Roadmaps to managed competition: to what extent does Ireland meet the preconditions for equity and efficiency?

Abstract Ireland has a long-standing voluntary private health insurance market (PHI) which is regulated to meet the public policy objective of achieving risk solidarity to promote affordability of PHI. Under the regulations underpinning the market, many features are common to those of universal mandatory health insurance markets, that have wider equity objectives of ensuring universal equitable access to care for everyone. The market acts a complete/partial alternative to the public health system, and has been criticised for leading to a two-tier system with consequent implications for equity. To improve equity, these criticisms led to the adoption of a new public health reform plan, called Sláintecare, which seeks to build towards equal access to services based on patient need and not their ability to pay. Given this context, this paper re-examines how might the current voluntary health insurance system be adapted to meet the central Sláintecare objective of increasing health coverage on an equitable basis. It does so by considering to what extent does Ireland meet the preconditions for equity and efficiency under the Enthoven managed competition model. It provides a roadmap for the use of health insurance as a tool for bring this equity.