Abstract
This article examines the accessibility of healthcare in Ireland between 2003 and 2011 in the context of strong economic growth (2003–2007) and the subsequent financial crisis, which began in 2008. It investigates, in particular, changes in self-reported difficulties in accessing healthcare with regard to distance to health services, waiting times for appointments and the costs of seeing a doctor, and identifies particular risk factors that increase the likelihood of facing barriers in accessing health services. We conduct logistic regression analyses of cross-sectional data from the three rounds (2003, 2007, 2011) of the European Quality of Life Survey of 2682 individuals living in private households in Ireland. The study finds that the number of individuals reporting difficulties in accessing healthcare increased over time. Of particular concern are difficulties with the financial costs of covering doctor’s appointments, which started to increase dramatically prior to the economic crisis and continued to rise during the crisis, in particular for higher income groups. Difficulties with distance and waiting time declined gradually over time and appear unaffected by the financial crisis, at least until 2011. Subgroups that face significantly more difficulties are women, younger individuals, the full-/part-time employed and individuals with poor health status. Our findings contribute to the recent discussion on the effects of institutional barriers on accessing health services in the context of significant economic change.
Keywords
Introduction
In 2005, World Health Organization (WHO) member states committed to take action towards ‘universal health coverage’, a term that encompasses universal access to high-quality services and financial risk protection (Cylus and Papanicolas, 2015). Although European countries show a particular commitment to these goals, research suggests that individuals, particularly those with poor health and low incomes, still face barriers in accessing healthcare with severe implications for population health and health inequalities (Allin and Masseria, 2009; Chaupain-Guillot and Guillot, 2015; Devaux, 2015; Van Doorslaer et al., 2006). To further improve access to health services, more research is required on the institutional barriers of particular health systems and the vulnerability of certain subgroups. Here, time-comparative case studies appear especially useful as they enable researchers to explore the dynamics of institutional change on access to health services while minimising cross-cultural biases that typically arise in cross-country comparisons. Of particular concern are countries that have experienced severe pressures due to the recent global financial crisis and that have introduced a series of policy measures that have reduced rather than increased accessibility to health services (Burstroem, 2015; Reeves et al., 2014; Thomson et al., 2014a).
This article examines people’s self-reports on the accessibility of healthcare in Ireland between 2003 and 2011 in the context of strong economic growth (2003–2007) and the subsequent financial crisis, which began in 2008. Access to healthcare, as it is defined in this study, refers to the ability to obtain needed health services and to benefit from financial risk protection. We focus on two dimensions of access: (1) financial affordability, which refers to people’s ability to pay for services without financial hardship; and (2) physical accessibility, which refers to the availability of good health services at a reasonable distance and of service organisation and delivery which allows people to obtain the services when needed (Evans et al., 2013). We investigate changes in self-reported difficulties in accessing health services in terms of costs, distance and waiting time, and study their relation to changes observed in public spending, institutional regulations and the supply of services and personnel within the Irish context. Furthermore, we identify particular risk factors that increase the likelihood of facing barriers to accessing health services (e.g. income, health needs, age). We do so by means of secondary analysis of cross-sectional data from three rounds (2003, 2007, 2011) of the European Quality of Life Survey (EQLS).
This study complements previous research on unmet need for healthcare across European countries (Allin et al., 2010; Devaux, 2015; Reeves et al., 2015). While self-reports on unmet need study the inability of individuals to receive treatment when needed, measures on self-reported difficulties in accessing medical services provide more nuanced information on the particular barriers individuals have faced on the last occasion, when they needed to see a doctor/medical services (Eurofound, 2014). Furthermore, this study complements recent research on changes in healthcare coverage and activity in Ireland (Burke et al., 2014; Eurofound, 2014; Nolan et al., 2014; Thomson et al., 2014b). While scholars have emphasised the rise in private spending on healthcare in the context of the financial crisis and the resulting increase in cost-related difficulties in accessing healthcare (Burke et al., 2014; Eurofound, 2013a; Thomas and Burke, 2012), we highlight the fact that the cost deterrent to accessing healthcare was already a problem prior to the crisis due to increases in hospital charges, outpatient fees, doctors’ fees and dental fees. Furthermore, our article contributes to research on the delivery and physical accessibility of healthcare in Ireland (Burke et al., 2014; Thomson et al., 2014b). Despite the reduction in healthcare resources in response to the economic crisis, scholars did not observe a decline in the levels of activity of hospital services but rather an efficient use of available resources, at least until 2012 (Burke et al., 2014; Thomas and Burke, 2012). As comprehensive data from official registries on primary care services are, however, largely unavailable and data on secondary care services provide counter evidence (e.g. on waiting times), a detailed picture of the physical accessibility of health services from the perspective of the patient is difficult to produce. The empirical analysis of subjective indicators can help to identify the overall direction of change in the physical accessibility of healthcare in Ireland prior to and during the economic crisis.
