Free healthcare, but at what cost?

I may not always see eye to eye with former Justice Minister Tonio Borg. But I’ll say one thing for him (actually, two): he’s been part of the Maltese political establishment for the better part of 25 years (and a Cabinet minister for most of that time); and he was also European Health Commissioner for four years. 

I’d say that qualifies him to make statements about Malta’s healthcare system, no matter how unmusical those statements may sound to our ears. Even if his own portfolio was never actually health, Dr Borg will have attended practically every Cabinet meeting between 1995 and 2013 (minus 96-98, etc.) Surely he will know a little more than you, me and both our dogs about how much Malta’s free healthcare system actually costs to maintain. 

So if he says that “the time will come when someone will have to introduce fees [for health care services] in Malta...” I, for one, would be inclined to listen.

In this case, there are additional reasons to prick up one’s ears. Tonio Borg was not talking to NET TV or any other local news outlet... but to Politico.com, in his capacity as former European Commissioner. It is, of course, hugely debatable whether he (or any other Maltese politician from either side) would have spoken exactly the same way in a local context. But it matters little in the long run. 

Leaving aside all the fanciful conspiracy theories (the latest I’ve heard is that Dr Borg was trying to sabotage the PN’s electoral chances, so that he could run for the leadership himself)... I find the possibility that he was simply speaking his mind – unfettered by local partisan interests – far more convincing. 

This is partly because Tonio Borg’s views coincide neatly with what medical professionals usually say when speaking off the record.  Politicians, too: I myself have been told the same thing by MPs from both sides... though never by a sitting health minister, nor anyone speaking officially on behalf of a political party.

That in itself says a lot about the reality of the situation. The sustainability of the healthcare system has become one of our island’s most cherished political fairy tales. It is part of that make-believe world in which we all choose to partially live: knowing full well that it is the stuff of fancy, yet publicly clinging to it all the same... because the alternative is too unbearable to even imagine.

But another reason to pay attention is that Dr Borg also spelt out exactly why the system, in its present form, is so unsustainable. “The island’s two major political parties have shied away from charging fees because the political cost would be enormous. That reluctance may have to give, said Borg...”

Interestingly, he was almost instantaneously proven right on the first part. As if to graphically underscore just how exorbitant the political cost would be, both parties came rushing out to contradict him... using exactly the same arguments.

According to Health minister Chris Fearne, Borg’s words ‘proved’ that the PN intended to dismantle the free healthcare system: "This is a basic difference between Labour and PN, and indeed a Labour government is the only guarantee for free healthcare [...] We fully believe that the health sector can be excellent, comprehensive and sustainable, while remaining free of charge."

I suppose it will not exactly surprise anyone that the PN’s reaction was almost identical, only in reverse.

“For the PN, an essential part of the social contract in Malta is universal access to free public health care. This is why people pay their taxes - to get good public services when they need. And this is what the PN is committed to. At the moment, this access is being rolled back by Prime Minister Joseph Muscat's policies. [...] The PN will address these injustices in its proposals on health and its proposals will retain its long-standing policy of universal access to free public health services as its foundation...”

And there you have it. Both sides claim that they themselves are the only guarantee that healthcare will remain free. Both point the same accusatory finger at the other: arguing that, through deliberate strategy or woeful mismanagement, ‘the other party’ will somehow manage to screw it up for everybody.

But you will also notice that both statements are rooted in blind faith, and nothing more. Labour ‘fully believes’ it can retain an ‘excellent, comprehensive and sustainable system’... without telling us exactly how, or at what cost to all the other departments that depend on government funding. 

The PN likewise is committed to the same thing... and it talks about ‘great future policies’ that will somehow magically solve all the sector’s known sustainability problems ... even if they haven’t actually been drawn up yet, and nobody has a clue what they are. 

As for the rest of us... well, we too are supposed to share in this mystical experience of faith. We are all expected to simply ‘believe’ that one side has all the answers, and that the other will make a mess of things... not because of any policy that has been explained to us; but merely because it chimes in with a political mantra we all already know by heart.

Em... sorry, but no. The dial on my dashboard marked ‘faith in political parties’ is currently pointing towards ‘empty’. Even the reserve tank has dried up. I do not for a second believe that either party has a grand plan to keep Malta’s healthcare system ‘free’ for all eternity...   not, at least, without creating additional costs across the board. 

And if you sift through all the above quotes, you will see exactly why, too. For starters, Tonio Borg made his comment in an article about obesity in Malta. The same article also points out that obesity cost Malta 36 million last year (5% of total health bill)... ‘with that amount expecting to increase if the obesity rates do not change over the coming years’. 

Up pops the first of many problems. Malta spends approximately €630 million on health in a year, and it all goes towards treating the consequences of ill-health. In other words, our health policies are not producing healthier people... they are providing better care for people who are unhealthy (which is not the same thing at all).

Naturally the same applies for other conditions that represent an annual cost for our health system: heart disease, cancer, etc. But obesity is a better example, because (far more than others) the issue can be very successfully addressed on a preventive level. 

How much of our national health (or, for that matter, education transport, etc) policies are concerned with tackling the endemic lack of exercise, for instance? Or with promoting healthy eating, and so on?

Clearly not enough, as we seem to just keep getting fatter and fatter by the minute. But instead of approaching the issue directly, the government (any government) will simply boast that obese people in Malta have more access to public health – and to a much higher standard – than anywhere else in Europe.

Already, you can see the approach is unsustainable. All it means is that we are willing to allocate an ever-increasing budget to a health issue that can only be expected to (literally) get bigger and bigger.

To that bleak scenario, you have to add the quasi-exponential population growth the island is currently experiencing. Part of that growth is fuelled by a drive to attract the world’s wealthiest to acquire Maltese citizenship... and we even include our generous free health service as one of the main selling points.

OK, sure, this has to be counterbalanced by a corresponding drive to attract ‘medical tourism’ (i.e., paying, third-country patients) to Malta’s new private hospitals, which are rented from government. But Maltese citizens still get their health service for free... regardless whether they descend from countless Malta-born generations, or simply bought their passport for 1 million last year.  

So not only does our health service have to contend with rising costs – medicines, equipment, etc – but the number of people it is expected to service is also skyrocketing... and set to skyrocket further.

Does this mean that retaining a ‘free health service for all’ is impossible? Not quite, no. It all depends on how much you’re willing to sacrifice in every other department. I don’t doubt that both Labour and PN sincerely think they can resist introducing healthcare fees forever. They probably can, too. But only by constantly cutting back on expenditure everywhere else. 

That sets an automatic price-tag on our national health service. It’s ‘free’, yes... but that only means you pay for it in other ways.