Dáil Éireann debate -
Thursday, 30 Nov 2017

Vol. 962 No. 5

Health Insurance (Amendment) Bill 2017 [Seanad]: Second Stage

Minister for Health (Deputy Simon Harris)

I move: "That the Bill be now read a Second Time."

The Health Insurance (Amendment) Bill 2017 was published on 17 November and concluded its passage through the Seanad last week. I welcome the broad support in that House for the core principle of community rating which is a long-established aspect of Government policy on the health insurance market. This short Bill comprises seven sections dealing with the specific issue of health insurance, particularly the risk equalisation scheme which supports the system of community-rated health insurance. Risk equalisation means that everyone pays the same price for the same product, irrespective of age, gender or health status. In other words, older and sicker people pay the same price as younger and healthier people.

In a community-rated market like ours the risks are shared across the market as a whole, making insurance more affordable for less healthy and older people than it might otherwise be. In risk-rated markets, on the other hand, the premium charged is based on the insurer's estimate of each person's risk, taking into account relevant factors such as age and existing medical conditions. Under this model, healthier people pay low premiums, while sicker people pay high premiums. Moreover, under a risk-rated system, the premium for someone who has held health insurance for many years will rise if his or her health deteriorates.

The Health Insurance Act 1994 requires all insurers to apply community rating. However, older and sicker customers are not shared equally across the Irish insurance market because of the relatively recent arrival of competition.

Community rating is supported by a risk equalisation scheme, where the cost of insuring older and less healthy people is spread across the market through the imposition of a stamp duty levy on every health insurance contract issued. Levies are paid into a fund, out of which risk equalisation credits are paid to insurers in order to reduce some of the additional costs they incur when insuring older, less healthy members. The scheme does not take money from the market, rather it distributes it to subsidise the health insurance costs of older, less healthy people. The aim of risk equalisation is to look at the market as a whole, and to distribute fairly the differences that arise in insurers’ costs due to the differing health status of the insured population as a whole. This is an important point because we often hear insurance companies using this to suggest that somehow or other it takes money from the market; the scheme does not do that at all. It tries to ensure equity and fairness, which I believe is reflected by a societal belief that is held across the State.

The number of people who currently hold private health insurance is more than 2.1 million, with three commercial insurers operating within the market. There is, however, a clear disparity in the membership profile and thus the associated costs being incurred across the various commercial insurers. Community-rated health insurance systems across the world use risk equalisation to share some of the higher costs of older and sicker patients across the whole market. The US, Australia, Germany and the Netherlands are just a few examples of other countries that use risk equalisation to support community-rated health insurance. The overall goal is to channel competition in the health insurance market in a way that benefits everyone who wishes to purchase private health insurance. The benefits of our system of community rating can best be seen as supporting the market as a whole and ensuring that, through the provision of risk equalisation credits for older customers, they can be helped and supported to purchase health insurance at a more affordable price if that is their wish.

Legislation is needed each year to update the amounts of credits paid to insurers under the risk equalisation scheme and the amounts of stamp duty levied on health insurance contracts to fund the credits. As part of the process, the Health Insurance Authority carries out an evaluation of the market and recommends the level of credits that should apply next year, taking into account the changing demographic profile of those insured and market developments including price and product developments. I have considered and accepted the recent recommendations made by the authority for the rates next year. The first is a general decrease in the amount of risk equalisation credits payable in respect of those aged over 65 years, based on age, gender and level of cover. The second is the stamp duty to remain unchanged in respect of advanced contracts at €444 per adult and €148 per child, and a reduction of the stamp duty in respect of non-advanced contracts to €177 per adult and €59 per child. In general, insurers will receive lower levels of risk equalisation credits next year. The provision of lower credits is possible as there has been a reduction in the market average claims cost per insured person in the previous 12 months. Given that the scheme is designed to be self-financing, with the total amount of credits provided matching the stamp duties raised, the main stamp duty levy on health insurance products remains unchanged next year. In addition, the stamp duty for non-advanced contracts is being reduced by 20%.

I am mindful that the risk equalisation rates need to support the sometimes competing aims set out in the legislation and increase the scheme's effectiveness, without substantially increasing stamp duty levels. I am pleased, therefore, that this year it has been possible to maintain the main stamp duty at the existing level. In addition, I believe the revised rates strike the right balance by ensuring that the scheme continues to be as effective as possible and, at the same time, remains robust, transparent, and promotes fair and open competition in the market.

The risk equalisation system currently allows for a small measure of compensation for health status through a payment of €90 for each overnight stay in a hospital and €30 per day case admission. I believe the support for insuring less healthy consumers should be increased and, therefore, small increases are also proposed to the existing level of hospital utilisation credits provided to insurers under the scheme, increasing to €100 per night for overnight stays and to €50 for day case admissions. These utilisation credits are a proxy for health status and will provide additional support in respect of less healthy people. This change results in a higher proportion of credits being directed to less healthy people than to older people. This is a step towards improving the health status element of the scheme within the boundaries of the current risk equalisation scheme.

As a necessary support to community rating, I am committed to making the risk equalisation scheme as effective as possible in a way that promotes fair and open competition. While the changes to the credits will help to maintain levels of support for community rating, further improvements to the scheme are also planned. The scheme is a state aid and requires approval from the EU, with the current scheme approved to 2020. As part of ongoing development, it is planned to further enhance the risk equalisation scheme with the introduction of a more refined measure of health status. The most appropriate measure is based on diagnosis related group, DRG, activity data, which will allow better targeting of credits to all people who require higher levels of health care. I have asked officials to focus on progressing this, in conjunction with the Health Insurance Authority, in the months ahead. A working group has been established to inform the private hospital data collection aspect of this process and any implications arising. Refining the health status measure using DRG data will further reduce the incentive for insurers to attract low-risk people and avoid high-risk people.

