvement is low
with the top 125 private insurance companies collecting over $744 billion in 2013 (Heilbrunn 2014).
Various health insurance packages are also provided by certain employers (McKenzie et al. 2016).
Under the Affordable Care Act of 2010 health insurance companies became obliged to provide
prompt payment, lifetime cover, no exclusion based on pre-existing conditions, and to reduce
discrimination, fraud and abuse (GPO 2009).
Emergency services
In Ireland emergency care in publically provided and free of charge except for the possible €100
accident and emergency charge and the various hospital stay costs discussed above.
Emergency services in the USA tend to be very expensive but should be at least partially covered by
most basic insurance plans. Tragic cases reported in the Irish media include “an Irish man paralysed
from the neck down after diving into a pool in Las Vegas and his bills coming to almost €450,000 and
an Irish holidaymaker who was injured in a motorcycle accident being charged €100,000, including a
€60,000 bill to have him flown back to Ireland by air ambulance (McBride 2013).
General ambulance services in the USA are also extremely high. According to the ACT Ambulance
Service (2016) it costs a minimum of $918 for treatment and transport ($637 without transport);
coverage of these costs by health insurance is likely but varies across packages.
In Ireland if someone does not have a medical card there is a possibility they may be charged for
ambulance services, however, the practice varies between different parts of the country and charges
may be waived in certain cases, for example, in cases of hardship (Citizens Information 2015a).
Firefighting services which fall under the role of the Department of Housing, Planning, Community
and Local Government in Ireland (Citizens Information 2013a) also play a critical role in emergency
events, i.e. fires and traffic accidents. In Ireland the 220 fire stations are managed by 30 local
authorities who receive funds from the government and commercial premises, and are permitted
charge additional fees for services (Citizens Information 2013a). Service charges range between 0
and 750 euro for different counties (McQuinn 2013, O'Neill 2014).
In the USA costs of firefighting services vary with possible spot pay of about $2,200 per 2 hours and
some areas having annual fees where fires will not be extinguished if not paid (NBC News 2011).

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Equity
Equality here refers to a system that treats people based on need rather than their ability to pay or
other characteristics such as gender, religion, race or ethnicity.
Access to basic health care
In Ireland in 2015; 37% of the population had a medical card, 9% had a GP visit card, 28% had the
Drug Payment Scheme and 5% had the Long Term Illness Scheme. Assuming no overlap these public
services thus provide affordable care to 79% of the population of Ireland. 43% of the population also
have private health insurance and those without any of these can probably afford hospital stay
charges. What makes Ireland a fair system is that unless you chose to go fully private all cost are
either covered or capped.
While costs are considered affordable the OECD (2016) found in 2014 that 3.7% of people in Ireland
reported unmet need for medical examination, 1.8% for those with a high income and 4% for those
with a low income. This report also found poorer results for dental examination with 5.9% reporting
unmet need 2.7% for high income and 6.9% for low income. The precise reasons given for these
rates in Ireland were not provided.
In the USA coverage is not publically provided and thus difficult to compare with Ireland. Since costs
are so high without health insurance, the coverage of this insurance can be used as a rough indicator
of health care coverage. In 2015 28.6% of the American population were not covered by health
insurance which was a decrease from previous years, but still illustrates that nearly one in three
people would probably struggle to access health care (CDC 2016a).
Access to emergency care
As discussed above Ireland’s emergency services are far more affordable than the USA and payment
for ambulances is free for GMS patients and subject to a consideration with others, whereas in the
United States one ambulance journey could place someone into debt even if they did not request it.
However the USA does appear to provide emergency treatment regardless of payment options; as
the CDC (2016b) reported that in 2012 the expected payment method for 11% of admitted
individuals aged 18-64 years was unknown, and according to American Hospital Association (2016)
estimates between 1990 and 2015 about 4% to 6% of emergency care went uncompensated
annually, that is more than $538 billion since the year 2000. However while access to emergency
treatment “appears” to be equally provided people are still paying large amounts for services free in
Ireland and in worst cases they will not be able to afford subsequently needed convalescent care.
Annual fees for firefighting services in the USA is also unequal and promotes waste. In Ireland such
charges only apply to large corporations, not homes.
Minority and ethnic groups
The CDC (2014) found that in 2013 there were significant differences in insurance rates between
ethnic groups: Hispanics (30.3%), non-Hispanic blacks (18.9%), non-Hispanic Asians (13.8%) and non-
Hispanic whites (10.6%). This is theorised to be the result of income disparities between these
groups. In addition over 70% of homeless people in the United States in 2003 reported at least one
unmet health need (Baggett et al. 2010).

