Dáil Éireann debate -
Wednesday, 9 Dec 2020

Vol. 1002 No. 3

Health Insurance (Amendment) Bill 2020: Second Stage (Resumed) and Subsequent Stages

Question again proposed: "That the Bill be now read a Second Time."

Deputy David Cullinane

I thank the Minister of State for his contribution to what has become an annual debate on private health insurance. I will support the Bill. Having said that, we should take the opportunity every year when we debate such a Bill to review where we are with Sláintecare and with the commitments that all parties in the House gave to phasing out private health insurance and the private health sector, and to working towards a public, universal healthcare system where people are treated on the basis of need and not of how much money they have in their pocket.

The Minister of State set out what the Bill will do, which we will support, but there is a fundamental question to be asked as to why people take out private health insurance. The vast majority take it out because they feel that they need it, that they cannot depend on our public system and that if they get sick, or if a family member gets sick, the fastest route to help them is through private health insurance to get a scan, a test, an assessment, an appointment or treatment. That is true. The problem is that all those who cannot afford to take out private health insurance are left on public-system waiting lists. According to the most recent figures, 613,000 people in the State are waiting to see a hospital consultant, with 150,000 of them having waited more than 18 months. Where in God's name is the delivery of Sláintecare, which promises that people should not have to wait longer than four months, when 150,000 people in the State have been waiting more than 18 months, some of whom, in areas such as orthopaedics or scoliosis, are children? It is a scandal and it will not happen until we make a commitment to properly resourcing our public hospitals and to recruiting the consultants, the specialists, the nurses and the healthcare assistants we need, and until we put public beds into public hospitals.

There is also an issue with what people get for private health insurance. Most people who take it out pay tax, PRSI and PAYE, and if they get sick and go to a GP, they have to pay for that as well. That is the reality for many people. We are charging, double-charging and treble-charging people for healthcare instead of committing to delivering on the promises we all collectively made in respect of Sláintecare to deliver a better public health system. When the public system does not provide a service, the private, for-profit system will step in to deliver it more quickly if it gets the opportunity to do so.

There was an example in my constituency. Ten years ago, there was a campaign for a second cath lab at University Hospital Waterford. I was a member of Waterford City Council at the time and a delegation from the hospital explained to us that if somebody had a heart attack outside of 9 a.m. to 5 p.m. anywhere in the south east, he or she would have to travel to Dublin or Cork for an emergency cardiac procedure, or what is known as a PPCI. Two years ago, the then Minister for Health signed off on a second cath lab, but to this day, not one brick has been laid in that area because the political will was not there to make it happen because of the way in which capital projects are delivered in the State. The private hospital built a cath lab, which I do not blame it for, and it is providing a very good service. From conception to delivery, it took the hospital six months. Within that time, a private hospital was able to say it would build a second cath lab, open and staff it and provide the service, yet after ten years of campaigning, and two years after it was first supported by the then Minister for Health, still not a single brick has been laid. The same Government - Fianna Fáil, especially - that promised people that it would deliver 24-7 emergency cardiac care in our public hospital still has not done it and is still hiding behind reviews, yet it is now talking about expanded out-of-hours services but not the 24-7 care that was promised. That is what happens and part of me thinks that is what Fine Gael wants, namely, not to deliver for our public health system and to allow the public healthcare system to step in.

I will support the Bill, only because change needs to happen, but an awful lot more needs to be done to advance Sláintecare and to phase out once and for all the private, for-profit healthcare system, which means that some people get treated more quickly depending on how much money they have, as opposed to people being treated fairly depending on their health need.

Deputy Patricia Ryan

The Bill concerns an issue dealt with every year in similar Bills to provide risk equalisation. Risk equalisation is a mechanism designed to support the objective of a community-rated health insurance market whereby customers pay the same net premium for the same health insurance product irrespective of age, gender or health status. The Health Insurance Acts have provided for a risk equalisation scheme for the health insurance market since 1 January 2013. Under the scheme, insurers receive risk equalisation credits to compensate for the additional cost of insuring older and less healthy people.

The differences across the political spectrum are most obvious in terms of the health service. We need to address the imbalance in healthcare to remove private healthcare from our public hospitals and our public healthcare system. It is high time we moved from away from a two-tier health system. I could not afford health insurance as a private citizen and I know many people who make sacrifices to keep their health insurance because they are afraid that without it, they will end up waiting 24 months for a colonoscopy or some other procedure, and this is wrong.

There are many people stuck in the middle of earning too much to qualify for a medical card and too little to be able to afford health insurance. This is also wrong. Ability to pay should not have any bearing on how one is treated in the healthcare system. The American healthcare system is the extreme side of a private healthcare system but we are not far behind. I spoke to a lady this week who is scrimping on Christmas this year so that she can pay €250 to a private consultant for an ear, nose and throat, ENT, assessment. She is in her third year on a waiting list in Tullamore hospital. A year ago, she received a letter from the hospital asking if she still needed to be on that list and she has had no communication since. She is one of the lucky ones in that she has health insurance which she hopes to use to have that procedure in a private hospital. People are languishing on waiting lists getting sicker while those with health insurance are fast-tracked to the front of the queue. In some cases, they are treated by the same doctors and even in the same hospitals. As a "Prime Time Investigates" programme in 2017 showed, consultants sometimes treat private patients on public time. A question by my colleague, the former Sinn Féin councillor, Mr. Thomas Redmond, to the midlands health forum in 2017 showed that this happens in rent-free rooms in our public hospitals.