Background
Access to health services in the Irish health system
Universal access to health services and financial risk protection are primary concerns in Ireland, where the state has never provided universal access to healthcare (Barrington, 1987; Finn and Hardiman, 2012; Wren, 2003). The Irish health system is a mixture of a universal tax-financed public health service and a fee-based private system; the extent of duplicate private health insurance, private beds in public hospitals, public hospital charges and General Practitioner (GP) fees per service sets the Irish system apart from other tax-financed national health systems. There are two categories of eligibility under the public General Medical Service (GMS) system. Category 1 residents, those with largely means-tested medical cards, are entitled to GP and hospital care, free of charge, as well as support towards the cost of pharmaceutical drugs. Category 2 residents are obliged to pay GP fees (€40–€60) unless they are eligible for GP visit cards (introduced in October 2005), which provide free access to GPs for those just over the income threshold for medical cards. 1 Category 2 residents are entitled to public hospital care; however, they must pay user charges, which are set per day and capped per annum. 2 They have access to various public assistance schemes, for example, they are covered by the public Drugs Payment Scheme if their monthly expenditure on prescriptions exceeds a defined limit (€120 in 2011). All residents are free to sign up for private health insurance, which provides faster access to hospital care. Private patients can be treated in private or public hospitals and pay higher charges as well as specialist fees, a proportion of which is reimbursed by private health insurance companies (McDaid et al., 2009; Smith, 2010; Thomson et al., 2014b).
Unlike most other European countries, Ireland only guarantees free access to health services to lower income groups (i.e. medical card holders) while the financial burden is particularly high for middle and upper income groups (Central Statistics Office (CSO), 2012). Results of a 2011 survey study report that the percentage of respondents who forewent medical treatment due to costs, waiting lists or distance was highest among middle-income groups (Rodrigues et al., 2013). With regard to the utilisation of health services, research reports that medical card holders/Category 1 residents are more likely to consult a GP and do so more frequently than Category 2 residents or the privately insured, who have to pay for primary care services (Nolan, 2008a, 2008b; Nolan and Smith, 2012). Specialist care, such as dental and optician services, as well as hospital services are, on the other hand, more frequently used by higher income groups (Layte, 2007; Layte and Nolan, 2004).
Changes in the cost and provision of healthcare prior to and during the financial crisis
Like other tax-financed health systems, the budget of the Irish health system largely depends on economic conditions and the government’s fiscal policy decisions. Ireland experienced unprecedented economic growth in the 1990s, becoming a centre for high-tech industry by the early 2000s with the fastest growth rate in the Organisation for Economic Co-operation and Development (OECD) (Daly, 2005). However, the Irish economy was hard hit by the recent global financial crisis; it officially went into recession in September 2008 and did not emerge again until the first quarter of 2010 (Loyal, 2011). Furthermore, the Irish government accepted a bailout agreement with the Troika (the European Commission, the European Central Bank and the International Monetary Fund) in November 2010, which ran to the end of 2013, and which enabled or forced policymakers to make unpalatable decisions (Nolan et al., 2014). While the Irish health system has suffered from historic underfunding (Barrington, 1987; Wren, 2003), this economic boom followed by a sharp downturn further affected the costs of and the provision of healthcare with considerable consequences for the accessibility of health services.