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Ireland has not looked at unmet need in the case of homeless people and we tend to publically cover
access to care so financial restrictions between ethnic groups should not be present. According to
the Citizens Information Board (2014) emergency medical cards are given to anyone who is
terminally ill, a homeless person in need of urgent medical care, a person with a serious medical
condition in need of urgent medical care, a foster child in need of urgent medical care, or an asylum
seeker with a serious medical condition in need of urgent medical care.
It is worth noting however that in the
USA The National Association of Free
and Charitable Clinics (NAFC) founded
in 2001 in North Carolina now has
1200 (see figure 4) free health clinics
across the States which act as a safety
net for those with limited or no
access to health care (NAFC 2016b).
In 2015 these served 1.7 million
unduplicated patients with 5.9 million
visits (NAFC 2016a).
Efficiency
Potentially preventable admissions
In the USA in 2012 potentially preventable adult inpatient stays constituted 1582 stays per 100,000
population, a 18.5% decrease from 2005 (Fingar et al. 2015). In Ireland this has not been measured
making comparisons impossible however our rates of hospital admission for asthma patients are the
highest in Europe, and it is likely that some may be unnecessary (OECD 2016). This area needs
further research.
Cost
According to the World Bank (2016) in 2014 the USA had the most costly health system in the world
with the total health expenditure being 17.1% of their GDP whereas in Ireland it was only 7.8% of
GDP. Alternative estimates for 2014 reported by the Department of Health (2016) show Ireland to
be 10.1% and the USA to be 16.6%. It is estimated that about 20% of the cost of health care in the
USA to due to waste; overtreatment, failures of care coordination, failures in execution of care
processes, administrative complexity, pricing failures, and fraud and abuse (Berwick and Hackbarth
2012). A comparable assessment has not yet been published for Ireland.
Figure 4: The 1200 National Association of Free and Charitable Clinics (NAFC 2016a)

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Effectiveness
A report by Rafter et al. (2016) found that the prevalence of adverse events in admissions in Ireland
was 12.2% (95% CI 9.5% to 15.5%) with 9.9% of these causing permanent impairment and 6.7%
contributing to death. This report also estimated a mean of 6.1 added bed days was attributed to
these events, representing an expenditure of €5550 per event. The adverse event rate varied
substantially (8.6%–17.0%) when applying different published adverse event eligibility criteria.
However in the USA adverse events have been previously estimated at only about 4% (Rafter et al.
2015).
Gay et al. (2011) looked at mortality amenable to health care under two different and well cited
definitions for each country. As shown in Figure 5 the USA is 103/124 per 100,000 which are far
higher than in Ireland where it is 82/95 per 100,000. It is worth noting however that the data for the
USA is from 2005 whereas Ireland’s is from 2007.
Figure 5: Mortality Amenable to Health Care in 31 OECD Countries (Gay et al. 2011)

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Concluding remarks
The systems by which health care is provided to a population are extremely complex and influenced
by a wide range of social and environment factors (e.g. time, economic, cultural, political, and social
values) while trying to maintain equality, efficiency and effectiveness. For this reason I would argue
that there is no single healthcare system that will work well everywhere, and that each approach will
have be tailered to to its specific areas.
Unfortunatly good dynamic comparisons where difficult to make between Ireland and the USA as
there was not comparible data or indicators for may of the aspects this report aimed to examine.
However where possible tentative comparisons have been made. It is worth noting that the USA has
conducted excellent research that is currently not matched in Ireland for all these areas.
This report suggests that there are far more sources of inequality within the US healthcare system
and there is a significant lack of safety nets and price caps as provided in the Irish system. It is also a
far most costly structure than that of Ireland. However the USA can have excelent health outcomes
and good quality research data may make outcomes appear worse than they really are.
Also the United States of America is composed of 50 very different states and iconically much of the
inequality stems from policies imposed at the state level, and the resulting variations between them.
Unlike in Ireland its political and cultural geography adds increased problems when trying to
introduce policies that are “equal”. I would recommend comparisons between states and the raising
of manditory entitlements at the Federal level.
Also while it is outside the scope of this report the US health system is currently in a state of flux
with various significant changes being proposed, making this a very important time for US Health
Care and for the assessment of its successes and shortcommings.

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