Health Insurance (Amendment) Bill 2012: Committee Stage (Resumed) and Remaining Stages


Amendment No. 5 not moved.

I move amendment No. 6:

In page 4, line 35, to delete "old."," and substitute the following:


(e) the imperative to ensure that all persons receive, in due time and to the

highest standard possible, health services on the basis of need alone and

not on the basis of ability to pay.",".

The Minister will recall that during my contribution on Second Stage I mentioned that my vision, and that of my party, of how health care should be delivered in this State is radically different from his. His position and that of his party is based on the Dutch model and he is of the view that opening up our health service to the private health insurance market is the best way to deliver equity in our health system. I do not believe that is the case. Health care should be delivered on the basis of need. It should be free at the point of delivery, funded through general taxation and delivered on the basis of need alone and not on somebody's ability to pay. I gave the Minister the figures on Second Stage showing that many health insurance companies are seeing a drop in the number of people taking out private health insurance. That is obviously because many people cannot afford to pay for it. Every year, at least once if not twice, we hear that private health insurance companies are increasing premiums and effectively pricing people out of the system.

The Minister said several interesting things in his exchanges with Senator Barrett. If one considers the term "health insurance market", one can see that we are going down the American road of regarding people as consumers or customers and not as citizens or patients who need to be treated. That is the thrust of this Government's policy. There is no doubt that private health insurance is institutionalised queue-jumping. People who can afford private health insurance can jump the queue and get better and faster treatment than someone who must depend on the public health service. The Minister was very vocal in objecting to many of the cuts imposed by previous budgets and governments but every time that I and other members of my party mention cutbacks in the health service, the Minister says we are obsessed with inputs and not outputs. Inputs are important. Spending money on health care is important, as is making sure our public health system is equipped to meet the demands of citizens. When the ability of the public health service to deliver high-quality health care on the basis of need and in a timely fashion is reduced by cutbacks, I make no apology for making those points about cutbacks in our health service.

There is always a ding-dong between Government and Opposition, and the Minister would have made the same arguments in Opposition about consultants carrying out their private practice in public hospitals and availing of taxpayers' money to do so. That is only possible in a two-tier system when the whole health care system is opened up to the notion that people are customers. The Minister said he wants a fair, market-driven process. That is an oxymoron. It is not possible. We will not be able to achieve it. The Minister said in his exchanges with Senator Barrett that he wants a fully regulated system. We will not be able to achieve that. He is trying to do something that goes against the grain of how a market system works by trying to force the market to do things it does not want to do. I support the risk equalisation measures as covered in this Bill, but only because it is a sticking-plaster solution, not because it is a long-term solution. I do not believe we can move to a situation in which we genuinely have a health system which is delivered free at the point of delivery or, if not free, on the basis of need. That will not be possible if we open up our health service to the health insurance system.

The Minister claimed he wanted to have a fair market-driven process. A fair market-driven process is an oxymoron, as we will not be able to achieve it. The Minister, in his exchanges with Senator Sean D. Barrett, claimed he wanted to have a fully regulated system. However, he is actually forcing the market to do things it does not want to do. I support the risk equalisation measures but only because it is a sticking plaster solution. I do not believe we will have a health system which will be delivered free and on the basis of need if we open up the health service to the health insurance system.

The Minister will establish hospital groups and trusts. I do not understand how he wants private health insurance companies to compete against each other, as well as hospitals competing with each other. He talked about the money following the patient. How will this work in practice? Many of the larger hospitals will see this as an advantage when they attempt to gobble up many of the services delivered by smaller hospitals. Patients should receive health care as close as possible to where they live. To this end, we need regional and specialised services. There is a concern that tertiary services will be delivered in places such as Cork, Dublin and Galway, while services elsewhere will be diminished.

And Waterford, too.

We will wait and see what the Higgins report recommends for Waterford Regional Hospital which delivers very good services with its limited budget. It offers excellent oncology services without radiotherapy facilities, as well as excellent neurology and trauma services in the south east. It is a good model for regional and tertiary services.

