Voluntary Health Insurance Bill, 1956—Second Stage.

Minister for Health (Mr. O'Higgins)

I move that the Bill be now read a Second Time. In recent years this country, like many others, has been more and more concerned with the provision under legislation of health services of a variety of kinds for individuals. The steps taken in this direction have in the past led to much controversy and discussion. We have not followed the example of our nearest neighbour in providing a comprehensive State-aided health scheme for all citizens irrespective of means. We have, however, travelled some distance along that road in providing a fairly comprehensive measure of free or partially free health services for a substantial section of the population. It is, however, implicit in the steps already taken under our health legislation that many citizens whose need may be as great have not in fact been provided for. Present health services do not, generally speaking, confer any benefits of free or partially free services on those whose income exceeds £600 yearly or on farmers whose valuations are over £50. There is, therefore, an appreciable section of the population who under present circumstances must themselves bear the full cost of health services. The number of such persons has been estimated very roughly at 170,000. Adding their dependents, this category of the community might total between 400,000 and 500,000 persons in all.

It will be appreciated that expenses arising from the treatment of ill-health have increased steeply in recent years. The cost of medicines, appliances, dressings and so forth has advanced and modern developments in medical and surgical techniques require the use of more costly equipment and more elaborate investigation and treatment than they did ten or 20 years ago. Indeed it is probable that these expenses will advance further as time goes on. The picture, therefore, so far as it concerns those above the limit of £600 yearly income, or £50 valuation in the case of farmers, is that these people may find themselves at very heavy, even crippling, expense should illness requiring hospitalisation or extensive surgical or medical treatment befall them or members of their families. No one could regard with complacency a continuation of this state of affairs and it is desirable that some way be found to help such people to meet such heavy and unforeseeable expenses. One way of doing this would, of course, be to provide substantially extended health services of the kind already available under present legislation. This would mean the provision of a comprehensive scheme of State medicine with all that such a scheme implies. I and my colleagues in the Government are convinced that that would not be the best way to meet this problem. We feel that it would be far better to find some way by which those on whom these heavy costs fall could meet such costs themselves without having to be dependent upon the State or upon health authorities to assist them in doing so.

It has appeared to me that some scheme organised after the pattern of voluntary health insurance schemes operating extensively and successfully in other countries might meet our circumstances here and, in order to establish whether we in this country might proceed on similar lines, I set up in January, 1955, a widely representative Body to advise me in the matter. I asked this Body to advise on the feasibility of introducing a scheme of voluntary insurance which would enable citizens to insure themselves and their dependents against the cost of hospital, surgical, specialist and other treatments and against the cost of medical or surgical appliances. I asked the Body also, if they considered that such a scheme would be possible, to recommend the type of organisation best suited to operate it; the minimum benefits which should be provided under various headings; the contributions which would need to be made by the persons in the scheme and to advise me on some other points— such as the methods of collecting contributions from the participants.

The Advisory Body reported to me that they considered that it would be feasible to introduce a scheme of voluntary insurance against the cost of hospital maintenance, surgical and medical services and maternity. They also felt that certain medical and surgical appliances could be included on stated conditions and that the cost of drugs and medicines could also be covered in a scheme, again on certain conditions. The Body considered that the best type of organisation to administer a scheme would be a non-profit making company, specially established for the purpose, and with a Government guarantee at the commencement at least. It was also considered that the Body should be exempt from the obligations regarding share capital, etc., imposed under insurance law. The remaining recommendations of the Body mentioned the premium which it was felt would be necessary for a minimum scheme and dealt with some other less important matters. The Body were unanimous in their views, except in one matter to which I will refer later.

Since I received the report to which I have referred, I have given detailed consideration to this whole question of making a scheme available on the lines recommended, and I have decided to adopt the principle of entrusting the business of voluntary health insurance to a non-profit making body. I feel that if this were done we should take the line that there should be a scheme which would help people to protect themselves against the major unforeseeable expenses of ill-health, and that while the promoters of the scheme should be required to operate it economically and without making a profit, the contributors or subscribers should, for their part, carry the full cost themselves and that they should not expect to be subsidised directly or aided financially by the State.

I feel that as a matter of ordinary prudent management the heads of families and others joining it should be expected to put aside out of income the subscriptions or premiums necessary to obtain the desired cover. Making advance arrangements to help oneself to pay the unforseeable heavy costs of illness is a form of prudent provision very much like taking out life or fire insurance—and nobody looks to the State or to anybody else to pay his premiums for that kind of insurance, or to contribute towards them. I have every hope that it will be possible to work out a fairly comprehensive scheme, the cost of which should not be excessive. Moreover, a valuable concession was introduced under a recent Budget whereby an appreciable abatement of income-tax is available in respect of premiums payable under a scheme of this kind.

The aim of such an insurance scheme is to help people to help themselves. This idea of self-reliance is fundamental and unless the proposal is received on this understanding it cannot operate successfully. The cost of our present services has been such as to tax the resources both of central and local funds and the time has surely come when further expansion must be along the lines of making it easier for participants to fend for themselves. I hope that it will be possible to create a worthwhile public opinion behind this idea of voluntary health insurance, a public opinion expressive of the determination of our people to preserve their natural dignity as individuals and at the same time to make prudent provision for the hazards of ill-health.

The object of the Bill now before the House is, therefore, to create machinery under which a satisfactory scheme of voluntary health insurance can be provided for everybody who wishes to participate in it. It is proposed under the Bill to establish a Board called the Voluntary Health Insurance Board for the purpose of carrying out schemes of voluntary health insurance. Power is reserved in the Bill to the Minister for Health to specify the medical, surgical, hospital and other health benefits to be afforded in a particular scheme to be operated by the Board, but the Board will have the power also to carry out such other schemes as they think fit— subject to the consent of the Minister in regard to the scope and extent of the benefits, and with the approval of the Minister to amend any scheme which they may introduce. There is a provision in the Bill that the charges payable by subscribers must be fixed at a level which is sufficient, but only sufficient taking one year with another, to allow the Board to carry on their business, due provision being made for the payment of outgoings properly chargeable to the Board's revenue. The effect of this will be that the Board on the one hand cannot make a profit, and on the other that it must fix its charges at such a level that it cannot incur a continuing loss.

The financial provisions in Sections 16 and 17 of the Bill do not, of course, mean that the Board is going to be subsidised in the ordinary sense of the term; under the first of these sections the Board may be given a loan from the Exchequer not exceeding £25,000 to be used in setting themselves up in business and in meeting their expenses until subscriptions commence to come in. This loan must be repaid under such terms and conditions as the Minister for Health, with the consent of the Minister for Finance, may lay down. There is a provision in Section 17 for the loan to the Board of a further sum of £25,000 towards meeting the Board's losses during the first five years of operation of the scheme or schemes of voluntary health insurance, and here also the Board must pay back this loan on such terms and conditions as the Minister for Health with the consent of the Minister for Finance may lay down. The reason underlying the provision of a loan to meet losses will be obvious. The Board will be starting without financial resources and without exact experience of the nature of claims which they may encounter. If that claims experience should prove to be adverse in the initial years, the Board having no reserves at that stage must have the means to meet their claims until such time as the situation has been adjusted.

The Bill also contains a number of normal provisions designed to secure that information on the activities of the Board will be available to the public. For example, they will be required to keep any accounts which the Minister for Health may direct them to maintain; to have their accounts audited annually by an auditor appointed with my consent; to send a copy of the auditor's report to the Minister and five copies of their certified balance sheet and income and expenditure account and to publish those documents and place them on sale. These documents must, moreover, be laid before each House and the Board will have to publish an annual report of its proceedings, which will be laid on the table of each House of the Oireachtas. Finally, the Minister for Health is given power to require the Board at any time to submit any information which he may seek on its activities, and to direct them to include in their annual report information on any particular aspect of their activities as he may specify. This machinery will secure that, broadly speaking, the Board's activities will be subject, not alone to the Minister's scrutiny but to the scrutiny of both Houses of the Oireachtas and the public.

There is one type of benefit to which I would like to refer specifically, namely, cover in respect of the cost of normal maternity. The Advisory Body were of opinion that it would be feasible to include cover against the cost of normal maternity—but only if such cover were subsidised to the extent of rather more than half of what it would actually cost. They estimated that to obtain a cash benefit of £20 for normal maternity each adult subscriber would have to pay for that particular benefit alone a premium of £1 15s.: and the Advisory Body felt that of this sum the State should contribute £1 per adult contributor. To enable the premium to be fixed at £1 15s. for maternity it would be necessary for all adults in the scheme to take out maternity cover—which means, of course, that those who could never encounter the cost of maternity —for example, single persons, and married subscribers who were past child-bearing age—would have to pay for it. Many of these would object to being made pay for maternity cover either on the grounds that they could derive no benefit from their payment of subscriptions, or on the grounds that they were paying for other people's maternity costs, or on both grounds. If we are to accept the Advisory Body's figures the amount of benefit for maternity would have to be small for a fairly high premium in respect of that particular benefit.

It can be argued, moreover, that maternity is not really an insurable risk—and, in fact, two of the members of the Advisory Body put forward this view in a reservation to the Body's report. Finally, since the Advisory Body's report was submitted I have had before me the views of a number of organisations representative of a large number of the potential customers for a scheme of voluntary health insurance. Their opinions differed somewhat on the question of inclusion or non-inclusion of maternity benefit in a scheme, but in general these organisations seemed to feel that the ordinary prudent bread-winner could himself budget for his maternity costs without recourse to an insurance arrangement. They felt that these costs were in a different category from those of unexpected illness or surgical emergency, against which there is frequently no opportunity to prepare. Some of these organisations did indicate that they would not be adverse to a subsidy for maternity if a 100 per cent. subsidy were offered. I could not agree to this. The desirable basis of voluntary health insurance is that the scheme introduced should offer protection against the major unforeseeable expenses of ill-health, that the public in general should utilise it if they so wish, that the premium or subscription should be at as reasonably low level as possible, and that its whole cost should be met by the subscribers themselves without help from any other source. It is claimed that for normal maternity in particular there is a strong argument against subsidising the cost since this is a contingency which does not arise without warning and for which there is reasonably adequate time to prepare.

I do not propose under this Bill to debar the Board from including maternity benefit in any scheme which they may carry out subject to ministerial consent, but for the reasons mentioned there is no provision in the Bill under which this or any other type of benefit can be subsidised. It will be for the Board to determine, subject to my consent, whether a maternity benefit will be included in the policy, or policies, it offers to the public and in the light of actual experience gained by the Board this whole question may be reconsidered after some time has elapsed.

Since the drafting of the measure was put in hands it has become apparent to me that an extension of the terms of the Bill in one respect will be needed. I think it will be necessary to provide, by way of an amendment which I will move at a later stage, that the Board to be established will more or less have a clear field in operating voluntary health insurance business here.

At one time following the report of the Advisory Body it appeared that no existing insurance body was prepared to engage on this type of insurance and accordingly the need for any restriction was not obvious. I now fear, however, that a need for some such restriction does exist.

I indicated that the estimated number of potential subscribers might be in the region of 400,000 to 500,000 persons, including dependents, but the actual number of persons likely to join a scheme, particularly at its inception and making due allowance for the lack of knowledge and experience of our people—especially in the rural areas— of this class of insurance, can be expected to be very much less. The market for this business in this country will, therefore, be fairly small for some time and I do not think there is room for more than one organisation to conduct it successfully. Moreover, if a scheme of voluntary health insurance is commenced it would be most desirable in the public interest that the public should have the guarantee of its continuing to operate. There can be no such guarantee if, for example, a commercial organisation were the only one in this field. Such an organisation could retire from this particular business at any moment, and, in fact, we have seen this happen within the last couple of years with a commercial company which operated a scheme. Another important consideraction which has impelled me to the conclusion that, broadly speaking, the Board to be established should be the only one to be authorised to conduct this business is that, if the general need in this matter is to be met satisfactorily, it is desirable that whatever organisation is to conduct it should be required at all times to provide reasonably extensive cover. This, again, would be impossible to achieve unless the Body entrusted with the responsibility for the conduct of the business is required to work on fairly well defined lines—which could not be applied under the normal free commercial system.

Finally, the profit element must be considered; I think that it would be inappropriate to have a commercial organisation earning a profit for itself on business of this kind by the exploitation of what is undoubtedly a national need. I think most of the House will agree with me when I say this, that this very important type of health insurance should not be a profit-making one. For this reason, therefore, I propose to introduce an amendment later on which, broadly speaking, will provide that the new Board will have a clear field in operating health insurance business.

I do not intend to put out of business a number of small organisations already in the field but I want to indicate clearly at this stage, in the consideration of the Bill, that I do propose to seek power not to allow any firm or organisation to continue to enter into voluntary health insurance business to an extent which might prejudice the chance of success of the new organisation by offering schemes designed, possibly, to capture the cream of the limited market available leaving only the less profitable business to the new body. There are a number of organisations providing limited cover against the cost of ill-health at the moment and there will be as little interference as possible with these. Examples of these would be Trade Unions supplying health benefits, Friendly Societies, certain professional vocational organisations, and so forth. The amendment which I will introduce will probably take the form of prohibiting the conduct of voluntary health insurance by any body except the Board, save under licence, and licences will be limited to those who are at present working in such a restricted field that they cannot be regarded as competing seriously with the Board.

The details of schemes which may be introduced, and their cost to the customer, are matters which will have to be worked out when the proposed Board has been established. As was mentioned in the report of the Advisory Body it is very difficult to calculate, in the absence of actual claims experience, the appropriate contribution for any scheme of voluntary health insurance, and the first couple of years' experience of a scheme or schemes must be experimental.

