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1. IntroductionUniversal healthcare (UHC), sometimes referred to as universal health coverage, universal coverage or universal care, usually refers to a healthcare system, which provides healthcare and financial protection to all citizens of a particular country. It is organised around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes [1]. The World Health Organization (WHO) defines a universal health system as one where ‘all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’. In Ireland, the definition used in current policy for the introduction of UHC does not mention the issue of affordability but instead places the emphasis on access based on clinical need [2]. This is contrary to a key underlying tenet of UHC which is risk protection. Health payments are a heavy financial burden for millions around the world. Financial risk protection is concerned with safeguarding people against the financial hardship associated with paying for health services. The concept of financial risk protection, or conversely the absence of a risk of financial hardship, has been the focus of interest to economists and researchers for many years, and measuring the ability of a health system to protect people against the financial hardship associated with paying for health services has become an important issue for research and analysis across countries at all income levels [3]. It is unclear why health policy in Ireland has chosen to adopt a definition of UHC which is silent on the issue of affordability.The WHO has advocated UHC as the best means of improving global health. However, achieving UHC is not without challenges: from defining the goal of UHC to identifying the most appropriate methods to achieve it. The idea of UHC can be seen in the 1948 WHO Constitution [4] of which Ireland is a signatory. The concept of UHC was first introduced in Ireland through the 1948 Health Act [5]. UHC is also embedded in the 1978 Alma-Ata declaration that contains a number of important principles in relation to health. It specifies that all people regardless of race, religion, political belief, economic or social condition be entitled to enjoy the highest attainable standard of health as a fundamental right. In 2005 [6], 2011 [7] and 2013 [1] UHC has become the focus of various WHO campaigns as the importance and benefits of universal coverage become ever more apparent.Over recent years funding for the health service in Ireland has declined, amidst the most severe economic crisis since the 1930s, while the demands for care and patient expectations have increased [8], [9]. The health system managed ‘to do more with less’ from 2008 to 2012, achieved mostly by transferring the cost of care onto people and by significant resource cuts [10]. This is evident in reduced home care hours, increased wait-times, expensive agency staffing and accentuated inequities of access for patients within the health system. Alongside this there was a growing discourse in society to have a health system that is accountable, effective, efficient and capable of responding to the emerging and on-going needs of the public. This has been illustrated through debates on UHC internationally [11] and in Ireland [2].The structure of the Irish healthcare system has a number of unusual features [12] and is commonly referred to as a ‘two-tiered’ system. ‘Two-tier’ refers to the fact that people who can pay privately or have private health insurance (PHI) can get a diagnosis quicker and can secure faster hospital treatment, even in public hospitals, because they can afford the monthly premiums [13]. About 46% of the population have PHI [14]. Those who cannot afford PHI must often face long waiting lists for acute care [10], for example longer waiting times for minor operations and diagnostics such as CT scans [15]. About two fifths of the population have medical cards under the General Medical Services (GMS) scheme, which are means tested and mostly allocated on the basis of income. These cards enable people on low or no income to access general practice (GP) and hospital care without charge and medicines at a low cost. Healthcare financing relies predominantly on general taxation, which accounted for an estimated 69 per cent of total financing in 2015, with out-of –pocket payments by individuals and PHI contributing an estimated 13 per cent each [16]. Ireland is unusual amongst its European neighbours in not having universal access to primary care [17]. A recent analysis conducted by the European Observatory on Health Systems and Policies found that the highest formal payments in any primary care system exist in Ireland, where patients without a medical card (e.g. when income rises above a specified threshold) pay between €45 and €65 for each GP visit, with no reimbursement [17]. According to recent OECD data on 34 countries, Ireland is in