I should first of all like to express to the House my pleasure at the manner in which this Bill has been received. Generally speaking, Deputies have welcomed the Bill and the slight opposition expressed in the debate came from a Deputy who had not read the Bill, who did not know anything about it and, I think, cared less as to what was in it or what might not be in it. At the same time, I could not help feeling, listening to the speeches made by Deputies, that in some respects there was, perhaps, an understandable lack of knowledge of what it is hoped to achieve by this proposal.
When I had to consider the health problems in this country over two years ago, I found a situation which was chaotic in some respects, but a situation which was potentially good for the people. I have always felt, in relation to health services and, indeed, many other matters, that we are inclined to forget that all of us have a primary responsibility to look after ourselves and to look after our families. I do not say that from any moral point of view. I say it from the ordinary point of view of any decent person who has any regard for himself and his family. If a man has the means to look after his wife when she is sick and his children when they need medical treatment, I am sure he would regard it as a gross impertinence if his neighbours came in and offered to pay the bill. There is, therefore, that point of view which, I think, should colour our approach to matters such as this.
It is understandable and necessary, where there are people who, unfortunately, are unable to provide for themselves, that any Christian State must fill the gap in order to ensure that those in need will get necessary services. I regarded the Health Act of 1953 as being an effort to provide free, or partially free, services for those who were unable to pay. Regarding it in that light, I have made every effort to see that the services promised under that legislation would in fact be made available to our people. But, at all times, I regarded some system of co-operation amongst the people, in the way of insurance, as being equally necessary with legislation to help those in need.
I would not regard voluntary health insurance as being in any way an alternative to some form of State assistance for needy people, but I would regard the mere provision of State assistance for needy people without something such as we are proposing here as being a very incomplete way of facing up to these matters. I felt, therefore, that, once steps had been taken to provide for those in need, then we should proceed with a measure such as this to provide for other sections of the people who have sufficient means to pay something towards their health expenses but who would be unable to pay all if a sudden sickness or illness came upon them.
A suggestion has been made—I think it was by Deputy McQuillan—that the proper expansion of existing services should be along the lines of providing a system of State medicine here. May I express the hope—and I mean this sincerely—that here in Ireland we will cease to ape other countries? May I express the hope that we will try more consistently to bring about an Irish solution to our own problems without seeking merely to apply here something they have done successfully or otherwise elsewhere?
To introduce here a system of State medicine would be, leaving aside the question of cost, a very simple way of providing for the needs of those sections I have mentioned in introducing this Bill. It would be the simple way of doing it. It would cost money, but so far as the actual legislation is concerned, there would be no trouble about it at all—a simple amendment to the Health Act of 1953 and there it is. But to do that would, in my opinion, be to belittle the people of this country. It would be, in effect, saying to what I believe to be the majority of our people that they were going to have their own natural obligations fulfilled by their neighbours through taxation and that henceforth they had no responsibility for the medical treatment and care of themselves and their families. That, I think, would be quite contrary to our ideals, our traditions and our principles and certainly I feel it would not be a proposal that should be entertained by any Irish legislature.
Accordingly, this idea of voluntary health insurance is not intended to be in the way of a subsidised service for any person who takes out this insurance. It is intended to be insurance and nothing else. It will not and should not cost the taxpayer anything. There may be some slight reflection to be made later on with regard to maternity services for the reasons I have explained in introducing the Bill, but, so far as the broad cover aimed at under this scheme is concerned, there will definitely be no subsidy whatsoever. There are already people suggesting that here and elsewhere the taxpayer should be asked to contribute. I do not believe he should. I think it is quite possible under this scheme as it operates to get people by co-operation under insurance to provide in a simple and easy way the necessary cover for themselves.
I know it is easy to say that the premiums suggested in the advisory report are too high. I would like to remind Deputies—and I am not to be taken as saying these are the premiums that the insurance body will eventually offer—I do not know; that will be a matter for themselves—that the advisory body in its report suggested certain premiums for the cover they regarded as necessary. The highest premium for a married couple with four or more children is £15 per year. To any of us £15 is a sizable amount if we have to produce it quite suddenly, but, remembering that it is payment we are asked to make for the discharge of the very definite responsibility we have towards the health of ourselves and our family, I do not think it is too high. It means two packets of cigarettes or a few bottles of stout in a week. It means something less than 6/- each week to meet what is one's responsibility to look after the health and welfare of one's family.
