Dáil Éireann debate -
Wednesday, 21 Nov 1956

Vol. 160 No. 9

Committee on Finance. - Voluntary Health Insurance Bill, 1956—Committee Stage.

Sections 1 to 3, inclusive, agreed to.

SECTION 4.

Question proposed: "That Section 4 stand part of the Bill."

Mr. MacEntee

Would the Minister be good enough to explain precisely what it is intended to do under this section? As I read sub-section (1) of Section 4 it states:—

"The board shall make and carry out a scheme of voluntary health insurance for defraying, to such extent as the Minister may from time to time specify, the cost to persons paying subscriptions to the board in respect thereof, and to dependents of such persons, of such medical, surgical, hospital and other health services as the Minister may from time to time specify."

It seems to me that there are three principles—I was going to say, submerged—in this sub-section. There is, first, the obligation which is laid upon the board of making a scheme. In relation to the making of a scheme it would seem to me that certain principles should be laid down. I think that is particularly desirable in view of the power which is conferred on the Minister in this sub-section to limit the activities of the board, because the board can only make a scheme of voluntary health insurance to such extent "as the Minister may from time to time specify." Perhaps the Minister will get up and say this: "You are misconstruing it; that is not how the section is to be construed at all. The section provides first of all that the board shall make the scheme and the board can make a scheme as wide or as limited as it likes."

But not only must the board make a scheme but it must also carry out a scheme and it is in relation to carrying out the scheme that the Minister's power to limit the operations of the board is designed to operate. I think that before the House proceeds to discuss this Section 4 of the Bill the Minister might have had the courtesy to tell us what was intended by Section 4 and what precisely sub-section (1) does provide for.

I would say—and I concede this at once—that it provides for the making of a scheme. But what type of scheme? A scheme to be limited by the Minister by certain directives which the Minister will issue? It would appear to provide for the carrying out of a scheme. Again, to what extent? What is to be the ambit of the board's operations? Are they to be limited by the circumference of a circle which the Minister will draw for the operations of the board? And what type of persons is the board to provide the scheme for? I submit these are real matters which arise immediately and directly from the manner in which this sub-section has been drafted, but we have not yet had a single word from the Minister by way of explanation. I suppose he does not know himself yet. He has not an idea in his mind as to what specifications he will make to the board. I would like to hear from the Minister on that point.

Mr. Bartley

In the general welcome which this Party gave to the Bill on the Second Reading, there were certain very important qualifications stated by each speaker and Deputy M. J. O'Higgins who purported to quote me here a short time ago certainly did not quote me in relation to Section 4 to which I referred on the Second Reading.

We have a choice of appearing to accept the piece of mechanism presented to us by the Minister because of our desire to accept the principle of voluntary effort on the part of the public to insure against ill-health. We thought that the principle of voluntary effort was important enough to accept the Bill as presented to us for the time being in the hope that it might be improved and amended on this stage. The other view might as reasonably have been taken that the piece of mechanism was so defective in itself that the principle could not possibly have any chance of being implemented under it. We did not take that risk and we gave a very general welcome with certain reservations and each Deputy specified his reservations.

I remember remarking in relation to Section 4 that the Bill seemed to be all board and no insurance and that we expected that the Minister would do something to improve it so that it would have a little larger element of insurance and less of bureaucracy about it. I asked specifically if the Minister would not eliminate certain things. This section contains one of the things to which I expressed objection. Deputy MacEntee has just been speaking about it. It is the provision that benefits are payable only to such extent as the Minister from time to time specifies.

I think anybody paying a premium for insurance against certain risks would expect that the people who provided him with the insurance and quoted him a premium would pay the precise extent of the risks covered and the amount of compensation or other benefits which the premium bought. It does seem to us that the Minister is to be allowed to decide the extent to which this board can interfere and to what extent they can provide benefits for the premiums they charge. I think that action on the part of the Minister destroys the insurance character of the measure. It would, in my mind, create one of the gravest doubts as to whether this Bill was capable of giving effect to the ideal of voluntary effort against ill-health. We asked the Minister to consider it with a view to offering an acceptable amendment but that apparently has not been done.