the bottom third for both out-of-pocket expenditure and also unmet medical needs particularly in relation to medical examinations [18], whereby people indicated that they need medical treatment in the previous 12 months but did not receive it [18]. Cross sectional analysis of health seeking behaviour within primary care in Ireland revealed that those who had to pay out-of-pocket payments to see a GP were more likely to put off going to the doctor than those with a GMS card [19]. Similarly analysis on the impact of the introduction of copayments on prescriptions reported a reduction in medication adherence [20]. An antidote to this inequitable two-tiered system is UHC. Possible options for the implementation of UHC, including funding and restructuring as well as dealing with possible positive and negative outcomes are outlined in the Slaintecare report [2]. Details of the complicated nature of the Irish health system are explained in a recent analyses [21].In more recent years Ireland has recommitted its intention to introduce UHC by looking to change the underlying funding model to an insurance based system – universal health insurance (UHI). The 2011-16 Programme for Government states, “under this system there will be no discrimination between patients on the grounds of income or insurance status” [22]. In the final days of the previous Government, UHI became seriously delayed and abandoned in the run up to the 2016 General Election, with the Minister for Health indicating on foot of the publication of costings for UHI that the multi-payer model of private competing insurance companies is not viable stating it was ‘not acceptable, either now or any time in the future’[23]. More recently the Government has formed a cross-party committee, the primary role of which is to ‘establish a universal single tier service where patients are treated on the basis of health need rather than on ability to pay’ [24]. This committee, called the Oireachtas Committee on the Future of Healthcare, published its report entitled Slaintecare in May 2017 outlining a ten year plan for the introduction of UHC in Ireland [2].The issue around universalisation has therefore been an ongoing background debate for decades and periodically comes to the fore when the standing Government seeks to institute reforms. Despite these commitments by Ireland at international and national level, the two-tiered system still exists. This begs the question as to why?The legitimacy and sustainability of any major policy decision increasingly depends on how well it reflects the underlying values of the public. Experts and stakeholders provide essential technical input but their role is distinct from that of the citizen and cannot replace it. It is increasingly understood that citizens should be a stakeholder in framing health policy decisions [25] and it is recognised that citizens’ values should define the boundaries of action in healthcare in any democracy[26], [27], [28], [29]. This is particularly the case for UHC as patients and the public have been identified as key enablers for the implementation of any universal programme [30]. According to the OECD the general public bring new ideas and experiences to the decision-making process; encourage policy makers to think more carefully about the objectives of health services and to be more open and explicit about the choices being made [31].The call for public participation also suggests a shift in political philosophy about who has the democratic right to make healthcare decisions. The WHO have also used the language of rights when arguing that: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’ [32]. Members of the general public want to be involved in decision-making at the national level [33] and they overwhelmingly want their preferences to inform priority-setting decisions in healthcare [34].Public input into healthcare decision-making, at least in theory, is clearly advocated in Ireland. The importance of patient involvement has been acknowledged in numerous policy documents such as ‘A Vision for Change: Report of the expert group on mental health policy’ [35], ‘The National Health Strategy: Quality and fairness – a health system for you’[36], the Madden Report [37] and most recently in ‘Healthy Ireland – A Framework for Improved Health and Wellbeing 2013–2025 [38], as well as in numerous Health Service Executive (HSE) national service plans [39], [40], [41]. In Ireland researcher-administered questionnaires with 738 patients and family members attending outpatient services reported that 86.2% were supportive of greater patient participation in national level healthcare design, delivery and policy [42].The key prevailing issue relating to the Irish health system is how to end the inequitable two-tiered health system that exists. There has been one formal assessment of the general public’s views and opinions on