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Seanad Éireann debate -
Tuesday, 20 Nov 2018

Vol. 261 No. 6

Health Insurance (Amendment) Bill 2018: Second Stage

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

I welcome the Minister of State, Deputy Finian McGrath, to the House.

I thank the Leas-Chathaoirleach. It is great to be back in the Seanad.

I am pleased to have this opportunity to address the House on Second Stage of the Health Insurance (Amendment) Bill 2018. This is a short and technical Bill comprising eight sections all focused on the specific issue of health insurance. The amendments outlined in the Bill will ensure the ongoing sustainability of the private health insurance market and seek to keep health insurance policies at an affordable price for all citizens - young or old, sick or healthy.

Health insurance in Ireland is provided according to four principles: open enrolment, lifetime cover, minimum benefit and community rating. Open enrolment means that insurers in Ireland cannot refuse to provide cover to someone who might be a risky customer for them, and there are maximum waiting periods for pre-existing conditions. Lifetime cover means that once a person has health insurance, an insurer cannot stop cover or refuse to renew their insurance, except in very limited circumstances such as fraud. Minimum benefit means that all insurance contracts must abide by regulations issued by the Minister for Health to make sure that everyone who holds health insurance has a minimum level of cover.

Perhaps the most important principle of health insurance in Ireland, and the principle which is the central focus of the Health Insurance Bill each year, is community rating. This has the greatest effect on affordability of health insurance for those who are most likely to need health insurance coverage. Community rating means that health insurers cannot alter their prices based on an individual’s current or potential health status. Instead, insurers set the price for each product according to their overall expected claims costs. This helps to keep health insurance affordable for older and sicker people, who might otherwise be priced out of the market.

Community rating is supported by providing cross-subsidies between insurers with different risk profiles. It is essentially a financial transfer mechanism whereby money flows from insurers with healthier members to insurers with sicker members. This is called risk equalisation and without it, an insurer with older and sicker members would be required to charge much higher premiums than their competitors to cover their claims costs.

Risk equalisation seeks to level the playing field and encourage insurers to compete on the services they can provide to their customers, rather than simply trying to attract younger people who are less likely to make health insurance claims. The risk equalisation scheme was introduced in Ireland in 2013. Under the scheme, credits are paid to all insurers for their older and sicker members. These credits are funded directly by stamp duty levies on all health insurance contracts written. In effect, the scheme redistributes funds between insurers to meet some of the additional costs of insuring older and sicker members. None of the stamp duties on each health insurance contract goes to the Exchequer.

They are all redistributed to compensate for the additional cost of insuring older or less healthy people. In 2017, the risk equalisation fund redistributed approximately €670 million in premiums out of a total of €2.5 billion in premiums paid. The scheme is carefully monitored to ensure that none of the insurers is overcompensated, which would contravene the scheme's approval under the EU state aid regulations. In this way, the cost of insurance is shared between all insured people and we can ensure sicker and older people retain access to affordable private health insurance.

Legislation is needed each year to update the amount of credits paid to insurers under the risk equalisation scheme and the amount of stamp duty levied on health insurance contracts to fund the credits. As part of the process, the independent market regulator, the Health Insurance Authority, carries out an evaluation of the market focused on the claims costs every insurer has paid over the year. Based on that analysis, the authority recommends the level of credits that should apply the next year. The Minister for Health has considered and accepted the recent recommendations made by the authority for the rates next year. I am pleased to announce that this year's Bill will provide for a general reduction in the credits across genders and age groups, and there will be no change in the stamp duty on the contracts. Maintaining stamp duty at the existing level should ensure the health insurers do not increase premiums and that contracts remain at an affordable price for all citizens.

In addition to the technical amendments, this year's Bill provides for a number of amendments to the Acts governing the Health Insurance Authority and the VHI. In short, it is proposed to expand the membership of the Heath Insurance Authority board, to broaden the composition of the VHI board and to enable the VHI to set international healthcare plans directly. I will outline each of these proposed changes in turn.