For the reasons which I have given, the Government consider that the Bill is necessary in order to establish a scheme under which a substantial section of the public will be enabled to protect themselves against the costs of ill-health, and I recommend it to the House for a Second Reading.

Dr. Ryan

I think this Bill is appropriate for the purpose which the Minister has in mind. Therefore, I shall not devote my time so much to discussing the merits or the demerits of the Bill as to the necessity for a Bill of this kind. We have introduced various health schemes from time to time. At the moment, according to the figures given by the Minister in his speech, the position is that everybody in the country is covered with the exception of the 500,000 people of the higher income groups. That is, of course, as far as hospital and specialist services are concerned.

Under the Health Act put through the House in 1953, the lower income group continued to get free medical services to which they have been entitled since 1939, and indeed before that under an earlier Act. Under the 1953 Act the middle income group, again referred to by the Minister in his speech—people with an income of £600 and over or landholders with valuations of over £50—as well as all insured people were entitled to free hospital and specialist services and often to maternity services, so that the number remaining is not very considerable.

It has been said by enthusiasts for a scheme of this kind that, even in the lower income groups, you will get people who would prefer to pay for medical treatment. The same would apply to the middle income group. Personally, I do not believe there are very many of that kind, but there may be some. I would not say the number would be very great. What it will be we do not know. Therefore, in forecasting the membership for a scheme of this kind, we cannot count on very many coming in from either the very low or middle income groups. There is a potential membership of 400,000 or 500,000 people who are at present not entitled to any of the free medical services.

With regard to finances, a scheme cannot be really successful unless there is a fair number of applicants. There must be a required minimum number before the scheme can be successful. It is not easy to see in a case like this what that number should be, but it must be fairly obvious, if they are spread all over the country, that the number must be fairly substantial to make the scheme a successful one.

One of the big dangers in a voluntary scheme is that the people who are health conscious are likely to join because people who are health conscious, who are accustomed to going to see doctors very often for treatment of various kinds, will be likely to join a scheme of this kind. They are people who would require more attention than the average individual.

If, therefore, statistics are based on the normal individual in this country, the statistics are likely to be out somewhat when a voluntary scheme like this comes along. However, after a time it will settle down into a more normal level. Insurance schemes generally are based on the normal population. Take the National Health Insurance Scheme which is now part of our Social Welfare code. When the authorities were working out what the contributions should be per year and what benefits should be paid, they made calculations after considering normal conditions existing throughout the country. That was all right because it was compulsory. People who are working in certain categories —manual workers for instance and non-manual workers under a certain wage rate—must be insured under the Social Welfare code and, therefore, insured for National Health Insurance, or sickness benefit as it is now called.

As I have already said, that works out satisfactorily when the scheme is a compulsory one. You will get a large number of average individuals and, in such cases, figures based on statistics will work out all right. In the case of commercial life insurance the companies try to keep their insured people within normal limits by rejecting the medically unfit. I think that anybody who takes a keen interest in the result of that system will find that insurance companies get the same death rate as the normal average for the population in general and that, therefore, their finances work out all right.

In a voluntary health scheme it is different because certain types of people may or may not come in. If a person is health conscious, he is more likely to become a member than a person who never had an illness in his life. As far as I can gather from studying the scheme, the people who are operating it have not got the option of rejecting a person whose ill-health history has been bad. Another difficulty is that the numbers who apply for membership may be small. In that case it will be very difficult, if not impossible, to make the scheme pay. However, the Minister is providing for that by arranging that a certain sum of money may be advanced during the first five years. That will give the Board an opportunity of making this scheme a success within that period. I would advise that care be taken that we do not involve ourselves in too high a cost for this scheme until we see whether or not it will be successful. There are certain appointments to be made of officials and so on and I think the Board should be warned not to offer terms that would involve the State afterwards in more than ordinary cost, if the scheme should not be an out-and-out success.

I am not opposed to the Bill; I am pointing out the difficulties I see. I think anybody reading the report of the Advisory Body would come to the conclusion that they themselves saw even more objections to the scheme than they saw points in favour of it. Personally, when I read through their report, I found it strange that without giving very much by way of reason why, they recommended the scheme and then went on to outline what that scheme should be. As a matter of fact, in my dealings with the Irish Medical Association when I was Minister for Health and when they were pushing a voluntary health scheme at that time instead of the Health Bill, I offered to introduce the legislation necessary to enable them to carry on the scheme side by side with the Health Bill when the Health Bill would go through the Oireachtas. That is why I am not opposing the Bill, but I have always had doubts as to whether it could be successful. I am only voicing my doubts now and warning the Minister not to go too far in the way of commitments on finances until we see whether this can be made successful or not.

I think every Party in the House has subscribed to the principle from time to time that no person should be deprived of the best medical attention on account of means. We have all interpreted that principle in our own way. We passed a Bill giving complete, free, medical attention to people of the lower income group and provided for the expenses of some of the unforeseen medical hazards for the middle income group. That is as it should be. The Government, of course, brushed aside naturally what the limit is, where you should draw the line between the lower and middle income groups for the complete, free services, and between the middle and higher income groups for limited services. That is a practical and sensible way of looking at it, that the Government should do it, and it also accords with moral principles.

A voluntary health scheme cannot, however, replace a scheme of that kind, and if it is true, as the Minister has pointed out—and I am sure the Minister is right in this—that there are individuals in the higher income group who are not able to meet the expenses of operations, let us say, paying for hospitals and paying specialists' fees for surgical operations and various other fees that are paid to other specialists who are necessary to give advice at a time like that, a voluntary scheme does not altogether meet that case, because a person may neglect to join the voluntary scheme and, therefore, is not covered by the scheme when the time comes that he has to have medical attention.

It may happen that a person who is just above the line in the higher income group is, perhaps, not a very provident person and has not saved any money. He may not be very provident either in that he may not have joined the voluntary health scheme. He may suddenly come up against a very big expected expense in connection with hospital treatment. Very belatedly, if you like, that man may think of his family and how they would get on when they have to meet these expenses. He may postpone such an operation, and that may prove fatal. Whatever way you approach this matter you can always have very hard cases. It was provided in the Health Act, as Deputies are aware, that County Managers had discretion in helping people of that kind when hospital treatment or specialist treatment was necessary. I presume that provision will have to remain because this is a voluntary scheme and we may take it for granted that everybody will not join and that, therefore, there will still be hard cases. That provision must remain and it will be necessary because the voluntary scheme will not cover such persons.

At this stage, we have only an opportunity of talking, as it were, on principles; we cannot talk about details until the Committee Stage, but I must confess that this appears to me to be a Bill that is not likely to require much discussion in detail on the Committee Stage. There are a few principles which occur to one's mind when speaking on the Second Reading. As I already said, I read the report of the Advisory Committee and I saw how they discussed the question in regard to maternity and I must say I cannot agree, technically speaking, of course. You cannot, I suppose, look upon maternity as an unforeseen medical expense, but the point that was put to me when I was drawing up the Health Bill in 1953 was that there are young people who, let us say, have purchased their house by way of loan and are repaying that loan over the years. Perhaps they have purchased some of their furniture on the hire purchase system and are finding it hard to make ends meet so that they dread the expense of maternity. The danger would be that they would be inclined to avoid maternity on the ground that they could not afford the expense.

That is a consideration we should keep in mind. Again going back to the people in the higher income group, above the borderline who are not in a position to meet the expenses of an operation or hospital costs, these same people may not be in a position to meet the costs of maternity either, and it would be a very serious thing for us to rule them out so that they would be inclined to say, if you like: "We cannot afford maternity," and we would say: "We cannot help you in your difficulties."

I am glad that the Minister has decided to leave the option with the Board of bringing in maternity at a later stage. In fact, I think it should be brought in if the scheme is coming in at all. It probably would add to the attraction of the scheme to have maternity included. I admit, of course, it might add on a number of people who would be rather costly on the scheme, but in a voluntary scheme like this sponsored by the Government we should not exclude it for that reason.

I have no more to say at this stage. I am not opposing the Bill, and any doubt I have is as to whether it will get sufficient support to make it what one might call a real success.

Mr. Casey

I think it can be said that this Bill will be generally welcomed in principle on all sides of the House and by the country generally providing, as it does, an opportunity for those who are regarded as being in the higher income group to insure against the cost of hospitalisation, illness, medicine, drugs and so on. I sincerely wish the scheme every success but candidly I have some misgivings about it at the moment, if it is to be implemented in the way I now feel it will be implemented.

I think the Minister must have the goodwill of the people he expects to participate in the scheme and must place himself in such a position that organised bodies, such as trade unions, vocational and professional groups, will be able heartily to recommend the scheme. I have some contacts with such groups and I know many of them have studied the report of the advisory body referred to here. I can candidly tell the Minister that the groups I refer to will not recommend the scheme at all and I think very few will recommend it with any kind of enthusiasm. The reason is this: here is a Bill wherein the Minister has certain powers to set up a board. The Bill bristles with powers given to the Minister, but on the whole it is the insured person who is expected to pay the total cost of the scheme.

They feel, and I must say that I agree with them, that the Minister might at least have gone so far as saying: "We will subsidise the scheme to a certain extent even if only for a stipulated period." All he has done in the Bill is to say that: "For the time being and under certain circumstances we will give you a loan which will be repayable." In other words, the Minister will have continuing powers under the scheme but the State will not pay anything at all towards the running of the scheme.

The people that this scheme is intended to benefit are mostly border-line cases as far as the Health Act is concerned—people who could not be regarded as extremely well-off and who in very many cases are struggling to try and rear families. But they were over the border-line so far as the previous Health Act was concerned and were not entitled to any benefit. Nevertheless, these people are paying taxes and paying rates to subsidise the scheme and when they get an opportunity of setting up a scheme to cover themselves—and they welcome it —they find that the State is not coming to their aid. Some of these people are people who remain voluntary contributors under the Social Welfare Act. They are insured now, I think, only for widows' and orphans' pensions, but because of the fact that they remain voluntary contributors under the Social Welfare Acts, they are entitled to certain services under the Health Acts. In other words, because these people with incomes in excess of £600 per annum are voluntary contributors, they are entitled to services from the local authority under the old Act. There are other people who are in the same income group who did not remain voluntary contributors and they are now being asked to finance this scheme to cover themselves and to pay fully for it, without assistance from anybody else.

I think the Minister appreciates the fact, and he referred to it in his opening speech, that, if this scheme fails, you inevitably will have a cry for a further extension of the present Health Act. Every step possible should be taken to ensure that the wishes of the people who are prepared to play a reasonable part should be met. I think they can be met and encouraged in one way only and that is by the Minister saying: "For at least five or six years, the State will subsidise the scheme to a certain extent."

I share the view of Deputy Dr. Ryan that, if at all possible, maternity benefits should be included in the scheme. Otherwise, I fear that it will be confined to the "old crocks" and the younger people will not find the scheme attractive at all. From the contacts I have had with organisations catering for people who might reasonably be expected to be members of this scheme, I find the greatest flaw in it at the moment is that there is no provision at all for any kind of State subsidy, despite the fact that the Minister continues to have his finger in the pie so far as the running of the scheme is concerned.

Like Deputy Dr. Ryan, I would also question at this stage whether or not it is advisable to visualise so much expenditure in the running of the Board. The Minister will recall that the old national health insurance committee was run by a voluntary committee of management. I can well imagine that the managing director and chairman of the Board should receive remuneration commensurate with their duties, but as regards the other members of the Board—there is a maximum of three, I think—I believe if the Minister set about it he would find that there are organisations catering for vocational and professional groups in this country who would gladly provide competent people to sit on that Board voluntarily, expecting only the normal out-of-pocket expenses. I sincerely ask the Minister to consider the points I have made between now and the Committee Stage.

Mr. S. Collins

Voluntary health insurance has been advocated in this House on many occasions. I take it that this Bill in its present form is virtually no more than the outline of the machinery envisaged by the Minister for the setting up of such a scheme. Bills per se will not achieve anything. Deputy Casey, and to some extent Deputy Dr. Ryan, have put their fingers on the main problem. For a voluntary health scheme to be successful it will have to have a good deal of attraction. In the main it will have to have a good deal of attraction for the normally healthy person if it is to be an economic and workable scheme.

I think the Minister may be slightly precipitate in his views on this measure. Whether it will be practicable at all to get a voluntary health scheme going without any initial sinking fund to secure it is something about which I have very grave doubts. I know that there is provision within this Bill for the Minister to make a certain type of advance but, mark you, if the Minister wants to try and get a voluntary health scheme which will have a large membership, he will have to go further than merely giving a repayable advance. I cannot see at the moment or cannot envisage, even on the basis of the report on which this scheme is founded, any attractions that would negative the opportunities offered to the normal healthy person by way of subscription to private enterprise insurance groups for the same type of cover. In fact, I will go so far as saying that, on a general analysis, the normally healthy person in the 30 to 40 age group, earning the type of income that is envisaged by this voluntary health scheme, can, unless the Minister will make his scheme attractive, find far more attractive cover for himself in outside insurance groups. That is the problem with which I want to try to get to grips.

Under this voluntary health insurance scheme, will there be a contribution by the State to the medical expenses of those who are faced with the contingencies envisaged in the Bill and who are excluded from the operations of the Health Act? It is all right to lay down a scheme and it is very necessary to envisage, as this Bill does, the mechanism by which it will operate but, having regard to the limited scope of the scheme, its limited appeal and the limited number of possible participants, I would urge the Minister to review the theory on which the scheme is founded. Initially, it will be difficult to attract a large membership. Membership will grow only as the full value of the scheme is proved by effective propaganda to the group that could benefit by it.