Rising costs and the financial affordability of health services
In the context of strong economic growth, healthcare costs, including doctors’ and dentists’ fees and hospital charges, increased significantly from the early 2000s onwards (CSO, 2016), 3 contributing to the significant rise in total health expenditure from US$1761 (PPP) in 2000 to US$3571 (PPP) in 2007. In this context of rising healthcare costs, the government increased its contribution to the healthcare budget in the early 2000s (from 75.1% in 2000 to 77.3% of total health expenditure in 2004); this public contribution levelled off, however, in the mid-2000s, resulting in a public health expenditure of 75.7 % in 2007 (Nolan et al., 2014). Nonetheless, certain categories benefited financially from new regulations introduced during this period. For example, people over 70 years of age were made eligible for medical cards in 2001, and those just over the income threshold for medical cards could access free GP care from 2005 by applying for GP visit cards (McDaid et al., 2009).
During the financial crisis, which began in 2008, Ireland experienced the greatest fall in health spending of 53 countries in the WHO Europe group and a significant rise in private contributions to healthcare spending (Burke et al., 2014). Public expenditure on health fell by circa 9 % in nominal terms between 2008 and 2012. In 2011, government funded 67.0 % of health spending, compared to 75.7 % in 2007, while out-of-pocket payments as a percentage of the total health expenditure increased from 14.8 % in 2007 to 18.2 % in 2011 (Nolan et al., 2014). Moreover, the fall in the population’s income and the increase in unemployment rates contributed to a rise in the number of medical card holders between 2008 and 2011 from 30.1 to 37.0 % (Department of Health (DH), 2014) and a reduction in the number with private health insurance from 51.7 % in 2008 to 47.1 % in 2011 (Thomson et al., 2014b). Along with a growing and ageing population, these developments resulted in increasing pressures on the public health system (Burke et al., 2014).
The reduction in the public share of health funding was achieved through the introduction of a series of measures that made the public pay more for health services, including increases in hospital charges for Category 2 residents (in 2008 and 2009) and in the share of direct payments for prescribed medicines and appliances for both categories (in 2008, 2009 and 2010), the cutting of dental and ophthalmic entitlements for Category 2 residents (in 2010) and the reintroduction of means-testing for medical cards for the over-70s (in 2009) (Nolan et al., 2014). Together with the increase in private health insurance premiums – by 22 % in 2011 – partly due to a significant drop in numbers signing up to private health insurance schemes and recent government attempts to ensure the full economic costing of private treatment in public hospitals (Burke et al., 2014; Nolan et al., 2014; Turner, 2015), cuts in public spending caused a dramatic increase in the financial burden placed on the shoulders of the Irish public. Thus, due to the rising cost of healthcare that started in the pre-crisis period together with the cuts in public spending during the financial crisis, the cost barrier to accessing healthcare is likely to have increased both before and during the crisis, in particular for Category 2 residents, the sick and the old (Thomas et al., 2014).
Insufficient evidence on the physical accessibility of health services
Economic and demographic change in Ireland also resulted in increasing pressures on the public health system with regard to the provision of health services and personnel. While in 2003, the Irish population counted only 4 million residents, population levels increased to 4.5 million in 2008, largely due to high inward migration (Nolan et al., 2014). At the same time, and with the beginning of the economic crisis, a large part of the population fell into unemployment (4.6% in 2003; 14.4% in 2011) and experienced large drops in gross income that increased the demand for more public health services. Thus, the Irish health system faced new challenges to provide more services for a growing and ageing population with less financial resources (Burke et al., 2014). Surprisingly, and despite the cuts in public spending during the financial crisis, scholars suggest that the Irish health system has provided ‘more with less’ at least until 2012.
As regards the provision of primary care, data on GP practices suggest that the availability of services may have improved prior to the economic crisis and continued to do so thereafter. The number of GPs per thousand population rose from 0.51 in 2003 to 0.53 in 2007 and continued to rise to 0.56 by 2010 (OECD, 2016). Furthermore, the number of GPs working together rose from the early 1990s onwards, which may have reduced the wait for an appointment. The number of practices employing assistants, clerical and nursing staff also rose from the early 1990s onwards, which may have reduced the wait for appointments and the waiting time on the day of appointment (O’Kelly et al., 2016). In the absence of a centralised register for primary health services in Ireland (Teljeur et al., 2014), detailed information on the distance, distribution and waiting times of primary health services is, however, unavailable, which impedes clear-cut conclusions on changes to the physical accessibility of primary health services in Ireland during the period of interest.