There is a fundamental difference between what the Minister and I want for the health service. He is trying to force the private health insurance companies to do something which is not how the market system works. He has said a free market system is wrong and that he wants to regulate it. He will not be able to do so because a market system has to be free. How will he ensure patients will only be treated based on their ability to pay, not on need? The Dutch model did not bring about a fairer system but pushed up costs. For all the criticism Sinn Féin receives about what happens in the North, at least in the North there is free health care which is delivered on need alone. Why did the Minister not embrace this model? Why do we have to put more money into private health insurance companies which are out to make profits on the backs of people's health care needs? Why does the State want to see this as the solution and not use taxpayers' money to ensure public health services have the capacity to meet the needs of all citizens? I do not see the logic in the Minister's approach. Is it an ideological obsession that the Fine Gael Party has? It is certainly not the Labour Party's policy.

The amendment aims to bring equity to health care provision. We want to move to universal health care, not insurance, funded though progressive taxation measures and delivered free on the basis of need.

Senator David Cullinane's comments deserve a response from this side of the House. There is an impression that the private health care sector is not providing a service. There are over 2 million appointments per annum in the private health care sector outside hospitals. Is the Senator suggesting this should be abolished and adopted into the public hospital system? I do not believe the public hospital system could adjust to such a volume of appointments overnight. It is important that criticism is constructive. There is value for money in the private health care sector. The Minister has outlined how the insurance industry has brought down some of the costs charged in the private sector. It is about getting value for money and reducing costs.

Every time the issue of health care is debated in the House, an impression is given that there is nothing happening in health care provision. The figures I gave this morning clearly indicate a comprehensive service is being provided in a large number of areas. I accept that there are delays in some areas, but they have been reduced. This country has one of the best records on maternity care and long may this continue. That record still stands, despite the fact that there are increased demands on the service, from 54,000 deliveries per year to over 75,000.

I am not defending consultants, but Senator David Cullinane is of the view that those involved in the medical care sector are only in it for the money.

I was referring to private health insurance companies. Their primary focus is on making money.

There are people providing comprehensive services in the health care and insurance sectors who are very dedicated to their jobs. We need to be careful when we criticise those working in the health care sector, that it is at least constructive. I am concerned about how we are dealing with consultants. I know of seven consultants who have resigned in the past six months, two of them in Waterford who are moving to the United Kingdom.

Why did they resign?

I do not know.

Why raise it then? What has this got to do with my contribution?

The Senator says people are only in the health system to make large sums of money. That is not true. There are very dedicated and committed individuals who are providing health care and many of them are doing much more than what their contracts require. We need to be conscious of this in any debate on the health service.

We also need to be careful how we proceed on the issue of junior doctors. I am not satisfied that we are doing enough forward planning and I am concerned that we will face major problems in June 2013 unless we do more. In our debates on health care it would be constructive if we looked to the future rather than the past. By all means we should examine the mistakes we made in the past but we should not focus solely on them.

This amendment has nothing to do with the Bill. The Bill deals with the current market, which is voluntary and open to those who wish to avail of it and can afford to do so. The Government believes in a health system that provides care to people on the basis of medical need rather than ability to pay. Unlike Sinn Féin, however, we have a plan that has been enacted. It is not a fanciful or simplistic plan but it involves reforming our entire health service.

To quote John Donne, "No man is an island, entire to itself". No part of the health service is an island. There is leadership in the Department of Health with the appointment of a new Secretary General. The HSE will be dissolved and has new leadership at the top. The third leg of the stool is the VHI, which has a new chairman and CEO. I will be meeting them this afternoon to reaffirm my insistence on addressing costs in the private health sector.

We are going to reform the entire system, from primary care with the introduction of free GP care, through hospitals with the formation of hospital groups and the smaller hospital framework to long-term and community care. Senator Cullinane stated that inputs are most important.

That is not what I said.

What did you say?

I said that the Minister believes our view is that inputs are more important.

He is always focused on inputs.

That is different from what I said.

The Senator will have an opportunity to respond when the Minister is finished. Let us have an orderly debate.