The Bill makes a number of changes to the lifetime community rating, LCR, scheme in operation in the health insurance market. This scheme was introduced in 2015 to encourage people to take out insurance at younger ages. This Bill provides the basis for these amendments to LCR. Following enactment, I will make a regulation next year, which will set out the specific details of the changes and further enhance the operation of the lifetime community rating scheme. Since its introduction, LCR has had a positive impact with an increase of more than 150,000 persons holding health insurance between January 2015 and January 2017.

Earlier this year, the independent Health Insurance Authority reviewed the operation of the LCR scheme and made a number of recommendations. The changes being made now are to ensure the continued smooth operation of the scheme in a fair and balanced manner. Under the existing scheme, people holding health insurance who leave the country to go abroad for work or other reasons may incur loadings on their return. The main changes included as part of this Bill mean that people will be able to work, travel or live abroad and will not incur loadings on their return. This change is being made because the main objective of the LCR scheme is to encourage people to take out health insurance at younger ages, rather than penalising people who have spent periods of time outside the country. People will also be permitted to have breaks in insurance cover of at least six months while living in the country, without incurring loadings on resumption of cover. This will be based on having private health insurance for at least three years prior to taking a break in cover. The current LCR scheme provides for breaks in insurance cover for periods of unemployment, to recognise circumstances where individuals were forced to cancel their health insurance. The current legislation, however, does not provide any allowance for breaks in cover for reasons other than unemployment - for example, individuals who are involved in the full-time care of a dependent relative - so I am broadening the approach to provide for such circumstances.

In addition, a change is being made to take account of time served working in the Permanent Defence Force and as a staff member of the European Union working in this country to ensure that loadings are not unfairly incurred when these groups seek to purchase health insurance with an Irish provider. I am also ensuring that loadings are payable for ten years only, rather than for life as is currently the case. This amendment is being made to prevent circumstances arising where the application of loadings is of such magnitude and duration as to act as a disincentive for people taking out health insurance. Taken together, the changes being made to the operation of lifetime community rating will ensure that the scheme involves a fairer and more reasonable approach to loadings on health insurance premiums than has been the situation to date.

I will now outline the specific sections of the Bill. Section 1 defines the principal Act as the Health Insurance Act 1994. Section 2 amends section 7(a) of the principal Act to expand the Minister's regulation-making powers in relation to the operation of the scheme. This section also provides that, where increases in unadjusted net premiums apply, such increases are payable for ten years only.

Section 3 amends section 11(c) of the principal Act to provide for 1 April 2018 as the effective date for revised credits to be payable from the risk equalisation fund.

Section 4 amends Schedule 3 to the principal Act to provide for the revised amounts payable from the risk equalisation fund in respect of the hospital utilisation credit for health insurance contracts renewed or effected from 1 April 2018. Schedule 3 contains revised amounts for the provision of inpatient services on an overnight basis and for the provision of inpatient services on a day case basis.

Section 5 replaces table 2 in Schedule 4 to the principal Act with effect from 1 April 2018 whereby the applicable risk equalisation credits payable from the risk equalisation fund in respect of certain classes of insured persons are revised.

Section 6 amends section 125(a) of the Stamp Duties Consolidation Act 1999 to specify the applicable stamp duty rates for 1 January 2018 to 31 March 2018 and for 1 April 2018 onwards.

Section 7 provides for the Short Title, commencement, collective citation and construction of the Bill. This annual legislation for credits and levies under the risk equalisation scheme also provides an opportunity to reflect on the role of private health insurance within the health service.

One of the first priorities I identified was the need for a long-term consensus on the direction of health policy in Ireland. In this regard, I supported the establishment and continued work of the all-party Oireachtas Joint Committee on the Future of Healthcare. I am committed to working with Members of the Oireachtas and with Government colleagues to make tangible and sustainable improvements in our health services. I believe that the Sláintecare report now provides a framework and a direction of travel in which to do this.

There is an unprecedented level of consensus and support for the vision and strategic direction outlined in the report that I am determined to harness to work with colleagues across the political spectrum in moving forward with the reform agenda. The Government has given its approval to move ahead with the establishment of a Sláintecare programme office in my Department. The office has been tasked with implementing a programme of reform, as agreed by the Government, arising from the Sláintecare report. The office will be led by a senior programme executive with a strong track record in implementing reform. The recruitment process to fill this position is under way and being managed by the Public Appointments Service. It is essential that we be positioned to attract candidates of calibre to lead what will be a considerable reform programme. An extensive executive search is being undertaken as an important step in the recruitment process.

The majority of additional funding for new health initiatives in budget 2018 has been targeted at areas identified in the Sláintecare report. They include a new primary care fund, additional home care and transitional care beds, a reduction in medicine and prescription charges and targeted funding for waiting list reductions. Further to this, I recently announced the following steps to drive the reform agenda: an impact study of private care in public hospitals chaired by Dr. Dónal de Buitléir which is to report next summer; a public consultation process on the future alignment of hospital groups and community health organisations which will be launched in the coming days and the establishment of a board to oversee the performance of the HSE. I am committed to bringing to the Government before the end of the year a detailed response to the Sláintecare report and a draft programme of reform. It is vital that we do not waste this opportunity for change and real improvement in health services.

In addition to Sláintecare, work on the health service capacity review is progressing within the Department. The review will be more comprehensive than any previous capacity review because it is not just looking at the acute sector but also at aspects of primary and social care capacity. I expect to receive the final report on the capacity review before the end of the year.