Health insurance exploits a failed public health system that is being killed off by successive Governments that favour a private health system. As with the commodification of housing, the commodification of our health service is hurting those who need it most, such as our elderly and those who are on low incomes - in other words, the working poor. In an ideal world, we would have no need for the private health insurance market. The industry exists to paper over the cracks of our broken public health system. Our waiting lists in most areas are out of control. Vulnerable people are being exploited. I recently asked a parliamentary question in relation to the pain clinic in Tallaght hospital. There are over 1,100 people waiting for up to four years on an appointment there. These people are living with chronic pain and this is having a profound effect on their lives. Their mental health is suffering. In some cases, their life expectancy will be lowered. Sinn Féin in government will deliver an all-island health system that is free at the point of delivery and is based on need rather than income. People deserve nothing less.

Acting Chairman (Deputy Aengus Ó Snodaigh)

Bogaimid ar aghaidh anois go dtí sliotán Pháirtí an Lucht Oibre. Tá deich nóiméad acu. Tá siad as láthair. Bogaimid ar aghaidh anois go dtí an Teachta James O'Connor. An bhfuil sé i láthair? Níl sé anseo. Bogaimid ar aghaidh arís. An chéad cheann eile ná sliotán Shinn Féin. Glaoim ar an Teachta Darren O'Rourke.

Deputy Darren O'Rourke

Risk equalisation and lifetime community rating were to be the foundation of our health insurance sector but they remain an intervention to try to adjust what is an inappropriate infrastructure. The ESRI reported earlier on this year in terms of lifetime community rating. Like so many aspects of this regime, perverse incentives persist. What happened on the back of the introduction of lifetime community rating was that younger people responded as intended by entering the market, and the insurance industry responded in kind and developed cheaper plans that give less cover. The practical effect of it was that younger people were paying less and getting less for their money, which resulted in significant out-of-pocket payments and a lack of solidarity. The intention of solidarity that was there did not materialise. Out-of-pocket payments remained very significant. On top of that, the indications are that premiums will increase next year by up to 7% and we still wait for the implementation of the de Buitléir report. The solution in all of this is a move away from public investment in private healthcare. There is significant public investment in private healthcare. We need to move to a single-tier public health service on the back of the Sláintecare report. Sinn Féin wants to see an all-island health service that is free at the point of delivery and delivered based on need rather than ability to pay. That is where we need to go.

Acting Chairman (Deputy Aengus Ó Snodaigh)

Bogaimid ar aghaidh anois go dtí na Social Democrats agus an Teachta Róisín Shortall.

Deputy Róisín Shortall

As others have said, 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 that original legislation. The legislation is introduced at the end of each year to make adjustments to the risk equalisation scheme in respect of the stamp duty levies, risk equalisation credits and hospital utilisation credit rates. Private health insurance is regulated by the Health Insurance Authority and it is on its recommendation that these annual proposals are made. They are generally nodded through on the basis that there is general support for the principle of risk equalisation.

If one is going to have a system of private health insurance, risk equalisation is an important element of that insurance system because it prevents cherry-picking in the health insurance system. This is especially the case given the history of health insurance in this country where the VHI had the field to itself for many years. It is really only in the last decade that we have seen any competition within the market. As a result of the VHI having the market to itself for many decades, the company has a disproportionate number of older members and it would be unfair to allow new entrants into the market which could cherry-pick younger and healthier clients or customers. That is the purpose of risk equalisation and it is very difficult to argue against that scheme. Most of the new arrangements and rates will apply from 1 April 2021.

The Minister is proposing to tweak what can only be described as a dysfunctional private insurance system relating to what is a dysfunctional health system. In many ways, we are having the wrong debate tonight. We are talking about a situation in which nearly half the population feel they have no choice but to take out expensive private health insurance. That kind of two-tier system does not happen anywhere else in Europe. Many people who cannot afford private health insurance feel that they have no choice but to pay for it because of our public health system being so weak.

The standard plan B cover that many people take out costs in the region of €1,200 per person when taking all premiums into account. As we know, that figure can often be a great deal higher, especially for older people. The average figure for over-50s is more like €1,500 per person. That is way beyond the reach of many people, especially older people and people who are on pensions, but many of those people make sacrifices in many other aspects of their lives in order to maintain private health insurance. They do so out of fear that if they are faced with a serious medical condition, they cannot depend on the public health system to be available to them when they need it. That view of the public health system is a shocking indictment of our public health service. We are alone in Europe in this regard. 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 high premiums. In return for those expensive premiums, they do not get a terribly good deal. Obviously, over recent years many people have had to give up private health insurance. During the last austerity period, the level of cover went down to its lowest level with the percentage covered in the low 40s.

It has been gradually creeping up and last year it got to approximately 46%. The figure has remained at that level. Some surveys were done in the middle of this year showing it is still in or around 46%. It certainly did not go up. The idea that so many people would fork out for private health insurance is unheard of in all other European countries. Generally, people in other countries in Europe have access to an affordable public health system that is free, or almost free, at the point of use. That is the kind of system we should have in this country. It is the kind of system to which Irish people should be entitled.