Unless a substantial initial grant is given for the creation of a fund to meet early demands, I could not envisage the scheme doing anything but involving itself in a multiplicity of financial troubles because the repayment of advances to be made by the Minister at an undisclosed rate of interest and over an undisclosed period of time could involve the scheme in very serious financial trouble.

While one welcomes and must welcome, in principle, the theory of voluntary insurance, one must face the reality that there has been a tremendous extension of health services generally, which has left a very limited group in need of this particular type of voluntary service. The development and extension of a voluntary service would, initially, have to be done on the basis of some contribution by the Exchequer in acknowledgment of the fact that the particular group that it is hoped to aid are very substantial contributors to the general health bill and are excluded from the general health scheme by virtue of their earning capacity. Basically, it seems rather unfair that people who, as referred to by Deputy Casey, are paying a substantial part of the general cost of health schemes, through their contributions to central taxation or in rates to the local authority, should have to bear the complete brunt of contingencies over which they have no control. That is the point of view that I want the Minister to consider rather carefully.

I have always been a believer in voluntary health schemes. At the time when what I considered too wide extensions to health services were being made, I advocated that it would have been far better to have a voluntary scheme and to have more extended membership of such a scheme and a reduced premium for membership and more substantial benefits. I felt that such a scheme would remove a good deal of the mendicity and trouble that we are now envisaging under the Health Act. I always felt that, once we had made adequate provision for the best possible health service and medical service for those who could not pay, on a completely free basis, we should have been in a position to evolve a general health scheme with graded contributions based on the capacity of certain groups to pay. That would have made possible a very substantial and extended voluntary health service which would have been more readily workable and of far greater national value than the scheme now envisaged.

The inevitable has happened in this country under the health scheme. It has been loaded with a tremendous cost that would not arise but for the fact that it is completely free.

As I said, I welcome the Bill. It envisages something that is worthwhile, something that, with goodwill and effort, can be a realistic feature of our health system, but we must advert to the fact that attractiveness will be the basis on which it can succeed. The Minister may tell me, and we are all aware, that there are substantial benefits available to the subscribers to this scheme by way of remissions given in the current Finance Act, but the person who may consider contributing to this scheme will ask himself one question: how much have I to pay and how much will I get?

I do not often agree with Deputy Dr. Ryan, but I do feel that, in the case of the younger and probably healthier group, just over the £600 income group or the £50 valuation group, provision for maternity costs is a vital matter. I would say to the Minister, in all seriousness, that if he tries to get this scheme under way without making provision for maternity benefits, he will automatically exclude what I think Deputy Dr. Ryan, as an experienced insurance man, would agree are the best potential, because he will be excluding the younger and possibly healthier group of potential contributors. Any interest that they would have in the scheme in its early years would be almost exclusively in the benefits they could draw against the contingency of maternity.

Voluntary health insurance schemes run by the State are always fraught with difficulties particularly when membership is limited to a comparatively small group. What I do not like about the background to this Bill— and I am saying this to the Minister in a constructive way—is that we do not really know what is the potential of cover for this scheme. There is no analysis of how many of these 500,000 people who are potentially within the scope of this Bill have already made provision by way of different types of insurance against these contingencies. We are not put in the position at this stage of knowing what the potential membership of such a scheme can be.

The Minister was speaking about organised groups such as trade unions. Let us take the bigger professional organisations. If you are to get these people wholeheartedly into a voluntary insurance scheme it must have three essentials. It must have a degree of cover that is attractive; it must have a premium rate that is attractive; and it must have an easy method of disbursement so that the person who is within the scope of the scheme will not suffer inevitable delays as a result of a slowing up of disbursement.

Even though one may argue in regard to the way to initiate the scheme the Minister can rest assured that, on principle, there will be general welcome for the Bill. However, taking it that the report is really the basis on which we get the mechanics, is the scope of the evidence and material covered within this report either broad enough in its concept or generous enough in its cover to make this a worthwhile scheme? Candidly I do not believe it is. What I can see in the report is what one must regard as a fairly substantial premium rate, particularly when you go into the £13, £14 or £15 premium group rate. There is a substantial premium rate for relatively small benefits.

I want to say in all earnestness to the Minister, and through the Minister to any people who want to put a voluntary health insurance scheme on a proper basis, that the amount of goodwill necessary is extraordinary. Above all the initial subscriber cannot be left in the position in which this Bill could leave him, that maybe he would make his contribution for the period in which the Minister has power to make advances and after that find himself a contributor for years to a voluntary health scheme that might in the circumstances have to be wound up.

There must be a definiteness and a security of tenure about the scheme and I do not think it would be practicable for the Minister to have that on the basis of repayable advances to the organisation. It will have to be done on the basis of a reasonable calculation of what the likely membership of the voluntary scheme will be with a contribution by way of a reserve fund or sinking fund or a positive controllable fund being granted as a grant-in-aid to the voluntary health scheme and the question of any repayment of such grant-in-aid or such advances being deferred to such time as the scheme had become an effective and self-supporting scheme. If that happy situation were reached, it might be reasonable then for the Exchequer to recoup itself in some way. The scheme will not have any real chance of success—and I am saying this to the Minister in the light of what limited insurance knowledge and experience I have—unless it can have the widest possible appeal to the group of people we are trying to cover. There is a very live danger that if it has not such an appeal you will have a bunch of crocks, hypochondriacs and people of that nature enjoying the benefits that will have to be paid for in the experience of trying to work the scheme.

It is a very good principle to encourage people to insure themselves and their families against the contingencies envisaged in this Bill and I feel that if the Minister who, I know, is absolutely in earnest about this type of insurance, gives this voluntary scheme a chance by giving it a reasonable subvention in aid at the beginning, it can be built into something that will attract people who could possibly receive their benefits elsewhere. I am perfectly satisfied that, with some of the difficulties that have arisen in the administration of the Health Act, with some of the extraordinary variations there are in the interpretation of the Health Act in certain areas, if this voluntary health scheme were such that the premiums were reasonable and that the benefits were comprehensive, the Minister would find himself with an infinitely larger scope of people to appeal to than merely the higher income group.

When one takes the higher income group as envisaged on the standard of the general Health Act, some people with a reasonable number in family, maintaining a reasonable kind of establishment, discharging repayments, we will say, under the Small Dwellings (Acquisition) Acts or discharging disbursements on houses that have been bought through insurance companies or building societies, would find themselves completely in peril if the catastrophe of serious medical expenses entered into the annual budget. However, the premiums will have to be initially low to attract people into the scheme and the benefits will have to be fairly substantial. That must, as a natural consequence, lead to the necessity not for a repayable advance but for a contribution that the society, or whatever it is going to be called, could straightway have invested for the purpose of giving it an income that will meet shortfall of premium income against disbursements in the early stages.

It is in the early stages of any voluntary insurance venture that one will require that type of help. If the benefits are readily available, and the people taking advantage of the scheme find them so available, then membership is assured and so is the ultimate economic development of the scheme. The Minister wants to get large professional groups interested in this scheme. He wants to get the big trade unions interested. He cannot, however, tell me that, if these groups interest themselves, it may be possible to reduce substantially the premium rates. I am rather inclined to think that that is putting the scheme into reverse, as it were. These people will not come in in the initial stages unless there is a real attraction for them to come in. But once they come in and, as the scheme develops, it will probably be possible to adjust the premium rates to a more attractive level.

I am aware of the Minister's views on this matter, but I was not present during his speech and I do not know whether he made any reference to disbursements by way of administrative costs. I know there is a directorate envisaged. I take it that the managing director, at any rate, will be somebody who is expert in this particular type of insurance. His qualifications may necessarily involve the payment to him of substantial remuneration. Again, in order to initiate such a scheme, there will have to be a substantial allocation of money by way of grant-in-aid rather than by way of repayable advance. One will not get the best type of managing director or the best type of personnel to administer such a scheme unless such personnel is adequately paid. If one pays adequately, one runs into difficulty immediately because the premium income, particularly in the initial stages, will show a substantial shortfall as against disbursements.

This is a worthwhile scheme and one that is eminently desirable in our health services. It is imperative that it should get off to the best possible start and it is in that spirit that I refer the Minister to what may prove to be initial difficulties imperilling the ultimate success of the scheme. The design is a good one. The plan is effective but, on this Second Reading, one inevitably has to examine the principles. This Report of the Advisory Body provides the basis on which this scheme has obviously been drafted. It is only right that we should advert to what can be fatal weaknesses if we do not arrest them at the outset.

The whole theory of voluntary health insurance is that one has, for a reasonable cost, a cover for contingencies that may arise as a result of sudden illness, illness involving heavy expenditure perhaps on surgery and subsequent convalescence, or illness of a protracted nature. Such illness can be an intolerable burden on people in the so-called higher income groups who, in many cases, will find the liability as hard, if not harder, than those in less fortunate financial circumstances. In order to meet such a contingency any voluntary scheme will have to be wide in its scope and, as is inevitable, in widening the scope of such a scheme, the premium must bear relationship to the hazards involved.

I cannot see a scheme of this nature becoming effective for those who want cover unless the Minister alters his approach to the Bill and makes a certain calculated sum available by way of positive starting fund. We should have information, and it should be possible to get the information, as to what the potential membership of this scheme will be. It should be possible to find out how many have already made provision against these risks. There must be a substantial number of the 500,000 envisaged who, because of certain fortunate circumstances, do not have to make insurance provision, who are in the position that an illness involving expenditure of £500 or £600 will not in their income-earning capacity be regarded by them as risks worth insuring against.

I want an effective voluntary scheme. I want to ensure that this Bill does not just become yet another piece of legislation embodying a really worthwhile principle but averse to giving effective reality to that principle. There is general agreement on the necessity for this scheme. I think the best way to deal with this Bill would be to send it to a Special Committee of this House, as a measure agreed in principle, in order to establish the basis of a really successful voluntary insurance scheme. The Government and the Minister are right in their approach to this matter, but it is imperative that, before we embark on such a scheme, we have a scheme that has a real chance of succeeding.

This scheme has too many pitfalls and difficulties to give it the assurance of success that we would all want it to have. That is why I feel the Minister must review the position generally, particularly the method of financing this scheme, because if the financing of the scheme cannot be changed, I feel we may have difficulties that cannot possibly be surmounted or overcome in the five-year period laid down.

In this House on other measures we had experience of matters where advances had to be made by the Exchequer, but when the question of repayment arose later, in the case of some concerns, it involved such confusion that the repayment amounted to only a nominal sum. In fact, sometimes repayments were never realised. This will have to be an independently controlled fund; it will have to be one which will give people immediate goodwill for the scheme, so that many will join it immediately and so that the scheme will not run the risk of ultimate failure.

That is, to my mind, the kernel of the whole problem. Any insurance scheme, to be successful, must have an initial attractiveness and good quality in it. It must be attractive in a fairly competitive market. Has the Minister been able to tell us if he envisages in what way this scheme could be either underwritten or reinsured? Will it be carried as a State burden with ultimate redemption responsibilities to be thrown back on the Exchequer?

Possibly I am being a little bit too probing, but, after all, this is an insurance scheme. There has been an investigation into it by a very distinguished and very experienced commission. They have given a very speedy report to the Minister. It is the question of the actual financing of the scheme that is of paramount importance to me. I feel quite sure my friend, Deputy Doctor Esmonde, will deal with the scheme from the point of view of its medical content and from the doctor's viewpoint. It is with the financial side of the scheme that I am mainly concerned, because it is on the method of financing, underwriting or reinsuring that ultimately the success or failure of the scheme must depend.

If the scheme is not properly financed the doctors who may be attending to patients under it and the surgeons who may be operating under the scheme may find themselves in the position that they will not be paid for their services. The financing of the scheme must be done on a practical basis. If an ordinary insurance company were to branch out into a voluntary health scheme of this nature, the first thing it would have to do would be to make a substantial allocation form its reserve funds to enable it to get the scheme under way. The normal commercial insurance company dealing with that problem would not expect any profit return out of that branch of its business for a substantial number of years, until the membership had been built up to such an extent that the normal premium intake would cover the normal disbursements from the fund by way of benefit payments.

I want to know what are the likely costs of administration of the scheme, what provision will be made for the establishment of a reserve fund or a contingency fund which will be required to cover a shortfall in premium as against disbursement and initial costs. There is nothing I would like more than that this scheme would succeed and expand because I feel it would be a most excellent contribution to the Irish character and the Irish way of life that we would have more and more people providing for themselves instead of depending on the State to provide for them.

I feel it is a very good principle to encourage people to use their own earnings and savings to give themselves protection against contingencies such as sudden illness. It is because I believe that that I am urging upon the Minister the necessity for giving this scheme a proper financial basis initially, bearing in mind that practically any insurance scheme one may examine will show that, in its initiation, very substantial resources had to be put into it. I feel we should give a céad míle fáilte to a voluntary health scheme. On all sides of the House we should do everything we can to encourage and foster the development of that idea in our people.

However, I would urge upon the Minister that he should give to the scheme the financial backing that would ensure its success and expansion and that would attract the co-operation and goodwill of the public. If that is done, not only will the initial success of the scheme be assured but also its ultimate expansion into maybe something larger, something more comprehensive in benefit and something more general in application than is at present envisaged either by the Minister or by the framers of this Bill.