Taken together, the Sláintecare report and the capacity review of the Government's ten-year capital plan - particularly the latter - present all of us with a great opportunity to define a clear direction of travel for reform. The current and potential role of private health insurance, both as a source of funding for the health service and as a driver of the model of care people receive, will also be considered as part of ongoing work in this area. In the meantime, by revising the credits and stamp duties required next year, we can continue to provide the necessary support to ensure health insurance costs are shared across the insured population. Unlike previous years when the Bill has been brought before the House, 2018 will see stamp duty levels remain the same or, in some cases, decrease for everybody with or who is taking out a health insurance policy. I commend the Bill to the House.

Deputy Billy Kelleher

I thank the Minister for outlining the detail of the Bill. At this stage it is an annual event that we have to change the legislation before the end of the year to address the proposals outlined by the Minister. Fianna Fáil will be supporting the Bill which is in keeping with the ethos of the party and its view on lifetime community rating and risk equalisation, of which we have been in favour for many years, and there have been conversions along the road. The Government has converted to our view, which we welcome. If we can get to a situation where the vast majority of parties represented within the Parliament have a coherent vision for the health service, it will mean that we will be travelling in the same direction, no matter who is sitting in the Minister's seat. For too long, the health service has been without a clear and coherent plan from one Government to the next. This has done untold damage in the provision of health care services. That is not a political point but an observation. The Sláintecare report is the platform from which to make progress in that regard as there is broad political support for it and will be in the years ahead, regardless of where or even whether individual Members sit in the Chamber. I expect the same approach to be adopted by other political parties. That will give us a chance to invest in the public health system to ensure there will be access for all when needed.

There have been times in the private health insurance market when changing policies in the context of universal health insurance have undermined people's willingness to take out health insurance. They were unwilling to take it out in the years which it was believed would proceed the implementation of a policy which never actually happened. The downturn in the economy, the pressure on families, a reduction in incomes and the threat of compulsory health insurance meant people did not take out health insurance because they thought they would be forced to take it out at some stage in the context of universal health insurance system. There is no doubt that that undermined the health insurance market. However, there has been a recovery which we must acknowledge and welcome. The more people who take out private health insurance, the greater the extent to which the burden is lightened on the industry. That means that older people will not have to pay as much for health care.

Risk equalisation is to be welcomed and should be supported. Intergenerational solidarity transfers the burden from those who most need health care to a broader base of the population which in itself means that the health insurance market can survive and thrive. Lifetime community rating is critically important and something for which we have called for a number of years. It is welcome that it has been introduced and is having a very positive effect on the health insurance market. It encourages young people to take out health insurance or at least to take it out at an earlier stage in life than otherwise would be the case in the absence of incentives. They might not take it out while they are young and healthy; rather, they might wait for a number of years and take it out just before entering a certain age cohort, which undermines the concept of having an insurance fund because it means that they will take more from it than they will put into it.

When we talk about health insurance, we must also talk about Sláintecare, the policy direction in which we are travelling and, equally, what is happening at the heart of the public health system with reference to private practice in public hospitals. The "Prime Time" programme left a sour taste in the mouths of many. There are now a number of well paid professionals who are in breach of their contractual, ethical and moral obligations by spending more hours in private practice than they are entitled to do under their contracts. This is a matter which must be addressed very quickly, regardless of our direction of travel in the context of the Sláintecare report. The Minister referred to the matter when it was raised at the joint committee last week and agreed that we would ensure contracts were adhered to. I asked at the time - I hope the Minister can consider this - whether the issue was related to the Department of Health or the HSE or whether there was a need for an independent outside audit assessment of the contracts. There is a difficulty for hospital managers because of the incentives created by stretched budgets. While there is nothing in writing, there seems to be an incentive, a policy direction or an instruction from somewhere within the Department of Health or the HSE to engage in as much private practice as possible in the public health system.

When the redesignation legislation passed through the Houses to ensure all public beds would be available for patients with private health insurance, I said it would automatically incentivise hospitals to fill beds with private patients. That was completely obvious and it is what has happened. The question is whether it is happening because it is being driven by consultants who want to push as many of their private patients through the system as possible or if it is being done to address budgetary deficits by hospitals which want to undertake private work for which they can charge insurance companies. It is something at which we really have to look. That the public health system subsidises consultants to do additional work over and above what they are obliged to do, while public patients cannot access treatment or diagnostics, leaves a sour taste in the mouths of many. I urge the Minister to look at it in detail quickly. The perverse incentives created by the 2014 legislation were bound to encourage this activity.

The Minister has outlined the Bill in detail. I do not need to need to go through all of it again as we enact this legislation every year. However, I note that there are a few additions which we welcome.

For example, we welcome the ten-year cap.

There will be huge challenges in the provision of health care in the coming years. That fact is camouflaged at present because of the demographic of the population. We have a large number of young people but the balance will tip very quickly. The recent ESRI report should set off alarm bells for policymakers and we have to start addressing capacity issues very quickly. It will take time to build up capacity because it takes a lot of manpower, training programmes and advance planning. We do not seem to plan our health care provision. Instead, we react instead to one crisis or another. When the capacity review is published at the end of the year, using ESRI projections up to 2030, we will have a template for what is required. In addition, there is the Sláintecare report, which will set out the policy direction on which we have to travel.

We cannot pretend that we will get away without investing and we have to start the process now. Investment is required in the shape of bricks and mortar, in order to expand the public hospital system, and in health professionals. There is an expansion of GP training but we are light years behind what we will require in the years ahead in respect of secondary and allied health care professionals. If we are to shift the focus from the hospital-centric system we have to primary and community care, we need to enhance the capacity in terms of personnel and professionals in those settings. Moving chronic illness and disease to those settings will require a lot of nurse specialists and we will need increased training programmes to prepare for it. This is the right way to go and it has been confirmed by the Sláintecare report.