His party did a lot of shroud waving last February when people were told that we could not maintain a safe service with the numbers of staff leaving. The men and women who work in our health services have in fact improved it by reducing by 25% the number of people who have to endure long trolley waits, although I acknowledge that we still have a long way to go. They reduced the inpatient waiting times by 91% for people who wait nine months or longer for a procedure and 18% for those who wait three months. There are 800 fewer children on our waiting lists now than at the same time last year. I commend them on the extraordinary work they do against a background of less money and fewer staff. We have also seen a higher birthrate this year than previously. The birthrate was approximately 60,000 five years ago but it is more than 75,000 now. The current numbers of medical cards, at 1.8 million, and GP visit cards are the highest in the history of the State.

I do not accept the Senator's contention that we cannot fully regulate a market of competing insurers. It has been done elsewhere and we will do it here. If he keeps focusing on the amount of money invested and the number of doctors, nurses and allied care professionals working the system instead of how they are ensuring that the right patient is seen by the right professional at the right time and in the right place, we will continue to do what we always did, that is, pour money and resources into the system without getting the results we want. Only last January 569 people were on trolleys in this country, after several years in which we quadrupled the amount of funding for the health service and increased the numbers of doctors, nurses and allied care professionals. If that approach was going to cure the problem it would have done so a long time ago. What we require is a system that allows the many excellent professionals who work in our service to deliver the excellence they want to deliver. This will give us a health service in which people feel safe and which gives pride to those who work in it not just some of the time but all the time.

It is constructive to set out a vision for health care and it is relevant to this Bill to do so given that it deals with regulating the system and risk equalisation. The Bill reflects the Minister's plans for the future of health care but we take a fundamentally different view. Ours is not a fanciful view. We believe health care should be delivered on the basis of equity, free at the point of delivery, funded through general taxation and available on the basis of need. We have developed a health plan and I can send the Minister a copy of our latest health policy document if he wishes to take the time to read it.

He appears to agree with certain parts of our plan. We apply the full cost of private patients in public hospitals. He is going some way in that direction in the budget so that taxpayers do not have to subsidise private health insurance. We also call for savings to be made on drug distribution and use of generics. He has gone some of the way on that. I make no apologies for saying that we do not want consultants to avail of taxpayers' money to pursue private practice in public hospitals. That does not detract from the good work that all consultants do in our hospitals. The Minister was robust in arguing that consultant contracts needed to be renegotiated. I did not hear the same criticism from Senator Burke in regard to taking care with what we say about consultants when the Minister was doing the right thing in addressing the issue of consultant contracts, although that did not work out in the way he expected.

What he is trying to do here is unnatural and it will not work in the long term. The natural way to provide health care is as a public service funded through taxation and delivered on the basis of need. Private health insurance companies are solely motivated by profit. They are in this game to make money from people's need for health care. The Minister wants to open up our entire health care system to the private health insurance market but we do not want to see that happen. We are not alone in taking this attitude. I read with interest the IMPACT analysis of his plans for the future of the health service. It was scathing of the way in which the health care system in the Netherlands created a more inequitable and inefficient system of health care. The Minister can shake his head but I am entitled to my view.

I am not obsessed with inputs. I believe we must change work practices and that we must create health care settings where all health care professionals can provide the best health care possible. They are doing a Trojan job in difficult circumstances, despite all the cutbacks and reductions we have seen in wards, theatres and staff, and are trying their best to provide the best health care possible. We must also create greater efficiencies. The Minister may remember from his time in opposition that we have called for a health funding commission to be established to look at where we spend money in the health system and where money is being wasted so as to ensure we spend taxpayers' money on delivering frontline services rather than waste it on administration, branded medicines or on subsidising private health care.

That is our vision of the health service. It is obvious the Minister does not intend to accept our amendment, but I will press it.

I do not want to delay progress, but I must challenge some of the assertions made by Senator Cullinane. I apologise for not addressing some of the issues he raised in the context of bigger hospitals and money following the patient. I believe smaller hospitals will be well able to compete and will have an advantage in this area. We intend to ensure that people are not sent to have procedures carried out in bigger hospitals where they could be carried out in smaller hospitals. This is part of the underlying principle of treating the patient at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. We do not want people with inguinal hernias and gall bladders being sent to Waterford or Galway when they could be treated in Roscommon, Clonmel or wherever.

