In the past year, we have witnessed a never-ending stream of news stories about acute hospital bed shortages, overcrowded wards, underpaid frontline medics, and a dearth of medical workers in critical areas.

In Ireland, these are merely hallmarks of its unfit-for-purpose healthcare system, the Health Service Executive (HSE), that long predate the emergence of the novel coronavirus. But Covid-19 has magnified pre-existing issues in this overstretched, chronically underfunded two-tier system – proving the need for universal access to medical treatment, ideally on an all-island basis, to ensure uniformity with the NHS model in the North in the event of a vote for a United Ireland. It has also put paid to the notion that this flailing health model can maintain legitimacy into the 2020s, a sentiment that can only deepen as Irish voters continue their generational drift leftward.

As well as being pummelled by austerity, public healthcare in Ireland has been hollowed out by hyper-marketisation and privatisation, quintessential features of the neoliberal turn that has seized Irish policymaking for generations. Ireland, one should keep in mind, is a pharma-orientated tax haven whose fanatically Europhilic ruling classes idolise the Hayekian regime in Brussels. But political mismanagement at home during the current public health catastrophe cannot be completely explained away by structural weaknesses.

From the outset, the Irish government’s political response to Covid-19 has been marked by overlapping crises. Government ministers and backbenchers have issued gross miscommunications, circumvented and contradicted expert advice offered by the National Public Health Emergency Team (NPHET), become embroiled in criminal investigations concerning the leaking of confidential health contracts to friends, abandoned nursing home residents, voted against a motion to reinstate pay for student nurses and midwives, and endeavoured at every opportunity to blame a wayward public for spiking infection rates. Topping off this carousel of chaos, Ireland is on track to miss vaccination targets for the first quarter of the year by over a third, having been caught up in a farcical vaccine rollout blamed by the ruling coalition on supply issues.

As coined by health policy scholar Dr. Sara Burke, Ireland’s current state of affairs in health constitutes a kind of ‘apartheid’. Hyperbolic as that declaration may seem, Ireland’s public-private hybrid lays bare stark inequalities.

For the uninitiated, distinctions are made in Ireland between those two million people in possession of means-tested medical cards, who are entitled to free public hospital care, primary care, and other community care and social services, and the remainder, who do not meet these strict criteria and are subject to public hospital care and outpatient service surcharges. Worse still, they are required to pay in full for GP services (about €50 per visit) and A&E visits (typically costing €100).

In addition, close to 43 percent of the population are covered by private health insurance, one of the highest levels of take-up in Europe. And for good reason: as economist Sheelah Connolly has observed, the privately insured—disproportionately pulled from the upper-middle classes—receive preferential treatment and superior services to other, less affluent sections of Irish society, most of whom endure mile-long waiting lists and out-of-pocket expenses, among other drawbacks.

To complete the picture, however, we need to turn to Irish history. Why a former colony and geographical neighbour of Britain does not have a comparable health service is, for the most part, rooted in the state’s theocratic tendencies of old. The country’s far-from-universal model evolved, in a rather piecemeal way, from being run almost exclusively by religious groups to its present secular form (though religious groups still maintain deep ties at ownership level). The anti-communist Catholic Church and clergy have, in the past, openly railed against attempts to expand the state’s role in health provision, treating minor reforms as an existential, socialistic menace, threatening its hold over hospitals in particular.

In 1951, for instance, healthcare professionals allied with the Church to force out health minister Dr. Noel Browne, who had proposed a measure aimed at making healthcare services free for mothers and their children up to the age of 16. A month after his resignation a general election was called, and its victors, Fianna Fáil, went on to implement the 1953 Health Act and the Voluntary Health Insurance Board in 1957, marking the birth of the two-tier system.

Discontent has been brewing for decades at the status quo in Ireland’s health. Bowing to popular pressure intensified by the 2008 financial crisis, a Fine Gael-Labour Party coalition seemed in 2011 to commit to a universal healthcare system, in which ‘access will be according to need and payment will be according to ability to pay’, but the proposal was abandoned on cost grounds just a year later.