With regard to inpatient care, there is some evidence that hospital services became more efficient in the pre-crisis period. For example, between 2005 and 2007, there were rising numbers of inpatient discharges, outpatient attendances and day cases (Burke et al., 2014). Scholars have also found that during the crisis, at least until 2012, the hospital system managed to provide increasing levels of care (in particular, rising numbers of inpatient, day case and outpatient appointments and emergency admissions), despite the declining budget and overall staff numbers and hospital beds (Burke et al., 2014; Thomas and Burke, 2012; Thomas et al., 2014). However, with regard to changes in waiting times for hospital services, the evidence from the Quarterly National Household Survey (QNHS) reports rising numbers of patients on hospital waiting lists (7% in 2001, 6% in 2007 and 8% in 2010) and increasing waiting times for inpatient care for more than 6 months during the economic crisis (CSO, 2011).
In sum, data on primary care services and the delivery of hospital services suggest that the physical accessibility of services may have improved over time, due to increased health expenditure during the period of economic growth and the efficient use of financial resources, despite the severe cuts in health expenditure, during the financial crisis. However, due to counter evidence from administrative data on hospital waiting times and the unavailability of administrative data on the distance, distribution and waiting time of primary health services, conclusions on changes in the physical accessibility to health services are difficult to arrive at. The empirical analysis of available subjective indicators can help us identify the overall direction of change in the physical accessibility of healthcare in Ireland from the perspective of the patient with regard to distance and waiting times prior to and during the economic crisis.
Methods
Data
The empirical analysis is based on the Irish sample of the EQLS carried out by the European Foundation for the Improvement of Living and Working Conditions (Eurofound) in 2003, 2007 and 2011. In total, the survey includes information on 3041 individuals living in private households aged 18 and older. Our analyses are based on 2682 individuals for which valid information on all variables was available (2003: N = 849; 2007: N = 844; 2011: N = 989).
Variables
Difficulties in accessing health services were measured by the Rose index (Eurofound, 2013b), which provides detailed information on self-reported difficulties in the utilisation of medical services in terms of costs, distance and waiting time. The measure complements traditional measures of unmet need that focus on the reasons for forgone medical treatment but leave out information on the experienced difficulties when actually accessing health services. In the EQLS, study participants were asked the following:
On the last occasion you needed to see a doctor or medical specialist, to what extent did each of the following factors make it difficult or not for you to do so? (a) distance to doctor’s office/hospital/medical centre, (b) delay in getting appointment, (c) waiting time to see doctor on day of appointment, (d) cost of seeing the doctor?
Respondents rated the difficulty on a scale ranging from 1 (very difficult) and 2 (a little difficult), to 3 (not difficult at all).
We control for demographic and socio-economic characteristics of the respondent that potentially influence the accessibility of health services. Since self-reported health status and health-related limitations in daily lives/routines differed between the years of survey, health needs are measured by the respondent’s satisfaction with his or her health rated on a 10-point scale ranging from 1 (very dissatisfied) to 10 (very satisfied). Furthermore, we control for the level of education (primary, secondary, tertiary), the current status of employment (full-/part-time employed, unemployed, retired and others, that is, students, disabled, homemaker), the geographic area (urban, rural), the respondent’s sex and age, and the number of children and adults in the household. To study differences between income groups, we refer to income quartiles based on the equivalent household income adjusted for the household size and age of household members. To deal with the significant amount of missing income information (2003: 54.1%; 2007: 52.5%; 2011: 18.5%), we used two strategies: (1) we estimated missing incomes using multiple imputation techniques (Enders, 2010) based on 19 variables and 20 rounds of imputations for each year; and (2) we introduced a subjective variable on the difficulties of households in making ends meet (see Table A2 in the Supplementary Appendix). The results are similar and therefore we only present results on imputed household income. Unfortunately, no information is available on residence category/medical card eligibility or insurance status, and information in the EQLS is insufficient to estimate acceptable proxies. The two lowest income quartiles partly control for means-tested medical card eligibility, together with a dummy variable that was created to control for individuals above the age of 70 and older (eligible for medical cards until 2009). An overview on the independent variables of this study is provided in Table A1 in the Supplementary Appendix.