I urge all Deputies to read the Sláintecare report. A great deal of work was put into it and there were some exceptional presentations made to the committee. It is very positive that we were able to get consensus from all political parties represented on the committee to point our health services in a particular direction. It has to be accepted, however, by the Government and those which succeed it, that this will require investment.

At present, half the population have private health insurance and there are few waiting lists for those people. Of those who do not have health insurance, 687,000 are on some form of a waiting list. The 687,000 people on waiting lists come out of a population of 2.3 million, therefore, and not out of a population of 4.6 million. This shows that the health services are teetering on the edge of collapse in terms of their ability to deliver care in a timely manner. If it was not for the private health system being able to cater for those with insurance, the public health system would have collapsed long ago. Our public health system is dependent on a very active private health insurance market which encourages people to take out insurance or, indeed, forces them to do so out of fear that they will not be treated in the public health system. Many take out insurance for fear they will not get things such as diagnostics in the public health system. It is not because they want a nice room, menus or flat-screen televisions. Citizens want timely access to quality diagnostics and care but our public system cannot give that to them at present. People are leaving west Cork on buses heading for Belfast for cataract operations because ophthalmic services are very poor there and in certain other parts of the country. The situation would be far worse were it not for people feeling forced, out of fear, to take out private health insurance. A constituent of mine aged 90 was waiting for a cataract operation but he was told it could take three years. With some interventions and representations, the matter was subsequently addressed but a person aged 90 does not that have that much time. His wife also needed a cataract operation so they were dependent on each other. It was difficult to witness the hardship caused to that couple because they could no longer do the things they always did, such as walk the road, go to the shop or go to mass. They had to rely on neighbours and friends to take them places. We were hoping they would be able to get their operations within a year but were told it would take three.

If the Minister goes to the print room of these Houses, he would see that we are all sending leaflets out advising people how to get treatment abroad under the EU cross-border treatment directive or the treatment abroad scheme. That is an admission of failure on our part.

We welcome the contents of the Bill and the fact that there is now a vibrant health insurance market but we have to be conscious that people only have a certain amount of cover. We need to ensure that there is competition in the market place and that health insurance costs do not escalate again. There is health inflation and the cost of treatment is continually rising, while new technologies and advances in medicine, in implements and in devices such implants create additional costs that are borne by the people with private health insurance or those in the public health system who are on waiting lists. I welcome the Bill and hope it has a positive effect on attracting people into private health insurance. We should be under no illusions, however. Most people take out private health insurance not for the flat-screen television or the menu but because they fear the public system.

Deputy Louise O'Reilly

It is fair to say that the political differences between the Minister and me are most acute when it comes to health and, in particular, the issue of private versus public health care. We see legislation of this sort every year and with each year we are reminded of the body of work that progressive parties have ahead of them to address the imbalance in health care and remove private health care from our public hospitals.

The question of health insurance is a fraught one. On the one hand, it facilitates the skipping of queues and the bypassing of waiting lists. On the other, it represents a large number of people who go without other things in order to have health insurance because they are afraid that, without it, they will end up waiting 24 months for a colonoscopy or some other procedure. The health insurance market exists because the Government is a champion of it and because people are afraid of having to enter the public system and being left to wait for months or years for treatment. Nowhere would this be more starkly illustrated than if we took a trip to the print room.

It is not exactly a massive vote of confidence in the health policies being pursued by the Government, with the support of Fianna Fáil, when we see the Minister's own colleagues printing leaflets advertising to their constituents the facility to leave this jurisdiction and go abroad to get treatment. If that is not a vote of no confidence in the health policy of the Government, I really do not know what is.

We find ourselves where we are because successive Governments have driven as a matter of policy the privatisation and commodification of our health service. We have to ask whether this is the best way to run the health service. Is the manner of health insurance in this country fair given that a lot of cover is driven by fear and it constitutes an extra burden to be carried by citizens, and given how much is already contributed to the health budget by taxpayers? Is this a case of citizens carrying the can for the Government's failure to enforce and police the 12.5% corporation tax and other areas of non-income-based taxes?

The Oireachtas deals with a Bill such as this every year. It is about taking away the risk from insurance companies to equalise risk for certain policyholders - if only the Government was as quick to intervene in the market in other areas. While we will allow the passage of the Bill in order that older people and others are protected, we do so with serious reservations about a health service that buckles under the weight of demand, and we point out that fear drives people to take out private health insurance.

At present, the health care system is funded primarily through general taxation, accounting for 69%, with out of pocket payments making up 15.4%. Private health insurance only contributes 12.7% to the health care system, but almost 46% of the population has private health insurance. This is the case because successive Governments have failed to provide universal health care free at the point of delivery based on need and not ability to pay. Insurance companies trade fear for profit in the health market, and we have those in here who continue to cheerlead for them.

With regard to the Bill, it is important to see that lifetime community rating rules will exempt members of the Permanent Defence Force. Other new proposed changes with respect to no loading applying to people working abroad are also important, given that many people may be out of the country for a period and then return. This has particularly been the case of many young people who were forced to leave during the financial crash and subsequent austerity years.

Under close scrutiny, the Bill reveals the existing disparity between the health of men and women, and this cannot be ignored. If we look at the risk equalisation for men compared to women in the amendment to Schedule 4 of the principal Act contained in the Bill, we can see there is a higher risk rate for females, which is an indication that in older years there are greater health risks for me and all women. This is something which needs to be looked at from a health perspective and not from this insurance market risk equalisation perspective.

We have this debate yearly because of the necessity to intervene in the health insurance market, but we should be having a debate in here every week, if not every day, about the privatisation of health care by means such as this and others. The commodification of health care has been one of the most damning elements of the neoliberal privatisation agenda. The push to turn people's health and well-being into a revenue stream is morally repugnant. Where a public health system sees illness and patients in need, the private sector sees money and opportunity. Such a situation is how we end up with the unrealistic stretched income targets being set for hospital groups to generate private income, which then put hospitals under severe pressure, compromising patient care and creating myriad problems for the equitable delivery of health care based on need. The fallout is that private patients are treated ahead of public patients in our public hospitals. Deputies and Senators from the parties who push these policies then act surprised when they see the outworkings of their policies showcased on "Prime Time" again and again.