I want to see the voluntary insurance scheme tried successfully here; I want to see the position reached in which a young man who is progressing into advancing increment groups will have the opportunity of reasonably insuring himself and his family against any contingency that might arise through illness either of himself, his wife or his family. I am conscious, as any of us who are realists are conscious, of the difficulty that exists in the particular group we are trying to help, in endeavouring to educate and maintain their families and equip them for the battle of life. We are, too, conscious of how disastrous sickness and surgical costs, maintenance costs in nursing homes or other such matters have been in certain families; we know how completely they have disrupted the tenor of life and left these people crippled with debt which it takes years and years to clear and how the very accumulation of that type of debt has led to far more widespread consequences for the family than the mere disease or sickness itself.

It is because of that that I personally would be very anxious to see a worthwhile voluntary health scheme available to that category of people. It can be made worthwhile if approached realistically and if the financing of it is done on the basis of a calculated estimate that can readily be obtained by the Minister if he looks for it, of what would be necessary by way of lump sum to get the scheme under way. Having made that available to the society, what it would then want to get from this House, in the main, would be our blessing and goodwill and as little interference as possible, so that it may have a reasonable hope of becoming a practicable, worthwhile institution which will be of service to the community.

I do not wish to talk on other aspects of this scheme; I am more interested in the financial mechanisms and machinery that are behind it. I am interested, as I said before, more in the system and the practicability of either reinsuring or underwriting the scheme generally, so that when we go out into any area and meet a group of people with whom we may have any influence, we may be able to give them a recommendation in regard to the scheme, a recommendation over which we can stand and be enthusiastic, with the hope of getting more and more people to realise the value of the scheme and in that way ensuring its extension and financial success so that it will ultimately give the broadest possible protection against any type of illness that may beset the people in the income group not otherwise provided for now—the people who, given a reasonable chance and fair premium costs, would be more than willing to invest and so secure themselves against any contingency.

Mr. P.J. Burke

I want to make just a few comments on this Bill. Provided all the people the Bill is supposed to cover contribute to the scheme, I do not see any difficulty in making the Bill a success, but I am very anxious to hear from the Minister who is responsible for defining the higher income group, because we have had so many different interpretations of that section of the community in regard to the Health Bill. One manager interprets it one way and another in a different way, and we find a number of people who enjoyed the benefits of trade union or other contributory schemes have been deprived of benefits and also graded as in the higher income group.

The higher income group that I know in County Dublin consists of the people who to a great extent are hardest hit, the people buying their own houses, and their outlay is anything up to £3 10s. per week——

An Leas-Cheann Comhairle

The Deputy may not discuss the question of housing on this Bill.

Mr. P.J. Burke

I am not discussing housing. I am discussing the higher income group.

An Leas-Cheann Comhairle

The Deputy seems to be discussing the cost of housing in County Dublin.

Mr. P.J. Burke

Pardon me, I am discussing the higher income group and I want to indicate why the higher income group, as I know them, are the people who have very heavy outgoings. If this voluntary insurance scheme is not to be within reach of these people and give them reasonable cover for a reasonable contribution they will be excluded from it. For that reason alone the scheme, as envisaged by the people who have spent much time trying to bring this Bill before the House and by the commission that investigated its possibilities, will not succeed.

Like other Deputies who have spoken here, I am in favour of voluntary insurance provided it covers that particularly hard-hit section of the higher income group, the people who are nobody's children at the present time. They are not in a position to look after themselves or to pay hospital expenses for their wives and families and they are not covered by the recent Health Act. That is the group I am deeply concerned about. While people who are able to look after themselves through their business activities or because they have reasonably high salaries may be hard hit, they are not as hard hit as the people I have in mind. I am thinking of the border-line section of the community which has to pay through the nose for everything, the section just a little above the Health Act. They now come under the voluntary insurance scheme. They do not benefit by the Health Act although they are contributing towards it but for one reason or another they are not benefiting although I believe they should. I hope that the Minister on the Committee stage will try and meet our views as best he can by not having the contributions beyond people's means and by doing everything possible to see that this section of our people have the necessary insurance cover.

I hope that when this Bill becomes an Act there will not be any misrepresentation about it, that it will be a clear-cut issue and that we will not have people saying so-and-so should get so much because he has only paid so much. I want to see all that kind of misunderstanding removed completely. The one thing I do see in the Bill, as others have already pointed out, is that in the initial stages it may be hard to get on without a contribution from the State. I know the State is asked to pay almost everything. Nevertheless, people who are contributing towards national taxation and to a free health service for other people are entitled to financial aid in order to ensure the success of this voluntary health scheme. I would like to say also that the maternity benefit should be included in the scheme because I believe it would encourage people to join the scheme. I hope the scheme will be a success. I hope the people I have referred to will be able to join it at a low cost; otherwise I do not believe it would be practical for them to join it at all.

Mr. McQuillan

I listened very carefully to some of the previous speakers, particularly Deputy Collins. It is quite apparent from his remarks here that Deputy Collins is very anxious to see in operation in this country what he describes as a voluntary health insurance scheme. That anxiety of his was running right through his contribution here this evening. But apart from that anxiety, it was quite evident that Deputy Collins, who is a supporter of the Government, has no confidence whatever that the feather-brained proposals introduced by the Minister will ensure that this voluntary health insurance scheme about which Deputy Collins is so anxious will be put into operation.

I must say that I share completely the worries expressed by Deputy Collins. There are two approaches to this question of health. There is one from the point of view of those who believe that, once the State has gone so far interfering with health legislation to the extent it has in this country, now is not the time for the State to call a halt and that the State should pursue logically the course upon which it has set itself over a number of years. That is one point of view. The other point of view—and the people expressing it are entitled to their views—is that sections of the community here should be responsible for insuring that their own sickness disasters are met by a voluntary insurance scheme.

As long as we have got away from this old bogey of arguing health services on moral issues, I am prepared to argue in this House or outside it on the practical issues and the financial complications. I hope we have at long last got away from the idea that it is morally wrong and morally indefensible to suggest that voluntary health schemes are not practicable and that instead we should have a comprehensive, free-for-all and no means test health service in this State. As long as we can argue that on a financial and practical basis I am satisfied. As long as the Deputies and other people outside this House have decided to forget the advice of the lay theologians and to forget the urgings of the Irish Medical Association with its moral cloak, as long as we are finished with that, I am satisfied.

I am speaking here as one who believes that to be fair to the community as a whole we must have equality of opportunity and we must have the best possible medical services available to all our citizens without this degrading stigma of a deplorable type of means test. I know that it will be many a day before we shall see the position as I envisage it with regard to health legislation. Some people in this House have had the courage to take a few faltering steps on what I consider to be the right road. The result of these few faltering steps taken in health legislation here has left the country in a mess in regard to our health services to-day. On all sides of this House there are members of local authorities who will wholeheartedly agree with me that the Health Acts as now operated are beyond comprehension and that the interpretation by each local authority varies to an extraordinary degree. We have a multitude of prying individuals to decide who is entitled to what, and the degrading means test previously in operation has, if anything, got worse as a result of this fairly recent legislation.

I say to Deputies who believe in a voluntary health service and who are anxious to see it in operation: is this the right time, when all this confusion exists all over the country in regard to health services, to bring in a so-called voluntary health insurance scheme? To those who argue that a voluntary health insurance scheme is the ideal scheme, I suggest that this Bill will be disastrous so far as the proposals which the Minister and members of his Party wish to see in operation, are concerned. There is a feeling of dissatisfaction, annoyance and genuine indignation amongst the people at the moment because of the manner in which the present health services are being administered. Nobody seems to know who is entitled to certain services. One particular area——

An Ceann Comhairle

The administration of the present Health Acts does not arise relevantly on this Bill.

Mr. McQuillan

I suggest, a Cheann Comhairle, that I am drawing a picture to show that the time of the introduction of these proposals is not the most suitable or diplomatic time, in view of the situation that already exists.

An Ceann Comhairle

The Deputy may do that but he may not, in doing that, discuss the administration of the Health Acts.

Mr. McQuillan

I will not elaborate, a Cheann Comhairle.

An Ceann Comhairle

To elaborate is one thing but discussing——

Mr. McQuillan

Surely we are entitled to say that the legislation that is in operation is unsatisfactory and that the proposed legislation will make the confusion worse?

An Ceann Comhairle

The Deputy said that several times. He is going into the administration of the Health Acts. He is referring to a particular district——

Mr. McQuillan

I shall not refer to a particular district.

An Ceann Comhairle

——where nobody knew what the provisions were.

Mr. McQuillan

I say that the implementation of the health services now in operation varies according to the interpretation placed upon the Acts by the local authorities concerned.

An Ceann Comhairle

Surely that is discussing the administration of the existing health legislation?

Mr. McQuillan

I am exercising great restraint here. I say, Sir—and you can rule me out of order if you so desire—that the time is not ripe for the introduction of a voluntary insurance scheme on the grounds that the people are bewildered at the manner in which the health legislation is being implemented throughout Ireland. In order, therefore, to get the goodwill of the public for any scheme, is it not necessary to have their approval, to have their blessing, if it is nothing else? Is it not necessary that the goodwill and the blessing of the public should be forthcoming? Is it not necessary that the proposals must be very attractive before you can change the sour attitude that obtains at present amongst he majority of citizens? Anyone who examines this measure cannot honestly suggest that there is anything very attractive in the proposals as put by the Minister to those people who are excluded in many local authority areas from the services of the existing health legislation.

We will see the position after this scheme goes through. I do not know what the position is in County Cork, but perhaps in County Cork there are people who are benefiting greatly by the existing health legislation, as a result of the interpretation of that legislation by the local authority, whereas, in Galway, there may be a tighter interpretation of that legislation. The result will be that in County Galway a number of people will be expected to join a voluntary scheme, whereas people belonging to a similar income or wage group in County Cork may be benefiting under the legislation already in operation.

According to the Minister, the scheme is to meet what I describe as those people not at present catered for, namely, those whose income is higher than £600 or whose valuation is over £50. I do not think it is unreasonable or out of order to suggest that a valuation of £50 and an income of £600 are, as far as health services are concerned, a figment of the imagination. As far as the Minister is concerned, those figures may be in writing but when it comes to that matter being enforced by any local authority the Minister knows the answer that will be given by the county manager.

I shall not go into details but will it be the case that, under this voluntary insurance scheme, a man who at present has about £2 10s. or £3 a week and is refused a white card by the local authority, must cater for himself under a voluntary insurance scheme? There are examples of that in the City of Dublin under the Dublin Corporation.

Mr. O'Higgins

It may be of assistance to the Deputy if I tell him that this insurance scheme will have reference to hospital and specialist expenses. The Deputy is obviously concerned with free medical service. This has nothing to do with the domiciliary service.

Mr. McQuillan

It is one of the snags in all this that individuals—I do not want to refer to them here but many cases could be brought to the Minister's notice—have been excluded from medical assistance cards. Those people are sour. They felt, when the former legislation was going through the House, that they would be attended to.

An Ceann Comhairle

I have given the Deputy much latitude. He is really discussing the legislation that is in operation at the present time.

Mr. McQuillan

Many of the people who are not catered for by the existing health legislation, I presume, are expected to take advantage of the voluntary insurance scheme and I maintain that it is more than doubtful that they will. There is another point that I would bring to the Minister's attention. This will be a voluntary insurance scheme. To be successful, it must be attractive. Anything of a voluntary nature must be very attractive and must have the goodwill of the public and must be widely spread. I do not know much about insurance but I know that the more people you have partaking in a scheme the better the chance of success. If it is to be a voluntary insurance scheme, why is legislation necessary? Are there not many insurance companies in the State who are prepared to insure breadwinners and other individuals in regard to health?

Mr. O'Higgins

Unfortunately, none.

Mr. McQuillan

If that is the case, it means that it will not be a paying proposition, even as it stands, with the widest possible support.

Mr. O'Higgins

It is not intended to be a paying proposition.

Mr. McQuillan

I should not have used the words "paying proposition" but "self-supporting". I am sorry to have used the words "paying proposition". Will the scheme be able to pay the benefits out of the premiums or must there be a substantial State subvention? If it is necessary to have large-scale State subsidisation, then we are going away from the principle of voluntary insurance. There are many bodies in this State that are subsidised and it is the subject of criticism by Deputies on both sides of the House that it seems that very few bodies can operate to-day without substantial subsidy. Now we are going to add another body.

From the arguments as I can see them, at any rate, there is no hope in the world that this scheme as envisaged will pay its way. It will undoubtedly need large-scale State assistance in the form of subsidy. We have already the Health Acts in operation which are subsidised as they stand. Now we are going to introduce fresh legislation with the possibility of further subsidisation of a heavy nature. Would it not be a more practical suggestion to extend the existing health legislation which is already subsidised than bring in so-called voluntary legislation that will need a subsidy as well.

That is speaking generally on the problem but there is more to it than that. The difficulty all through this has been: where is the line to be drawn? In view of the fact that I may not refer to legislation that is already in operation, I think I am entitled to put it this way. This proposed voluntary insurance scheme is to affect certain people. Would the Minister be able to tell us what is the lowest pay likely to be for an individual coming under this, and what is the lowest valuation with regard to the farming community? I do not want to have to make reference to the existing one, the £50 valuation and the ceiling of £600, as I understand that has been ruled out of order. However, other Deputies should be able to extract from the Minister an idea as to the amount of money which will be needed from State sources to put this voluntary insurance scheme on its feet, because that is the kernel to all this.

I do not like the idea of having two types of health legislation coming into operation and, if we are to have State help, let us have it all the way through and let the one body be responsible for it. What we are going to do now is to set up a board to deal with voluntary insurance. That means more work at the administrative end. That means more pay for more red tape. Surely at the present time, when everybody is in agreement that administrative costs should be cut to the bone, it is nonsensical to suggest that a further body be set up to do work that a body already in operation is capable of doing if the money is made available to it. The reason why the present health schemes will not be extended is that we have that snob mentality. This is a form of snob legislation to suit so-called categories in the State, a form of snob legislation that will at the same time, have to have State subsidisation if it is to be a practical proposition and not collapse.