universalisation in Ireland, however, this study included a convenience sample of patients attending for treatment in a primary care setting[43]. Beyond the media headlines little is actually known about the general public’s views on universal healthcare. We sought to identify what demographic factors and opinions influence the support of the general public for the introduction of universal healthcare (UHC) in Ireland.2. Materials and methods2.1. DesignA cross-sectional survey on the views and opinions of the general public on the introduction of UHC in Ireland.2.2. SamplingA sample of 972 participants were recruited. This provided a 3% margin of error with a 95% confidence level and total population of 4,757,976 based on the 2016 National Census [44].Random sampling was employed with random digit dialling of 85% mobile numbers and 15% landline numbers. This ensured listed and non-listed numbers have the same probability of being contacted. To ensure a representative sample soft quotas for age, gender, location, and social class were monitored. The data was weighted at analysis stage. Weightings were based on data from the 2011 Census and the Joint National Listenership Research (JNLR). The JNLR includes a sample of over 16,000 respondents aged over 15 conducted annually over 50 weeks of the year [45]. This was used alongside Census data to keep weightings as up to date as possible.2.3. ProceduresData collection took place over a two-week period in December 2016. A market research company who specialise in healthcare research were contracted to conduct questionnaires over the phone as part of an omnibus poll. The research team provided the data collectors with definitions for all key terms used in the questionnaire and meetings took place to ensure in depth understanding of the topic and questionnaire. All data collectors were provided with a full day of training, a briefing on the project and 10–15% of interviewer calls were monitored for quality control.The questionnaire was anonymous and researcher-administered over the phone. Consent was implied in completing the questionnaire.Ethical approval was provided by the School of Medicine Level 1 Research Ethics Committee in Trinity College Dublin (reference 20160208).2.4. MeasuresThe questionnaire was developed based on a literature review with standardised questions employed where possible. For example, Question 3b, ‘The government should prioritise spending on healthcare rather than reducing taxes’, was based on work by the Think-tank for Action on Social Change (TASC) which asked about investing in public services in general [46]. A definition of UHC based on the WHO definition was read out to participants after question one (‘I feel well informed about universal healthcare’) was answered. The definition provided was ‘“Universal Healthcare” is that all people have access to the health services they need (prevention, promotion, treatment, rehabilitation and palliative care) free at the point of access.’ (See Supplementary File A: Questionnaire). Further explanation was provided as required throughout the questionnaire after question one was answered. The questionnaire was piloted with 384 members of the general public in two locations in Dublin, Ireland with contrasting levels of deprivation in a face-to-face researcher-administered format. The pilot data was not included in the current paper as the data were collected through different mediums (telephone versus face-to-face) and also a convenience sample was utilised in the pilot.2.4.1. DemographicsParticipants were asked about their age, gender, where in the country they live (location) and level of education. Self reported health, level of healthcare cover, social class and knowledge of UHC were also recorded.Self-reported health (SRH)SRH was assessed by the answer to a single item ‘How is your health in general?’. There were five response categories: ‘very good, “good”, ‘fair’, ‘bad’, and ‘very bad’. This question has become a standard measure for SRH and due to its format can be compared with Irish and international data [47]. For analysis this variable was collapsed into ‘good self-rating of health’ including ‘very good’ and ‘good’ and ‘poor self-rating of health’ consisting of ‘fair’, ‘bad’ and ‘very bad’.2.4.2. Level of healthcare coverWhether the participant was eligible for the GMS scheme, had private health insurance or neither. Due to small numbers for analysis PHI and neither were collapsed together.2.4.3. Social classThe social grading classification system from The British National Readership Survey (NRS) has been well established and used since the 1960s and was employed in this study [48]. This was determined based on a series of questions about the chief income earner of the household in which the participant resides. This included questions on their employment status, type of employer, occupation, role and