I do not believe that there are any large sections of our people who can afford to pay something who would regard a policy with a maximum premium of £15 per year as being such a crushing burden that they would have nothing to do with it and would rather throw themselves on the charity of their neighbours to have their medical expenses and other necessary services provided for them. The £15 per year, which is the highest premium, represents the gross premium. As Deputies will recall, in, I think, the Finance Act of last year, an important concession in relation to income-tax was made available to any person paying premiums for health insurance and the net premium might work out at something around £12 or so, which would be the highest premium, on the Report of the Advisory Body, that would be chargeable for this type of insurance.
Deputies have asked, not unreasonably, what kind of cover will be provided by the policy when it is offered. Again, it is not possible to answer that question with accuracy at this stage, but under the Bill the insurance body will be directed, will have a statutory obligation in this respect, to carry out a scheme of voluntary health insurance for defraying to such extent as may be specified by regulations the cost to persons paying subscriptions and to dependents of such persons of such medical, surgical, hospital and other health services as may be specified by the Minister.
The purpose of that section and the object sought to be achieved is that regulations, which I or the Minister for Health will make, will contain a certain minimum cover along the lines of the cover set out in the Advisory Body's report, which is a pretty extensive and comprehensive cover. The benefit rates which the Advisory Body suggested provide for a payment up to £7 per week for a maximum period of ten weeks in respect of hospital and nursing-home charges. It provides, in effect, for full cover for surgical and medical fees. It provides for payment up to three guineas per X-ray. It provides cover for pathological and bacteriological services. It provides cover in respect of specialist consultations, in respect of physiotherapy for in-patients in a hospital and for various other services of a specialist kind provided for in-patients. It also provides a limited cover up to £5 in any year for drugs and medicines for in-patients in hospitals. It provides cover for medical and surgical appliances up to two-thirds of the cost, and so forth.
That is a pretty general comprehensive form of cover for any subscriber. In all probability, the regulations which I would make under Section 4 of this Bill would impose on the insurance body a statutory obligation to offer a policy to the public which would contain at least these benefits and this cover. Of course, it is understood that the insurance body may themselves say: "We will regard that as our minimum cover but we will also offer a more expensive policy to persons who might be willing to pay more." Quite a number of the present prudential associations engaged in health insurance have, in fact, quite a number of policies which they offer at varying rates of premium. Under the Bill power is given to the insurance body to offer a choice of policies to the public provided they have a minimum policy with the minimum benefits that will be prescribed by regulations.
Some Deputies rather thought that this scheme was designed solely for the higher income group. May I emphasise that that is not so? In fact, I should be profoundly disappointed if a number of persons now entitled to health services under existing legislation did not decide to avail themselves of this insurance. Deputies will appreciate that, under the Health Act, 1953, particularly in our country, it was not possible to arrive at a standard of means which would ensure that you were helping only those who, in fact, needed help. A farmer with a £50 valuation in one part of Ireland might be a comparatively poor man while, in another part of Ireland, he might justly be regarded as a rancher. That, itself, in the county economies, has had the unexpected and, I think, undesired result that a number of persons who could well pay their way do now, in fact, get free, or partially free, services. I hope that many such people who now have available to them a cheap form of health insurance will decide to avail of it and will be encouraged to do so.
I do not want to go into any great detail but I mentioned that the cover suggested by the Advisory Body for hospital and maintenance charges was a cover of up to £7 per week. At present, if an eligible person under the Health Act exercises a choice of hospital—in other words, if he goes to a hospital which he selects himself or if he does not go into the public ward of the hospital to which he is sent but goes instead into a semi-private or private room—the health authority can contribute a sum of only four guineas per week in respect of his maintenance in the hospital of his choice or in the private or semi-private room. In addition, the health authority cannot pay any medical fees. Such a Health Act patient, going to a semi-private or private room in a hospital, gets nothing more than four guineas per week. If, however, he decides to avail of health insurance, he will get, under the suggestion here, a contribution of £7 per week in respect of his hospital bill and full cover for surgical and medical fees. There is quite a definite attraction, therefore, to those who can afford to pay something to avail of health insurance and, if they do so, then the burden on the ratepayers and taxpayers will be reduced to some degree.