I did not hear some of the speakers here who spoke on behalf of the trade unions but, from my own experience of discussing these health problems with men who are members of trade unions, I am sure that as far as they are concerned they are already paying through taxation for the health services that are now in operation and that they feel they should be entitled to these health services that are in operation without having to take out further policies on themselves or their wives through voluntary insurance. They are to be asked to pay twice over. If that argument is put forward in this House by other individuals, and I am sure it will be, then the Minister should be able to see that one of the most important necessities to make a success of any scheme, which is goodwill and enthusiasm from the groups towards whom the Minister is directing his attention in this voluntary insurance scheme, is lacking.

Deputy Collins, I think, suggested that the Minister should be generous at this stage and grant a big lump sum. He asked the Minister to tell what the lump sum would be that would be made available in the initial stages to see that this scheme got on its way properly. Deputies are entitled to take that view but let them remember that legislation is being introduced here to suit a certain limited group and that they are asking for generous State funds to be made available to that special group. I do not think there should be any lump sum made available. I do not believe this Bill should have been introduced at all but that the money that will be made available now to start this voluntary insurance scheme should be made available to extend, improve and clarify the existing legislation that is there to deal with health services.

One point I would like clarified is in connection with sufferers from T.B. and their families. Will there be any difference in the present arrangements in regard to sanatorium treatment for T.B. patients? As Deputies know, there is no such thing as a means test of any description for sufferers from T.B. and that as far as specialist treatment is concerned the most skilful treatment that can be made available is provided, and there is no necessity for individual payments to be made for T.B. patients. I hope the Minister will clarify that point, and indicate that there will be no change in the system in operation as regards T.B.

On principle, I am opposed to the introduction of this so-called voluntary scheme. I believe that the State has a duty to give the best possible treatment to all citizens without any degrading means test. This Bill is an extension of the means test again. It is introducing a means test in relation to yet another group within the State and it reeks——

Mr. O'Higgins

There is no means test in this Bill. Search it from beginning to end, and the Deputy will not find it.

Mr. McQuillan

I know perfectly well there is not a word in the Bill about a means test, but does the Minister not realise that he had to introduce this Bill because of the means test already in operation? He is, therefore, confirming for all time the means test that exists at the moment when his aim should be to get away, even gradually, from all idea of a means test? It would have been a far better proposition if the Minister or his predecessor had come along here and said: "Health legislation is about to be introduced. It will come in by degrees. I will take the most important aspect first, namely, maternity and deal with it over the country as a whole and not for certain income groups." Had that been done there would now be no question of introducing a voluntary insurance scheme for certain categories. When such a maternity scheme proved successful in operation, then successive aspects of health legislation could have been introduced here. That has not been done. Perhaps it is a bit late in the day now to be talking about these aspects. I suggest that the Minister's proposal here is a continuation of a system which has been condemned in every country in the world, namely, the degrading system of the means test. This Bill represents yet another retrograde step in that direction.

Mr. James Tully

The most annoying thing for a Deputy waiting to catch the Ceann Comhairle's eye is having to sit here over a long period of time listening to Deputies talking to a Bill which they obviously have not taken the trouble to read and upon which they, therefore, make entirely unnecessary comments. More than one Deputy has done that this evening and delayed the House because he did not appreciate the provisions of the Bill to which he was addressing himself.

I am one of those who believe that nobody should be deprived of the finest medical treatment that can be got merely because he cannot pay for it. I think we must eventually reach that point but I am afraid there does not appear to be much chance of any very revolutionary change along those lines in the near future. For that reason, I welcome some kind of scheme providing for those who do not come within the scope of the provisions of the 1953 Health Act. I was surprised to hear the figure given by the Minister of between 400,000 and 500,000 as coming under this new scheme. If he is confining his figures solely to those who are over the £50 valuation and the £600 income, he is very much out because, in that calculation, would come many people who would not be interested in this scheme. On the other hand, there are numbers of people who, while they are nominally under £600 per annum and nominally under £50 valuation, for one reason or another, and mainly because local authorities cannot agree as to what is right or what is wrong with the 1953 Act, find that they must pay for their medical treatment.

Deputy Casey referred to people who are not insured under the Social Welfare Acts except for widows' and orphans' pensions. It is amazing the number of people who are paying contributions under the widows' and orphans' scheme who are receiving absolutely no benefit as far as the 1953 Health Act is concerned. You have, too, those who were paying into schemes run by trade unions and other organisations who now find themselves with no such schemes because of the 1953 Health Act. Those schemes have been discontinued and the people who hitherto contributed to them must now pay for their treatment. All these categories will be very interested in having some scheme which will guarantee them against heavy expenses should they or any members or their family fall ill.

I know of cases where farmers with only £20 valuations, and with one or two members of the family working, have been deprived of the provisions of the 1953 Act. By no stretch of the imagination could it be said that they live very well. There are thousands of such farmers who would welcome a scheme such as that introduced by the Minister to-day.

It is a mistake not to include domiciliary treatment. Such treatment would be a tremendous attraction and bring in many people—yes, even those in the lower income groups who now have to pay for domiciliary treatment. If they are sent to hospital, the bills are so high they take years to clear them off. It may be asked: how does that occur if they are in the lower income group? It occurs because, while they may have an income of £4, £5 or £6 per week the local authority concerned has decided that they are not entitled to free treatment.

The Minister should have a second look at this and include domiciliary treatment. That will prove an added attraction. Indeed, it may prove the making of the scheme. I have no worry about the numbers who will be prepared to avail of this scheme. If it is made attractive enough, the numbers will be high. I know hundreds who, so far as the 1953 Health Act is concerned, are now neither fish, flesh nor good red herring. These will welcome this scheme because it will afford them some measure of protection against illness should it befall them.

There are a number of questions I would like to ask the Minister. It might be better to leave them for a later stage in view of the inordinate length of time some speakers have already taken to say nothing at all and some to say very little. Is it intended that everybody—I presume it is—who wants to avail of this scheme, even if he is in the lower income group, will be permitted to avail of it? Is it intended that the scheme will be self-supporting? Will provision be made, in the event of its not being able to support itself, to carry on with State aid? I know arrangements have been made to give a start to the scheme. If something happens which puts it out of operation in a very short time, unless State aid continues, will State aid be then forthcoming to keep it going?

I ask that question because I appreciate there is a danger, until the scheme is well known, that people may not come in in the initial stages as fast as they will at a later stage and also because of the fact that the Minister will have to be very careful about the amount of money which the person availing of the scheme is required to pay. I would be glad if the Minister could give even a rough idea of what the cost of the various benefits under the scheme will be because I think that is one of the main things which will affect the success or failure of the scheme. I believe that if the scheme is put forward at a reasonable cost, if domiciliary treatment is included and if a genuine attempt is made to cater for the people who need to be catered for, it will meet with every success.

Mr. Bartley

The Minister has been assured of the goodwill of this Party in his efforts to establish a voluntary health insurance scheme. I take it, therefore, that any questions we may put to him, or any criticisms we may offer, will be surrounded by that goodwill and that we will not have anything in the nature of the acrimony that attended former discussions on health matters.

I agree with some of what has been said on this measure. I, too, am in an inquiring mood with regard to some aspects of this important scheme. The Minister has stated that he is actuated by a desire primarily to serve those who are known as the higher income group. However, he has produced a scheme which will not exclude other categories. I think Deputy James Tully said that those in the higher income group are so circumstanced that they are not so likely to be attracted because the necessity is not there.

They are not as likely to be attracted by this as are people in the other category. That being so, it does seem to me that the scheme will not achieve sufficient support to give it the character of self-sufficing mutuality which the Minister wants to achieve in order that the scheme would operate through its own momentum from a certain point. We all agree with the Minister's opinion that some subvention is necessary in the early stages, and the Minister is taking steps to provide that it will be possible for him to give the board two sums, each of £25,000, if necessary.

I do not think anybody will quarrel very much with that provided the board is one which knows its business, particularly in view of the high ideal which the scheme enshrines. We are not discussing this question from this side of the House on the ground of principle; we feel anything that it is necessary to do for the health of the public should be done quickly by whatever means are most practicable. I think that was the attitude we adopted in relation to other legislation.

I want to endorse what the last speaker has said about making the scheme as attractive as possible. If he is to get the support that will really make the scheme work, the Minister must make it attractive. The suggestion has been made that if he could provide a scheme that would cover domiciliary service he would be doing more to make the scheme work than any other amendment that has been suggested.

The second last speaker referred to a matter that is not provided by either the Health Act or this scheme; that is the question of domiciliary service. Any trouble there is is mainly centred around the question as to who is entitled to free domiciliary service and who must pay for such a service. If this scheme is to work, in my opinion it should attract also the middle income group. I cannot see anybody in the middle income group availing himself of this scheme, seeing that he can already get these services because he is in the middle income group.

Therefore, if he is to be attracted to it, something else must be added and that something else seems to me to be this question of domiciliary service. If the Minister can work out a scheme which will cover a domiciliary service he will, in my opinion, attract very large numbers in the middle income group and so will help to swell the numbers necessary to make the scheme a self-sufficing one financially. If he cannot do that, I fear the scheme will never pass the stage of being a pious hope.

Criticism has been offered of the fact that there is more emphasis on the State's part in this scheme than on its insurance character. That seems to be so. Every section of the Bill seems to have the word "board" in it right down to the very last section. I do not quarrel with that point but would like some information on other aspects of it. It is said there is no compulsion, but there is compulsion against bodies who are already in this business, if I am interpreting the Minister's opening remarks correctly. It is intended to prevent other bodies from getting into this field, lest such intervention would stultify the efforts of the board. That is a character of this Bill which is not at all attractive. I wonder if it is necessary for the Minister to give himself that power.

Unless it is absolutely necessary I think he should discard that power as a measure of control. In Section 4 there are certain phrases used which I think require some elucidation by the Minister. In the first three subsections, the board is permitted to carry out a voluntary insurance scheme to such an extent as the Minister may from time to time specify. If the board is trying to operate a scheme that is intended to be self-sufficing, surely they ought to be given the freedom in this respect which they are given in several other respects outlined in the Bill.

Would the Minister say whether the board will be allowed to employ its own actuaries? If they are allowed to employ them surely it should not be necessary for the Minister to interfere in this way with the carrying out of their functions. Section 22 seems to detract from the insurance character of the measure also, inasmuch as it relieves the scheme from the obligations imposed on ordinary insurance companies by the Insurance Acts. If the Minister wants to establish the insurance character of this scheme he should reconsider the powers, which are the exception, which he takes off the voluntary insurance scheme in this section.

I do not agree at all that if the scheme, as has been suggested by some speakers, is to meet a considerable number of border-line cases just above the middle income group limit— if that is its purpose—that such a scheme ought to be introduced. I think what should be done if that were the purpose, would be to enlarge the existing limit and so cover these marginal cases. I disagree with the speaker who used the word "stigma" in relation to the means test. I think when you fix a limit of £600, and £50 valuation, that covers such a very large section of our population that the question of stigma can no longer arise and it is quite inappropriate to apply that expression. Whatever stigma still tarries in relation to health services is, in my opinion, connected not with the scheme or with ordinary provisions of the Health Act, but with the administration of medical cards.

I have nothing further to say on the matter, but I would ask the Minister to try to improve this scheme in such a way as to attract a very large section of the population covered by the middle income group, and the only way I can see that the Minister can do that is by adding to the scheme the domiciliary service and also by stating very definitely what the maternity service will be under the scheme.

Deputy Dr. Ryan has indicated that this measure has the full backing and hearty goodwill of this Party and that anything we can do to make it successful, and in generally trying to achieve the very sound ideal of inducing people to provide against their own ill-health, we will do it. I think it would be entirely unwarranted, however, to wait for the implementation of any such ideal before coming to the aid of people who really have been unable to meet the heavy cost of ill-health. We know in times gone by that certain medical services, such as maternity, always had to be paid for no matter how poor the patients were. We came across cases where fatalities occurred because families did not have the money to meet the fees required. If we had only half a dozen of that type of case all over the country, in my opinion we would be justified in going to very extreme limits indeed to ensure they would never occur again. I think it was knowledge and experience of that sort which actuated this Party in introducing previous health legislation. In so far as the Minister is trying to repair what he thinks has been damaged by that previous legislation in the matter of inducing people to do everything they can themselves, he has the full support and blessing of this Party.

Dr. Esmonde

The Bill itself, as far as I read it, is for the purpose of setting up a business administration to run the voluntary health scheme. I sat listening to many speeches here by different Deputies who talked about means tests. The simple fact is that this is a voluntary health insurance scheme and anybody who wishes may opt into it. There is no means test; the lower, the middle and the higher income groups may come into it. Essentially, of course, it is a Bill to facilitate the higher income group. The Minister said that some 400,000 to 500,000 people are included in that group and that means, in effect, that under existing health legislation there is no means of dealing with these people otherwise than by direct and full payment to the hospitals or doctors concerned.

I welcome this Bill very much. First of all, I feel that anything that gets us away from State control and State administration is desirable for many reasons. It gives us a sense of independence, particularly in medical matters, to look after and be responsible for those who are our particular care. It will also inevitably reduce taxation. Inevitably, in one way it will create an opportunity or an urge to save.