Methods and research strategy
The descriptive overview of changes in access to healthcare across the years is followed by multivariate regression analyses using binary logit models. 4 Odds ratios are reported on the risk of particular subgroups reporting major and minor difficulties in accessing health services, and changes over time. In analysing changes in healthcare accessibility for different income and age groups (+70) over time, interaction effects are calculated between income quartiles, age group (+70) and year of survey. At all stages, we control for individual characteristics, that is, the demographic and socio-economic characteristics of the individual including health needs. To ensure representative estimations for the population resident in Ireland, standard weights are applied following the recommendations of Eurofound. Note that we cannot empirically test intra-individual changes in the accessibility of healthcare across time, since the analysis is based on cross-sectional data. Therefore, any assumptions on causality remain speculative and require the inclusion of relevant indicators in longitudinal survey studies.
Results
Difficulties accessing healthcare in Ireland: changes over time
On average, more than half of the respondents report difficulties (minor: 46.6%, major: 8.6%) in accessing health services within the observed time period (2003–2011). Difficulties most often relate to the cost of seeing a doctor (minor: 24.3%, major: 13.6%), followed by the waiting time to see a doctor on the day of appointment (minor: 26.6%, major: 7.9%), the delay in getting an appointment (minor: 16.5%, major: 5.3%) and the distance to medical services (minor: 12.2%, major: 3.1%).
Furthermore, we find difficulties to have increased over time (Figure 1). While in 2003 49.3 % reported difficulties with at least one access dimension, numbers increased to 52.8 % in 2007 and 62.3 % in 2011. While increases in the first time period are largely related to the increase in major difficulties (from 5.2% in 2003 to 9.8% in 2007), increases in the second time period are largely driven by the increase in minor difficulties (from 43.1% in 2007 to 51.9% in 2011).
Population (%) reporting difficulties in accessing healthcare: across time.
In line with our argument, difficulties in covering the costs of medical treatment increased dramatically in both minor and major terms. In 2003, 29.2 % of the population experienced difficulties in covering the costs of treatment (minor: 18.6%, major: 10.6%), while 39.2 % reported difficulties in 2007 (minor: 25.4, major: 13.9%), and 44.2 % in 2011 (minor: 28.2, major: 16.0%).
In contrast, access in terms of the other dimensions improved over time, mainly driven by the decrease in reports of minor difficulties: 11.4 and 9.6 % of individuals experienced minor difficulties in reaching medical services in their area in 2007 and 2011 compared to 16.0 % in 2003; 16.5 and 13.9 % faced minor difficulties in delays in getting an appointment in 2007 and 2011 compared to 19.7 % in 2003; and 25.0 and 24.5 % perceived the waiting time to see a doctor on the day of appointment as a minor difficulty in 2007 and 2011 compared to 30.7 % in 2003. At the same time, the share of population reporting major difficulties remained rather stable.
The results of the binary regression models support these trends, even after controlling for standard demographic and socio-economic characteristics (Table 1). They reveal that overall, odds in facing at least one difficulty in accessing healthcare increased significantly by 1.8 times between 2003 and 2011. The odds of facing difficulties in covering the costs of healthcare were 1.5 times higher in 2007 and 2.2 times higher in 2011 than in 2003. In contrast, odds of facing difficulties with the distance from a doctor significantly decreased and are 1.4 times lower in 2007 and 1.7 times lower in 2011 compared to 2003. For the other two dimensions, we also observe a gradual decrease in difficulties, with significant differences observed only between 2003 and 2011: the odds of perceiving difficulties as regards delays in receiving an appointment were 1.4 times lower in 2011 compared to 2003 and 1.3 times lower for waiting times on the day of the appointment. Results of the multi-nominal regression analysis confirm the descriptive findings and show that decreases in difficulties with regard to the physical accessibility dimensions only occurred for minor difficulties, while no changes are observed for major difficulties (see Table A4 in the Supplementary Appendix).
Difficulties in accessing healthcare: results of binary logistic regression analysis (odds ratios) (N = 2682).
Source: Irish sample of the European Quality of Life Survey from 2003, 2007, and 2011.
Table reports exponentiated coefficients; t statistics in parentheses.
p < 0.05; **p < 0.01; ***p < 0.001.
Accessing healthcare in Ireland: identifying vulnerable subgroups
Women, households with children and full/part-time employed are more likely to report at least one difficulty in accessing Irish health services, while the better the health and the older the individual, the lower the likelihood of individuals to report any difficulties (Table 1).