Unfortunately, we are in a situation where a large number of people in this country feel they have no choice but to take out health insurance. That must be seen for what it is. In effect, it is an extra tax on people. On the basis of a premium of €1,500 per year, it amounts to an additional tax of €38 per week, or some €167 per month, in order to buy private health insurance. If it had been announced in the recent budget, or any budget, that new taxes of €167 a month were to be introduced, the Government would have been laughed out of it. Somehow, people seem to think it is all right to put this kind of charge or tax on people just to access health cover. This goes on year after year. On the one hand, there are Government representatives talking about cutting taxes and, at the same time, people are paying out for a very basic service. There is nothing more basic in terms of meeting people's needs than having access to a public health service. We cannot even provide that for people in this country and we tax them to the level of €167 a month in order to be able to access timely healthcare.

The basic plan B health insurance provides people with basic health cover. It really only enables people to skip the queue and jump ahead of others who do not have private health insurance. There is cover for elective surgery but there are a lot of other things the premium does not cover. By and large, the health insurance policies that are available in this country give very poor value for money. Even where a person has plan B, they will still, in the main, have to fork out to see a GP. Again, this is unheard of in other European countries. I do not know whether the Government appreciates that we are the only European country where people have to pay the full amount to see a GP. It just would not be tolerated anywhere else. A charge of €50 or €60 is a real disincentive to accessing care when we should be encouraging people to access that care at an early stage. Even if people have private health insurance, they still have to fork out €200 or €220 to see a consultant. There are very few policies that give any relief in regard to those charges. What about accessing medicines? Again, the standard policy does not provide any relief in that regard. In all other European countries, medicines are available free of charge or for a nominal charge. We are completely out of line with what is standard for all our neighbours in Europe.

The other element of the private health insurance issue is that tax relief is provided to those who access it. It is a reducing tax relief, which used to be at the higher rate but is now at the standard rate. The cost of providing tax relief for health insurance is estimated at €355 million. That is a direct transfer of public money from the weakest to the more affluent. Everybody contributes to the tax relief but only 46% of people, who make up the most affluent part of society, benefit from it. There are huge issues of equity there.

In conclusion, we are having the wrong debate tonight. The debate that should be happening is about implementing Sláintecare and accelerating its implementation. Everybody is signed up to that but the Government needs to account for its tardiness in this regard.

Deputy Ruairí Ó Murchú

Several speakers mentioned that in discussing risk equalisation, we are dealing with another failure in regard to healthcare provision. The entire Covid period has shown up the many weaknesses in our systems, including the healthcare system. At least the conversation has moved on. In fact, it had already moved on prior to the election. When we talk about Sláintecare, we are talking about the need for a national health service. We would like to think that any such system would be designed on an all-Ireland basis.

We need to move beyond talk and on to delivery. We need healthcare provision that is available from cradle to grave and free at the point of entry. We must have a system that enables people to get the healthcare they need when they need it. It is as simple as that. We need to look at how the whole system operates. Healthcare provision is lacking in many instances. We are all aware of the difficulties with acute services in hospitals but we also need more primary care centres. There is one promised for Dundalk and we must ensure it happens and will have the suite of services that are required, including mental health services. I have spoken to the Minister a number of times about the part of his remit that relates to drugs. We all agree that we do not have the addiction services that are required. We are missing wholesale elements of the care package people require. We need to start having the right conversation and delivering healthcare for all.

Deputy Donnchadh Ó Laoghaire

There is an old cliché about asking for directions only to be told that one should not start from one's particular location. The Irish healthcare system is the classic example of that in policy terms. I speak to constituents who have arrived here from other countries in recent years and cannot fathom the system we have, including the mixture of public and private provision, the cost of visiting the GP - which some people have to do frequently - and the cost of prescriptions. Somewhere in there is an ostensibly public system. It is a crazy mishmash and it is extremely ineffective and wasteful.

The provisions in this Bill relating to risk equalisation make sense only in the context of our crazy system. It is necessary to equalise risk. However, as every speaker has said, we need to alter the system fundamentally. We need a healthcare system where people can rely on public provision. Healthcare provision is a public good and everyone should be able to expect a decent quality of care through the public system. That is where we need to get to. We have all made that point but the past few Governments have not done very much about it.

I want to raise a specific issue in regard to health insurance. It is one that has been raised with me by constituents on a few occasions. People who are going into hospital for a procedure may be told by the doctor that they should be admitted the night before. They go in the night before, they have the procedure the following day and they might stay that night as well. However, their health insurance company will only cover the second night. That is not something patients expect because they went in through private health insurance. They could be left footing bills of €800, €900 or €1,000 for that bed night.

It is crazy. Constituents do not expect it. The health insurance companies should be picking that up. There is evidence from doctors that consultants are writing to the hospital claiming the stay was necessary for the person's care. It might be a relatively small issue in terms of the numbers of people affected. It is a serious issue, however, if people get a bill for €1,000 which they are expecting their insurance company to fork out for. It really is not good enough.

Deputy Denis Naughten

The issue I am going to raise will not come as a surprise to the Minister because I am sure it was provided in his briefing note. I gave ample notice this time last year that I would revisit this issue this year if nothing had been done about it.

What have South Tipperary General Hospital in Clonmel, Roscommon County Hospital, Our Lady's Hospital, Navan, Louth County Hospital, Dundalk, St. John's Hospital, Limerick, Our Lady's Hospital, Manorhamilton, Naas General Hospital, St. Luke's Hospital, Rathgar, St. Michael's Hospital, Dún Laoghaire, St. Joseph's Hospital, Raheny, St. Columcille's Hospital, Loughlinstown, Peamount Hospital, Newcastle, County Dublin, Connolly Hospital, Dublin and Mallow General Hospital got in common? First, they are all public hospitals. Second, if one is unfortunate to buy one's health insurance from Irish Life Health and goes for list 2, 3 or 4 in coverage, one cannot be treated in any of those hospitals.

