I move:—
That it is expedient to authorise the payment out of moneys provided by the Oireachtas of any expenses incurred in the administration of any Act of the present session to amend the National Health Insurance Acts, 1911 to 1936.
Committee on Finance. - National Health Insurance Bill, 1941—Money Resolution.
On the Money Resolution, Sir: I received notice from you that amendment No. 1, standing in my name, is out of order, and while I appreciate the basis upon which your ruling is made and, naturally, accept your ruling, I think that the point I sought to make in that amendment is one that properly arises for comment, of at any rate a brief kind, on the Money Resolution. We are asked here, in the Money Resolution, to provide the necessary expenses for carrying out the administration of this Bill when it becomes an Act. I object to the limitations in the Bill, as presented by the Minister, to such an extent that I am against the voting of additional money for a Bill of this particular kind. The Parliamentary Secretary, in his Second Reading speech on the Bill, indicated the decimal point, the logic and calculation of the actuary in a certain number of matters which enabled the Parliamentary Secretary to come before the House with the proposal that something like £175,000 would be available annually for the next five years in additional benefits. As I say, the actuary brought his thinking on that particular matter, according to the Parliamentary Secretary, to quite a number of decimal points. I drew attention, on the Second Reading, to the fact that the national health insurance scheme at the present moment provided for a man who went sick 15/- in money benefits, and I indicated how utterly inadequate that was for the maintenance of himself and his family, and how badly it related even to the amounts of money to be paid to persons in unemployment assistance payments. So that, where a man had no other income but his wages, although he had a wife and family to maintain, if he got sick, under the national health insurance scheme he could only get 15/- a week as cash coming into the house and was inevitably thrown on outdoor relief for any additional moneys that would be required to sustain himself and for all the moneys required to sustain his wife and family. I indicated that it was wrong that the Minister should be approaching this matter, to spend £175,000 more, without giving an undertaking that it would be spent upon cash benefits.
In addition to that, I wanted to ascertain whether either the National Health Insurance Society or the Minister, in reviewing the national health insurance position, had given any systematic consideration to what it takes in money or in kind to maintain a man and his family through sickness, irrespective of the additions in the line of medicine or medical attendance of any particular kind that would have to be added on, because I suggest, and I think the Parliamentary Secretary and everybody else will take it, that unless the basis of maintenance as regards food is provided, there is very little use in giving medicines. In response to questions as to whether an examination of how much it would take to maintain a man and his wife and family had been made, or whether any investigations of that kind had been carried out, I got very unsatisfactory answers. The purpose of my amendment would have been to secure that the actuarial brains and the actuarial judgment, that were available to so many decimal points for considering the basis of this scheme and its possibilities, would be directed in some measure to considering what is required in cash benefits to maintain a family as the basis which was absolutely necessary to have before medicine or any other treatment could be brought to it. That is why I object to voting for this Money Resolution, because the Bill is not framed on lines that would suggest that the consideration had been given to it that, in 1942, the House would expect would have been given to this particular matter.
I have a further objection to this Money Resolution. I asked the Minister yesterday whether, as a preparation to the presentation of this Bill to the Dáil, he had received from the National Health Insurance Society any representations as to the inadequacy of the cash payments at present being made in respect of sickness benefits, or whether any proposals had been brought forward for their increase. The Parliamentary Secretary answered that he had received no representations on that matter. I asked him had he received any indication from the National Health Insurance Society as to the actual benefits which it was proposed to include in any such scheme of additional benefits as were contemplated under the Bill, and the Parliamentary Secretary told me that no formal submission of an additional benefit scheme had yet been made. So that here we are asked to pass a Bill, which the Parliamentary Secretary has indicated is a far-reaching measure and in connection with which £175,000 will be available each year for additional benefits, and the Parliamentary Secretary tells the House, by way of formal Parliamentary answer, that no discussions have taken place between himself and the society as to what kind of benefits they have in their minds to include in a scheme that will be submitted under this Bill.