I believe the money follows the patient. I have the document on that and it will be ready to go to the Government shortly. This is another big step on our road to reforming the system. Senator Cullinane mentioned Sinn Féin's plan and I would welcome sight of that plan. I reject what the Senator had to say about the consultant contract. The talks at the Labour Relations Commission, LRC, were very successful. For the first time, we have an agreement that consultants will be contractually obliged to work any of the hours 24/7 as opposed to Monday to Friday from 9 a.m. to 5 p.m. I accept what Senator Burke has said, that many consultants have been doing this pro bono, not as part of their contract. The clinical programmes which encourage this sort of work practice saved us 70,000 bed days last year, the equivalent of €63 million. I acknowledge the work done by the consultants. However, I cannot run the health service on a pro bono basis, which is why the LRC talks were so important.

Another benefit arising from the LRC talks is the fact we now have clinical directors with real powers, in terms of directing their consultant colleagues and how and where they work and in regard to their obligations. Furthermore, because consultants are leaders within the health service, they are now leading from the front, which will make it easier for other members of the caring professions to follow suit in terms of showing flexibility around rostering, etc.

Some Members seem to assume the Government is fully adopting the Dutch model, but that is not the case. We are designing an Irish model of universal health insurance that will best meet the needs of the Irish system and citizens. As I said before, when it came to the insurance model, we looked at the Dutch model, when it came to the patient safety authority, we looked at the Danish and Canadian models, when it came to the trust model for hospitals, we looked at the United Kingdom model and when it came to how we could improve performance within our service and the special delivery units, SDUs, we looked at the North of Ireland model. We do not have any one system. We are choosing the best elements of the other systems that we believe will best suit our purposes.

Of course, Senator Cullinane is entitled to his view, but that does not make his view a fact. The fact in the case of the Dutch system is that the cost increase is due to the extension of the scheme to cover dental care. I do not accept the amendment.

Question, "That the word proposed to be deleted stand", put and declared carried.
Amendment declared lost.
Section 2 agreed to.

Amendment No. 7 in the name of Senator Barrett is out of order as it is consequential to amendment No. 2, which is not relevant to the subject matter of the Bill.

Amendment No. 7 not moved.
Section 3 agreed to.

I move amendment No. 8:

In page 6, lines 12 to 14, to delete paragraphs (b) and (c).

The purpose of this amendment is to ensure we have adequate scrutiny of regulations and maximum oversight and transparency. I understand that section 4 as it stands will remove the requirement to lay regulations before the Oireachtas in draft form. The substantive Act of 1994 was amended in 2001. We propose to transpose those changes in this Bill so that other than for the sections deleted, regulations shall not be made until a resolution approving of the draft has been passed by each House. We want to ensure the Oireachtas has the opportunity to deal with these regulations. This is important. While we are moving to the kind of private insurance based model the Government is moving towards, there is an even greater need to scrutinise these regulations and that is the reason we have tabled this amendment.

This is something we should reflect on seriously and we should, perhaps, come back to it on Report Stage. The explanatory memorandum says that section 4 removes the requirement for the Minister before making regulations to present them in draft form to be approved by the Houses of the Oireachtas. This is an important function all parliamentarians should think about. They should think about it in the context of page 35 of the Supreme Court decision which states, "The issue before this court is not the intention of the State or State bodies, but the intention of the Oireachtas as the Legislature." Therefore, the Oireachtas is invited by the Supreme Court to take control in this area.

I applaud the Minister on the reform he is trying to bring about. Everybody is concerned that we make the right decisions here. Therefore, a measure that alleviates or reduces in any way any obligation to present regulations for approval by both Houses of the Oireachtas is something any Member would balk at. I invite the Minister to reconsider whether this is a good idea. This Minister is a participatory Minister and I commend him for his attendance here so often and his involvement in robust debate here and outside of here. We have both participated in such debates before being in our current positions. The involvement of the Legislature is important, particularly since the Supreme Court has pointed that out. I do not see the point of this section as it does not further in any way what the Minister is attempting to do, with significant support from our benches. Is this section necessary and is it desirable?