The Health Insurance Authority was established in 2001, with a provision for five board members to be appointed. Since that time, the health insurance market has become more complex, with insurers adopting innovative marketing and product propositions to expand their client base and improve their risk profile. Further significant changes can be expected as the Sláintecare programme is implemented. The role of private health insurance in our health system could change significantly and the regulator must be able to react to its changing role and advise the Minister appropriately.

Public sector governance obligations have become more prescriptive. The 2016 code of practice for the governance of State bodies places much greater emphasis on accountability of State boards. For the objective and effective discharge of its functions, it is desirable that the authority include a broad mix of skills and experience, and expanding the membership of the board will ensure that it can deliver its strategy and address any challenges it meets.

The Bill contains two amendments to the Voluntary Health Insurance Acts, which comprise the governing legislation for the VHI. The first VHI-related amendment deals with board composition. Currently, the VHI board is restricted to having only two persons who are health service providers. The amendment is to remove this restriction, and it includes a new provision that the Minister will give due consideration to the mix of skills present in the VHI board when making appointments, thus ensuring the highest standards of governance.

The second amendment to the Voluntary Health Insurance Act deals with one specific area of the VHI's business activities. The amendment will permit the VHI to sell international healthcare plans directly not only as an agent, as it is allowed to do currently, and it will remove the requirement for the VHI to seek ministerial approval before selling these plans. This development is consistent with the VHI's current status as an insurer authorised by the Central Bank. The VHI is competing in a highly competitive, regulated marketplace, and the amendment will remove the impediment to its ability to compete with its competitors and thereby allow it to avail itself of potentially significant business opportunities. I will now outline the specific provisions of the Bill.

Section 1 defines the principal Act as the Health Insurance Act 1994. Section 2 amends section 11C of the principal Act to provide for 1 April 2019 as the effective date for revised credits payable from the risk equalisation fund.

Section 3 amends Schedule 1 to the principal Act to provide for the expansion of the membership of the board of the Health Insurance Authority from five to seven, and to provide for an increase in the quorum from three to four.

Section 4 replaces table 2 in Schedule 4 to the principal Act with effect from 1 April 2019, whereby the applicable risk equalisation credits that are payable from the risk equalisation fund in respect of certain classes of insured persons are revised.

Section 5 amends section 4 of the Voluntary Health Insurance (Amendment) Act 1996 to provide for a change in the composition of the VHI board. It will remove the existing restriction on the number of healthcare providers on the VHI board, and includes a new provision that the Minister will give due consideration to the mix of skills present on the VHI board when making appointments, thus ensuring the highest standards of governance.

Section 6 amends section 1 of the Voluntary Health Insurance (Amendment) Act 1998 to amend the VHI's current function as solely an agent for the provision of international healthcare plans to permit the VHI to sell international plans directly without an intermediary. It will also remove the requirement for the VHI to seek ministerial approval before selling these plans.

Section 7 amends section 125A of the Stamp Duties Consolidation Act 1999 to specify the applicable stamp duty rates initially from 1 January 2019 to 31 March 2019, and thereafter from 1 April 2019.

Section 8 provides for the Short Title, commencements, collective citation and construction of the Bill.

As I said, the Bill allows the Department of Health to maintain its support for the core principle of community rating, which is a long-established and well-supported Government policy for the health insurance market. The amendments to the legislation governing the Health Insurance Authority and VHI are to allow these organisations to plan the future developments in this ever-changing and complex environment. I commend this Bill to the House.

I welcome the Minister of State to the House. I am taking this matter on behalf of my colleague, Senator Swanick, who is a doctor.

The Bill is designed to support risk equalisation, which will mean our health insurance market will allow older citizens and people with illnesses to afford health insurance. Community rating ensures these people are not discriminated against in favour of younger, healthier people. My party, Fianna Fáil, has always supported risk equalisation and community rating.

The main purpose of the Bill is to revise the number of risk equalisation credits to be paid in respect of age, gender and level of cover from 1 April 2019 as required annually. It will amend the Stamp Duties Consolidation Act 1999 to revise the community rating stamp duty levies required to fund these equalisation credits.