The absence of that information, or the absence of any contact like that between the Parliamentary Secretary and the society, is all the more difficult to understand when we were informed to-day that the reason why the Committee Stage of this Bill was taking precedence of the Vote on Account was that it was very desirable to have this measure passed through the Oireachtas before the end of the financial year. I think that the House is being asked to deal with this matter in blinkers. It is an important matter; I think few things are as important as a real national health insurance scheme, and I think the Parliamentary Secretary is unfair to the House and unfair to a very important subject when he approaches us in this particular way. I do still suggest to the Parliamentary Secretary that we ought to know what consideration has been given to the health basis as necessary to be provided for by means of financial benefits, and I think he ought to take us more into his confidence as to what has transpired between himself and the society as to the lines on which additional benefits are likely to be made.
Will the Parliamentary Secretary inform us whether he is in a position to indicate when, in fact, these additional benefits will be provided for? Certain benefit periods are set out in the Bill, but the striking part of the Bill and of the discussion on it has been that, so far, we have got no idea as to what type of additional benefits are to be made available.
Now, I do not know, but I should imagine that by now the National Health Insurance Society have indicated what, in their opinion, would be the best method of expending the additional money available. It is scarcely credible that so far the society has concealed its mind in that regard. I should imagine that by now the society and the Department would have discussed what is the best way of expending this money, what is the best type of benefit to make available, what is the most pressing benefit applied for by insured persons, what is the type of benefit most calculated to cure the disabilities which cause such heavy demands on the society's funds. I wonder if the Parliamentary Secretary at this stage will take us into his confidence and tell us what type of benefit it is proposed to pay or to make available to insured contributors under this Bill when it becomes an Act.
Reference has been made to this sum of money which, I gather, is in the order of £175,000 per annum. I think the Financial Resolution is an appropriate time for the Parliamentary Secretary to tell us where the sum of money is to come from. I remember when the actuary's report was published and commented on in the daily Press, the outstanding feature of the report was that if disablement benefit claims continued on the same scale as the society had experienced for the last few years, there were doubts as to whether the funds of the society would be solvent at their valuation. It may have been that there were some paragraphs in that report which were not adequately emphasised, and which would have gone towards counteracting that impression. But it is something of a surprise to me, having read the terms of the actuary's original report as reported in the Press, to hear us talking glibly about a surplus which is to be distributed in the form of additional benefits.
All of us are anxious that there should be additional benefits, and some of us who were associated with approved societies before they were all amalgamated naturally want our old members to get back the additional benefits they once enjoyed, and which they had to sacrifice when they were amalgamated into a common fund. But I do not think anybody in this House desires to have the National Health Insurance Fund of this country administered in such a way as to bankrupt it at the end of a period of years. It has to be borne in mind that the actuarial examination of a fund of this kind depends on certain factors which do not apply to ordinary life insurance funds, because the solvency of this fund depends not only on the actuarial probability of sickness incidence, but also on the probability of the regularity with which subscriptions by members will be made to the fund.
The times we are living in are disturbed enough, but the future holds prospects of probably far greater disturbance, certainly economically, and the possibility of very widespread unemployment which will vitally affect the income of the fund. These are factors which I am sure the Minister and his Parliamentary Secretary have considered. But I think it would be a reassurance to the public mind if at this stage the Parliamentary Secretary would say what are the facts upon which he bases his assumption that there is a distributable surplus, what are the facts which led him to believe that the National Health Insurance Fund is in a position to give extra benefits to-day, which he declared to be quite out of the question when the amalgamation took place some years ago in very much more settled times than these in which we are living at present. Is the Parliamentary Secretary authorised by the Government to say that out of public funds the Treasury will make up any deficit the present proposals may create during the years to come? Is he prepared to give the Treasury's guarantee that, whatever the consequences of these proposals may be on the solvency of the fund, the Treasury undertakes in the last analysis to restore that solvency if it should be impaired by the distribution of what the Parliamentary Secretary regards as surplus funds at the present time?