I appreciate what Senator Barrett has said. There is no attempt of any kind being made to diminish or undermine the Legislature's involvement. The fact is that the previous risk equalisation scheme of 2003 was mainly set out in regulations. However, the new scheme, including rates for risk equalisation, credits and stamp duty levies, will be strengthened in the future by being set in primary legislation. Therefore, it is primary legislation now, not regulation, and the House will have ample opportunity to deal with the primary legislation each time it comes before the House. The House will also have ample opportunity to discuss rates every year. Therefore, there is no diminution of powers. This is an unnecessary provision now because it is no longer being done by regulation, but by primary legislation. That is what is behind this move.

As I will not be making regulations to provide for risk equalisation schemes in the future, these subsections are no longer required. As I said, it will be done by way of primary legislation which this and the other House will have ample opportunity to discuss and debate. There is no attempt to diminish in any way the power of this or the other House. If it were, as a legislator, I would not be comfortable with it. On that basis, I do not accept the amendment because it is not necessary.

Amendment, by leave, withdrawn.
Section 4 agreed to.
Question proposed: "That section 5 stand part of the Bill."

The penalties to be imposed on insurance companies are to include imprisonment not exceeding five years and fines of €50,000. I do not see the point of criminalising the independent health insurance sector, particularly as we ourselves are in breach of a European Court decision of 29 September 2011. Six years before that date we were invited by the European Commission to regularise the position but declined to do so. As far as I can see, we are still in breach of that decision. Therefore, proposing draconian penalties to be enforced within 30 days reads strangely for a Department which has a strange record in complying with decisions of the Supreme Court and the European Court and ignoring messages from the European Union. I do not believe the conduct of the health insurance business is inherently criminal in any way. The existing penalties are adequate because there were never infringements in this regard.

I thank the Senator. This provision is necessary and I will explain why. God knows, we have had enough concerns about regulation in this country, so much so that, when in opposition, I did not like to even talk about having a regulator of the health insurance agency and much preferred to talk about having a scrutineer because regulation had become devalued. If we are to have serious regulation, regulators need real teeth and there have to be consequences for individuals, as well as organisations. As they say, success has many parents and failure is always an orphan. It is the same in this case. When something goes wrong and one tries to find out who is responsible, suddenly nobody knows anything about anything. We need to have a situation where the people who work for these organisations, if they are asked to delay in providing information for the HIA or give it in such a way that it will mislead the HIA, know there will be consequences. A fine is one thing for an organisation, but it is important for an individual working in it to realise there will be personal consequences for him or her also. We should, therefore, maintain this section. It is a sign of our seriousness in regulating this market and insurers that, if people try to play fast and loose, they will suffer the consequences. One of the things we said before we entered government was that we would bring transparency and accountability to this issue and that perhaps then we might have some chance of ensuring fairness. This is to underpin that accountability in order to ensure there will be fairness.

I would prefer if the Senator could see his way to withdrawing his objection. I will not be in a position to accept his amendment because this issue is critical and goes to the core of what we are about as a Government.

There is no amendment before the House. Senator Sean D. Barrett is opposing the section.

I know we are working to a timeline and perhaps I misunderstood how the Order of Business was to run. However, there are a few points I want to make, more on the general tenor of the Bill.

When I heard my colleague talk earlier about the evil markets, I was reminded of the advertisement, on which the little meerkat accused people of confusing the term "compare the market" with "compare the meerkat". There is such a problem like in this instance. There is an assumption that markets always mean "for profit" and Darwinian survival of the fittest and starvation of the poorest. While I am sorry my colleague is not present to hear this, he needs to understand the market in many parts of the world is a socialised one. The idea is that market forces are brought to bear which allows patients to have a choice in where they go for health care, what doctors they see and institutions they attend. These patients are equally empowered by the possession of a uniform insurance instrument which gives no citizen an advantage over any other in terms of access to health care and obliges every hospital and doctor to regard patients equally because of this solitary transferable insurance instrument. That is the system in Israel which has a number of not-for-profit health systems that compete against each other. It is the system in place in Canada where there is one provincial health insurer to which everybody has access. It is the system in place in Germany where a mixture of public and private insurers provide a generally uniform insurance instrument for citizens who can use it to freely negotiate in any part of the health system they wish to attend.