The Bill will make changes to the governance of the VHI. The board of the Health Insurance Authority will be increased from five to seven members and the quorum from three to four. It will amend section 4 of the Voluntary Health Insurance (Amendment) Act 1996 to provide for a change in the make-up of the VHI board, which removes the restriction on the number of healthcare providers on the VHI board and requires the Minister to give consideration to the mix of skills present on the VHI board when making appointments. It will also amend section 1 of the Voluntary Health Insurance (Amendment) Act 1998 to permit VHI to sell international plans directly without ministerial approval.

During the last Dáil, experts recommended the introduction of lifetime community rating, which seeks to address the inequity of people waiting until they are older to take out health insurance and paying the same as those who have been health insurance consumers for decades. From 2010 to the end of 2014, the number of people under the age of 60 with health insurance declined, while the number of those over the age of 60 increased. In the six-month period after the introduction of lifetime community rating in 2015, there was an increase of almost 56,000 in the number of people with health insurance. From mid-2017 to mid-2018, the market increased by approximately 48,000 and now stands just below what it was in December 2010.

My party's values support our older people and our sick. We genuinely value older people and the dignity of each person in his or her illness, medical condition or disability, which is why in government we decided on a comprehensive plan to support older and sick people who have private health insurance.

We are firm in our view that the principle of solidarity should apply in private health insurance as well as in public health services. More than 2 million people in Ireland have private health insurance cover, nearly 445,000 people are aged 60 years and lower. Many have paid for health insurance their entire adult lives. They have a fair expectation that the health insurance market will not be permitted to diminish their coverage. It is right for people to expect not to face higher health insurance prices because of their age or because of a particular medical condition. This country's policy has long been that the health insurance market should be community rated and people know this and rely on it.

I thank the Minister of State, Deputy Finian McGrath, for coming to the House and for giving us a comprehensive review of the Health Insurance (Amendment) Bill 2018. I welcome the introduction of this Bill. Ordinarily it is an annual Bill that deals with the amount of risk equalisation credits to be paid from the risk equalisation fund in respect to age, gender and level of cover from 1 April 2019. Substantive changes are being sought to both the operation of the VHI and to the corporate governance of the Health Insurance Authority and I welcome the clarity with which the Minister of State set them out today. After years of surging health costs, we should pause to remember that Fine Gael has been in government for the past seven years and one of the big issues in its campaign during the previous election was this great promise of universal healthcare. It is a bit like the universal social charge, USC. When one googles the words "we will abolish USC", one finds them all over the place and yet people come in and out of here as if there is no problem. Fine Gael also broke a promise that it would provide universal healthcare. Why do the public pay for private health insurance? What are they getting for it? Why are people waiting for years to get a health service? I am a proud member of the VHI. It is not a choice any more as I have to have health insurance. Most of us, if we can afford it, will pay for health insurance because one has to have it. I would like to spend my money on other things.

There was the great promise of universal healthcare, but suddenly the party walked away from it. Whenever the election is called, and I do not want to deviate from the discussion on the Bill, we will have to ask who broke the promises? Who spoke about the abolition of the USC? Who talked about universal healthcare? Who talked about no more people waiting months for cataract operations? Who talked about rehabilitation beds being opened for people who want essential rehabilitation? I am mindful of the only six beds designated for children at the National Rehabilitation Hospital in Dún Laoghaire being closed.

We have to talk about the VHI and private healthcare which is essential for people because they have no choice. We have to ask ourselves what we are doing about healthcare. Where are we in terms of a Republic that talks about equality of opportunity, supporting the vulnerable and enabling and assisting people who need critical care and home care packages? Somehow the private sector is doing one thing while the public sector is doing something else. We have to come together to provide proper decent healthcare for everybody. That is the challenge for people. I accept the potential of Sláintecare and the acceptance across the political divide it will be important as we go forward.

I do not want to be negative as I know the Minister of State, Deputy Finian McGrath, is a very positive person who gets things done. I acknowledge that he is very focused and does not get sidetracked. I know it is as frustrating for the Minister of State as it is for me and Members of the Seanad. Healthcare is going to be one of the big issues people in the public realm will have to stand over and be held accountable for. Whenever this election happens, the people will be ready and will demand accountability from the political masters who promised them they would fix the healthcare service, which is far from fixed.