I should like to make it clear that, while the premiums that will be offered must be such as to make this insurance scheme a solvent one, nevertheles, every effort will be made—because this is a purely voluntary scheme—to make the premium as popular and as attractive as possible. That is done on the clear understanding that there will be no means test or means limit or anything in relation to means which entitle or disentitle a person to avail of this scheme. It is open to everyone, provided they are able to pay a premium which, with other premiums, will meet the total call on the funds but which will contain no element of profit for the board running the scheme.
I should just like to emphasise that. I know that certain British prudential associations and insurance bodies have for some time been engaged upon health insurance work. They have offered different policies to the people of Britain and the people of the North of Ireland. It is notable that even in a land operating a full system of State medicine these health insurance bodies still find thousands of people who prefer to make their own arrangements.
At least one of these associations offered a policy in this country some four years ago or so. In doing so, they offended the provisions of our insurance legislation. They were not entitled to operate here, but many people have regard to the size of the premiums which this body offered when they were seeking business here and the premiums are very much lower indeed than the premiums suggested by the advisory body.
I would, however, express my belief that if these British associations had, in fact, been entitled to operate in this country they would have very quickly become insolvent because the size of their premiums was based on the particular circumstances in Great Britain and on the fact that there is a comprehensive State health service which allows a certain amount of selectivity with regard to whether a person would call upon the insurance fund or not and, of course, in addition, the families in Britain are just half the size of our families here.
The rate of fertility amongst married women in this country is particularly high. According to figures in recent years, the number of births per 1,000 women of child-bearing age was 254 compared with 111 in Britain. That means that the average size of our families is more than twice that of British families. Accordingly, I think that these low premiums which are possible in England, where they have a full State scheme already, where families are small and where it is possible to get large groups of population in dense areas, could not under any circumstances apply here. In any event, I only mention that because, when I say that the premiums offered here will be as attractive as possible, they cannot at the same time be competitive with the premiums suggested or on offer from similar bodies outside this country.
Some Deputies expressed concern as to the necessity for providing this new body with what, in effect, may be almost a monopoly. Frankly, I could sympathise with the Deputies who expressed such a doubt. My original concern, as will appear from the Bill as drafted now, was to provide that this body should be able to meet any competition from any other groups or syndicates that might wish to engage in this business. I found, however, on closer study of the matter, there was a danger that certain groups outside the country who were still entitled under our Insurance Act of 1936 to operate here, might, in fact, decide to engage in such health insurance business.
They could do so for a time, but during that time they could so operate a policy that this new board would find itself unable to compete. The result might mean the disappearance of any home-controlled insurance body that would have to provide this form of insurance. In the circumstances, I felt it was wiser to provide for this new body what, in effect, has been frequently done in the past for other similar bodies, a certain amount of protection, particularly in the early stage to enable it to get under way.
That is all I care to say in closing the debate. I could not attempt to deal with the many particular points raised by Deputies. I should just like to emphasise that this legislation is designed to provide the machinery to operate a scheme of health insurance. The body that will be established under this legislation will be guided largely, I have no doubt, by the very detailed report submitted to me by the advisory body established last year. I should like to avail of the opportunity in Dáil Eireann to express my gratitude and the gratitude of my colleagues to all members of that advisory body for the excellent work they did. The report itself was submitted very expeditiously. It is a well-documented report. It contains interesting information and illustrates considerable study and considerable work by everybody associated with it and I would like to express my gratitude, and that of my colleagues, to everybody who helped to compile it. The board will have due regard to it when it proceeds to offer its policy to the public.
In conclusion, I should like to repeat what I said in my opening statement. This idea of health insurance is a voluntary one. It cannot operate and it cannot succeed unless it is backed by a worthwhile public opinion. That public opinion can only be moulded and formed if people realise that they have an obligation and a responsibility to stand on their own feet and to fend and provide for themselves. The State has an obligation to look after those who need help and, where necessary, to provide the means for people, even with money, to meet unexpected hazards of ill-health. The purpose of the State, in my opinion, should be to supplement, and not supplant, individual effort. If that is understood by the public generally, if more and more of us realise that we have a responsibility ourselves which we cannot shelve, shirk, or delegate, and that our responsibility must be discharged by our own efforts, then, with health insurance, an easy means is provided to meet that responsibility. If people realise that, I have no doubt that this scheme will eventually be a success.