Results for particular access dimensions reveal that younger and employed individuals as well as those living in urban areas face higher difficulties in covering the costs of healthcare compared to subgroups that are more likely to be eligible for medical cards (such as older aged groups and the unemployed) or those living in rural areas with lower rents/housing prices. Difficulties with the distance to medical services are more often experienced by individuals with poor health, those living in rural areas, single adult households and lower income groups. These results imply that the problem of distance is tied to the infrastructure within a given geographic area, in particular the number of GPs/medical centres, as well as an individual’s access to private or public transport. Difficulties with the delay in getting a doctor’s appointment are more often reported by women, the lower educated, individuals of younger age and those with health needs. The lower likelihood of having private health insurance among the lower educated and younger age groups and the more frequent need of medical attention among those with poor health and women, in particular those with young children, are likely to heighten these difficulties. Difficulties with the waiting time on the day of appointment are more often reported by those with health needs who are more dependent on health services and further increase with the number of children living in the household. These difficulties are less often reported by older age groups who are less likely to face time pressures due to work and family life.
Changes in cost barriers over time and vulnerable subgroups
The results of the interaction effects between year and income groups in Table 2 support the expectation that difficulties in covering the costs for medical services changed most pronouncedly for the two upper income quartiles, in particular during the crisis period. In 2011, the odds of facing difficulties with the cost of medical services were 3.1 times higher compared to 2003 and 2.0 times higher compared to 2007 for the third income quartile. For the fourth income quartile, the odds increased in 2011 by 4.4 times compared to 2003 and by 2.9 times compared to 2007. Furthermore, the results reveal that the two lowest income quartiles did not experience any significant changes in the difficulty of covering the costs of medical treatment, a finding that is most likely due to the concentration of medical cards and GP visit cards among these two income groups.
Changes in accessing healthcare over time for different income groups (odds ratios) (N = 2682).
Source: Irish sample of the European Quality of Life Survey from 2003, 2007, and 2011.
Table reports exponentiated coefficients of interaction effects between year and income/age groups; t statistics in parentheses. Analyses control for demographic and socio-economic characteristics (see Table 1).
p < 0.05; **p < 0.01; ***p < 0.001.
The odds of difficulties covering the costs of healthcare increased for the over-70s by 2.7 times in 2007 compared to 2003 and decreased by 2.8 times in 2011 compared to 2007. These findings are surprising since individuals of 70 years of age and older gained automatic entitlement to medical cards in 2001, but lost this entitlement in 2009 when means-testing was reintroduced. 5
Discussion and conclusion
In the context of the recent discussion on the effects of institutional barriers on accessing health services, this article evaluates the accessibility of healthcare in Ireland between 2003 and 2011, in the context of strong economic growth (2003–2007) and the subsequent financial crisis, which began in 2008.
Previous research on changes in healthcare coverage and activity in Ireland during the financial crisis (Burke et al., 2014; Nolan et al., 2014; Thomas and Burke, 2012; Thomson et al., 2014a,b) highlighted a dramatic increase in the financial burden placed on the shoulders of the Irish public during this period. Our results show that the cost deterrent to accessing healthcare was already a problem prior to the crisis, possibly due to significant increases in hospital charges, outpatient fees, doctors’ fees and dental fees in the context of strong economic growth. Difficulties covering the costs of healthcare in Ireland continued to grow during the crisis, as residents experienced increasing levels of co-sharing and the reduction of entitlements to public healthcare supports. These increased difficulties in covering the cost of health services, in particular for higher income groups, are concerning as they may cause people to refrain from seeking medical help, which can moreover create further pressures on public health services.
Our results are more positive with regard to the physical accessibility of health services, that is, distance to medical services, delays in getting doctor’s appointments and the waiting time on the day of appointment, showing an overall decline in the reported difficulties over the time frame. These results enrich our understanding on changes in the physical accessibility of Irish health services and support previous research based on administrative data, which shows an increase in the efficiency of hospital services (Burke et al., 2014; Thomas and Burke, 2012). They also provide evidence for an improvement over time in the accessibility of medical services in general, including primary health services, for which data from official registries are largely unavailable.