Mr. T.F. O'Higgins

I should like to explain one or two of the points raised by Deputy Bartley. I do not propose in any way to deal with the speech of the Deputy who preceded him. The purpose of Section 4 is hard to explain. Its object is not to limit the benefits being provided by the scheme but rather to define how far the Board must go. I hope I make myself clear. The best way of putting it is this: under the Bill, the Minister for Health must be satisfied that there is offered to the public a minimum cover relating to hospital and nursing home expenses, surgical and medical fees, other allied fees, X-ray for patients, physiotherapy and a variety of matters of that kind. That would represent the very minimum that the Minister would approve as a cover being offered in the policy. The extent referred to in sub-section (1) has in mind, or rather intends, that the Board will be told: "You must at least provide cover along those lines; you must go the full way and half way will not do."

That is what is aimed at in sub-section (1). Sub-section (2) gives power to the Board to provide other policies of insurance and to give additional cover above the minimum. For instance they may provide a maternity scheme not included under the minimum scheme. The Board, subject to the Minister's consent, might decide to provide maternity and some other benefits not included in the minimum scheme. Thus, sub-section (2) is aimed at empowering the Board to provide alternative policies for different additional benefits. Sub-section (3) is merely an amending sub-section. I hope that covers Deputy Bartley's comments.

Mr. S. Flanagan

In relation to sub-section (4), which refers to the principle that the board should not control any more revenue than is necessary for the payment of grants and benefits, during the course of the Second Reading two points of view were expressed regarding the way the scheme should be operated. One was expressed by Deputy Doctor Hillery who, being a practising doctor, would have a considerable amount of experience in these matters. His view was that the State should subsidise, for a period of three, four or five years, the benefits that would be paid and also that the initial amount provided for the board should be given by way of grant rather than by way of loan. Some of us had a different point of view, but I should like to know from the Minister whether he has considered giving a grant in accordance with Deputy Doctor Hillery's wishes or whether he prefers to stick to the principle of providing loans only. Deputy MacEntee expressed the view that if we give a loan now it will turn itself into a grant because the board will not be able to repay us.

Mr. T.F. O'Higgins

My view is quite clear. I think it would be fatal to the success of this idea of providing voluntary health insurance, and to the philosophy that is contained in the scheme, if it were not, straight from the beginning, put standing on its own feet. I have no intention whatever of providing grants or subventions. The board will have the statutory obligations contained in sub-section (4). They must run their business in such a way that they will be able to meet their liabilities and must repay such necessary sums as are advanced in the preliminary stages.

Mr. S. Flanagan

Sub-section (4) sets out the allowance proper for reserves, depreciation and other like purposes. The Minister seems not to have reserved to himself any right to watch over the activities of the board in that connection. There is a suggestion that the principle of the Bill—that the board would make no profit—could be got around. The board could make provisions for reserves and other like purposes and might be able in that way to put aside money which they would be able to use in blowing up salaries of their officials rather than in giving the benefits to the people paying premiums. I would prefer if the Minister had some right to examine the balance sheets of the board from time to time.

Mr. T.F. O'Higgins

There are subsequent sections dealing with that point.

Mr. S. Flanagan

Yes, but there is no mention of it in this section.

Mr. Bartley

The Minister has mentioned a number of things which may form the basis of a minimum service offered in return for a premium, but surely that is going to bring the Civil Service flush into the scheme. After all, the Minister will have to be advised in taking the power to specify what the board must provide as a minimum service. The Department advisers will quite often have to come in on the scheme now. Not alone have we a board but we have a board that the Minister does not trust to give good value for the premiums paid. If the Minister thinks it is necessary to take powers in the Act to specify a minimum service, it is obvious that he must have some reservation in his mind about the ability of this board to implement a genuine voluntary health insurance scheme. Why does he bring the Civil Service into it in this way by specifying that you must have a certain minimum?

Mr. T.F. O'Higgins

The reason for that is that under the Bill, and even apart from the Bill, the Minister for Health has deep responsibility with regard to the health problems of the people generally. Up to this that responsibility was discharged by providing merely for the services enshrined in the Health Act of 1953, leaving uncatered for such citizens as did not qualify for services under existing legislation. In order to discharge the responsibility which I conceive to be mine as the present Minister for Health, the Health Insurance Board must have imposed upon it a statutory obligation. It must be bound by the statute we are passing here to discharge a particular function. Were I to write into the legislation here such benefits as at the moment I would regard as being minimum, then the statutory obligation of the board would be tempered merely by what the Act says. In 12 or 18 months' time it might transpire the benefits which at the moment appear to be the desirable minima might be insufficient. Circumstances might change and it might be found that the cover should be greatly increased. Then it would be necessary to come back into the Dáil amending the present legislation by providing for increased benefits.