We will allow the Bill to pass, but it is high time we had a debate and addressed the issues of private health insurance and private health care in our public system. A total of 46% of people in the State have private health insurance. A total of 34% are covered by medical cards. I am very proud to say I am member of the 20%. This is because I do not believe in private health insurance. I do not believe that privatisation has any place in a public health care system. I look forward to the day when the 20% become the majority, by virtue of the fact that the public health system provides for people who now feel they have to go to private health insurance to get decent quality health services.

Deputy Richard Boyd Barrett

Private health insurance is a fundamentally parasitical enterprise. It preys on the fears of people about the prospect of being ill and needing care and the inability of the public health system, for which they pay through their taxes, not being able to provide them with that care. This is a shameful enterprise that, week in week out, with wall-to-wall advertising on the radio, plays on those fears to profit from a fundamentally unequal health system, and from what is euphemistically known as the two-tier system. As I have said many times in the House, it just absolutely drives me round the twist listening to advertisements about going to the accident and emergency department at the Blackrock Clinic or to the Beacon Hospital if people can pay. If people cannot pay, they must line up on a trolley in St. James's Hospital for the rest of the day and maybe into tomorrow, or go to St. Vincent's hospital for hours and hours, or wait years for vital operations.

Incredibly, some people wait four years for cataract operations and people in chronic pain needing hip replacement wait two years. Children needing scoliosis operation wait months longer than they should have to, and in some cases wait up to two years. All the while, somebody is making money out of it. In fact, the worse the situation is in the public health system, the more there are waiting lists, and the longer those lists are, and the more accident and emergency units are overcrowded, the more these private health care operators stand to profit. It is really sick. I accept that in a sick, unfair, fundamentally unequal health system such as this, the Bill is a very moderate attempt to level an unequal playing field through risk equalisation and community rating. Of course, it is simultaneously propping up the whole market, as the Minister calls it. This is another thing that drives me mad. I do not know how many references the Minister made to the market for health.

Deputy Simon Harris

It is a market.

Deputy Richard Boyd Barrett

That is the difference between the Minister and me.

Deputy Simon Harris

The private health insurance market.

Deputy Richard Boyd Barrett

I fundamentally object to the health needs of humans being referred to as a market. Our State has an obligation to provide health care as a matter of human right to our citizens. There is an idea that a market has sprung up because we have been unable to do this, because we have underfunded our health service, inflicted savage cuts on it and slaughtered staff numbers and the budget and, consequently, have driven more and more people out of fear to take out private health insurance, in the hope they can skip a queue when they really need to. There should not be a queue, but if there is a queue, people out of fear and anxiety will seek to get up the queue when they are sick and vulnerable and need help. It is the failure of the political system to establish a national health system with cradle to grave health care of the highest quality as a matter of right for our citizens that has spawned this rotten profiteering parasitical two-tier system.

We saw the extreme end of that with incredibly well-paid private consultants not even doing the hours they are supposed to do. In case anybody gets me wrong, I am aware that there are many decent consultants who would not do that. However, we create the conditions for that and we have the ultimate responsibility for the profiteering and self-serving, selfish behaviour of some well-paid consultants who want to make even more money. We have created those conditions through our chronic under-funding and under-resourcing of the public health system and our support of the parasitical private health insurance industry. There is no doubt about that.

Obviously, and correctly, I am not entitled to a medical card. At a time when health care is being rationed, it would be shameful if I were. However, I believe every citizen should have access to the cradle-to-grave health care that a national health system would provide. As a matter of principle I would not take out private health insurance. It is absolutely wrong that one could jump a queue by dint of one's income. I would never take out such health insurance. Contrast that to the behaviour of the Taoiseach when he was Minister for Health. He introduced an additional levy on people who did not take out private health insurance by the age of 35 years before a deadline of May 2015. He had posters and T-shirts that touted, advertised and threatened on behalf of the private health insurance industry, urging people to get private health insurance or they would pay. He said at the time:

As Minister for Health, I wanted to take a lead. I also wanted to avoid the levy ... I can honestly say that I feel a lot better having taken out health insurance again.

What is the message there? It is that if one does not have private health insurance, one has something to worry about. He could afford to get it and he was relieved. What was he relieved about? He was relieved that he does not have to rely on the public health system.

Is it not absolutely shameful that the person who was in charge of the public health system said he was relieved he did not have to rely on that system because he got private health insurance? That is shocking. No Member of this House should have private health insurance. If we have it, we are saying that the system over which we preside cannot provide for citizens. People must take out private insurance if they can afford it. Huge numbers cannot. The fear tactics on that occasion worked. Some 150,000 additional people took out private health insurance after the scare tactics mounted by the then Minister for Health, Deputy Varadkar, in 2015. It was dragooning people into taking out private health insurance to the benefit of the private health insurance industry. What happened at the time was shocking.

Consider the profits these health insurance companies make and the extraordinary waste in advertising. The money is not going to health care but to advertisements that urge people to go to the companies' hospitals so they will not have to queue. That is all waste. It is money diverted from the front line of public health care. I do not know why the Minister is shaking his head. That is a fact.

Deputy Simon Harris

It is not public money.

Deputy Richard Boyd Barrett

People are spending €2 billion on private health insurance. Would it not be far better if that money went into the public health system? It would go a hell of a long way towards sorting out the problems in that system. That is in addition to the €2.5 billion to €3 billion, or 18%, they fork out on out-of-pocket charges, such as accident and emergency charges, overnight stay charges, general practitioner charges and so forth.