qualifications. Social class was divided into 5 categories; AB upper/middle class, C1 lower middle class, C2 skilled working class, DE other working class and F farmers.2.4.4. Knowledge of UHCParticipants were asked to indicate how much they agreed with the following statement on a 5-point scale from ‘strongly agree’ to ‘strongly disagree’. ‘I feel well informed about universal healthcare’. Participants were asked to answer this question before being provided with the definition of UHC. Categories were collapsed down to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse of the answer categories was determined by those participants who indicated that they did not definitely ‘agree’ or ‘strongly agree’.2.4.5. Opinions and views on UHCParticipants were asked to indicate how much they agreed with the following statements on a 5-point scale from ‘strongly agree’ to ‘strongly disagree’. ‘Having the health service as a public system is important’, ‘The government should prioritise spending on healthcare rather than reducing taxes’, ‘I want healthcare free at the point of access’, ‘People who can pay for healthcare should pay’, ‘I am prepared to pay higher taxes for healthcare free at the point of access’. During analysis categories were collapsed down to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse of the answer categories was determined by those participants who indicated that they did not definitely ‘agree’ or ‘strongly agree’.2.5. AnalysesA weighted logistic regression model was employed to assess the odds of participants who did not support the introduction of UHC in Ireland versus the odds of participants who did support the introduction of UHC in Ireland, taking demographic factors and opinions into account.Contingency tables were examined to ensure adequate sample size for each parameter. The final logistic regression model was selected based on the lowest Akaike’s information criterion (AIC). Interactions were checked for and none found. Tolerance and generalised variance inflation factors (GVIF) for independent variables were assessed to determine the presence of multicollinearity. All values were within acceptable limits with tolerance values lower than 1 [49] and GVIF values less than 2 [50].Results are displayed in terms of odds ratios (OR) and 95% confidence intervals (CI). ORs range from 0 to infinity with 1.0 meaning no difference in odds and ORs greater than 1.0 meaning that the ratio of those who support the introduction of UHC versus those who do not support the introduction of UHC in the selected group is greater than the reference group. If the 95% CI for OR crosses 1 this indicates that there is no evidence to suggest that there is any difference between the reference and selected group when comparing those who do and do not support the introduction of UHC in Ireland.Analysis was conducted using statistical software SPSS Version 22.3. Results3.1. Response rateA total of 1102 people were invited to complete the questionnaire on UHC after random digit dialling and eligibility checks. From this 972 participants completed the questionnaire providing a response rate of 88.2% as illustrated in Fig. 1: Flowchart of participants.Download high-res image (434KB)Download full-size imageFig. 1. Flowchart of Participants.3.2. Descriptive analysesA demographic description of the sample is provided in Table 1 (non-weighted) and Table 2 (weighted). These are broken down by support for the introduction of UHC in Ireland. An overview of opinions relating to UHC in Ireland are also illustrated.Table 1. Non-weighted demographic description broken down by agreement with UHC.CovariateAgreeDisagreeNeitherTotal84687.0%656.7%616.3%972100.0%Age18–249110.823.1711.510010.325–4428033.12030.82744.332733.645–6430636.22436.92134.435136.165+16920.01929.269.819420.0Missing––––––––GenderMale45954.34467.73659.053955.5Female38745.72132.32541.043344.5Missing––––––––ProvinceDublin24328.71624.61219.727127.9Rest of Leinster22927.11929.21931.126727.5Munster23327.51726.21829.526827.6Connaght/Ulster14116.71320.01219.716617.1Missing––––––––EducationSecondary level or lowera39246.83250.01626.244044.7Third levelb44553.23250.04573.852254.3Missing––––––101.0GMS StatuscGMSd21225.11116.9711.523023.7Private health insurance46655.14467.74472.155457.0Neither16819.91015.41016.418819.3Missing––––––––Social ClassUpper middle class13816.31015.42032.816817.3Lower middle class23227.42132.31829.527127.9Skilled working class13816.3710.8813.115315.7Other working class29635.02436.91016.433034.0Farmers425.034.658.2505.1Missing––––––––Having the health service as a public system is importantAgree80595.24975.45386.990793.3Disagree/Neither414.81624.6813.1656.7Missing––––––––The government should prioritise spending on healthcare rather than reduce taxesAgree73186.42944.63760.779782.0Disagree/Neither11513.63655.42439.317518.0Missing––––––––I want healthcare free at the point of