These improvements are, however, only observed for the population reporting minor difficulties in the physical accessibility of health services, while reports on major difficulties remained stable. At the same time, improvements may also be restricted to the period prior to 2012. Burke et al. (2014) reported that Irish health services managed ‘to do more with less’ in response to the major cuts in healthcare spending up to 2012, but faced greater difficulties in providing healthcare afterwards (Burke et al., 2014). From the end of 2012 to 2014, at least, inpatient activity decreased and day case activity levelled off, despite an increase in demand, and waiting times for treatment grew (Burke et al., 2014). Further cuts have been made to healthcare spending since 2011, which will have placed more financial pressures on residents, for example, the cutting of dental entitlements for Category 2 residents in 2012, increases in hospital charges in 2013 and the lowering of income thresholds for medical cards for the over-70s in 2013. On the other hand, the introduction of a number of low-cost plans as well as lifetime community rating in May 2015 resulted in a rise in the number of people with health insurance (Turner, 2015). Furthermore, in 2014, free GP care was extended to all under-6s, followed by an extension of this eligibility to the over-70s in 2015. Survey data for the years after 2011 would be required in order to draw conclusions on whether the new government regulations have led to a rise or fall in difficulties accessing Irish health services.
The results also underpin the vulnerability of specific subgroups. In particular, those who report poor health and thus a higher dependency on health services also more frequently report difficulties with accessing health services, in particular with waiting times and distance from a doctor. A good proportion of these individuals are probably dependent on the public health services, which suggests that despite improvements in the physical accessibility of Irish health services, significant barriers remain. Other subgroups that face significantly more difficulties in accessing healthcare are women, households with children, young respondents and the full/part-time employed. Interestingly, difficulties in covering the costs of medical services do not differ significantly between income groups.
Before drawing any conclusions for policymakers, some limitations of our analyses must be highlighted. Significantly, the EQLS indicators used in this analysis do not define the type of health service (GP/specialist, in/outpatient care) respondents are asked to report on and thus do not allow specific conclusions. Private payments and waiting times vary with the type of medical service. Health services are also variously used by different subgroups and thus may cause biases in the results on different risk factors. The data also do not allow for the analysis of the effects of medical cards and insurance status, and thus preclude the investigation of changes in perceived barriers to health services by type of medical status and the painting of a more nuanced picture of vulnerable subgroups. Future research would certainly benefit from more extensive administrative data, in particular on primary care services, and refinements in the EQLS data.
Despite these shortcomings, our study has important implications for the recent discussion on the effects of institutional barriers on the accessibility of health services in the context of significant economic change. While past research has emphasised the negative impact of the financial crisis on the accessibility of healthcare in many European countries, particularly those bailed out by the international community (Kentikelenis, 2015; Reeves et al., 2014, 2015), our research provides a more in-depth analysis of the Irish case. We found that the particularities of the Irish health system are reflected in people’s self-reports on the accessibility of health services and observed contrasting trends for the different access dimensions. While, for example, lower income groups were often found to be the most vulnerable (Kentikelenis, 2015), our analysis reveals that middle and upper income groups faced the largest increases in cost-related difficulties in accessing healthcare in Ireland. This pattern is largely attributable to the increases in medical costs over time and the institutional set-up of the Irish system that guarantees free access to health services to lower income groups, while individuals above the income threshold for medical cards have to pay user fees for primary and secondary health services. Furthermore, and in contrast to prior research (Reeves et al., 2015), our findings suggest that access to healthcare had already decreased before the economic crisis, largely due to the fact that the cost deterrent to accessing healthcare was a problem prior to the crisis as a result of increases in hospital charges, outpatient fees, doctors’ fees and dental fees. These findings, among others, demonstrate the importance of in-depth research on the institutional barriers to access of particular health systems and encourage scholars to make further use of time-comparative case studies and to explore the dynamics of institutional change on particular access patterns.
Footnotes
Acknowledgements
The authors would like to thank Peter Mühlau, Richard Layte, Anne Nolan, the attendees of a seminar held at the Economic and Social Research Institute (ESRI) Social Division, the editors of the Journal of European Social Policy and the anonymous reviewer for their valuable comments on earlier drafts of this manuscript. For all statements of fact, data analyses and interpretation of results, the authors alone bear responsibility.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is part of the NORFACE Welfare State Futures funded research project ‘The Paradox of Health State Futures’ (HEALTHDOX) (EC ERA-Net Plus funding, grant agreement number 618106, File Number 462-14-070).
Supplementary Material
The supplementary appendix is available online.
Notes
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