Deputies have spoken here about the extension of full health services but it is difficult enough under present administration to carry on the services that exist. It is bound to be the case, if everybody is free to get the same thing out of the pool, that there will be a waiting list and the weakest person is bound to get to the end of that list. This Bill enables anybody who wishes to pay a certain sum to insure against the hazards of operations and other things that may come his way and over which he has no control. It enables people to prepare against these hazards and I think the Bill should be thoroughly welcomed by everybody in the country.

The Bill itself, taking it by and large, is a good Bill although I shall have some few criticisms to make of it. It is well drafted and, in the main, it meets the requirements that must be met for the purpose of setting up a voluntary health insurance. Some Deputies who have spoken already have referred to the fact that this Bill may be prejudicial to existing insurance institutions which administer the same type of insurance as that envisaged in this Bill. As I know the facts, there was only one company operating in this country running such an insurance and that ceased to operate some years ago. I admit that there are smaller societies, provident societies, and I gather there are benefits provided, as has been mentioned by the Labour speakers, by the trade unions. Certain larger firms have their own medical arrangements. These will not really come into opposition with this Bill as its primary intention is to facilitate and deal with the upper income group. That does not say it will not—I believe it will—extend into any other sections, or that it will contain itself within the higher levels. I believe that it will extend to many other groups as well.

There are one or two other things I would like to say on the Bill. Section 4 covers practically the entire scheme envisaged, and I think it is a good section. I think it permits considerable elasticity which is a good thing because nobody can foresee what is going to happen under this voluntary health scheme. There may be a very heavy demand for it. Many people may join it. It may be a solvent concern in a very short space of time and it may be possible vastly to extend those benefits. Section 4 amply covers that. It gives elasticity so that extending schemes may be brought in by the board and added to the existing organisation.

One thing I feel about Section 4 is that we are legislating for the future, not for this year, next year or the year after, but for 20 or 30 years to come, and it may so happen that a person may have this voluntary insurance, which by the way is a renewable contract each year, and may have taken on that renewable contract over a considerable number of years. Under Section 4 it is possible that there may be a considerable extension of benefits and that these benefits may offer a great deal more to the insuree. There may be increases to cover those benefits. It may be possible that there may be a slight increase or a fairly considerable increase in the benefits themselves. I think it should be operative in this, if it is possible to put it in— it appears to be a matter for a draftsman more than anything else—that anyone who has a contract at a certain figure with the board should be left in a position to renew that contract at the same figure for the same benefits if they so desire. That is to say, if there are increased benefits, considerable extension of benefits, and an extra premium is to be charged, it should be optional to those who have already been in contract with the board to remain at the original figure and to contain themselves if they so desire within the same benefits.

Now I come to the composition of the board. I have not really very much to say against the board or the method of election of the board. I think it is the only feasible way in which it can be done but it does seem to me that the board is a little bit small. Of course the Minister has not really indicated in his opening statement what is really in his mind in relation to this board. I take it from what I read in the Bill that we shall have a chairman, managing director and three other directors or members of the board. I take it that it is envisaged that the managing director will probably be somebody who has considerable experience in the administration of insurance business and will probably be a fairly highly-paid and, naturally, whole-time official.

I would like the Minister to indicate to us what is envisaged with regard to the rest of the board. Are they to be part-time? Are they to be paid? Are they to have only travelling expenses or are they to be whole-time? My own view would be, taking it by and large, that you are dealing with a difficult question in the setting up of a voluntary health insurance scheme. Other countries have done the same but the circumstances have perhaps been somewhat easier than in our own country and they were dealing with bigger populations.

If it is in the Minister's mind not to have members of this board as whole-time officials—perhaps they may be only drawing small directors' fees—the board could be considerably enlarged. I cannot help feeling that this scheme if it is to be a success—I sincerely hope it will be and I feel it will be when it gets over its teething troubles —will need all the advice that it can have. In a board of five you cannot cover a very wide field. Naturally you want insurance representation there. As I have already stated, the managing director will probably be an insurance agent, but I feel you could very well have on that board as well somebody else also concerned with insurance.

I feel you could have somebody who would be a representative of the medical profession because, after all, when it comes down to the final analysis, the people who will sell this idea to the public will be the medical practitioners. They will be the people who will actually advise the people to join the scheme. They will do so in their own interests as well as in the interests of the people concerned. I feel also that you would need someone in the business world, such as chambers of commerce. I feel you would need someone who has a knowledge of local administration. I cannot help feeling that, if the scheme is a success, it may be possible at some future date for the local authorities to consider partially opting in themselves for the purpose of amalgamating the existing services and the voluntary services to the benefit of the ratepayers and everybody concerned.

I have in mind somebody like county managers or county secretaries who have already a good deal of experience in running health services or, I should say, in trying to contend with the difficulties of health services at the moment. They would be suitable people to give the benefit of their advice to this board as well as advising in the matter of co-operation between these voluntary health services and the existing health services, such as they are.

That would fill up the board. I feel that, as well, the Minister has in mind, I am sure, the inevitable civil servant for this board, so that would seem to put us over the number of five. If they are not whole-time officials I would suggest a slightly larger board.

Section 7 says: "The Minister may at any time remove a member of the board from office." The Minister elects the board but it really does seem rather drastic that a Minister has the power, if he is dissatisfied with the administration of the board, to remove them in toto without apparently any recommendation to anybody whatever. I will speak on the subject of Government subventions later on and the assistance of the State in this concern. Already the Minister for Finance has given his consent for a certain sum of money to be placed at the disposal of the board. However, I think that section is too drastic.

I would suggest that the Minister after prior consultation with the board may then take what action he deems necessary for the purpose of removing members of the board. Surely that is a better approach to the situation and one in which you will have more co-operation with all the parties concerned. I do not say that any Minister would suddenly go out and dissolve a board. If you are going to nominate a board for the purpose of setting up this organisation to administer a voluntary health service, it does seem rather foolish to have that extreme provision there. As the House knows, I am not in favour of strict ministerial and State control over the affairs of this country where it is unnecessary. I accept the method of election of the board and I accept the Minister's jurisdiction over the board, but I would suggest that, at least, it be limited to that extent.

With regard to the moneys that are payable, the total sum provided in all is a sum of £50,000. As I read it, Section 16 would mean that a sum of £25,000 is for the purpose of setting up the managerial content, the offices and so forth, which they must procure somewhere, and the administration of the board. Section 17 says that:—

"... the Minister may from time to time during the period of five years commencing on the first day on which a subscription in respect of a scheme under Section 4 of this Act is received by the board, with the consent of the Minister for Finance lend out of moneys provided by the Oireachtas to the board."

I cannot help feeling that in a country such as this where we have never had anything like this before, where the people have been led to believe, and a lot of them do believe, that there are now free health services for all—it is only when they get sick they get disillusioned and find out exactly where they stand—it may be difficult in the beginning to get this scheme into full operation.

I feel it is almost certain that for the first period over a few years this scheme may lose money. After all, we have got to prove to the people that we are giving them something that is worth while before they will come into it. Perhaps a sum of £25,000 might be sufficient for the purpose of setting up the board and starting the administration, but I feel that a greater sum should be available to carry the board over its initial difficulties and, subject to something I shall refer to later on with regard to subvention, I suggest that the sum could reasonably be increased to £50,000, if we are to succeed in establishing a satisfactory voluntary health insurance scheme.

From my own experience when practising as a doctor, I know that the average person wishes to be independent in as far as he can of State ties in his relations with medical men, and one particularly good thing about the recommendations of the advisory body is the direct connection between the insurance company or the board and the patient, eliminating the doctors. The patients will be collecting the money and paying it over directly. When the public come to realise that that is the main thing behind the scheme, the scheme will become acceptable to them and many people will come into it and after a time it will become a good and solid scheme. That will take time and must take time. In order to create confidence, a bigger sum than £25,000 is required, and I suggest £50,000.

I took it from the Minister's speech that he is basing the scheme on the report of the Advisory Body. They appear to have to put in a great deal of work and have evolved a scheme which, in my opinion, is feasible. I do feel, however—and I am not alone in this, I am glad to say; I have listened to other Deputies expressing the same view—that an insurance scheme will not be a success without a maternity scheme. In order to make the scheme a success, you must get the people into it and there is no use in getting elderly people into the scheme because there is grave risk that it will not pay its way. The only way to get the young people in is to have a maternity scheme.

The Minister dealt with the matter of maternity, both normal and abnormal maternity. The opinion of the Advisory Body seems to be that, if you are going to have a maternity scheme, the cost must be staggered over all subscribers and that, if that is not done, it cannot be made to pay. The number of times that people would use the maternity scheme is naturally limited and people would tend to insure only for such a period as was necessary. Therefore it would be impossible to make it pay. I do not say that the suggested premiums are unreasonable, but by raising the premiums you run the risk of having fewer people coming into the scheme. Long experience has taught me that the foundation of all medical practice is the family. Any doctor who wants to build up a practice must build it up from family attendance. If you have a scheme which includes maternity, you will get the young people into the scheme, and they will stay in the scheme because the children afterwards will need treatment. Undoubtedly, an insurance scheme is a security and anybody who experiences such security will stay in the scheme.

That is the reason why I believe it would be good policy on the part of the State to give a subvention so that it will be possible to bring maternity within the ambit of this scheme. It is estimated that it will cost approximately £1 15s. per adult to include maternity and it is suggested that the State should contribute £1 per adult contributor. That would be to obtain a cash benefit of £20 for normal maternity. It is suggested that the subvention by the State at the rate of £1 per adult contributor would cost somewhere in the neighbourhood of £17,000 to £20,000. That is a small price to pay if we want to make a success of the scheme and I believe it can be made a success.

I believe that the scheme will be a revolution in our medical treatment when we get it going. I believe that local authorities will look to this scheme in future. I am certain that many of the middle income group will feel safer and more satisfied to be under the scheme. I would even go so far as to say that it is possible that well-paid and thrifty people in the lower income group would be prepared to join the scheme. I warn the Minister that, from my experience as a doctor and from the wide discussions I have had with people—and I am sure every Deputy has had the same experience since we started health legislation—many people are dissatisfied with the present state of affairs. Many people have said to me that they would like to have some scheme—they do not want free treatment—whereby they would pay a certain amount and would deal directly with whatever hospital or medical authority they wished.

I have great pleasure in supporting the Bill. It brings us into a new phase. For a long time I felt we were going the wrong way, throwing more and more on the State, higher and higher expenditure. This Bill will bring us back the other way. I wish it every success and I wish the Minister every success in implementing the scheme.

Mr. O'Hara

The Minister said that the idea of self-reliance is fundamental. Deputy Dr. Esmonde and other Deputies have agreed with that point of view. I agree with it. For many years past we have been told in this House and through the Press and the radio that it would be a desirable state of affairs if we could have a free-for-all in this country. Even here this evening, Deputy McQuillan seemed to express the same point of view. He seemed to suggest that such a state of affairs existed in other countries and that these were the countries from which we should take a headline. I certainly do not agree at all with Deputy McQuillan's viewpoint on that matter. In fact, I could not disagree more with him. We in this country have been reared in a tradition in which we were taught to be independent, to have self-respect, to try, as far as humanly possible, at all times, to provide for the needs of ourselves and our families. I was glad to hear Deputy Dr. Esmonde speaking here this evening along the same lines from his long experience of the medical profession. I feel that we owe a great debt of gratitude to the medical profession generally for the manner in which they have carried out their duties, in face of great difficulties, in the past.

I am glad to see a Bill introducing a voluntary scheme coming before the House, and I am particularly glad because of the reception it has received from both sides of the House. It is heartening to find responsible members of the Fianna Fáil Party welcoming this measure, making suggestions and offering constructive criticism. However, in my view there is not much to criticise. Without trying to set myself up as an authority on the types of speeches made here, I would say that the suggestion made by Deputy Dr. Esmonde seems to have a lot of weight. His suggestion that this voluntary body should be given a loan of £50,000 is a really good one.

This scheme is a new departure. It could be made a really worthwhile scheme and have the effect of encouraging our people along the right road. It could have the effect of encouraging people who now depend on what are known as the free schemes to be thrifty and to enter this scheme, thus making provision for the future. The Minister stated in his opening remarks that he intended to create the machinery whereby the people can make provision for future illnesses however expensive and whatever the nature of those illnesses might be.

The people engaged in the insurance business are specialists in their particular line. We know that business people, especially big business people, insure their businesses against fire, theft and various other things. They do so because they know it affords them certain protection. If that is necessary in the case of business houses surely it is necessary in the case of individuals. If people expert in insurance matters can guide our people and help them, as I feel they can help them in this matter, we are really making progress. The principle behind this Bill is really the ideal thing for this country, and the Minister himself and anybody else who contributed in any way to having this Bill introduced in its present form deserve our best thanks.

Then there is the question of cost of administration. Deputy Dr. Esmonde seemed to think that the board would need to have more members on it and I am inclined to agree with that viewpoint. However, I would not like to think that by adding another half dozen members to the board it would make it too costly or encourage people outside to say: "Here is another board set up for this purpose; they are all getting big salaries" and so forth, and thereby create a prejudice or ill-will towards the Bill from the beginning. I do think the suggestion made by Deputy Dr. Esmonde in that regard should be carefully examined by the Minister. I would also urge upon the Minister that it should not be necessary to have all these gentlemen, much as we would appreciate their services, remunerated. I believe there are still in this country people who are prepared to make their time and experience available to such bodies and help in any way they can, free, gratis, and for nothing. I believe that type of person is the best person we could appoint. I think politicians have that experience themselves, that any man who is paid to help never helps in a genuine way. Therefore, if we could get voluntary help and voluntary advice in connection with this Bill it would be the best type of help and the soundest advice in the long run.