I recall what the Government said when it tried to defend the savage cuts it imposed on the public health system during the austerity period. It boasted that we spend one of the highest proportions of GDP on health, forgetting that a huge proportion of this does not go to the public health system. Only 69% of the spend goes into the public budget when one strips out the out-of-pocket charges ordinary people must pay and the €2 billion spent on private health insurance. That money and a system of progressive taxation could be used to fund a state-of-the-art national health system so that when people need health care, they need not worry. The last thing people need to worry about when they need health care is whether they can afford health insurance premiums or, if they do not have insurance, the out-of-pocket charges they might have to pay.

The other issue with this Bill is that the industry report prepared for the Government has not been not published. Is it available to the public? Can we see it?

Deputy Simon Harris

It will be published.

Deputy Richard Boyd Barrett

We are passing the legislation without seeing the report. Is that correct?

Acting Chairman (Deputy John Lahart)

This is not a question-and-answer session.

Deputy Simon Harris

I will publish it before Committee Stage.

Deputy Richard Boyd Barrett

That would be useful. I am glad I asked because I do not believe we should pass legislation without either seeing the report on which it is based or being certain that the levies and the distribution of credits are all being passed on. Is it guaranteed that they will all be passed on to where they should be in terms of equalising the cost of insurance and not into the back pockets of certain health insurance companies? Does the legislation ensure that is the case and that there is accountability for the disbursement of the levy credits?

That is an aside to my fundamental point. We will not oppose the Bill because it is trying to equalise a fundamentally unequal system. However, I object in the strongest terms to the fact that this Government has propped up the private health insurance industry, touted on its behalf and exacerbated people's fears and anxieties about having or not having private health insurance and also the concerns that arise from our abysmal failure to fund and resource the public health system properly, which is what should be resourced in order to ensure that there is genuine equality, not risk equalisation, in access to health care. All citizens deserve that as a right because they are human beings, not because they are players in the so-called market.

Deputy Mattie McGrath

I welcome the opportunity to speak on the Bill. Clearly, there is a huge crisis for the health insurance market and it is deepening by the day, if not by the hour. I first started thinking about health insurance when I got married in 1984. I started my family and established a business. When health insurance products first come onto the market, I welcome them with open arms. I do not dismiss those who cannot afford private health insurance but there is some comfort to be gained from having it.

This issue has been abused and hijacked over the years. There was a problem in the insurance industry due to spurious claims being made. I recall seeing a television advertisement by the insurance companies which described how a person named John, played by an actor, had an accident and decided to claim. The advertisement showed him putting his hand in everybody else's pocket. Many people have their hands in pockets with regard to the costs of the insurance industry. That is unacceptable. I recall being quite ill in hospital on one occasion. I received the best of care at Shanakiel Hospital, which has since closed, in Deputy Kelleher's city of Cork. On the morning I was due to leave, a little envelope was slipped under my tea and toast. It contained a hefty bill in respect of the cost of a private ambulance to take me from one hospital to another.

I could have walked from Shanakiel Hospital across to the regional hospital but I could not walk back because I was under anaesthetic. I could nearly have bought the ambulance for the amount I was charged. This is happening and it is being hijacked. I am aware that medical professionals are bound by the Hippocratic oath. I sympathise with medical staff in the hospitals, for example, those involved in the tragic case of Savita Halappanavar. I know a full investigation into this case is ongoing. Accidents will and do happen. The private costs are spiralling out of control and the charges are being heaped on. I profoundly object to people who might be in difficult situations or who might be very ill entering accident and emergency departments and having forms shoved in front of them and being asked to sign in order to show that they are private patients. The Minister looks perplexed but he knows this is happening all the time.

Deputy Simon Harris

It is just how I look.

Deputy Mattie McGrath

Is it? Well it is happening all the time in the hospital in Clonmel and in other hospitals. A patient might then be on a trolley for two or three nights and be charged the price of a bloody top-class hotel room when they do not even have a bed. This practice is widespread - certainly in Tipperary. I would not say that unless it was the case. What is happening is wrong. I heard a solicitor on the radio advising people not to sign the forms. Hospital staff should not ask sick people to sign forms because they might not have 100% of their faculties if they are very ill. This is happening and it is distasteful. The HSE is getting the funds through charging private companies but the patients might never get hospital beds. It is another way of operating in the HSE which is literally robbing the system and that is not good enough.

While I have dealt with many consultants and while I have the highest respect for them, there was a recent exposé involving hospital consultants. I go back to Barry Desmond's time as Minister, which was long ago when I was a young man. He was fighting so that the consultants would be sorted out and could not use public hospital facilities to treat private patients. That was a long time ago. I think Barry Desmond is still alive; I am not sure. I wish him well if he is alive. He fought that battle but he did not win it. The problem was not tackled and it still obtains. A vet or a dentist must set up his or her own laboratory and deal with patients in his or her own way. Why should consultants use public hospital facilities to treat private patients? It should not be happening, full stop. It will go against the consultants but fair play is fine play as far as I am concerned. Are consultants supposed to work 30 hours per week under their contract? I am not sure about the figures. I compliment RTÉ on the exposé to which I refer. What is happening is not acceptable.