accessAgree73086.33146.22947.578981.2Disagree/Neither11613.73553.83252.518318.8Missing––––––––People who can pay for healthcare should payAgree56767.01523.14268.965967.8Disagree/Neither27933.05076.91931.131332.2Missing––––––––I am prepared to pay higher taxes for healthcare free at the point of accessAgree56666.91929.22642.661162.9Disagree/Neither28033.14670.83557.436137.1Missing––––––––I feel well informed about UHCAgree42149.82335.41118.045546.8Disagree/neither42550.24264.65082.051753.2Missing––––––––Self-reported healthPoor16920.01624.669.819119.7Good67780.04975.45590.278180.3Missing––––––––– = Not applicable.aSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.bThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.cParticipants could select more than one method of health cover. A total of 74 (7.6%) participants indicated having private health insurance as well as some form of a GMS card. These participants were included within the GMS category.dThe state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes (HSE, 2015). This provides free at the point of contact access to healthcare services.Table 2. Weighted demographic description broken down by agreement with UHC.CovariateAgreeDisagreeNeitherTotal84887.5%616.3%606.2%969100.0%Age969100.018–249711.423.3711.710610.925–4432938.82236.13050.038139.345–6427232.12032.81830.031032.065+15017.71727.858.317217.8Missing––––––––Gender969100.0Male40647.93861.33355.047749.2Female44152.12438.72745.049250.8Missing––––––––Province969100.0Dublin25129.61727.41322.028129.0Rest of Leinster22726.81625.81728.826026.9Munster22927.11625.81627.226127.0Connaght/Ulster14016.51321.01322.016617.0Missing10.1Education969100.0Secondary level or lowera38646.03151.71626.743344.6Third levelb45354.02948.34473.352654.2Missing101.2GMS Statusc969100.0GMSd22426.41219.7811.924425.1Private health insurance44452.33963.94067.852354.0Neither18021.31016.41220.320220.9MissingSocial Class969100.0Upper middle class10212.0711.51525.912412.8Lower middle class23227.42032.81931.727128.0Skilled working class17720.9914.81016.719620.3Other working class28633.82236.11016.731832.8Farmers505.934.9610.0596.0Missing10.1Having the health service as a public system is important970100.0Agree80795.34775.85488.590893.6Disagree/Neither404.71524.2711.5626.4Missing––––––––The government should prioritise spending on healthcare rather than reduce taxes969100.0Agree73086.22947.53660.079582.0Disagree/Neither11713.83252.52440.017317.9Missing10.1I want healthcare free at the point of access969100.0Agree73887.13150.82948.379882.4Disagree/Neither10912.93049.23151.717017.5Missing10.1People who can pay for healthcare should pay970100.0Agree55965.94674.24066.764566.5Disagree/Neither28934.11625.82033.332533.5Missing––––––––I am prepared to pay higher taxes for healthcare free at the point of access970100.0Agree56066.12032.32744.360762.6Disagree/Neither28733.94267.73455.736337.4Missing––––––––I fell well informed about UHC969100Agree40748.12134.41118.043945.3Disagree/Neither44051.94065.65082.053054.7Missing––––––––Self-reported health970100.0Poor16919.91524.2610.019019.6Good67980.14775.85490.078080.4Missing––––––––– = Not applicable.aSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.bThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.cParticipants could select more than one method of health cover. A total of 65 (6.7%) participants indicated having private health insurance as well as some form of a GMS card. These participants were included within the GMS category.dThe state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes (HSE, 2015). This provides free at the point of contact access to healthcare services.Examination of Table 1 (non-weighted) shows that females account for 44.5% (n = 433) of the sample, 33.6% (n = 327) were aged between 25 and 44, 54.3% (n = 522) had a third level qualification and 57.0% (n = 554) of participants had PHI.The introduction of UHC in Ireland was supported by 87.0% (n = 846) of participants. The majority of participants also supported the Government prioritising spending on healthcare rather than reducing taxes (82.0%; n = 797), healthcare free at the point of access (81.2%; n = 789) and that having the health system as a public service is important (93.3%; n = 907).3.3. Regression analysesThe final logistic regression model as determined by the AIC is presented in Table 3 with crude and adjusted ORs for participants who support the introduction of UHC in Ireland compared with those who do not support the introduction of UHC in Ireland (‘disagree’ or ‘neither’). The model was statistically significant and fit the data well [x2[20] = 159.712, p < 0.001; Hosmer and Lemeshow, p > 0.05]. This was the most parsimonious model with the lowest AIC.Table 3. Factors Associated With Agreeing With the Introduction of UHC in Ireland (n = 962; 99.0%).Independent variablesCrude OR95% CIAdjusted