After years of surging health insurance costs, I welcome the fact prices are finally beginning to level off. In the case of the VHI, its customers have seen cuts in their insurance premiums. Indeed, I received a cheque for €50 in the post, a rebate from VHI. I was thrilled. This move has forced others to follow. I understand Laya Healthcare and Irish Life Health have also reduced their premiums, with a typical family saving €270 a year. Competition is good in the health sector; it is good in every sector. I am glad to see people are tackling the cost of healthcare. That is important.

I was alarmed, however, to read recently that according to a survey by Dermot Goode of "older people are paying double what they need for health insurance" because of what he describes as their unwillingness to switch providers. Why are people unwilling to switch providers in the health insurance market? I know why. I switched a few years ago because I was saving some money but trying to get back into the VHI was another matter. There was a cost and I was not getting the same coverage. Older people who are not familiar with different companies chose to stay with the familiar, safe and predictable service. There are no policies where one can compare like with like.

I was a director of the National Treatment Purchase Fund, NTPF, for two terms and I know more about private health cover than most and how the NTPF would negotiate with the private health sector as part of its remit to provide beds and services for patients who were classified as the longest on the waiting lists. That was the principle then, but it may have changed somewhat. The prices the NTPF can secure versus the cost of the procedures for those with private health cover are different. Casemix compares the cost of procedures in the context of the private and public sectors and it is worth looking at that but that is an issue for another forum. We need to be mindful of costs and value for money but ultimately it is about people's healthcare. We have to ask ourselves why are people unwilling to change. I suggest one of the reasons relates to simplification, plain English, plain speaking and comparing like with like. No two policies are the same and that is an issue we need to look at in the broader debate on private health cover. What service are people getting for the money they pay? Where can they see comparisons because no two policies are alike? The policies are deliberately designed by these private companies to be different so that one cannot compare like with like.

I welcome the Bill as it will increase the number of members on the board of the Health Insurance Authority. The view in the past few years has been that we should have tighter and small boards, be it in the private sector or the public sector. I think at last we are realising that small boards are not necessarily good boards and the smaller the board, the tighter the outfit is and sometimes one does not pick up some of the problems.

I was a member of another board, which I will not mention, that was the subject of great debate a few weeks ago. We are now seeing the company being wound down and a number of issues of concern being raised. I think the bigger and the more diverse the board membership is, the better for corporate governance per se. I welcome the fact the Minister is increasing the number of board members on the Health Insurance Authority. It is important that we ensure that the Health Insurance Authority promotes customer choice because this has to be the backbone of all this. Customer choice increases information so that young and older people are not paying above what they ought to be paying for the cover they need. Some policies are for cover way in excess of what people need. Again people cannot get independent information.

I look forward to the Minister of State's response and ask him to respond to two issues. The first is the rationale behind the VHI's coverage capacity internationally. On the face of it, I welcome it and think it is good, but what is the rationale for it? The second issue is the increase in number of board members of the Health Insurance Authority and the reasons for it. Some years ago before I became a Member of this House, the VHI was in dire straits but now it is a stronger and better organisation. It is leaner and keener and it is a great tribute to its chief executive, chairman and staff. The VHI is now at the cutting edge. It is very professional, very slick, keen and competitive and it is an organisation we should be justifiably proud of.

I thank Senator Boyhan. Senator Colm Burke has eight minutes.

I welcome the Minister of State to the House to deal with this matter. It is extremely important that there is risk equalisation.

It is interesting that the Bill provides for risk equalisation for all persons regardless of age. For example, €3,300 per annum is paid from the fund to support a male aged 80 years or over with private health insurance. In the case of a female aged between 80 and 85 years, it is €2,475, and the contribution from the fund for a male over 85 years is €4,600. People of that age cannot afford that amount to pay for private health insurance but that is what they would have to pay for it. It would be beyond their reach and, therefore, the Bill is important. It is about giving equal treatment to everybody, regardless of age, with regard to the cost of private healthcare.