I feel that the more workmanlike way of doing it is to provide that the board must from time to time have on offer a scheme providing such benefits as may be specified by ministerial regulations that will ensure that from time to time the cover is kept up and kept in accord with rising expenses and rising costs. For instance, just to illustrate the matter. Deputy Bartley will recall that the schedule of benefits in the report of the Advisory Body on the voluntary health insurance scheme, which was published last June, which will be a model in so far as the regulations are concerned, provides for cover up to £7 per week in hospital with a maximum period of ten weeks. They suggested that as one of the benefits in the circumstances now obtaining. It might well be in two or three years' time that it might be felt that £7 per week was completely inadequate and if it were felt to be inadequate then the regulations themselves would alter the obligation on the board to provide more than that particular cover. In the way it is framed I feel it does allow the necessary flexibility in what, after all, is a new and experimental scheme about which one cannot have a very clear or definite view now. I think it is necessary, certainly in the initial years, that every possible scope should be given for manoeuvre and for changes in the benefits being offered and so on.

Mr. Bartley

That does not answer my question. We have been attracted by the Minister's proposal to initiate a scheme whereby the public would be induced to provide against their own ill-health. In previous legislation we were pilloried because of our imposing standards and practices on the public and on the medical profession which were not in vogue heretofore. We thought a complete break was to be made from that philosophy by the Minister who was very vocal about it when we offered our co-operation here. I am asking him, if he is setting up a board and if this House is agreeable to pay a certain sum of money, why does he not trust that board to draw up a scheme and let that scheme operate as nearly as possible to commercial lines? Why must the Minister inject the Civil Service into it after the board is set up?

Mr. T.F. O'Higgins

I thought I had explained.

Mr. Bartley

The Minister has not explained.

Mr. MacEntee

I had to go out for some time but I had asked the Minister certain questions in relation to sub-section (1) of Section 4 which he has not answered. Let me protest against the manner in which the Minister is treating the House. When it was put by the Chair in the usual way the Minister did not get up to explain to the House what was provided, what would be the effect of provisions of Section 4 and in particular what would be the effect of sub-section (1) of Section 4. I think the House is entitled to hear from the Minister his answer to the points I have raised. I think the Minister is bound to disclose to the House what precisely is in his mind in relation to sub-section (1) of Section 4.

Whether deliberately or inadvertently, the Minister has let some part of the cat out of the bag. He referred to certain proposals which were published elsewhere—certain proposals of which the House so far has no official knowledge, suggestions which were made elsewhere and which would be taken as models for the regulations under which the Minister will presumably act. I would like to know what is in the Minister's mind in regard to this. We are entitled to know that before we proceed from Section 4. I will sit down until I hear the Minister dealing with the points I raised in opening the debate on this section.

Mr. T.F. O'Higgins

For the information of the Deputy I have already given that information, not in reply to the Deputy, but in reply to Deputy Bartley. I take some umbrage at the audacity of Deputy MacEntee to raise questions here and then to leave the House. I have no intention of dealing with that.

Mr. MacEntee

That is just the type of discourtesy with which this Government is treating the House and the contempt with which it is treating the people. I am not asking this in my personal capacity. I am here as a former Minister for Local Government and Public Health—the Minister responsible for setting up the Department of Health, the portfolio of which is now held by the one-time Deputy O'Higgins. Whether the Minister takes umbrage at it or not, the Minister is bound to treat Deputies with respect and the House with respect and the public outside this House with respect. I am not asking this in my personal capacity. I am asking it here as a responsible member of the Opposition and I am putting the questions——

Mr. T.F. O'Higgins

Wait now. Surely the Deputy listened to what I have said. I have given that information to the House. The Deputy was outside.

Mr. MacEntee

I am sorry if I have in any way misrepresented what the Minister has said. I was informed that the Minister had not replied to the questions which I raised. I am sorry if I have, in error, accused the Minister wrongly. I wish to tender, through the Chair, my apology to him. But I did feel annoyed when the Minister told me that he had taken umbrage.

Mr. S. Flanagan

As Deputy MacEntee was not here at the time, may I say that the Minister said that he had no intention whatever of replying to the statement that had been made by Deputy MacEntee?

Mr. T.F. O'Higgins

What I said was that I was giving the information to Deputy Bartley, not to Deputy MacEntee, and I gave it fully.

Mr. S. Flanagan

Later, Deputy Bartley made a speech, and the Minister may or may not have replied to Deputy MacEntee's point, but, immediately after it was made, the Minister said he had no intention whatever of replying to Deputy MacEntee and I conveyed that information to Deputy MacEntee.

