Risk equalisation and voluntary health insurance markets: The case of Ireland

Ireland has a system of private health insurance (PHI) which acts as a voluntary alternative to the benefits provided under the Irish public health system. As part of this, community rating has long been a cornerstone of the Irish private health insurance market with the objective to make PHI affordable to everyone regardless of their risk profile. Until the mid-1990s one insurer had a legal monopoly. However, in 1996, following the Third Non-Life Insurance Directive, the market was opened up to competition and a number of regulations were introduced to support community rating. This includes the introduction of a risk equalisation system. Its aim was to prevent selection and thus protect the community rating system while still enabling a competitive health insurance market. There have been significant obstacles to the introduction of risk equalisation due to political, legal and implementation issues. The objective of this paper is to review the history, structure and likely effectiveness of risk equalisation in Ireland. The paper provides lessons for other countries with risk equalisation systems or seeking to introduce such a system. Amongst other conclusions, it outlines the difficulties in introducing risk equalisation.