When the Chairperson of the Housing Agency claimed recently that some people were ‘gaming the system’ by declaring themselves homeless in order to jump the queue for the housing waiting list, it made news for a day or two and even attracted denials from politicians. In fairness, the claim seems to have been made to highlight the perverse incentives in the system rather than to criticise those who adopt a resourceful approach towards solving the housing need they are experiencing, writes Denis Doherty.
This particular incentive was introduced by a former Minister for Housing who made self declared homelessness a priority in the allocation of public housing.
Public services in Ireland are bedevilled by the range of perverse incentives around every corner as citizens struggle to navigate the system to obtain their entitlements. Administrators struggle to differentiate between needs and wants in their decision making, and many politicians harvest votes pretending to do favours for constituents by obtaining for them what is no more than what their entitlements.
If we didn’t have a housing crisis and instead had a rights- based approach to social housing, gaming the system wouldn’t arise. Even in a housing crisis, if accommodation were allocated by lottery, opportunities to game the system would disappear but it would not contribute anything more than the existing system to solving the housing problem. What is needed is more social housing and affordable rents.
Even in a rights-based system, if demand exceeds supply, incentives to game the system are quickly identified. Every child in Ireland is entitled to education in a primary school and so, in theory, good forward planning would match the numbers of available places with the numbers exercising their right to avail of education. In practice, because, in some places, demand exceeds supply, parents are reduced to gaming the system by seeking enrollment for their children in every primary school in the area they live in and school authorities are reduced to gaming the system by imposing admission criteria bordering on the unacceptable and the bizarre. Is there a legislature anywhere else in the world currently enacting legislation to outlaw a practice that prioritises baptised applicants over others? Our elected legislators engage in heated argument on political issues of this sort apparently oblivious of the fact that their job is to provide the resources to enable sufficient school places to be provided where they are needed. By doing their job, phony political issues like this would disappear.
If our politicians were serious about reducing the cost of administering our health service, they would invest in simplifying the rules for entitlement to services, with a strong emphasis on reducing administrative costs and invest the money saved in improving services.
Then, there is the most enduring political football of all – our healthcare system. For decades the inequities of our two tier system, the inefficiencies inherent in our network of small acute hospitals, the length of our waiting lists and our overreliance on hospital based care, to name just a few, have given rise to many memorable political football matches that have made, altered and even ended political careers.
Gaming the system to obtain a medical card, to get on a waiting list, then to get seen by a Consultant and then, for some, to get a place in residential care have exercised the ingenuity and patience of countless patients and their representatives.
Inevitability, it has got to the stage where the numbers on waiting lists are so vast as to be unmanageable and probably meaningless. Validating waiting lists is an inadequate and costly response to an inefficient and overwhelmed system. One reason the lists are so big is that many people, not surprisingly, game the system by obtaining referrals to a number of hospitals in the belief that their chances of ‘being called’ are improved by their name being on multiple lists
Our political system creates the environment for gaming the system. When increasing public expenditure, politicians like to give something to as many as possible rather than seek to make the greatest impact with what they have to give.
For many years medical cards were available only to those who had the greatest difficulty paying for healthcare. There are now full medical cards and doctor only medical cards. For the latter, age rather than need is the criterion and the definition and interpretation of exceptional needs have been changed to increase the numbers entitled to a card. The list of long-term illnesses has lengthened and co-payments, where users pay a cost of the service, have expanded greatly over the years.
One might be forgiven for taking the cynical view that politicians at national level create the obstacles that provide opportunities for other politicians, at local level, to negotiate ways around them, while conveying the impression to individuals they are obtaining favours for what is in fact an entitlement.
It is sadly true that the more convoluted entitlement criteria become, the greater the likelihood that many will miss out on their entitlement to services while others, by gaming the system, will succeed in obtaining services they are not entitled to. This pottage that sustains our healthcare system is very costly to administer. Serial underinvestment in information technology and the proliferation of stand-alone localised systems compounds that problem and adds to the cost.
If our politicians were serious about reducing the cost of administering our health service, they would invest in simplifying the rules for entitlement to services, with a strong emphasis on reducing administrative costs and invest the money saved in improving services. The reaction to this suggestion is likely to be along the lines of – if it’s that simple, why haven’t we done it before now? It is that simple. A simpler, clearer and efficiently structured health service has the potential to produce a range of benefits, a minor one of which would be a reduction in opportunities to game the system. A downside of that approach for politicians is that a clear rights based approach would represent a blow to clientism.
Fifty years ago this year, the Fitzgerald report was published. It is well worth rereading, as much for the purpose of considering how much we could still learn from it as what we have learned.