All of the hospitals in question happen to be level 2 hospitals. As the Minister knows and would have pointed out ad nauseam himself in the past, it has been the priority of Governments over the past decade to put more work through level 2 hospitals. However, these specific level 2 hospitals, public hospitals, are not being provided with hospital cover from one of the major health insurers.

This time last year I raised this specific issue with the then Minister for Health, Deputy Harris. I had been pursuing him on the issue of the injury units in hospitals like Nenagh, Roscommon, Monaghan and so forth. I was arguing that we needed to utilise those particular hospitals and get more patients to use them. In fairness to the then Minister, he took on board what I said and reduced the fees for people attending an injury unit from €100 back to €75. He would not go any further than that because he feared the service would compete with general practice. People might go to the injury units rather than their GPs if the cost was reduced further than that, he felt.

This morning, I happened to be on Galway Bay FM discussing another health issue. The HSE is actively promoting the minor injury unit at Roscommon County Hospital, encouraging people to go to it to avoid going to emergency departments. Over the past number of years, people from as far away as Eyrecourt would be better travelling to Roscommon hospital where they would be treated quicker for injuries than going to Portiuncula hospital in Ballinasloe where they would wait hours for an X-ray.

It is wrong that any health insurer should be blatantly acting against stated government policy, which is to put more work through our smaller hospitals and take pressure off our bigger acute hospitals where beds are being occupied for very sick patients in our emergency departments. Deputy Shortall earlier said this was effectively a tax on access to health cover, amounting to €167 a month. Not only is it a tax, it is a disincentive in some cases to go to the most appropriate hospital. Instead, the insurers want people to go to the bigger hospitals, putting pressure on them and their accident and emergency departments, when they can be treated in local hospitals. It is not right that any insurer should be availing of risk equalisation while at the same time going blatantly against the Government's policy of putting less complex work through our smaller local hospitals.

On foot of taking up this issue last year with the then Minister, Deputy Harris, he stated he would ask his Department, working with the Health Insurance Authority. to review the current regulations that allow Irish Life Health to do what it is doing with a view to removing those particular exclusion clauses whereby providers are effectively banning people from attending smaller hospitals. Insurance companies should not be allowed to carry out that particular practice. We are 12 months down the road now. The Department has been given fair warning on this. I have not put down an amendment on this occasion because last year the then Minister said the amendment I put down then would have unintended consequences. I do not see in this legislation provision being made to ban this particular practice. When the Minister responds, I hope I get a detailed response as to what specific actions have been taken. The difficulty is that we are 12 months further down the road but nothing has changed. The list I read out to the Minister is from the Irish Life Health website tonight. It precludes people from using smaller local hospitals and discriminates against those who do so. Irish Life Health wants people to spend hours sitting or lying on trolleys in accident and emergency departments rather than accessing the local injury units or elective surgery in our smaller hospitals where we do not have waiting lists.

These were the hospitals which were able to continue to deal with outpatient appointments during the first Covid lockdown. That did not happen in our bigger hospitals. If one happens to use Irish Life Health, it wants one to be left waiting or be unable to access outpatient appointments during Covid lockdowns or to get timely access to treatment. Instead, it wants people to wait and put further pressure on our busiest hospitals.

I want to see movement on this issue. I was promised this time last year that would happen by the then Minister. I was informed we would have action and an update by this time today. This evening, however, I see we still have the same practice from Irish Life Health, advertising openly the blatant discrimination against level 2 hospitals. This practice must stop. As someone who knows how urgent and necessary it is to encourage people to use our smaller hospitals, will the Minister directly intervene and ask his officials to table an urgent amendment on this and ensure all health insurers cover all hospitals?

Deputy James O'Connor

The Health Insurance (Amendment) Bill is somewhat akin to the Finance Bill or the Social Welfare Bill, as it arrives in November every year. The measures within are designed to support risk equalisation and to sustain community rating in our health insurance market so that older citizens and people with illnesses can afford health insurance and are not penalised in favour of younger healthier people.

There is no increase in the risk equalisation levy this year. Risk equalisation and community rating have many merits. Our values as a people are to support older people and the sick. This is not just out of a sense of obligation but because we respect and value our older people and the dignity of each person in their illness, medical condition or disability. We are firm in our view that the principle of solidarity should apply in private health insurance as well as in public health services. However, I ask the Minister of State what are the potential costs of maintaining this system over time and what are the implications on competition. The maintenance of a community rate causes a barrier to entry for outside providers. I understand the balancing act needed to ensure adequate access to care for all of those paying to get value for money but I am also conscious of the rising unfunded liability over time, which has the potential to collapse the private health insurance system. Ireland has had a murky past in private health insurance provision and I want to flag that, if left unchecked, the current set-up would lead to similar outcomes.

While I recognise the current measures in place are interim in nature until the full roll-out of Sláintecare, the values executed through the risk equalisation scheme are those we should uphold in the provision of our healthcare systems, specifically, equal access for all. I want to ensure everyone is working towards a system that will enable us to continue to uphold these values and provide care in the most cost-effective manner.

At an individual level, some of the most challenging issues facing all Deputies, including me, are those arising from people's health insurance. Some very difficult and desperate cases have come through our offices, whereby people may have gone as far as getting insolvency practitioners involved as a result of healthcare bills. It is critical that the State continues to legislate in this area.