In fairness to the insurance companies in the market, all of them provide a good service. It is interesting that the number of people who pay for private health insurance has increased. We should also consider the contribution insurance makes. With regard to the HSE, approximately 3.2 million outpatients are seen in our hospitals per annum. That equates to between 63,000 and 64,000 per week. In addition, I may be off in my figures but to give an idea of the level of input from private health insurance, more than 2,000 consultants provide healthcare on their own premises. If they see an average of 20 people per week, that means there are a further 2 million attendances for healthcare. It would not be possible for the HSE to provide that unless there was a significant increase in the number of medical staff across the HSE.

As regards increasing the number of medical staff, it is important to be careful about how we fund healthcare and ensure we get value for money. I have concerns in that regard. Last week at a health committee meeting, I received figures on HSE employment. I note that the number of people employed has increased by 13,460 in the four years since December 2014. My concern relates to administration and management where the number has increased from 15,100 to 18,100. I have expressed my views on that issue previously. That is an increase of 3,000 in the number of people in administration and management. Likewise, in hospitals, the number of nurse managers has increased by 1,100 from 6,600 to 7,700. Additional staff are being provided but the question is whether we are using staff time and the work they do in an efficient manner. Can the increase in staff continue to be permitted without seeing a return in respect of the numbers going through the hospital service? We must be careful about that.

I agree with colleagues regarding the VHI board. Many complex issues arise for the board, ranging from the employment of staff to dealing with outside people across the healthcare sector whom the VHI board pays every day. It is important, therefore, that there is a range of expertise on the board, such as on legal matters, accountancy and cost effectiveness. The number on the board should be increased from five to seven. We must ensure we have a board that has the necessary skills to deal with management and the important decisions that are required to provide an efficient board. There must be value for money in the service it provides in respect of the care it is prepared to pay for and in the management of money. The VHI is not a for-profit organisation but it must collect a sufficient premia to discharge the claims that are made. It is important that there is efficiency through having a good board. My colleagues referred to how the VHI has changed over the past few years. They are welcome changes and long may they continue.

I welcome the Bill. It is important to retain risk equalisation and ensure that all parties are treated in an equal manner. That is what the Bill is about. Whether somebody is aged 18 or 80, he or she should be able to afford private health insurance if the person deems it necessary for his or her healthcare into the future.

I welcome the Minister of State, Deputy Finian McGrath. I wish to respond to a point made by Senator Colm Burke regarding the increase in the number of nursing staff managers by 1,000. That does not reflect an overall increase in the total number of staff. There are 2,700 nursing staff vacancies today. That was done to retain people by giving them a promotion but it is not an increase of 1,000 staff.

For clarification, the number of staff who are nursing managers-----

There is no clarification allowed. It is a point of order.

On a point of order, the number of nurse managers has increased from 6,600 to 7,700.

That is not a point of order.

That does not count in the mathematics.

That is an increase.

No, it is an increase in the number of nurse managers but not an increase in the number of staff.

The Senators make their contributions through the Chair.

The number for the increase in nursing staff is 2,700.

Yes, it is. The Senator should check the figures.

The Senators should not be talking to each other across the floor. Senator Devine, without interruption.

I had to make that point because it is a fudge.

It is not a fudge. It is an increase of 2,700 in nursing staff in four years.

We should not delay the Minister for Justice and Equality, Deputy Flanagan.

We must have the Judicial Appointments Commission Bill 2017.

Please, I cannot have all Senator contributing. There should be one speaker at a time and every Member will get a turn. Senator Devine has the floor and there should be no more interruptions.

The main deficiency in our healthcare system is the absence of universal healthcare. I support Senator Boyhan raising this in the debate. Sinn Féin repeatedly raises the inherent inequality in our health system during these debates every year and each year the inherent inequality has been allowed to flourish. Rather than navigating a way out of reliance on a two-tier system, it appears that oxygen has been given to the private sector at the expense of vital investment in public health services. This Bill is a prime example of that.

