Ability to pay and geographical proximity influence access to liver transplantation even in a system with universal access

Ireland, in common with many countries, has a mixed private and public health care system. Concern has been expressed that this system may lead to inequity in access to medical treatment. To investigate this concern, all contacts and first admissions to the national liver transplant unit were identified between April 1, 2000, and March 31, 2002. The effects of private health insurance and area of residence on the likelihood of receiving a liver transplant were assessed. A total of 202 patients were admitted. Forty-three patients from this cohort received a liver transplant (21.3%). Of patients with private health insurance, 17 of 50 (34.0%) were transplanted, compared with 26 of 152 (17.1%) without private health insurance (relative risk [RR] =1.99; 95% CI, 1.18-3.35; P =.01). For residents of the Eastern (close to the liver transplant unit), patients with private health insurance were no more likely to be transplanted (RR =0.95; 95% CI, 0.35-2.54; P =1.0), whereas for residents of other areas, patients with private insurance were 3 times more likely to receive a transplant than those without health insurance (RR =.11; 95% CI, 1.59-6.08; P =.001). Patients living outside the Eastern region without private health insurance were only half as likely as all other patient types combined to receive a transplant (RR =0.52; 95% CI, 0.29-0.92; P =.02). In this study the possession of private health insurance appeared to increase the chances of receiving a liver transplant. Patients without private health insurance living distant from the liver transplant unit appeared particularly disadvantaged. In conclusion, these findings suggest significant inequity in liver transplant allocation in Ireland and deserve further assessment.