I have a significant concern for the many families in the squeezed middle for whom the cost of private healthcare may be just beyond their means. As a Government, we have to try to do more to assist these families because getting access to a medical card or an emergency medical card can be quite a challenge in some cases, where there are issues with regard to the eligibility criteria. This causes major issues with private health insurance and people trying to get access through the public system. It is an area on which we need to see greater emphasis placed by the Government. It is a significant issue. I take this opportunity to raise this matter while speaking about health insurance.

Deputy Martin Browne

What we are speaking about is the continuation of a two-tier health system that has been allowed to develop because of underinvestment in our public health service. The situation is such that we have citizens who have become reliant on a private system that many cannot afford but cannot afford to give up either. Many people in my constituency are faced with regular increases in already huge health insurance policies and must give up something to pay for them. In one case, a parent had to postpone going to the doctor because it was not free for him at the point of entry and he could not afford the doctor's fee while continuing to pay for his family's health insurance. This is one example of how the two-tier system has failed us. People cannot afford to go to a doctor. This is wrong on all counts.

What about those who cannot afford private health insurance? They are left with the prospect of lengthy waiting lists in an under-resourced public health system. Over the years, Fianna Fáil and Fine Gael have promoted a policy that allows those who can afford to pay to skip the queue. All others must tighten their belts and take out a policy or else deal with waiting lists in the public system while their conditions get worse. Where are we now? We find ourselves being asked to ensure older and sick people will not have to pay more for health insurance. While we support this, ultimately people should not need private health insurance. We should not have to be here today taking measures that spread the cost of private insurance. We should be discussing universal healthcare. The system is broken, as is the Government's record of ensuring our health system works for us all.

Deputy Michael Collins

The health insurance issue is scandalous to say the least. I speak to people who want to use health insurance and the greatest issue is that the cost prevents them from doing so. Recently, people have been contacting my office to say there have been several increases that are putting health insurance out of the reach of the ordinary person. This is an issue that needs to be addressed because we cannot have everybody in the medical card system. People try to put some money aside for health insurance but the cost is getting out of hand.

The entire health system is in trouble. I know people who have health insurance but still cannot access specialists. This week, my office is trying to access a specialist for a very sick child in west Cork but the earliest appointment for a paediatric gastroenterologist is at the end of March. The child is extremely ill, can barely get out of bed with pain, cannot go to school and cannot go about daily life in the same way as other children. The family cannot get an appointment with a paediatric gastroenterologist because there are only five in the country. The earliest appointment is 25 March. It is outrageous. Today, I was in contact with doctors in Germany to see whether we can do something. This is the problem with the system in this country. We are exporting all of our problems. We have been looking to Northern Ireland and everywhere and anywhere as we frantically try to find a specialist that could look after this child and give her some relief coming up to Christmas. God knows the stress it must be causing to her family because we are stressed about it. Our hearts and souls go into someone, especially a young person, and we try our living best to make life somewhat easier. I would appreciate if the Minister of State could intervene and perhaps I can speak to him afterwards or he can contact me. I would like to look after this person.

Private health insurance is in crisis. We also have issues with Covid. Someone rang me recently who drove for two hours to Cork city to get a Covid test carried out but the person was having a procedure done in Bantry General Hospital. The Covid test should have been carried out in Bantry General Hospital rather than the person having to make a two-hour journey to Cork and a two-hour journey back. It took almost a day to get a Covid test and then the person went to Bantry General Hospital for a minor procedure. We are afraid to use local smaller hospitals that can deliver so much.

Quite a few people in west Cork who have fallen ill have been told when the ambulance arrived that they are being taken not to Bantry General Hospital but to Cork. They are then left in the ambulance outside Cork University Hospital, which cannot cope. That is not the fault of staff at the hospital, which just cannot cope with the number of people who go there, while we have a beautiful hospital in Bantry that serves a massive population. People told me when I was canvassing out east along Bandon that they go to Bantry General Hospital and not to Cork University Hospital, CUH, because they get looked after by the excellent staff there.

There is nothing wrong with the staff in Cork University Hospital but they cannot cope with the demand. We tend to look as if we would shut all these smaller hospitals. We do not give them the resources they need or provide ambulance services. It is nicely done behind the scenes, and people say, “Oh, CUH is actually much better than Bantry General”. It is a closure. It is a nice way of closing the door. However, we are keeping a very close eye on what is going on.

People are suffering. Regardless of whether they have health insurance or not, they cannot get cataract operations. Bus 63 has just come back into Cork this evening and bus 62 went up on Sunday, and there are another 28 people who have had their eyesight saved. That procedure should be taking place in Cork. However, the worry now is that, given the fact it is not happening enough to get some solution, they are going to Northern Ireland. From what I gather, the Government is lying idly by, and is going to put in a scheme that is not going to work. All it has to do is replace the scheme that is there with a new scheme that operates across the Border into Belfast. I would appreciate if the Minister would work on that.

Deputy Mattie McGrath

Cá bhfuil an tAire Sláinte? Tá sé as láthair arís. It is like: “Cad a dhéanfaimid feasta gan adhmad? Tá deireadh na gcoillte ar lár”. Cad a dhéanfaimid feasta gan an tAire? Cá bhfuil sé? He is never here to deal with serious debates. That is no disrespect to the Minister of State, Deputy Frankie Feighan, but the Minister for Health is so precious. If he was here, he would leave before any of our group come to speak. It is a total abdication of his role as Minister and our right to have him present for these debates.