An Ceann Comhairle

I do not think any useful purpose is served by rehashing what a previous speaker has said.

Mr. S. Flanagan

There is no apology called for from Deputy MacEntee.

Mr. MacEntee

This is very important. If the Minister takes up the attitude of remaining mute of malice, I cannot compel him to speak.

Mr. T.F. O'Higgins

I do not think the Deputy is serious.

Mr. MacEntee

If the Minister wants to take up the attitude of the Sphinx because he has the brains and intelligence of the Sphinx, he is quite entitled to do that but I know that nature has somewhat better endowed him. I know the Minister is an able man.

An Ceann Comhairle

The Deputy should deal with the matter before the House—Section 4.

Mr. MacEntee

The Minister said he took umbrage about certain questions I directed to him.

Mr. T.F. O'Higgins

I took umbrage at the Deputy raising the questions and then leaving the House.

Mr. MacEntee

The Minister is sometimes called away on personal business. After all, we are not here as members of a chain gang, to be released——

An Ceann Comhairle

The Chair cannot allow this type of discussion to go on. It leads nowhere. It is of no value to the House and of no value to the measure under discussion. We must revert to Section 4 of the Bill and discuss it on its merits.

Mr. MacEntee

I was discussing it on its merits. I put three pertinent questions to the Minister and have not had an answer from him. The section is somewhat peculiarly worded. I am not a parliamentary draftsman but it seems to me ambiguous. Sub-section (1) of Section 4 reads:—

"The board shall make and carry out a scheme of voluntary health insurance for defraying, to such extent as the Minister may from time to time specify, the cost to persons paying subscriptions to the board in respect thereof, and to dependents of such persons, of such medical, surgical, hospital and other health services as the Minister may from time to time specify."

There are three possible interpretations of that sentence. One is that the board shall make a scheme to such extent as the Minister may from time to time specify. I asked the Minister, when he had failed to explain to the House what, in his view, the section meant, to say to me whether the board could only make a scheme to such extent as the Minister may specify. That is one interpretation of it. Another interpretation was that the board might make a scheme and then proceed to carry it out but only carry it out to such extent as the Minister may from time to time specify. The third possible interpretation is that the board should make and at the same time carry out a scheme, both operations to be done to such extent as the Minister may from time to time specify.

Mr. T.F. O'Higgins

If the Deputy is serious in these questions I will be glad to give the information. I gave it already but the Deputy was not here. It is not easy, as I explained to the House earlier, to explain what is aimed at. If I may put it this way— sub-section (1) is the sub-section under which the Minister for Health must assess what he believes to be the minimum requirements of those availing of health insurance. For example, the regulations may provide that the Schedule of Benefits set out on page 13 of the Advisory Body's Report which was circulated to Deputies——

Mr. MacEntee

It was not mentioned in the debate on this Bill.

Mr. T.F. O'Higgins

Does the Deputy want me to give the information or not?

Mr. MacEntee

I do.

Mr. T.F. O'Higgins

I am only answering the Deputy, I assure him, because I thought that he was seriously raising these matters. If I thought the Deputy was doing anything else, I would not bother about it.

Mr. MacEntee

If the Minister likes to follow in the footsteps of the Minister for Agriculture, he can do so.

Mr. T.F. O'Higgins

I am not a bit afraid of Deputy MacEntee. I can assure him of that. The purpose of sub-section (1) is to provide a minimum cover in accordance with regulations and the phrase "to such extent" represents the minimum cover. In other words, the board must provide the extent of benefits set out in the regulations. They may not provide anything smaller than that. They must go the whole distance along the road set out in the regulations. In the Advisory Body's Report, under Schedule of Benefits, which is set out on page 13, the Deputy will see the type of cover envisaged. It includes medical, surgical, hospital and other health services, expenses that might be incurred by a person as an inpatient in hospital and other allied expenses, but the full cover to the minimum laid down in the regulations must be provided by the board.

Sub-section (2)—and I think Deputy MacEntee had this also in mind—is the sub-section which empowers the board to provide additional benefits. Under sub-section (2) the board is entitled to say, "We will provide a choice of policy"—of course, at a higher premium and providing in the additional policies benefits more than is required by the regulations. That is the purpose of sub-section (2) but, in order to ensure that the board's additional policies will not run the board into financial difficulties, there is still the requirement of ministerial consent, and that is the purpose of that.