The Health Insurance Act 1994 made provision for the establishment of the Health Insurance Authority, HIA, but the body was not brought into existence until 1 February 2001, which was much later. What is wrong with a system like that? Why did it take so long? The 1994 Act was amended by the Health Insurance (Amendment) Act 2001 providing for, among other things, an enhanced role for the HIA, with more responsibility than was envisaged under the 1994 Act. I welcomed that. The HIA is funded by a levy imposed on private medical insurers but, like everything else, this was passed on to the punters. Premiums were to be independent of the State. The role of the HIA includes acting as a registrar of medical insurers and undertakings and vetting new market entrants. It is also involved in consumer protection and the provision of information. It also provides advice on matters of medical insurance to the Minister for Health. The HIA receives returns from medical insurers every six months and, on that basis, makes recommendations to the Minister regarding risk equalisation. Since people are asking the Minister questions, can I ask him how often he has met representatives from the HIA? Does he meet them regularly? Is the HIA doing its job? Is it like the rest of the quangos in that it is costing us money but does very little and we get very little value for money out of it?

This country is affected by a plethora of issues. We are all regulated but nobody is doing anything. Most of them are toothless, useless and fruitless. They get paid and get their perks and Mercs but are often very ineffective. This is true not only in health but across the board. I do not understand why insurers cannot see that these increases are creating an even bigger mess. The dropout rate in respect of health insurance is enormous, which is a worry. I meet poor old dears. I met one about two years ago who cancelled her insurance only about a week before she got sick. She had been paying it ever since it existed but just could not afford the increase and dropped out. When she needed it, she did not have it. There are many issues to be dealt with. I moved from VHI to Aviva but found that the goalposts kept changing. Now we find if we go for a procedure, we are covered for very little. We are covered to get in the door. The health insurance industry could be compared to the people on Grafton Street with billboards coaxing customers into their premises. However, once customers go in, some of them are fleeced. I am not saying that about premises on Grafton Street. We need to regulate this because health insurers are getting customers in and are chopping and changing and people do not know the extent of their cover. That is a fact. I do not know whether the Minister is shaking his head in disbelief or asking "What's he talking about?", but it is happening.

Deputy Simon Harris

It is regulated.

Deputy Mattie McGrath

It is regulated but my point is that the regulator - as is the case with most regulators - is useless. We have seen it in the insurance industry and in the context of energy prices. Look at the concrete industry. It is a cabal of the highest order and the regulator is doing nothing. All the smaller people are being forced out of business and gobbled up. We have regulators and legislation but both are ineffective. This is true across the board. We saw what happened with the banking regulator. The same illness has spread across to health, an area one would think would have a clean bill of health, but they are not being regulated. If they were, RTÉ would not have to go in and expose what is happening. I am surprised the Minister is not aware that people are asked to sign forms when they enter hospital. This happens all the time.

I mentioned what Barry Desmond tried to do 30 years ago. I was not in politics at the time but he was fighting this battle. Why is it taking for ever? Are they too powerful to fight? Consultants should have their own facilities to treat private patients. We can do it. Someone can go to the Mater Private Hospital and be in and out. It is streamlined from start to finish like any private hospital I have visited. "Conveyer belt" is the wrong term to use but it is efficient. When someone is called for an appointment, it is not done the way it is done in public hospitals where 100 people could have appointments for the same time. That is incompetence of the highest order and it causes stress and trauma, blocks up the place and is frustrating. One sees managers running up and down with flipcharts and they are managing chaos - because it is chaos. It should not be this way. Private hospitals in Kilkenny, Waterford and Galway can do it. They are efficient and patients get the treatment. They pay for it but they get it. If someone goes into the public hospital for treatment, he or she will not get it but he or she will be charged for it out of his or her medical insurance. It is difficult to understand what goes on. The nurses and other front-line staff are doing great work trying to do what they can but there is no throughput. Every Christmas, and it will happen this year as sure as it will get dark tonight, there will be bedlam in every hospital because hospital administration offices close down for nearly three weeks. The last week of work involves parties and celebrations. This is a fact. It will be bedlam. When we come back on 11 or 12 January, nobody will be called because nothing is going out. This happens every year. If we are honest, we know this happens. We cannot continue to allow it. One could not do that in any private company because one would be out of business by March if one just abandoned the place and left a skeleton staff. It happens, including in my local hospital.

I heard a very disturbing report on my local radio station about a young man who lost his life in a hospital in Cork some years ago. The report in question related to the inquest into his death. His solicitor, Cian O'Carroll of Cian O'Carroll Solicitors in Cashel, spoke on the radio about this tragic case. The young man had visited the hospital with a violent headache and was sent home on three occasions. The hospital never carried out the proper procedures and did not follow protocol.

The protocols are laid down but the hospital did not follow them. I want the Minister to investigate that because the family involved got no satisfaction at the coroner's court in Cork. The young man died in Cork.

Acting Chairman (Deputy John Lahart)

We need to stick to the topic.

Deputy Mattie McGrath

This is the topic. A man died. He was a young man with five kids.

Acting Chairman (Deputy John Lahart)

I am not disputing that but the topic at hand is the Bill.

Deputy Mattie McGrath

It is a human life. He was a young, healthy man-----

Acting Chairman (Deputy John Lahart)

I am not disputing that.

Deputy Mattie McGrath

-----with four children. His partner was expecting another child at the time. I was aware of the tragic death.

Acting Chairman (Deputy John Lahart)

This is the Health insurance (Amendment) Bill.

Deputy Mattie McGrath

I am talking about health standards. What is the point in paying insurance if one is treated like that in hospital? Does the Acting Chairman not get it? Is it not connected? Let us be fair. If one pays health insurance, one expects it to be foolproof. I am not saying it happens every day but one person dying is one too many. It is appalling that the man in question was sent home without having a lumbar puncture performed, particularly when he had a violent headache and had scans and it did not show up. Apparently, in 10% of cases it does not show up. He saw ten junior doctors and one consultant during those visits to Clonmel. That is appalling. It will cost the State a fortune in a pay-out. He lost his life and his partner lost him. She has four kids and is expecting another child. He was a young man in full health and just got a violent headache.