Someone referred to this debate as being like the Finance Bill or the Social Welfare Bill. At least with the Finance Bill or the Social Welfare Bill people get something out of it, and while they might lose something too, at least it is a cogent piece of work. This is like papering the parlour for the stations mass.

With regard to health insurance, it is the wild west out there. People have health insurance but there are so many excesses and restrictions that they do not have the cover they need, and when they go into hospital, they have to pay all of these excesses on top. It is totally unfair. We have a two-tier system that is not working.

We went off and did a massive deal during Covid with the private hospitals instead of buying one of them under a compulsory purchase order. We brought in legislation to stop thousands of small businesses operating and we cannot do anything with private health because we know the powerful men who own them. That is what is going on. We are lining their pockets. We need to have proper, meaningful legislation that is robust enough and that will deal with the racketeering that is going on. There are powerful and excellent specialist surgeons and doctors, and I support them and salute them, but, as I said, they charge us.

My brother-in-law went into hospital lately after having a mini-stroke. My sister was with him to mind him and the nurse insisted at accident and emergency that she travel 11 or 12 miles back home to get his PPS number and his private health insurance number. Even though he was sitting on a chair and did not get a bed, they wanted to charge the insurer for the price of a bed. I could stay in the Gresham Hotel cheaper. The Burlington or other hotels are a lot cheaper and when people ask for service, they get it. The nurses are so stretched. It is shameful what is going on.

Insurance premiums are being hiked up because of the claims and people do not even know it is happening. If someone is there to have a test, a little form is slipped in front of them and they sign it because they would sign anything if they are ill and want better treatment. It is not right what is going on; it is very wrong indeed.

Why would we not have that? When we had the Minister, Deputy Donnelly, here all through March, April and May, the HSE seconded for Covid step-down patients a beautiful hospital in Carrick-on-Suir that has been there since about 1820. Councillor Kieran Bourke, a very hard-working councillor from the town, came up to Dublin and met the Minister, Deputy Donnelly, and I met him the same evening. He was sure it would be returned as a hospital. The three hospital units there do tremendous work. Huge fundraising was done by the locals of south Kilkenny, west Waterford and south Tipperary. We were told again by the Minister, Deputy Harris, that it would be reopened. However, the staff were informed this morning it is dúnta, shut, finito, gone as an institution - a proud institution, with wonderful staff and with the investments built. They built a huge monstrosity of a primary care centre right beside it that cost €10 million, and it is half empty – follaimh. Now, there are no more hospice beds.

I was promised by the Minister of State, Deputy Butler, there would be some private arrangement with nursing homes. Everything is private - push it out into the private sector, where people are fleeced. The care they got in the palliative care unit there, and the care they got from the specialist nurses and other ancillary staff, was fabulous and it was known locally. Many people from Carrick-on-Suir were born there because it was a maternity hospital. Now, it is no more.

The deceit and the lies we were told are shocking and there is no accountability. The Minister will not even reply to Councillor Bourke, even to registered letters. Neither will the Taoiseach, who is the Fianna Fáil leader. The councillor is so disappointed, a man who served the people on a voluntary basis, and he and others are trying to do their best. People have campaigned to have it reopened and now they find the lights are turned off and they will never again be turned on.

We were promised it was going to be a step-down facility for diabetes or something else. We want it there for respite. We want that as a hospital when people are ill in the area and as a step-down from other hospitals after surgeries. People have died without the palliative care they were entitled to. I know the palliative care teams and the nurses do tremendous work in people’s homes but people need a bed in a hospital. However, it is locked up, gone away from the people, with no access after people have been fundraising so much for years to put the facilities in there. They were put into the new extension in the hospital, which was beautiful, and I have been in to see people there during their last days. It is so sad.

The Minister is gone like snow off a ditch. As I said on another night here, a cat would not go out through a skylight as fast as when we get up to speak here. It is fear. He is not accountable to this House. It is scandalous.

An Leas-Cheann Comhairle

As Deputy Fergus O'Dowd is not present, I call Deputy Murnane O'Connor.

Deputy Jennifer Murnane O'Connor

Every year, legislation is needed to update and revise the scheme which allows our system of sharing of risk across the insured population in Ireland. This year we have had big challenges in this area, with the growing elderly population, with Covid and with long Covid, as it has come to be known, and the risks people may be taking because they are afraid to seek help in hospitals. We must maintain the affordability of health insurance to offer real choice to people.

One issue that has come across my desk is the availability of some services which customers are paying for under their health insurance. There are issues related to Covid, which we know cannot go on forever, but this is certainly something which concerns me. A 78-year-old Carlow lady with poor sight, who requires monthly injections, missed out on her appointment when the HSE took over the private hospitals for a short period earlier this year. She was informed by her health insurer that the private hospital was now public and her procedure would not be covered. She had to pay €1,600 herself in order to save her sight. She had paid health insurance all her life only to be told she had to pay this. This was an old lady who had paid her insurance and had a medical card. I am sure there are more cases like this. If she was not covered by her insurance, and her insurer has told her that where she went to was a public hospital for a few months, why will the medical card not cover her? That lady cannot afford €1,600. She depended on that operation because her eyesight was getting worse and she had to get this injection. This is unacceptable and I am sure there are more cases like this. I want the Minister and the HSE to refund this lady her €1,600. It is unacceptable that a lady who paid her health insurance all her life and had her medical card was not covered. It is very unfair. She was so upset and so were her family.