ORa95% CIAge18–24BaseBase25–440.69(0.31,1.54)0.64(0.24, 1.67)45–641.10(0.64, 1.89)0.88(0.41, 1.87)65+0.98(0.55, 1.72)0.84(0.31, 1.74)GenderMaleBaseBaseFemale1.52(1.03, 2.24)e1.10(0.70, 1.74)ProvinceDublin1.32(0.76, 2.31)2.16(1.13, 4.11)eRest of Leinster0.84(0.49, 1.43)0.78(0.42, 1.46)Munster1.05(0.62, 1.76)1.14(0.62, 2.10)Connaght/UlsterBaseBaseEducationSecondary level or lowerbBaseBaseThird levelc0.73(0.49, 1.08)0.90(0.54, 1.48)GMS StatusGMSdBaseBasePrivate health insurance/Neither0.54(0.32, 0.89)0.53(0.28, 0.99)*Social ClassUpper middle classBaseBaseLower middle class1.16(0.50, 2.72)1.57(0.59, 4.20)Skilled working class0.91(0.41, 2.01)1.52(0.62, 3.74)Other working class0.61(0.26, 1.43)1.09(0.41, 2.84)Farmers0.61(0.27, 1.35)1.18(0.46, 3.01)Having the health service as a public system is importantAgree4.31(2.45, 7.57)e1.65(0.81, 3.34)Disagree/NeitherBaseBaseThe government should prioritise spending on healthcare rather than reduce taxesAgree5.35(3.56, 8.04)e3.43(2.12, 5.57)eDisagree/NeitherBaseBaseI want healthcare free at the point of accessAgree6.80(4.52,10.23)e4.72(2.95, 7.54)eDisagree/NeitherBaseBasePeople who can pay for healthcare should payAgree0.82(0.54, 1.24)0.72(0.44, 1.19)Disagree/NeitherBaseBaseI am prepared to pay higher taxes for healthcare free at the point of accessAgree3.15(2.13, 4.67)e1.91(1.21, 3.03)eDisagree/NeitherBaseBaseI feel well informed about UHCAgree2.62(1.71, 4.02)e2.13(1.32, 3.44)eDisagree/NeitherBaseBaseSelf-reported healthPoorBaseBaseGood0.85(0.51, 1.40)1.21(0.68, 2.17)aLogistic regression- adjusting for other factors included in the model.bSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.cThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.dThe state provides a general medical services (GMS) card to households on low income. This provides free at the point of contact access to healthcare services.eStatistically significant.Statistically significant factors associated with support for UHC included location, GMS status and attitudinal related factors (e.g., ‘The government should prioritise spending on healthcare rather than reduce taxes’, ‘I want healthcare free at the point of access’, ‘I am prepared to pay higher taxes for healthcare free at the point of access’ and ‘I feel well informed about UHC’).Adjusting for the effects of other factors, the odds of participants living in Dublin agreeing with the introduction of UHC were greater than those living in Connacht or Ulster (OR 2.16, 95% CI (1.13, 4.11)). The odds for those who do not have a GMS card agreeing with the introduction of UHC were lower than the odds of those who have a GMS card (OR 0.53, 95% CI (0.29, 0.99)). The odds for those who agreed that the Government should prioritise spending on healthcare rather than reducing taxes were greater than the odds of those who indicated ‘disagree’ or ‘neither’ (OR 3.43, 95% CI (2.12, 5.57)). The odds of participants who agreed that they wanted healthcare free at the point of access were greater than the odds of those who did not want healthcare free at the point of access (OR 4.72, 95% CI (2.95, 7.54)). The odds of those prepared to pay higher taxes for healthcare free at the point of access were greater than the odds of those who were not prepared to pay higher taxes for healthcare free at the point of access (OR 1.91, 95% CI (1.21, 3.03)). The odds of those who felt well informed about UHC agreeing with the introduction of UHC were greater than the odds of those who did not feel well informed about UHC (OR 2.13, 95% CI (1.32, 3.44)).4. DiscussionGeneral public support for the introduction of UHC is influenced by demographic factors and related attitudinal factors. The introduction of UHC in Ireland was supported by 87.0% (n = 846) of participants. Of those that supported the introduction of UHC, this was influenced by factors including location, GMS status, opinions on the government prioritising spending on healthcare, healthcare being free at the point of access, taxes being increased to provide care free at the point of access and feeling informed about UHC.Differences in context and reform proposals generate differences in the interests of stakeholders and their positioning on reform making it difficult to make cross-national comparisons [30]. However, in the absence of general population information on this topic it would appear that the high level of support for UHC reported in this study is reflective of support for UHC demonstrated internationally. Web-based surveys with 2241 medical students revealed that 86.8% were supportive of UHC in Ontario and 51.1% in California [51]. A similar sentiment was reported from postal surveys with 1675 physicians in the United States with 89% agreeing that all Americans should receive needed medical care regardless of ability to pay [52].When asked if Government should prioritise spending on healthcare rather than reducing income taxes 82.0% (n = 797) of participants