During the last conference, I was asked the question contained in the title. These types of questions are often an invitation to unproductive amateur philosophising. However, at the same time, we cannot move the public debate forward without addressing fundamental issues.
The answer is Solomonic – we should be asking a different question. Most people have a correct, rough idea that healthcare is not free and that someone, somewhere, somehow pays for it. Some people are even aware of health insurance contributions, and the most knowledgeable among them even know how much these contributions are in relation to their salary.
Instead, we should explain what shared responsibility means. Public healthcare, as part of a claimable social welfare system, has suppressed co-responsibility in people. I am not just writing about co-responsibility for health, where it is self-evident – no system, no regulation will change the fact that we will always be our own best preventers. I am writing about co-responsibility for the economic functioning of the system.
When it comes to pensions, that cultural shift is already underway. These days, it is rare to meet someone in their thirties who truly believes the public pension system will be enough to support their lifestyle in old age. A large proportion of people understand the need to save and invest, although understanding does not necessarily mean they are taking action yet.
We need such a change of mindset in the healthcare sector as well and ideally as soon as possible. Saving and investing make sense here too, but I am thinking more of recognising the scarcity of health services and goods and changing the motivations for using them.
However, this awareness will not be achieved by a sudden enlightenment of the masses, not even through educational campaigns. If there is a free lunch, I have to eat it because otherwise someone else will. Behavioural change will only be brought about by a change in the system, which recognises a greater degree of co-responsibility.
In 2022, we commissioned an agency survey. In the survey, we wanted to learn the opinion of the Slovak population on the main role of public healthcare, priorities, willingness to consider the cost of quality, or to purchase additional services. The main question was to compare the inclination towards ‘non-targeted’ public healthcare (where the quantity of routine treatment takes precedence over the quality of treatment for severe conditions) and ‘prioritising’ public healthcare (where the quality of treatment for severe conditions takes precedence over the quantity of routine treatment).
As a result, two similarly sized groups of citizens hold conflicting views on healthcare. 51% would prefer everything to be free of charge, even if it meant lower quality or longer waiting times. The remaining 49%, on the other hand, were willing to compromise and contribute financially in routine situations in exchange for better quality care in critical moments. Roughly a quarter of citizens would be willing to pay up to 25 euros per month regularly for superior services, and about 4% would be willing to pay even more.
Now comes the philosophising mentioned in the introduction. Even those in the first group are already paying for healthcare today, not only through mandatory contributions, but also through increasingly common informal or ‘grey’ payments. Many of them still remember the so-called ‘free’ healthcare of not so long ago, when it was standard practice to knock on the doctor’s door with an envelope of cash. So why the resistance to formalizing financial co-responsibility?
They lack trust in the system – trust that it will not leave them without help in difficult health situations, even if they have no money. They fear that if we let ‘official’ price tags into the system, they will not be able to get treated. To some extent, this mistrust is justified — they can already see how real access to healthcare is faltering. Would it not be even worse then?
This is exactly the question that should be at the heart of the public debate. I am convinced it would not be any worse. The financial unsustainability of the current system is written into the birth rate statistics. What truly threatens us is a decline in the availability of healthcare at the most crucial moments — and that is what will happen if the status quo is not changed. But systemic changes must win the trust of the people.
Translated by Ina Sečíková