If there are protocols, they must be followed. They are followed in factories. There are protocols for everything. It is more vital to have protocols followed in hospitals than anywhere else. They clearly were not followed in this instance. As already stated, I heard the solicitor interviewed. It was broadcast on Tipp FM this morning after 9 o'clock. I am familiar with the case and that is why I listened in. I was not expecting it; it just came on. The family are seeking a judicial review because the solicitor was not allowed ask questions in the coroner's court. The medical personnel were not allowed to answer. They were debriefed before the inquest on what happened so they would not talk about it. They were debriefed and told it was over, finished and done with. This is very serious. Consultants at South Tipperary General Hospital, including Dr. Paud O'Regan and Dr. Peter Murchan, work very hard. My late brother was a paediatrician at the same facility in Clonmel. There are many good outcomes but also a lot of bad ones. It is appalling to lose a young man like that. It is ironic that I happened to hear the interview on Tipp FM this morning. Everyone in the region has been working on these packages to try to get issues sorted out in the hospital. We are working to get extra beds and extra capacity.

The most important thing is insurance. There is a widespread practice when people are on trolleys in hospitals. They are glad to have gotten there by ambulance or car, they are on trolleys and there is someone running after them saying, "Will you sign this please?" It is totally unfair and wrong. It is morally and financially wrong. One might be half comatose and in agony; they are delighted to be in the premises and this is happening. There are administration staff sending out bills. There is funding allocated to hospitals every year based on turnover and the money they bring in. There are a lot of things wrong with that and it needs to be sorted out.

Deputy Michael Collins

I am happy to have the opportunity to speak on the Bill. I thank the Minister for signing off on the legislation for medicinal cannabis and I am delighted to hear that Vera Twomey and her daughter Ava will be returning home from Holland to Macroom for Christmas. I hope other sufferers will benefit from the medicinal cannabis in future and that unnecessary delays can be avoided.

I have spoken many times on the issues of health, health insurance and the two-tier system that exists in this country. In recent weeks, I have raised the cross-border health care directive and the ability of people in the Republic experiencing long delays in the health system to avail of medical procedures in the North or in other EU countries. This directive refunds patients who cannot afford insurance, meaning that hip operations, cataracts, and other procedures do not cost Irish patients a cent. However, because of the endless failings of the HSE and their waiting lists, many Irish patients have been forced to pay for private health insurance to get their operations completed urgently but they do not receive any compensation. As Deputy Kelleher stated, and he is completely right, it is an appalling situation for Ministers to be handing out leaflets telling people they can go for operations abroad. That is a failure of our system. It is disappointing that I have to point people who are in need of cataract, hip and knee operations towards Northern Ireland. It is a failure for me and for any Minister to advise people to travel to the North in order to have operations. A constituent recently contacted me in tears after hearing about the cross-border directive. The person had waited for years for a hip replacement on the HSE public waiting list but, due to the enormous levels of pain she experienced, she was forced to pay close to €15,000 to get the operation done under private health insurance. It was €15,000 she did not have to spare and she was heartbroken to learn she could have availed of it for free under the directive. This is another example of the two-tier system that operates in this country.

Last week on "RTÉ Investigates" we saw how one poor lady was forced to sell her jewellery to have her procedures performed under private health insurance. That is not good enough. The biggest reason for the two-tier system is the incompetence of the HSE. There should not be a need for people to avail of private health care when we have a public system.

I welcome the Bill and am happy to support it because I believe the risk equalisation mechanism is very important to prevent ill or older people from paying huge premiums to health insurers. People should not feel forced into paying for private health insurance, which adds extra stress to their unfortunate health issues. There is a need for stricter regulations on private health insurance. Insurers are happy to put extras on bills for the simplest of reasons. They can totally exploit their customers and take advantage of the fact that they require urgent treatment and are in poor health. That is not good enough. As with the motor insurance industry, I favour the introduction of legislation to place stricter limits on the private health insurance sector.

On a semi-related matter, yesterday I met a group of parents and children, as many other Deputies did, who suffer from MPS. MPS is a rare genetic disorder and, Vimizin, the necessary medication for these patients, is not supported by the HSE and is currently only offered on a trial basis. Not even private health care can help these patients and I ask that the Minister approve funding for it as soon as possible. The drug is made in Cork but is not available for patients in Ireland. Pharmaceutical companies must take responsibility for their greed in the context of the prices they charge. We were able to help patients who needed Orkambi, so I plead with the Minister to do the same in this instance.

Deputy Róisín Shortall

This is the annual event at which we look at the 2013 permanent risk equalisation scheme and make the normal annual adjustments to elements of it. There are three provisions in this legislation that propose changes to the rates to come into effect in April 2018, to make related amendments to stamp duty legislation, to adjust the lifetime community rating system and to extend the Minister's powers. What the Minister is proposing to do is to tweak a very dysfunctional private insurance system relating to a very dysfunctional health system. In many ways, we are having the wrong debate. We are talking about a situation in which nearly half the population feel they have no choice but to take out very expensive private health insurance. That kind of two-tier system does not happen anywhere else. Many people who cannot afford private health insurance feel they have no choice but to pay for it because our public system is so weak. The standard plan B cover that many people take out costs something in the region of €1,500 per person. That is way beyond the reach of many people, especially the elderly, but they make sacrifices in a whole lot of other aspects of their lives in order to maintain private health insurance. They do so out of fear that if they are faced with serious medical conditions, they cannot depend on the public health system. This is an extraordinary indictment of our public health system. We are alone in Europe in this kind of thing. Every other European country has a reliable, dependable public health system whereby people feel that when they need care, they will be able to access it in a timely manner. In Ireland, 46% of people feel, mainly out of fear, that they have to fork out for huge premiums that are increasing year on year. In return for those expensive premiums, they get a very poor deal.

Debate adjourned.