More and more people have taken out health insurance because, sadly, it offers faster access. However, I have recently been informed of concerns regarding the rising cost. Somewhere in the region of half the population have health insurance in one form or another. During the Covid-19 lockdown, many health insurers refunded their customers, which was welcome, and I believe another refund will be coming shortly. It is very important that we look after people, particularly during Covid.

Equalisation is very important in this country so that older people can access health insurance at the same cost as younger, healthier people. We see in other jurisdictions and other health insurance models that the riskier the health of the customer, the higher the premium paid. It is so important that, in this Bill, we protect that access and protect affordability of health insurance.

For those who have health insurance, the renewal process is very confusing and there is a fear attached that to step down a level or take something off a plan is the same as tempting fate. It is amazing the number of people who will say that. There is a body of work to do to communicate ways to save money on plans and to eliminate aspects of plans which are wholly unnecessary.

It would be helpful if, when shopping around, which I would always encourage, customers could see in a straightforward manner the plans across different providers so they could know exactly what they were getting. That might be something we could examine. I thank the Minister of State.

Deputy Thomas Gould

We fundamentally disagree that people should have to pay for healthcare such as addiction services. I met with many groups recently who engage in addiction services and one issue keeps cropping up time and again. People are being forced to pay out of pocket for assessment for rehabilitation and detoxification services. In fact, there are five facilities in the State that charge people seeking assessments €90 100% of the time.

We have already had the issue raised that the time between assessments and treatment is too long. In 2019, 224 people waited more than 181 days for assessment for treatment. We need to stop putting barriers in place for people who need treatment. Financial barriers and long waiting times are damaging people's chances of recovery. We need real public access to treatment to ensure that when someone has put in the hard work and is stable enough for treatment, access to it is not being blocked. People looking to go into recovery should be supported by this State. They should not have to struggle to find the money to get an assessment. That is wrong and it is a problem we should work on together to fix.

Deputy Joan Collins

There is no justification for the subsidising of private healthcare by the State. The two-tier system of healthcare and, in particular, the mingling of private and public care in our public hospital system is the key obstacle to equity of access and a fit-for-purpose national health system open to all and free to use.

In the 1950s, the VHI was established as a not-for-profit State insurance company to provide health cover for the top 15% of income earners who were then not able to access the public hospital system. A key factor then, as now, was the determination of consultants to protect private practice and the lucrative nature of it.

The public hospital system, on paper, is open to all today, yet we know approximately 50% of the population buy private health insurance, which is one of the highest levels in the OECD. The question has to be asked why people on moderate incomes would take out expensive private health insurance when they are entitled to public care. They are not doing so because they can have luxury treatment in a private hospital. Much of the private care takes place in public hospitals. The reason is simple - waiting lists. The VHI helps people to jump the queue. That is inherently unfair and the fact that it is subsidised both by tax relief and the use of the public system by consultants to treat private patients defies all logic, unless one believes that the profit motive comes before people's health.

I have not been able to get a figure for the cost of tax relief on health insurance but the average premium is around €2,000. Twenty per cent tax relief on that is €400, and with half the population covered, it must be a cost to the Exchequer.

In terms of risk equalisation, my understanding is that the VHI dominates the market and that no transfer funds between companies has ever taken place. We need an end to this nonsense and a properly funded, single tier health service available equally to all and free at the point of use.

Deputy Thomas Pringle

The explanatory and financial memorandum on this Bill states:

The Health Insurance Acts 1994 to 2019 provide for a Risk Equalisation Scheme for the health insurance market since 1 January 2013. Under the Scheme, insurers receive risk equalisation credits to compensate for the additional cost of insuring older and less healthy members.

Is that not a sad and depressing statement? I believe it is. Nobody on the opposite side of the House will believe it but that is the case. It is the financialisation of human lives and the health insurance market, so-called. We are all commodities in this marketplace called neoliberalism.

The genesis of this Bill is to amend the 1994 Health Insurance Act and the Stamp Duties Consolidation Act 1999. The risk equalisation scheme was approved as state aid for the period 2016 to 2020 and this Bill is seeking to extend that scheme for a further 15 months.

I have been studying the instances and prevalence of Covid-19 in Donegal and areas around Donegal and our neighbouring counties in the North. The areas with the highest levels of deprivation have been most impacted. The higher levels of Covid can almost be mapped completely to the less affluent areas. Why? It is because an unequal society causes more people to become ill and die.

The Bill digest states that a study in early 2020 by the Health Information Authority, HIA, found that:

Those with PHI [private health insurance] are more likely to be from the more affluent white collar workers/professional cohort ... whilst those from more manual professions or reliant on state benefits are significantly less likely to have cover.

[...]

This finding on the social divide is consistent with previous studies commissioned by the HIA.

The programme for Government, Our Shared Future, committed to accelerating the implementation of Sláintecare, which, as I have said, is very welcome. However, because of Fine Gaelness and Fianna Fáilness, as it were, the Government explicitly states its support for private healthcare while it talks about supporting Sláintecare also. It states that it would retain access to private health services, ensuring choice for those accessing healthcare. The irony is never lost on the Minister of State. The only people who have a choice are those who have the means to afford private healthcare. He should have spoken about ensuring choice for those who could afford it. That would have been a truer statement to make in this regard.