agreed with this statement. The 2015 Behaviour and Attitudes Survey asked a similar question but focused on public services in general rather than just health services. A total of 69% of participants agreed with focusing on spending on public services [46]. This is lower than the support for prioritising spending on healthcare perhaps illustrating the importance placed on healthcare and the support for improving services in this area. This is of importance for health policy leaders and makers, particularly in Ireland, as recent examples of protest and demonstrations from the public have been proven to be effective. For example, public outcry against the removal of the GMS card for those over the age of 70, and the attempted removal of GMS cards to very sick children resulted in a rolling back of these policies during the economic recession.Higher socioeconomic status was the principal determining factor for the willingness of members of the general public to support participating in national health insurance in a cross sectional study in St Vincent and the Grenadines [53]. An examination of individual level dynamics in healthcare attitudes toward UHC between 2008 and 2010 in the United States revealed that respondents did not take a position towards UHC reflective of their income [54]. Similarly in the current study social class was not a significant factor influencing support for the introduction of UHC.The current two-tier system has been shown to be ineffective for all groups, GMS and private, with GMS patients facing long waiting times and private patients high insurance premiums and out of pocket payments for both groups [55]. Despite the system not working for any group GMS status influenced participants’ opinions on the introduction of UHC with those with GMS cards slightly more likely to support the introduction of UHC. This is to be expected as those who have PHI nor neither PHI nor a GMS card could be the ones who experience the most change from the introduction of UHC, and may anticipate that not all change will be positive. For example, the creation of a single tier service may mean that those currently with PHI could experience longer waiting times for hospital treatment under UHC than they currently do, but lower out of pocket payments for primary care services.The current research had a number of strengths and limitations. This is a nationally representative sample with 972 participants (response rate of 88%) providing the views and opinions of the general public on UHC at a time when one of the question marks over the implementation of a plan for healthcare in Ireland centres around public opinion. The questionnaire included questions that have been previously used and extensive piloting was conducted. Data collectors were trained and the data collection process was monitored for quality. However, the sample was not weighted in terms of GMS status with the proportion of GMS holders accounting for 23.7% (n = 230) of the sample versus 36% of the general population. Focusing on level of education 54.3% (n = 522) of the sample had a third level education or higher. This is comparison to 34% of the general population aged between 15 and 64 [56]. Additionally, caution must be taken when interpreting results as the number of respondents who selected the ‘disagree’ or ‘neither’ category for the introduction of UHC was substantially lower that the number of respondents whom agreed with the introduction of UHC.5. ConclusionThis paper is relevant and timely for policy leaders both in Ireland and internationally. In Ireland the Slaintecare Report [2] has been published outlining a ten year plan for the introduction of UHC in Ireland and implementation remaining the key question now. Internationally, these findings are of interest as countries with UHC, such as the United Kingdom, are facing difficulties maintaining health services in the public realm with ongoing debate on the privatisation of the NHS [57] and other countries, such as the United States, are debating universal elements for their healthcare system. The current study provides a template that can be used to explore public opinions of UHC in other countries. There is a high level of support for the introduction of UHC in Ireland, which is influenced by demographic, and related attitudinal factors. Patients and the general public have been acknowledged as having a key role to play in all areas of healthcare. This research provides timely information from a representative sample for the ongoing debate on the future of healthcare in Ireland. Future research should explore what people want to obtain from the introduction of UHC and what they are willing to contribute to ensure that the voice of patients and the public is heard at all stages of developments. It would be interesting for this to be explored from a number of different stakeholder groups such as clinicians.