Her Majesty's United Kingdom National Health Service, so beloved of colleagues here, consistently ranks among the poorest performing health systems in the developed world. That is a fact. Many have a misty-eyed, nostalgic love of the NHS because it was born of a wonderful egalitarian impulse in the grey bomb-strewn ashes of the post-Second World War United Kingdom. However, it has not moved with the times and instead perhaps owes more to the philosophy of Stalin in the way it actually delivers services than it does to a more modern approach. It consistently has the worst cancer survival rates and the longest waiting lists. In fact, if it was not for Ireland, the United Kingdom would have the longest waiting lists in the world. If one looks at a league table of OECD countries in terms of access to care, one striking feature is that the top five countries all use the alternative model - still socialised, still responsive and still based on need, not ability to pay - which is the Bismarckian model of a uniform insurance instrument. This is the model I know the Minister intends moving towards and it is the one we need to move towards.

I would like to finish with some quick points. We have heard much said today about consultants. I specifically came into this Chamber not as an advocate or defender of consultants and I have not tried to represent that constituency. However, a few facts need to be in the public domain.

On a point of order, there are other amendments. What does this have to do with them?

I have been informed we have two minutes left.

I have tabled an amendment. I thought we were only allowed to speak to amendments that have been tabled.

The section is being opposed. The Senator is correct that we should speak to it.

If I stop speaking now, will Senator Jillian van Turnhout's amendment be debated? If so, I will yield.

No, it will not. Would Senator Jillian van Turnhout like to make a general statement on the section?

My understanding is that everything is to be guillotined at 1.30 p.m. and that no other amendments will be discussed. As this is my chance to speak, I am sorry-----

If the Senator has finished, I will speak.

I will gladly yield to Senator Jillian van Turnhout if her amendment can be heard.

Will it be heard?

No, the amendment cannot be discussed. If she wishes to speak to the Bill-----

I will skip the point I wanted to make about consultants and focus on the issue of inputs and outputs, on which I am very sympathetic to the Minister's view. There is a necessity to focus on outputs, but there are still some inputs which are being yanked up, one of which is the appointing of financial coaches to teach people in a system which we believe will be obsolete in one or two years, when the entire system will be fundamentally torpedoed by the need to move to a new-----

I am sorry to interrupt, but I am under strict instructions.

I would like to object. My amendment is valid and I regret that we do not have time to discuss it. I have tabled just one amendment.

As it is now 1.30 p.m., I am required to put the following question in accordance with an order of the Seanad of this day: "That each of the sections undisposed of is hereby agreed to, that the Title is hereby agreed to, that Report Stage is hereby completed and that the Bill is hereby passed."

Question put:
The Seanad divided: Tá, 33; Níl, 18.

  • Bacik, Ivana.
  • Bradford, Paul.
  • Brennan, Terry.
  • Burke, Colm.
  • Clune, Deirdre.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cullinane, David.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Harte, Jimmy.
  • Hayden, Aideen.
  • Healy Eames, Fidelma.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Noone, Catherine.
  • Ó Clochartaigh, Trevor.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Reilly, Kathryn.
  • Sheahan, Tom.
  • Whelan, John.


  • Barrett, Sean D.
  • Byrne, Thomas.
  • Crown, John.
  • Daly, Mark.
  • Leyden, Terry.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • Mullen, Rónán.
  • Norris, David.
  • Ó Domhnaill, Brian.
  • Ó Murchú, Labhrás.
  • O'Brien, Darragh.
  • O'Donovan, Denis.
  • O'Sullivan, Ned.
  • Power, Averil.
  • Quinn, Feargal.
  • van Turnhout, Jillian.
  • White, Mary M.
Tellers: Tá, Senators Paul Coghlan and Aideen Hayden; Níl, Senators Sean D. Barrett and John Crown.
Question declared carried.