The second point I want to make arises from a matter mentioned by Deputy Mulcahy. He spoke of the inadequacy of 15/- a week for a sick man and the much greater inadequacy, of course, of 7/6 a week for a permanently disabled man. It seems to be manifest to us all that if the majority of insured persons had nothing but that 15/- a week to depend upon their families would have been in difficulties. But we all know that in practice what has happened is that most decent employers have continued to pay their sick employees the difference between their ordinary wages and the 15/- which they receive from the National Health Insurance Society, although it is paradoxically true that that procedure is illegal. Strictly speaking, the employer should continue to pay to his employee his total wage or dismiss him. There is no warrant of authority for paying a man his wages less the 15/- a week he gets from the society. I put it to the Parliamentary Secretary that, in order to go some way to meet the point raised by Deputy Mulcahy— and it is a very small point—occasion should be taken of this legislation to regularise the procedure whereby an employer pays his sick employee the difference between the benefit he receives from the society and the wages which he was receiving prior to the incidence of his illness. Otherwise many employers will feel bound to give their employees notice and terminate their wages altogether, leaving them exclusively on the funds of the society. That, in my opinion, would be a most retrograde development. While I am not prepared to suggest at this stage that every employer should be compelled to pay his sick employee the difference between his wages and the insurance benefit, I think those employers who are prepared to co-operate with the National Health Insurance Fund to that extent should be encouraged to do so and at least should have such action as they take towards that end made legal, so that they should not leave themselves open to an action at law in their effort to assist in relieving the distress of employees who become charges on the National Health Insurance Fund.
I think, perhaps, I might briefly deal with Deputy Dillon's main point before coming to the points raised by Deputy Mulcahy and Deputy Norton. If Deputy Dillon had been present at the Second Reading debate it would be unnecessary to deal with the point he raised here to-day. The whole principle of the Bill is based on the fact that we are changing from the system of capitalisation to the system of assessmentism. Deputy Dillon, I am sure, is aware of the fact that if we examined the financial position of national health insurance on the basis of assessmentism——
What is the word the Parliamentary Secretary is using?
Assessmentism—annual income and expenditure as against capitalisation. If we examined the financial position in the manner indicated, we would find that, in fact, the excess of income over expenditure would average about £150,000. Under the capitalisation system, a certain amount of the contribution income had to be put aside from year to year for the purpose of redeeming reserve values and paying interest on these paper credits. Had we continued on the capitalisation basis, we, certainly, could not, within the present financial structure, provide any additional benefits—cash or otherwise. We obtained actuarial advice as to the desirability and safety of departing from the capitalisation system and adopting the assessmentism system— annual income and expenditure. It is on the advice of the actuary that this legislation has been introduced, and it is on his advice that we propose to make available, for the five years beginning 1st April next, a sum of, approximately, £175,000 a year. It is not proposed to encroach on the reserve accumulated under the old system, amounting to about £4,500,000. It is proposed to leave that reserve there as an additional source of income to the society. The income from that sum of £4,500,000 should go a long way to meet the proposed expenditure under the additional benefits. Deputies will also observe that it is proposed to establish a new reserve fund under Section 6. We shall have some discussion on that reserve fund later in connection with an amendment.
Deputy Mulcahy complained that the amount of the cash benefits was inadequate. As I said on the Second Reading, I have a good deal of sympathy with that viewpoint, but this particular piece of legislation has nothing to do with the cash benefits. If it is considered desirable that the cash benefits should be increased, we shall have to consider where the money is to be found for the purpose of financing the new scheme. It can be found either by an additional State contribution or by increasing the contributions from the employer and employee. However, that is not the question before the House. Deputy Mulcahy is, I suppose, within his right in drawing the attention of the House to the fact that this Bill is not sufficiently comprehensive, and in urging that it ought to include provision for increased cash benefits. The principle of the Bill has now been accepted by the House, and, if additional cash benefits are to be provided, the insurance society, the Government and the House will have to put their heads together and decide where the money is to come from to give effect to the more comprehensive scheme.