After subsequent waves of postcrisis austerity cuts, however, there has been an appreciable increase in hostility towards the tiered system, seen most pointedly in the country’s recent general election, in which many voters registered their fury.

Here, in 2019, the insurgent Sinn Féin won 24.5 percent of total votes, while the combined vote share of centre-right parties Fine Gael and Fianna Fáil collapsed to an all-time low. The reasons for this historic, duopoly-smashing vote are many, but a creaking national health service featured highest among people’s grievances: in an exit poll conducted by Ipsos/MRBI, a resounding 32 percent of voters said that health swayed their voting decision, followed closely by housing at 26 percent.

Among the stopgap measures taken in recent years to place a plaster on this mortal wound was the introduction of free GP visits for children under the age of six, a policy agreed in July 2015. Last year, the current government outlined their plans to extend this to all children under the age of 12. But the broad blueprint for the future of Irish healthcare, Sláintecare, summoned by politicians of all stripes for varying reasons, still reigns supreme in conversations surrounding reform.

The final Sláintecare report in 2017 recognised the need to move toward equitable access and abolish the tiered structure, rightfully singling out the ‘Beveridge’ model as the most appropriate transition for the path to universal healthcare. The report contained a number of eye-catching recommendations, but some of the document’s proposals were—perhaps unsurprisingly—much murkier than many of its supporters would suggest. Now, eligibility expansion, rather than a truly egalitarian system, appears to be the guiding principle of many Irish parties.

In the Sláintecare document, as in the mealy-mouthed pronouncements of many politicians since, the definition of universality shapeshifts. This is perfectly encapsulated by a list of services that, the report says, ‘should come under the remit of universal healthcare,’ while in the same breath envisioning that charges will remain for access to public hospital emergency departments, prescribed medications, and long-term care, among other services. Such imprecise language, and the fact that reforms continue to be kicked into the long grass, open up the possibility of further revisions and ‘rationalised’ U-turns. Here is where Irish left must intervene, at both a local and national level, to steer the conversation towards a truly universalist model.

Naturally, powerful vested interests will strive to block any substantive change to a system that enriches them. In the Irish context, opposition will arise from those made whole by the private insurance market, including medical workers who gain from working within the private system and private insurance companies. Absent a revolutionary convulsion on par with Cuba materialising from a puff of smoke, nationalising private health service providers will not be a runner. Instead, as Connolly points out, convincing those with private insurance to support the prospect of an all-public system will be sine qua non of any movement for radical reform. Creating an exceptionally high-quality system will be crucial in this regard.

To achieve this fully tax-funded system, sustained mobilisation—enlisting grassroots activists and small community organisations, trade unions and patient organisations, frontline health workers and leftish politicians—could radically reconstruct Sláintecare or lead to the creation of an entirely new model, shaped by people from below and not by decree from above. Equally important is the taming of the metastasizing pharmaceutical industry, handmaiden to private health markets that regularly flexes its political and economic muscles on the island.

Even in a time of great human suffering, there is cause for optimism. As history has shown us time and time again, universal health coverage has often become a national priority following periods of socioeconomic tumult. Aside from the post-war reconstruction of healthcare in the UK, a prime example of this is China, where moves towards universal health coverage went into overdrive in the wake of the SARS outbreak. Meanwhile in Cuba, as Helen Yaffe recounts in ‘We Are Cuba: How a Revolutionary People Have Survived in a Post-Soviet World’, ideological fealty to universal welfare provision also helped the country to increase life expectancy and decrease infant mortality rates during the Special Period, a devastating economic crisis brought on by the sudden collapse of the Soviet bloc.

In isolation, of course, an all-island NHS in Ireland does not offer a panacea for all social degradations and capitalist ills. After all, healthcare systems, however well-funded, do not presuppose a healthier population. Other socioeconomic factors—class dynamics, material and working conditions, psychosocial issues—play an equal role in determining a person’s wellbeing. But, as the fledgling ‘Campaign for an All-Ireland NHS’ has demonstrated, such an unambiguous demand should form part of, if not constitute a big-banner policy for, a resurgence in genuinely emancipatory politics on the island. Now is an opportune moment, if there ever was one, for Irish socialists to demand root-and-branch change.