Insurance premium income in 2017 was €2.66 billion and premiums per person rose by an average of 3.7% in that year. The number of insured people at the end of 2017 was 45% of the population. That number had gone down following the economic crash and is now climbing again. Last Friday I took a friend to the hospital. There was not even standing room in the emergency department. This person did not have health insurance but has vowed to get it this week. It is not a choice but something that is imposed. People will scrimp and save for it when they see no standing room in an emergency department.

Some 21% of people over 60 years of age have private health insurance. It is a fair assumption that healthcare needs increase as people get older, but it is also fair to argue that most young and middle aged people simply cannot afford health insurance. In summary, we are discussing middle Ireland, the people who can just about scrape enough together to pay for health insurance out of fear or those who cannot afford the payments. However, what aspect of insurance is fair? By its nature it is making a profit from the suffering of others.

However, as far as I can see, this Bill every year, year in year out, is about taking the risk away from insurance companies. I know it is aimed to be Exchequer neutral but then why are we involved? Why are we discussing and meddling in the private sector? It is because our public health system is in a state of emergency.

Last year we tabled an amendment that would require the Department to produce a report on the impact of this legislation, specifically to address concerns that insurance companies would use this legislation to sneakily hike up their premiums. The Government rejected this amendment, leading to ongoing protection of private companies from scrutiny because they are propping up our failed health system.

Twice a year the Health Insurance Authority issues a report to the Minister on its evaluation and analysis of these returns. The second report includes recommendations on the amounts of the risk equalisation credits and the amounts of the community weighting levies. Why can a new section not be requested to monitor premium hikes under the guise of this legislation? We will consider tabling this amendment again as insurance costs are at unbearable rates for ordinary people. We need to address this head on. The authority assesses if any insurer has been over-compensated by the risk equalisation scheme, enabling it to earn in excess of a reasonable profit but what is a reasonable profit and how do we determine what it is?

I would also ask for some clarification on the newer parts of the Bill. Can the Minister of State outline the rationale for the increase of the number of Health Insurance Authority board members from five to seven under section 3? Senator Boyhan welcomed that but what pushed the increase in the board members from five to seven?

What is the rationale for both changes proposed under section 6? Why does the VHI wish to now sell without an intermediary? What are the benefits and possible risks of this change? While I imagine the removal of the necessity of ministerial approval is to save time and remove some red tape, how can we ensure there is still proper oversight? I would appreciate if the Minister of State could address this concern.

The issue of health insurance is not about the equity of premium; it is about the inability to pay or provide. That is what we should be discussing here today. The argument will be, as it has been year in and year out, that risk equalisation benefits ordinary people who may be more frail and more of a health risk than their neighbour, but we would not need this benefit if all of our citizens had access to a proper functioning public health system, universal health care. That is the real risk we should be managing today.

I welcome the Minister of State to the House. I also welcome this Bill. It is a good, important and necessary one. I have been insured with the VHI for more than 50 years. I joined the Trinity scheme. I am very glad it had a community scheme and I am still in it. I had hardly used it until four years ago when I developed a very aggressive cancer and I had a liver transplant. I do not believe I could possibly have afforded the cost of that operation without the VHI and I am very grateful we had this scheme in operation, although I probably had paid for it in my total subscriptions.

The principle and the ethos underpinning this Bill are highly important. The Minister of State said, "the Bill will ensure the ongoing sustainability of the private health insurance market and seek to keep health insurance policies at an affordable price for all citizens, young or old, sick or healthy".

Not all citizens.

That is a very important objective even if it has not been matched yet. We would all like an inclusive and encompassing health service for all but I am damned glad I had the VHI and did not have to wait forever like poor unfortunate Susie Long in Kilkenny who basically died from poverty. She was killed because of the lack of services and the fact she did not have cover with an insurance company. That was terrible but I am glad I have VHI cover. Thank God for it and I am glad this Bill will assist that continuing.

There are four main principles in health insurance, namely: open enrolment, which protects the so-called risky customers; lifetime cover, which means that the insured cannot be dumped; minimum benefit, which means that there is exactly that, a minimum level of treatment for everybody; and community rating, which means that health insurers cannot alter their prices based on an individual's current health status. It would be dreadful if one's plan was revised every time one made a claim. That is what happens in some of the other insurance markets. It happens with car insurance. If one puts in a claim, one will get one's claim settled but one's insurance premium will go up. This is an extremely good measure.