For a number of years there has been a considerable amount of pressure to provide additional benefits from people interested in national health insurance. So far as I am aware, there have been no representations in favour of the proposal to increase cash benefits. Nobody can deny that if the 15/- a week cash benefit is to be related to the earning capacity of a man in receipt of £4 or £5 a week, it is utterly inadequate to maintain himself, his wife and family, in times of illness. That raises the question as to whether the cash benefits and, consequently, the contributions, ought to be related to earning capacity or wages, instead of having them on a flat rate. That is a very big question on which I, personally, have an open mind. Again, it is a question that cannot be dealt with in this legislation. As to the question which Deputy Mulcahy was anxious to discuss, seeing that the amendment had been ruled out of order——
The Parliamentary Secretary might be equally out of order in replying.
I shall try to get around it in the same way that Deputy Mulcahy got around it. The type of investigation that Deputy Mulcahy has in mind is, in fact, being conducted by a Departmental Committee in connection with the question of family allowances. Without running the risk of a reprimand from the Chair, I might say that the question is more appropriate to such a committee than it would be to an inquiry in connection with this Bill inasmuch as the very difficult and complicated question of dietetics and the nutritional value of different foods must be related to the cost of maintaining a family in good health.
What Departments are represented on that interDepartmental Committee?
National Health Insurance, Local Government, Finance, Industry and Commerce, and Education.
In mentioning national health insurance, does the Parliamentary Secretary refer to the section of his Department dealing with the matter?
Yes. As regards the complaint by Deputy Mulcahy, backed up by Deputy Norton, that we have come to the House with this Bill providing a substantial sum of money for additional benefits without having any fixed idea of what these benefits are to be, there is a slight misunderstanding. My reply to Deputy Mulcahy's question yesterday was to the effect that no formal scheme had been submitted. While a formal scheme has not been submitted, exchanges of view have taken place between the insurance section of my Department and the society. These discussions are purely informal; they are merely exchanges of view. Until the necessary statutory provision made the money available, there was no point in getting down to the details of the scheme. I am not in a position to indicate the likely additional benefits. There may be a common outlook as between the national health insurance section of my Department and the society or there may be a difference of opinion. It is probable that many people outside the society and the Department will have their own view as to how this money could best be expended.
Deputy Norton asked when the benefits will be provided. It was hoped to have the scheme ready for operation on April 1st. It is quite clear now that it will not be possible to bring it into operation on April 1st, but the five years' period will begin on April 1st, and the money that will be earmarked for each of the five years in the first financial period will be available for the year beginning April 1st next. If it is not all expended in that year, because of the fact that we are a little bit late in starting, anything saved will be carried forward for the benefit of the scheme in the following year, or £175,000, if that is the exact figure, might be spent within six months, even though it might be two or three months before the scheme actually came into operation.
Could the Parliamentary Secretary refer to a matter that I mentioned in connection with employment, paying the difference between the amount of wages that a person receives from an employer, and whether the Government intends to legalise that position?
I am afraid I could not answer that question.
Will the Parliamentary Secretary consider it?
I will look into it.
Can the Parliamentary Secretary say what type of benefits it is intended to provide? He admitted rather reluctantly that they were to be provided.
No.
He admitted that the section of his Department dealing with national health and with the society had at least informal talks, and it is not unreasonable to assume that the question of providing adequate benefits was discussed. What will be provided? Is it dental benefit, surgical benefit, hospital treatment, convalescent home treatment and tuberculosis treatment? All come within the purview of the discussions. Could the Parliamentary Secretary not say which of these schemes it is intended to operate under the additional benefit scheme?
I could not answer. It has not reached the stage where any formal scheme has been submitted. There have been purely informal discussions in which those concerned put their heads together and pooled their knowledge of the problem.
Representatives of the board?
Representatives of the society and of the Department's insurance section.
Is that the position on March 5th, even though the new benefit year starts on April 5th?
Is the Resolution agreed to?
No. I want to divide the House as a protest against putting forward legislation that will empower the spending of £175,000 every year for five years, without giving the slightest information as to what the money is going to be spent on.
Additional benefits.
What kind?
The additional benefits to be provided are set out in the Acts. The Deputy knows that, and the benefits are confined to the additional benefits set out.
We cannot judge how much will go to one or the other.
No. The money must be made available first.
Resolution put and declared carried.
Resolution reported and agreed to.