Mr. MacEntee

The Minister has put his finger on my difficulty in relation to this section when he said that it is not easy to explain what is aimed at. If it is not easy for the Minister to explain what is aimed at, how are dunderheads on this side of the House, like myself, to apprehend what the Minister is aiming at? I must say that I have not got very much further, I have not gained very much light, from what the Minister said.

The Minister in the course of his remarks said "The Minister must assess.""Assess" is a word which is applied to the evaluation of things, for instance, the amount of tax due, the value of an article, but I cannot see how the Minister can assess the benefits which must be provided except to the extent of saying that the Minister shall say that the benefits shall not, either in toto or separately, exceed a certain amount. If by “assess” the Minister means that the Minister shall conceive the type of benefit, then we are at one. I can see the Minister has a function there. I suppose he would have a function, too, under the other head, but it rather seems to me like putting the cart before the horse if the Minister were to assess a thing before forming any idea as to the nature of the benefits which the board should provide.

Having said that, the Minister went on to say that these things were to be assessed, I think, by regulation. I have been looking through the Bill and, while I may be wrong, it seems to me that there is no power in the Bill, so far as I can read it, which empowers the Minister to make regulations. It may be in fact that for the purposes of this Bill such power is not necessary but in my experience I should be surprised if the Minister would not require to be empowered by regulation to specify the matters to be dealt with.

Mr. T.F. O'Higgins

I am advised it is not necessary to provide specifically for it.

Mr. MacEntee

If the Minister is so advised I am not going to say that he has been wrongly advised, but it is certainly to me rather unexpected, because hitherto in relation to the drafting of most Bills where the Minister is empowered to call upon a body to do certain things, as a rule, the Minister does, by regulation, oblige the body concerned to do these certain things. There is a provision embodied in the statute, as a rule, empowering a Minister to make regulations to that end. I concede that there is nothing like this measure on the Statute Book, but if the general body of Oireachtas enactments are looked at it will be seen that usually there is a section in them empowering the Minister to make regulations requiring certain people or corporate bodies to do certain things. I do not see such a regulation in the Bill.

Mr. T.F. O'Higgins

I shall have that matter examined between this and the Report Stage.

Mr. MacEntee

There is another matter I should like to raise on this section. Sub-section (1) says:—

"The board shall make and carry out a scheme of voluntary health insurance for defraying, to such extent as the Minister may from time to time specify, the cost to persons paying subscriptions to the board in respect thereof, and to dependents of such persons, of such medical, surgical, hospital and other health services as the Minister may from time to time specify."

That is a matter upon which I should like some guidance. First of all, I should like to know how the proportion to be defrayed is to be determined, whether the Minister has any views in his own mind as to how the proportion is to be determined and then again how the proportion is to be expressed, whether the defrayment will be pro rata to the amount of the contributions or to the cost of the service or whether the defrayment will be by the contribution of a specific sum. These are matters upon which the House is entitled to have some information.

As regards sub-section (4) there is a rather peculiar clause in this sub-section which has already been referred to by Deputy Bartley and Deputy Flanagan. Sub-section (4) provides:

"The board shall so fix the subscriptions provided for by schemes under this section that taking one year with another the revenue of the board from subscriptions together with its other revenues (if any) shall be sufficient, but only sufficient (as nearly as may be), after the board has made such allowance as it thinks proper for reserves, depreciation and other like purposes, to meet the charges (including repayments of loans to the Minister) properly chargeable to revenue."

I wonder if the Minister has considered what that will involve. After all sickness is not a thing that we experience or that visits the community in a sort of regular flow. Some years the community will enjoy comparatively good health. Therefore the contributions in respect of the good year, when the claims on the scheme will be proportionately lower, should be correspondingly less, but then, if we have an epidemic, as we had within the last year, or as we may perhaps have in future, and we have a bad year, will the contributions in respect of that bad year be considerably increased? It would seem to me that very little consideration has been given to the financial implications of sub-section (4) and as to the effect it will have upon the success or otherwise of the scheme.

What year will be taken with another? It is a very unsound basis to go on. I know that this section has been copied almost word for word— the Coalition are great imitators—out of the E.S.B. Act. That is the sort of thing which appears there and even in this House in our own time in relation to public electricity supply where the consumer is probably caught once and for all, if rates and charges are sent up he must grin and bear it. However, people will be able to adhere to and to secede from this scheme from year to year. The contract is a yearly one. How does the Minister think the scheme will work on the basis of sub-section (4) of Section 4?

Progress reported; Committee to sit again.