I have not had an opportunity of studying the Bill as fully as I would like to have done. I would like the Minister, when he is replying, to refer to the benefits that will be made available to cover death risk. I would also like to refer to the matter of benefit, the proportion of benefits, as is the case with some insurance companies, that would be made available for proportionately increased amounts.

Finally I should like to express my thanks to all those who made it possible for this Bill to be brought before the House. To me it has always been a revolting thing that anybody, particularly members of this Dáil, should try to make Irish people believe that they should get things for nothing from the State. If certain poorer sections of our people do benefit from the health services I am very glad of it. It is rather unfortunate that some people find themselves in such a plight that they need help, but where such a set of circumstances exists I am all for making provision for such people. On the other hand it is our duty to encourage our people to be self-reliant, to make provision as far as possible for their own wives, children and dependents. That is a duty imposed on us by the Almighty and we should bear that responsibility as far as is humanly possible to do so. It is a great thing that people who are expert in insurance matters are prepared to help this board and to give to our people this added facility.

I am proud that this measure has been received here with such warm welcome from everybody with the exception of one individual, who thought fit once more to repeat his erstwhile slogan: "There should be a free-for-all: this Bill is a snobbish Bill." It was quite apparent to everybody who listened to him this evening that he had not been present when the Minister made his speech, that he knew nothing at all about what the Bill contained and that his only concern was to get his name on the radio as having said something on the Bill, regardless of whether that something was helpful or harmful. That did not enter into his calculations at all.

It is comforting that the majority in this House take their duties more seriously than does Deputy McQuillan. We had this evening a magnificent display of Deputies taking their duties seriously, with one exception, and expressing their views on the merits, or otherwise, as they thought, of this Bill.

Dr. Hillery

I welcome this Bill and the establishment of a board for voluntary health insurance. I sincerely hope that the work of that board will be successful, for two reasons. The scheme is calculated to give coverage against illness to that part of our population which at present is not very well, or much better able, to meet these accidents and illnesses than is that part of our population already covered by the Health Acts. This is the third step towards covering the entire population against unexpected contingencies. Apart from that, I wish the Bill well because I see here the analogue of a much wider insurance scheme attractive to bigger sections of our community which may give us, combined with other schemes, a health scheme more suited to the temperament and desires of our people.

I compliment the Minister on the work he has done on the Health Acts. He has made many contacts with few collisions. Any suggestions I have to make to him, he accepts in good part. He has done his work to the best of his ability.

This board is calculated to cover a possible upper third of our population, the people in the higher income groups. Not all of them will need insurance. There are many who are will able to meet any emergency financially. It is possible that there is only a small marginal section in that group which will need the proposed coverage. But the fact remains they will need it and, for that reason, we should do our best to ensure the successful operation of this board.

Insurance against illness is already available to people. Possibly the reason why all these people for whom the Minister now intends to cater have not already insured is that the premiums are too high. The success, therefore, of this body will depend on making insurance available at a reasonable premium. That, in turn, will depend on having a big number subscribing. I do not know if, confining this to the upper third, one will get adequate numbers subscribing to make the premiums sufficiently low and make the scheme attractive. The only way in which the premium can be made attractive is, therefore, to have the board, continuously subsidised by the Minister. That is not an unreasonable proposition.

If we consider the expense of covering the needs of that part of our population already covered and balance that against the amount of money required annually to complete our services, we will find that it would be only reasonable for the Minister to subsidise this board in order to make a low premium available for three, four or five years. In that period other people, apart from those for whom this scheme is intended, would be subscribing and it would then be automatically possible for the Minister to withdraw his subsidy. I do not think an initial repayable grant will give the board sufficient finance to make continuous insurance available at an attractive rate. Therefore, the Minister should subsidise for some period of years until such time as this insurance has sold itself to the people in general and until enough premiums are coming in to permit the Minister safely to withdraw.

We all wish this scheme well, but the Minister will have to take some steps to give it a continuous life. This is a very interesting experiment. It is a very essential step in our health services. In its principles, it is very suited to the needs of our people who have to meet unexpected contingencies of sickness, accident and ill-health. The Minister must do his best to make it a success and that success will depend on its continued financing.

Mr. Finlay

I, like others who have spoken, genuinely welcome this Bill. Not only do I welcome it, but it is very gratifying to see the extent of the general agreement upon it and the general enthusiasm with which it has been received. With a single exception as far as I am aware, namely, Deputy McQuillan, its general proposals have met with the approval of the House. Possibly the speech made by Deputy McQuillan has also served a purpose in that it demonstrates the Bill will need encouragement and protection against the sort of uninformed and destructive prejudice displayed by Deputy McQuillan in his speech.

This is a new idea, persuading a large body of people to insure themselves against unforeseen or unforeseeable expenses in connection with ill-health. It is a new idea which we shall have to try and sell, like any other insurance, to those who are not prepared at present to consider buying it. The difference between the attitude of this country and that of other countries to this sort of insurance is pretty well exemplified by the figures which are to be found in one of the Appendices to the Report of the Advisory Body showing that in America in 1950 over half the total population was insured, in one way or another, against hospitalisation or medical treatment. Calculations show that since 1950 a much greater proportion of the population in America have been so insured.

As Deputy Dr. Hillery said, the reason why some people had not availed of existing commercial insurance for medical or hospital services is that premiums were too high. I think a great number did not avail of those services because they never thought of them, because it was not one of the things ever seriously considered. No commercial firm has made a serious attempt, by publicity or otherwise, to sell health insurance in this country. I do not think it has been tested and it is therefore doubly important that this Bill should get a welcome, that it should be protected from the sort of attitude we have had from one Deputy here to-night. At this stage, when the details are not being considered and are not known, it is important that a couple of basic ideas should be got across outside this House with regard to what this proposal means.

The first idea I heard about this proposal indicated that there was a great misunderstanding after the original publication of the Advisory Body's Report. It appears that what the people did not understand was that the proposal of the Advisory Body was an indemnity for money paid and nothing else. The first thing one is asked is: "Will I be able to go to my own doctor, will I be able to choose my own hospital?" The fact that one is asked such questions indicates that the people do not know the nature of the proposal at all.

It is of importance that it should be made abundantly clear the proposal is nothing more than an indemnity, that once you suffer an illness and have your treatment you are presented with a bill and you pay it and that the insurance company does not enter into it until the stage when you have incurred the liability, that they are not concerned with who is your doctor or to what hospital you went or what form of treatment you got, what operation you underwent or when or how you underwent it. What must be understood is that once you have genuinely incurred liability for treatment and become liable to pay, you get indemnity from the insurance company.

As Deputy Dr. Hillery said, in a sense it is possible to say that this Bill is aimed at the higher income group. I think, however, that is only half true. It is impossible at this stage to say what the premiums will be. We are, however, entitled to look at the Report of the Advisory Body and to see what one type of benefit is and the amount of the premium. As set out in paragraph 28 of the Report of the Advisory Body, the premium for a married couple with three children, exclusive of maternity benefits, would be 5/- a week. In short, the proposal of the Advisory Body is that a married couple with three children, for a premium of 5/- a week, could get any form of hospitalisation or treatment. That works out at 1/- a head per week. If we look at it in that way, if there is any reasonable chance that a scheme can be put into operation which would carry benefits equivalent to those set out in paragraph 28 and which would carry a premium as set out in paragraph 41, we can rightly claim that this is a scheme which would prove attractive to groups much lower than the third or higher income group.

Deputy James Tully said—and he would have considerable experience of the approach to this proposal of certain rural workers—that a great number of wage earners, craftsmen and certainly self employed persons with quite low incomes, would be anxious, if the idea of the proposal were put across to them, to pay 5/- a week so that they and their families would get these benefits. For that reason I find myself in marked disagreement with Deputy Dr. Esmonde and others. I do so with reluctance because Deputy Dr. Esmonde has much more experience of the position than I have. However, whatever cross section of views I could interpret led me to the conclusion that there is a lot of sense and psychology in the reservations of Messrs. Honohan and O'Dwyer in this Advisory Body's Report in their belief that it will not help to sell this insurance scheme if you ask people who are not obtaining maternity benefits or who are not likely to obtain them to pay premiums which include a charge to provide maternity benefits for others.

That may sound mean but we are dealing with a practical solution to a problem and, irrespective of what the premium rate is, irrespective of what relief could or could not be given, it will not help to sell this insurance if you ask a single man or married people who will never benefit by this maternity provision, to pay a premium to provide maternity benefits for others. I can fully appreciate all the advantages of having a maternity benefit included. I can appreciate that the State might not consider it agreeable fully to subsidise that maternity benefit, but I do believe it will be a hindrance in the selling of this insurance to a great number of people if they believe they are paying for more than they can possibly get in return.

It is on that basis that I should like to reinforce the point of view expressed by the Minister in his opening speech. He has said it is not his intention to shackle or tie the board with regard to this problem. I would urge him not to allow himself to be lightly moved from the attitude he has adopted, because I believe that people who are unlikely to get maternity benefits will not be likely to buy insurance, the price of which includes contributions to somebody else's maternity benefits.

The whole attraction of this is that you are putting money into something which is creating a benefit for yourself, that it is self-supporting and that a man is able to do this without borrowing out of another's pocket. You will spoil its whole appeal if people discover that they are paying a large amount to subsidise a benefit for somebody else. It is a large amount because it would be £3 10s. a year, as shown in the figures set out in paragraph 41 of the report. The premium for a married couple is £8 a year and if they contribute to maternity benefits the premium is £11 10s. The idea of such a premium being added will kill the popularity of the scheme.

There is only one other matter to which I should like to refer. Perhaps it is a matter of detail, inappropriate at the present time. It deals with the question of the no claim bonus. I have read the review of the Advisory Body and I can see a lot of sense in it. I believe, however, that the Minister might consider, and might give effect in this Act to some provision which would bring in the idea of incentive or no claim bonus.

There are two advantages under a no claim bonus, using that in a very broad sense. The obvious one is that people may be persuaded not to put down small amounts, not to claim small amounts, the cost of administering which would probably equal the amount claimed in order to retain their no claim bonus. One might take examples within the benefits contemplated. A person might go in for a very minor operation, something approaching a test only, or some small treatment for which he might be entitled to payment on his voluntary health insurance of £3 or £4 only. I believe that the administration of that, the making of the claim by him, the checking of it by the insurance society, the supplying of information, checking of that information and the payment of the money, would all mount up until you would probably reach a situation where it would cost £7 to pay £4. If that is so, I think the answer to it is a no claim bonus. The people who had a very good health record and who met some very minor liability of that description would find it better business from their own point of view not to claim under the voluntary health insurance for a few pounds. They would rather keep their no claim bonus. That is one advantage and it obviates also certain difficulties of administration.

The other advantage is, I think, more important and it is an advantage in principle. People who are fortunate enough to be healthy and who have paid over five or six years' contributions would expect to be entitled to either lower premiums or increases in benefit. Take the case of a single man who would argue on the basis: "I have been paying into this for the last ten years and I have never got a shilling out of it." That may not be good insurance logic but people expect that sort of thing and I think it is possible to devise something of that description which does not cut across the financial provisions of the scheme. If that is possible it will be well worth while.

The only other thing I wish to say is that I welcome this whole idea so much and so jealous would I be of this entire notion of health insurance and of its progress in our life that for once I am prepared to accept unreservedly the Minister's contention that he must create a monopoly. It is something I hate to see happening at the hands of this House in any way, but I think what the Minister says is unanswerable. If this is to be a success and is to work economically, it can only work on its own and cannot be expected to meet serious commercial competition. If that is the case I think it is entitled to its monopoly and that would be some measure of our enthusiasm for this scheme—that we are prepared to give it a monopoly.

For these reasons I have great pleasure in welcoming the Bill. I would ask the Minister again at this stage to set up a board, to set up a scheme of insurance, to give as much publicity as possible to this scheme, to what it will mean and the advantages of it.

Mr. S. Flanagan

Like all other Deputies who have spoken in this debate, I welcome the idea enshrined in the Bill. One of the things that used to worry youngsters playing games in times gone by was the danger of getting injured, and at that time, say 20 or 30 years ago, there was no scheme under which one could get compensation in the event of being injured seriously or otherwise on the playing field. Recently, one organisation, at least, has contrived a scheme whereby every club player, county player and so on, is automatically insured if his name is included in a list given to the club secretary or the county secretary at the beginning of the season.

The idea enshrined here is merely an enlargement of something that has been done by private organisations to their great credit. Its great attraction to me is that it is an extension of the co-operative rather than the State-managed type of effort. As I understand this scheme, once the board is set up and once whatever losses might be involved as a result of the initial purchase of offices, staffing and so on, are discharged the State will thereafter have nothing further to contribute. It will be a matter for co-operation between the people and the body. The body will expend the money it gets in, and will not be subsidised by the taxpayers or the ratepayers. That is an idea I would like to see extended as far as possible—the whole conception of protection against ill-health, injury, accident and disease.

Deputy Finlay mentioned that he rather thought no serious effort had been made by insurance companies to sell the idea of voluntary health insurance. I may be wrong but I think from my own experience with insurance companies that they have not encouraged this form of insurance because they have not found it attractive. To use an insurance phrase, their experience has been unfavourable with this type of insurance. In fact, I know people who were looking for cover for what would be called partial disablement and who have been unable to get cover from most of the insurance companies in this country and who have been able to get it only for certified total incapacity.