We facilitate a private health system - this Bill is facilitating it - and we will pay €350 million out of State funds to support wealthy people and people who can afford to have private health insurance and to fill up our hospitals so that people who cannot afford it cannot get into them. That is crazy. If the Minister of State had written this as a comedy, people would say it could not be true, but that is what we are doing. We are facilitating that so that wealthy people can access the health services over people who cannot afford them who are more likely to be sick and will actually cost the State more in the long run because they cannot afford private health insurance. That is what the Minister of State and the Government is facilitating and what every Fianna Fáil and Fine Gael Government in this State has facilitated along the way.

Members spoke earlier about elderly people who have private health insurance and cannot get access to healthcare, yet those same elderly people have a medical card and could get their care free of charge. I meet people all the time in my constituency and they talk about private health insurance. They do not know that there is no charge for hospital care other than the charge for the bed, which is maximised at €350 or €360. They believe that if they need an operation they have to pay the cost of that. The Government facilitates that because it pushes people into private healthcare to make sure they get it. People are putting themselves at risk by paying for it. I tell them, and rightly so, that they would be better off saving their money in the credit union and if they feel they need to buy a service such as a CAT scan or whatever, they can get a loan from the credit union to pay for it and they will still have their savings in the credit union. They would be far better off than paying for the private health insurance we have in this State. That would make far more sense for individuals throughout the country because this is an absolute disgrace. Ministers whose job it is to represent the people of this State should be embarrassed to stand up and push this along.

The Minister of State will say that the purpose of this legislation is to equalise the system and make it more fair, but it should not have to be made more fair. The bottom line is that this has been put into the Bill because the Government has broken the system. It is to facilitate wealthy people who can afford it.

I am totally opposed to this legislation. I have opposed it all the way. I will not call a vote on it but I am totally opposed to what the Minister of State is doing in regard to it because it is wrong, but he will continue to do what he is doing, which is fair enough.

We can then actually make the changes that would make healthcare in the State reflect the people who live here.

Minister of State at the Department of Health (Deputy Frankie Feighan)

I thank Deputies for their contributions to the debate on this Bill. Health insurance is held by a large proportion of people in Ireland relative to other countries, as has been stated by many Deputies. It is important that we took the opportunity to discuss this Bill and the positive effect that community rating and other aspects of health insurance regulation have on people's daily lives. The voluntary health insurance system in Ireland operates on the basis of community rating, meaning people who are old or sick do not have to pay more than the young and healthy. Community rating is a fundamental cornerstone of the Irish health insurance system and in other health insurance systems. The level of risk presented by an individual directly affects the premium paid. The objective of community rating is supported by a risk equalisation scheme which aims to keep health insurance affordable for older and less healthy members. Under the scheme, all the money raised on levies from insurers is paid into a fund for the sole purpose of supporting the market in the forms of credit payable.

The purpose of this Bill is to specify the revised credits and corresponding stamp duty levels to apply on health insurance. I thank the Deputies for the issues they have raised. Deputies Cullinane, Patricia Ryan, O'Rourke and Shortall talked about Sláintecare. I hope that Sláintecare will eventually impact on implementing the removal of private healthcare. It will happen progressively. Anyone with health insurance can continue to receive private care in public hospitals for the foreseeable future. After that, anybody with private health insurance will still be able to receive private care in private hospitals. When there is certainty about the timeframe for the implementation of Sláintecare and a public-only consultant contract, a broader discussion on the role of private health insurance will follow. We are committed to introducing Sláintecare as soon as possible.

Deputies Ó Murchú and Gould talked about addiction services. I would be concerned that the €90 cost for an assessment for treatment is a barrier. I ask Deputy Gould if he could raise that again because we want to support recovery, especially for people in addiction services.

Deputy Naughten talked about Irish Life Health, and how one major insurer was not supporting level 2 hospitals such as Clonmel, Louth, Roscommon and many more. There is no obligation for insurers to cover all the hospitals in the manner outlined because it limits the commercial decisions of the insurers. We would be concerned that this would increase the cost if legislation tried to oblige insurers to cover all hospitals for treatments, procedures etc. I agree with Deputy Naughten and I am familiar with Roscommon University Hospital. It is a level 2 hospital and much great work has happened there. We need to try to talk to the GPs and many other stakeholders, to say that there is better, quicker treatment available at level 2 hospitals than at level 3 or 4 hospitals. They have a role there and Deputy Naughten has a point.

Deputy O'Connor talked about cost systems and outside providers. We keep an eye on it.

Deputy Michael Collins talked about a young child in Cork. If he writes to me and the Department, we will follow up on that serious issue and try to sort it out or see exactly what is happening.

Although the private health insurance market has demonstrated resilience and remained reasonably stable amid significant uncertainty in 2020, the longer-term impact of Covid-19 on the health insurance industry has yet to be determined. Against the background of some uncertainty about the potential impact on market profile and membership, the credit and levy rates for next year strike a fair balance between the need to support community rating and maintaining the sustainability of the market.

Deputy Pringle has some interesting points about health insurance. He made an interesting point about credit unions and we must have a discussion about that in the future.

The Bill allows us to maintain support for the core principle of community rating, which is long-established and well-supported Government policy for the health insurance market. The Bill will ensure that we can continue to provide the necessary support to ensure that the costs of health insurance are shared across the insured population.

Question put and declared carried.

Bill reported without amendment, received for final consideration and passed.

The Dáil adjourned at 9.38 p.m. until 9 a.m. on Thursday, 10 December 2020.