The Minister of State defined "community rating" as essentially being "a financial transfer mechanism, whereby money flows from insurers with healthier members to insurers with sicker members". That is splendid. It is a good socialist principle, from each according to its capacity to each according to its needs. That is the real deal. That is what we need in this country-----

-----and that is why I support this Bill. The Bill may not be perfect but we will wait until the Senator's party is in government for perfection.

The risk equalisation scheme made available €670 million, which is a significant amount of money. That demonstrates the significance of that scheme. From the beginning I have totally supported both community rating and risk equalisation. There were times when the commercial markets were fighting against it as hard as they possibly could.

I note legislation is needed each year, but why is that the case? Is there no mechanism to produce a situation which would be more stable, that would last for a greater period than one year? Has this ever been contemplated? Is there not a way that could be devised that could meet these requirements?

I am glad that the Minister is opening up the board to a greater participation of health workers. I have a few questions. Under the definition section, only one term is defined, namely, ""Principal Act" means the Health Insurance Act"." That is fairly standard and obvious.

I do not know, although some of my colleagues probably do know, what international healthcare plans mean? Does it mean that we insure people who are not Irish citizens or does it mean that we insure people when they are going abroad? I would like the Minister of State to clarify that. That should be included in the definition section because it would make it more accessible to the ordinary public.

I also do not know the difference between advanced cover and non-advanced cover. That should be included in the definition section also because it is opaque to the average person reading this Bill. They will not know the difference between non-advanced and advanced cover. The Minister of State might put the meaning of these terms on the record of the House. I find it of great interest that a large part of the Bill is consumed with little boxes set out in a table about the different people who will be supported by the risk equalisation fund. The first 12 categories are completely blank. They will get nothing. These are people starting at 50 years of age and over but less than 55 years of age and climbing all the way up. The fund kicks in at when the insured person is 65 years of age and over but less than 70 years of age. We are then given the different figures to which Senator Colm Burke made reference. It is interesting to see the way in which the amount of premium climbs and also to see the difference between females and males. There are some very interesting statistics in that. I am glad the Minister of State is giving due consideration to the mix of skills involved. That is very welcome. The Minister of State said he was pleased to announce, and I was surprised to hear him announce, that "this year's Bill will provide for a general decrease in the credits across genders and age groups". I find that very interesting. We are in a position where the health budget, and this is really a mini-health budget, goes up and up every year but this year there has been a decrease. That is to be welcomed but I wonder if there is any explanation for this. Why is that happening? I congratulate the Minister of State. I commend the Bill. I will certainly be voting for it. I doubt if there will be a vote on it, as it will probably be passed unanimously.

This is about Second Stage.

Yes. I know that but I anticipate the passage of the Bill. It is unlike some other Bills.

Votes are more normal on Committee Stage in my experience.

Yes, indeed they are, but I am just anticipating joy. This is what life is about - the anticipation of joy and satisfaction.

Good on the Senator.

And this Bill will provide both.

On a point of order, this is Second Stage. The Leas-Chathaoirleach reminded me of that. It did not really occur to me. There is no time limit for speaking on a Bill on Second Stage.

It was agreed on the Order of Business that there would be eight minutes for spokespersons. Senator Boyhan had nine minutes.

I am delighted. I know the Leas-Chathaoirleach thought I used it effectively.

I was feeling generous at the beginning.

I just wanted to clarify.

The Senator used it very effectively and he did not read his speech.

The Senator will have plenty of time on Committee Stage.

That is grand. I know I will. I am happy. I just wanted to clarify it on a point of order.

I call on the Minister to address the various points raised.

I thank the Senators for their contributions to the debate on the Bill. I will go through some of the points raised by individuals and if there are any I omitted or do not have time to respond to, I will revert to the Senators. Health insurance is held by a large proportion of people in Ireland relative to other countries. It is important that we take the opportunity to discuss this Bill and the positive effect community rating and other aspects of health insurance regulation have on people's daily lives. As I mentioned in my opening remarks, Sláintecare will introduce change in how people access the health service, and it may mean that the role of private health insurance in our health service also changes. This Bill supports the role that private health insurance currently plays in our health service as a means of supporting people's access to affordable healthcare.