For that reason, I think that the figures given in the report are rather optimistic. As a person who is married and has three children, I cannot see that the figure of 5/- is realistic. I do not believe that experience will justify the statement in the report of the Advisory Body that 5/- would be sufficient to cover the services that they think it will and which are essential nowadays for a household of five people. My idea would be that the contribution should be scaled in such a way that a person can choose a maximum amount of compensation or a maximum benefit over the year so that if he pays in 2/6 a week he is entitled to draw up to a maximum of £X in that year, and, if he pays in 5/-, he will be entitled to draw £Y in that year.

I agree in principle with Deputy Finlay that a person should not be asked to contribute for something in respect of which he is not likely to draw any benefit, but against that, the whole basis of the co-operative idea is that you must give to take. I think if the other system were adopted it would lay itself open to abuses of a kind which it would not be tactful or, perhaps, necessary to detail. Therefore, I think people who are married and who might reasonably expect to have children should be obliged to contribute on the basis I have already outlined both for maternity and general health benefits.

As far as I am concerned, I not merely welcome the Bill but the principle enshrined in it, and I regret it has not been extended and that the idea has not been used before this in regard to the health service and indeed, to some extent, in regard to social welfare. At least, at long last, we are putting through a scheme designed to benefit the people without going to the taxpayer's pocket. I hope that we will be able in the future to extend that principle in such a way that we will be taking less money out of the people's pockets and giving more real and fewer illusory benefits to the people of the country. Much of the progress we have made in this State in the matter of social welfare—in that regard we have been copying other countries and we have been following the trend since the days of laissez-faire—has ceased to be progress and has become retrogression. If we are to survive as a country we shall have to revise our ideas about spending the taxpayers' money on what I describe as illusory benefits. I welcome this conception. I shall do everything I can personally to help, and any efforts I can make, inside this House or outside it, to extend the principle I shall always make because I believe we would be making a better country for ourselves by so doing.

Mr. O'Leary

I have listened to the doctors and other members on both sides of the House but I will speak now from my own experience as an insured person for a long number of years. Up to 1943 when I came into this House, I was paying into national health insurance and unemployment insurance. Now all these stamps I paid for are no longer any use to me. I asked one day about becoming a voluntary contributor. I was told I would have to pay the employer's share and my own as well. I asked what would I receive in return and I was told my wife would get the widow's pension. That was not very much encouragement to make one become a voluntary contributor.

Every Bill coming into this House looks very rosy; it is only when the Bill is working and put into operation, like the 1953 Health Act, that we find all the confusion. To my mind that Health Act is not of very great benefit to many workers. Deputy Dr. Esmonde says there will be 500,000 people willing to come in under this new Bill. I wonder.

We have pension schemes already in our local authority and we find that a lot of the road workers do not wish to come in under the pension schemes. In some cases where people had paid in, they got back their money because the amount deducted from their wages was excessive. I heard Deputy Finlay say a few minutes ago that a man would be paying 5/- a week. That means £1 a month, £12 a year. What benefit is that man to receive? He will probably be paying into that until he dies. I drew very little benefit from the national health system. Thank God, I was healthy, but I paid in a lot of money and got no benefit.

We are told that a lot of people will come in under this scheme and will benefit. While a majority of people may want a contributory scheme there is another section who do not want it, and no matter what the Minister or this House may offer they will not come into it. There are thousands of other workers like myself who have paid their contributions and the only thing they receive at the end is 24/- a week. I know as a member of a local authority that persons in my constituency who are sent to Dublin for treatment or an operation get a bill from the Dublin hospital——

An Leas-Cheann Comhairle

The Deputy seems to be discussing the administration of other Health Acts. That does not arise on this Bill.

Mr. J. O'Leary

I know that but that did not happen previously and that is why we have this confusion to-day. Perhaps there will also be confusion in the case of this Act if it is not put properly before the people and if they are not told in black and white what they will receive and how much they will have to pay. That is the important thing in this Bill if it is to be a success.

The doctors and lawyers say it will be a success but I want to see it working for the benefit of the people I represent. Deputy Finlay says a family of three may be paying 5/- a week. What will a family of six have to pay? I would like to see where I could come in myself. Everything is all right when you are paying your contribution, paying your motor tax or paying your insurance, but we know what happens when you look for benefits. It could be the same with this Act when it comes into operation. Take the Health Act. Take the means test. Half our people to-day, because of their wages, are outside it——

An Leas-Cheann Comhairle

The Deputy may not discuss the Health Acts.

Mr. O'Leary

I just wanted to know would there be any such snags in this Act as there have been in the last Act.

Mr. D. Costello

I do not intend to discuss the Health Act either. I would like to say at the outset there is no doubt there are many defects in the Health Act, one of the main being the number of people outside its scope and who are in need of some assistance in order to help them get over the grave expenses which illness brings on a family. This Bill is designed to fill that gap. For that reason I, along with everybody else in this House who has spoken, with one or two exceptions, recommend it. It is a very good principle. It is a very desirable principle which the Minister has enshrined in this Bill and if it develops as we all hope it will, it will add considerably to the social fabric of our country. I hope it will be a principle which may be extended into other fields.

The main discussion on this Bill which I have heard to-day has been whether or not the State should subsidise the scheme. I must say I have come to the conclusion after giving the matter careful consideration that the Bill should, in fact, remain as drafted and that an effort should be made to permit this scheme to work without subsidy. The House and the Minister have had available the very excellent work of the voluntary body that reported recently. It does appear from the deliberations of that body that the premium rates which it may be possible to introduce into the scheme need not be excessive and that the benefits for the premiums paid will be remarkably good. If it is possible to improve on the figures that the Advisory Body have reported on, all the better. We are all, of course, in favour of trying to bring down the premiums to the lowest possible figure in order to make the scheme as attractive as possible.

There is one matter against which this new board that is being set up must guard. It is being given a monopoly. It must see that the scheme which it operates is not such an expensive scheme as would not only not attract subscribers to it but would in fact charge higher premiums than the premiums at which insurance could be obtained by members of the public from private insurance companies. Many Deputies are aware of the experience, particularly in Dublin, in the last few years, of a well-known insurance company here which introduced a scheme of voluntary health insurance. Their experience was so bad that they had almost to double their premiums within a year or two and finally went out of business altogether.

There is the undoubted fact that such insurance has not been popular with private insurance companies but there is also the fact that there are foreign companies which do make available voluntary health insurance, admittedly to only a small public here. It is necessary to see that the scheme which we will develop will not have premiums very much higher than those at which insurance could be obtained from private companies. It is worth while paying a slightly higher premium to have an Irish company working on a national basis here but it is not worth while paying too high a premium for that benefit and I sincerely hope that it will be possible to have this insurance scheme, first of all, if possible, on an equal basis with existing private companies at the present time and, if that is not possible, at any rate at premiums not greatly in excess of the premiums at which such insurance is available.

This Bill, when the Minister's amendment will have been inserted, will give a monopoly to the new board. It is, in general, a principle to which I, like Deputy Finlay and other Deputies, would object, but I see great force in, and I fully accept, the arguments for giving a monopoly which the Minister put forward in his introductory speech.

There is the danger, if we do not, that certain insurance companies might compete, and compete unfairly, with the new board. It is even possible to see the principle, operated in the retail trade, of loss leader being applied in the insurance world. Insurance companies might indeed be prepared to suffer a loss on this particular branch of the business in order to attract customers to other parts of their business and, in so doing, undercut, to the irretrievable loss of the new board.

Again, the giving of a monopoly in these particular circumstances will not greatly affect existing companies inasmuch as the particular business carried on by existing companies is very slight but, in granting this monopoly and in the system of licences which it is proposed to operate under the Bill, I should like the Minister to bear the fact in mind that there is a number of organisations like the Irish National Teachers' Organisation, like a number of private firms, who carry out very excellent voluntary health insurance schemes of their own and who give quite adequate benefits to their members for comparatively small premiums. I sincerely hope that in the policy which the Department will formulate when granting and withholding licences it will see that these voluntary organisations, in so far as it is possible, are not interfered with and that the schemes that are in operation are, if possible, maintained. If the Act is worked on that basis and if the granting of licences is done in an equitable manner with regard to existing organisations, I cannot see that the giving of a monopoly to this board will do any great harm.

Again, I think the Minister's arguments for withholding maternity benefits from the proposed scheme are almost unanswerable and I feel that the scheme, without the inclusion of maternity benefits, could be a success and that, if maternity benefits were included, they might indeed cause grave difficulties to the whole success of the scheme.

The important thing in this scheme is to sell it to the public. The important thing is to advertise this scheme on a national basis and to get the co-operation of the voluntary organisations, trade associations and trade unions behind the scheme so that they can co-operate in selling it to their members. It is an obvious principle of insurance practice that there must be a large number of contributors to an insurance scheme in order to make it work and the success of this scheme depends on the number of contributors to it. With the co-operation of these voluntary organisations, trade associations and trade unions and with the widespread publicity campaign which would be very necessary, I am very hopeful that this scheme will be a success and, if it is, it will, as I said at the outset, bring into the Irish social fabric something very valuable which, I think, we all hope can be adapted and extended further.

Mr. Barrett

The welcome which this Bill has got from every part of the House indicates that the Minister should be congratulated on bringing in a measure which seems to have been delayed too long. I welcome the Bill particularly because, for the payment of very small premiums, the average head of a household can provide for himself and his wife and family in times of illness and tribulation and can, with his head held high, claim benefits instead of just beg them from the State.

There are some small matters to which I would like to refer. If I have anything to say against this Bill, it would be that the Minister has taken too many powers to himself and that this House is possibly surrendering to the Minister too many powers which are resident in the members of this House and not in the Minister. Section 4 and many other sections indicate that. The Bill is prolific in phrases such as "with the consent of the Minister", "the Minister may" and "the Minister shall". I deprecate that in any Bill and in this Bill I deprecate it too.

I should like to refer to Section 8 (2) which really is not necessary at all in view of the provisions of Section 7, where the Minister is given complete power to dispose of the whole board, if he likes, or any member. Section 8 (2) goes on to particularise as follows:—

"A member of the board shall be disqualified from holding and shall cease to hold office if he is adjudged bankrupt, or makes a composition or arrangement with creditors, or is sentenced by a court of competent jurisdiction to suffer imprisonment or penal servitude or ceases to be ordinarily resident in the State."

It is usual under these circumstances also to include the contingency of a man becoming a lunatic and I see no reason why that phrase should not be included in this sub-section.

Section 10 states:—

"A member of the board who has—

(a) any interest in any company or concern with which the board proposes to make any contract, or

(b) any interest in any contract which the board proposes to make,

shall disclose to the board the fact of the interest and the nature thereof, and shall not be present during any discussion by the board relating to the contract ..."

I think that section might be amended by adding the words: "or the making of any decision after any discussion."

Finally in Section 20 there is this provision:—

"(1) The board shall, in each year, at such date as the Minister may direct, make to the Minister a report of its proceedings under this Act during the preceding year and the Minister shall cause copies of the report to be laid before each House of the Oireachtas."

As the section stands, the Minister need not lay the report for 1958, shall we say, before the House until 1968, if he likes. I think that some period during which the Minister should lay the report before the House should be provided there.

Mr. Rooney

I wish to welcome this Bill. I believe it will be welcomed by people throughout the country realising that the first duty of every man to himself should be to provide for the maintenance of his own good health. Unfortunately we have not had previously a voluntary health insurance organisation established on a national basis with the blessing of the State. There are, of course, insurance companies providing health insurance benefits of various types at reasonable premiums but, generally speaking, the idea of voluntary health insurance amongst various classes of people needs to be popularised. The idea has not struck the public mind in general. We find that many people who cannot avail of the benefits provided under various Acts, the Social Welfare Act, 1952, the Health Act, 1953, and, of course, the National Health, do not look further to see if they can secure for themselves some kind of insurance cover which would ensure that, in the event of serious illness involving heavy expense they would not have the means of meeting, such a burden would not be thrown upon them.

I notice from the Bill that there is no indication at this stage that the Minister intends to provide a monopoly for the new Voluntary Health Insurance Board. However, I have learned from the statement of the Minister to-day that he intends to give a monopoly to this board on the matter of setting up and providing a voluntary health insurance scheme. I understand from the Minister that he intends to do so in order to ensure that the efforts on this occasion to provide a voluntary scheme of insurance on a national basis will not be upset in the early stages by competition from commercial firms. Now the State is going to make an effort, by the establishment of this board, to popularise health insurance and to encourage people of the upper income class to avail themselves of insurance that will be provided under this scheme and operated by the board.

We in this country have not got a comprehensive health insurance scheme such as there is in Great Britain but we have been given the opportunity of watching the operation of that scheme there, seeing the defects that exist and also seeing why the comprehensive health insurance scheme across the water is proving to be so expensive. We have been given the report of the committee which examined the prospect of providing this voluntary health insurance scheme and we have been provided with very valuable data which will be a very useful guide to the members of this board.

On examining the Bill I am inclined to think the board is rather small. With a chairman, a vice-chairman and three members, it is a rather small board, especially if it is to operate a voluntary health insurance scheme organised on a national basis. It is obvious that this board will be dealing with various groups, various societies and organisations apart from individual families who may desire to benefit under the scheme. This new board and the Bill will cater for the classes who are prevented at the moment from availing of benefits otherwise available under the Health Act, 1953, and the Social Welfare Act. The Health Act, 1953, generally speaking, prevents any family whose income exceeds £12 per week from getting free medical and surgical treatment.

Debate adjourned.

Dáil Éireann debate - Wednesday, 7 Nov 1956

Voluntary Health Insurance Bill, 1956—Second Stage.

Dáil Éireann debate -
Wednesday, 7 Nov 1956