To recap, the main purpose of this Bill is to specify the revised credits, and corresponding stamp duty levies, to apply on health insurance policies from April 2019. The voluntary health insurance system in Ireland operates on the basis of community rating, which means everyone pays the same price for the same product. This is supported by a scheme which aims to keep health insurance more affordable for older and less healthy citizens. As mentioned by a number of colleagues, in other health insurance systems internationally and in other insurance markets in Ireland, the level of risk presented by an individual directly affects the premium paid. Under this scheme, all the money raised in levies from insurers is paid into a fund for the sole purpose of supporting the market in the form of credits payable. The credits and levy rates for next year strike a fair balance between the need to sustain community rating by keeping health insurance affordable for older, less healthy consumers and maintaining the sustainability of the market by keeping younger, healthier consumers in the market.

This Bill will see an increase in the number of Health Insurance Authority board members from five to seven. This was raised by colleagues. This provision will ensure continued strong oversight and regulation of the health insurance market. This change was originally suggested by the Health Insurance Authority board. The Bill will also see some changes introduced with regard to the VHI. The first change is in the composition of the VHI board. The proposed amendment will remove the existing restriction in terms of having only two persons who are "health service providers" on the board. The amendment will also allow for due consideration of the mix of skills present on the board. The second change, which was raised by colleagues, is to ensure a level playing field and to permit the VHI to sell international health care plans directly without an intermediary. This will remove the impediment to VHI's ability to compete and will enable it to avail of significant business opportunities – opportunities that are available to its competitors.

Senator Ardagh made some important points on the legislation. Senator Boyhan referred to the health care, the VHI and the rehab beds. He knows I am working very closely with him on this. He asked, properly, what we are doing. We are spending an extra €700 million in healthcare in 2019. Fundamental questions are rightly asked about where it is going. In my portfolio, for example, we are spending €1.8 billion on disability services. On the broad question as to where we are going, we have a plan and road map in Sláintecare. That is the way forward. This is linked to Senator Devine's question about what we really believe in and the direction we are taking.

I totally agree with the points on simplification, VHI and the governance of the board. The board size is to be increased to make it more efficient and inclusive. As Senator Boyhan said, small boards do not necessarily work, although this view was held a couple of years ago. Senator Colm Burke referred to the rise in the number of board members from five to seven and to board efficiency. When I am in here, he regularly makes a point on value for money.

There was a debate between Senator Devine and Senator Colm Burke on the nurses issue. In 2014, there were 34,509 in the system. This year, 2018, there are 37,220, representing an increase of 2,711. Senator Devine raised the issue of nursing vacancies. It is a problem. I take her point on inequality in our health system. Senator David Norris touched on that also. We have to deal with this. As far as I am concerned, we have started but we have a long way to go. I take the valid points on the principle of universal health care. We have to achieve cross-party support on this. I feel very strongly that Sláintecare is the way forward.

Senator David Norris referred to his experience of VHI. One has to make tough decisions in one's personal life. The Senator obviously made the right decision. The best of luck to him in that regard. He made a very important point on supporting the community rating and unaffordable prices. These are all important points.

I mentioned the change to ensure we have a level playing field to permit VHI to sell international health care plans directly without an intermediary.

What are these international health care plans?

I will come back to the Senator with the details. There were specific questions to which I will be responding later. Every single issue raised here will be responded to.

I thank the Minister of State.

This Bill allows the Department of Health to maintain support for the core principle of community rating, which is long-established and well-supported Government policy for the health insurance market, and it will ensure that the necessary support is provided to ensure that the costs of health insurance are shared across the insured population.

I thank the Senators for their contributions. I will revert to them directly on any questions that were not answered. I do not have to hand the detail on some of them.

Question put and agreed to.

When is it proposed to take Committee Stage?

Committee Stage ordered for Tuesday, 27 November 2018.