Dáil Éireann díospóireacht -
Wednesday, 11 Jun 1924

Vol. 7 No. 22

DAIL IN COMMITTEE. - NATIONAL HEALTH INSURANCE BILL, 1924—THIRD STAGE.

Section 1 agreed to.

SECTION 2.

(1) There shall be debited—

(a) to the benefit fund of every approved society, the sum of tenpence in respect of each member of that approved society, and

(b) to the Military Forces (International Arrangements) Insurance Fund, the sum of tenpence in respect of each member of that fund, and

(c) to the Deposit Contributors Fund, the sum of tenpence in respect of each member of that fund, and

(d) to the Exempt Persons Fund the sum of fivepence in respect of each member of that fund.

(2) The several sums directed by the foregoing sub-section to be debited to the benefit fund of every approved society, the Military Forces (International Arrangements) Fund, the Deposit Contributors Fund, and the Exempt Persons Fund respectively, shall be credited to the Medical Certification Fund.

(3) For the purpose of calculating the total sum to be debited to any fund under this section, the total number of members of a society or fund shall be calculated in such manner as the Irish Insurance Commissioners shall direct.

Captain REDMOND

I desire to move the amendment standing in my name and in the name of Deputy Johnson to this section. The amendment reads:

In sub-section (1), lines 19, 22, and 24-25, to delete the word "tenpence" and to substitute therefor the word "twopence."

The object of Section 2 is to provide from the insurance fund the cost of medical certification. As far as I understand, that cost to-day is about £45,000 per annum, or something like two shillings per insured person. Up to March, 1922, the whole cost was defrayed by the State, and at that time the cost was about two and three pence per insured person. Then, what is known as the Geddes Committee came into existence, and as we all know, it successfully wielded the axe, so much so that the British Government decided to increase the weekly contributions by one penny, and that was to be borne equally by the employer and the employed person. The approved societies who, of course, are intimately concerned in this whole question, at that time did not consider that the moment was appropriate for this increase, but they agreed to meet the charge for one year and nine months out of their own funds, that period ending, I think, in December, 1923. Subsequently, there was an Act passed for Great Britain and Northern Ireland which did not operate in the Free State, as it was passed subsequent to the Treaty, and in that Act that agreement was embodied. No such Act was passed for the Free State, and the result has been that up to this the entire charge has been met by the State, but in Great Britain and Northern Ireland it was decided that there should be a contribution of twopence per insured person for the year 1924—that was, of course, subsequent to the termination of the period which I have mentioned—and that that 2d. per member of approved societies should be supplemented by a contribution from the unclaimed monies of the Stamp Sales Account, and also from the surplus on the investment account over the amount allowed by regulation. Now, that may seem rather difficult for Deputies to follow, but what it amounted to was this, that 2d. a head was the amount paid per member, and this was agreed to by the approved societies in Great Britain and Northern Ireland—2d. per head per insured person—and the balance was made up out of the funds which I have mentioned. Now, what is proposed here in this section is that 10d. a head shall fall upon the members of the approved societies and that the balance, namely, 1/2—the balance of 2/- —shall be derived from the funds which I have mentioned.

Now, sir, the approved societies say that their funds are not able at the present time to sustain that burden, and that the result will be deficiencies in valuation. And what the approved societies complain of is that the National Health Insurance Commission make this proposal without bringing forward any authorised report, say from an Actuary, showing that their benefit funds would be able to stand such interference. The benefit expenditure, as everyone can realise, of these societies, has been very severe for the last two years, and the societies themselves have represented at least on one occasion to the National Health Insurance Commissioners that they would not be able to stand the proposed burden. And what they complain of is that this alteration should be proposed without some authoritative report from an Actuary upon the matter. It is not that they desire that the old state of things should continue, or that they say that the State should bear the whole of this charge. On the contrary, they say that they shall be willing to bear what they consider to be their proper proportion of the burden, and that that proportion as far as they know up to the present, should be similar to the proportion that has been agreed to by the approved societies both in Northern Ireland and in Great Britain, namely 2d. per head, the balance to be made up from the funds that I have mentioned. Now, this fund of unclaimed monies from stamps runs, I think into quite a large figure. I do not know whether the Government are able to supply the figure or not, but I think it is incumbent upon them, if possible, to do so; and if the Minister could, in his reply, inform me what is the extent of the fund derived from unclaimed stamp monies, I should be grateful to him for the information. But at any rate, the fund some time ago I think for the whole of Ireland amounted to something like £113,000; and that certainly would be sufficient to cover the deficit if the insured persons were to subscribe 2d. per head, and if the amount altogether only totalled £45,000.

Now, sir, I think only a few months ago—perhaps it was last year—a conference was held between the representatives of the approved societies and the Insurance Commissioners, and at that conference, I am informed, the approved societies of Ireland unanimously opposed this proposed 10d. burden, and they gave their grounds for their opposition; and their principal ground was that they should have it in black and white, on paper, from an authorised actuary, that their society funds were able to bear this charge. And what they complain about now is that the Government are bringing in this proposal and that they have not produced that report. There is, I think, an Advisory Committee under the Insurance Act of 1911, and I think it would be a subject matter for that Committee. However, there is also, I understand, a Committee of Inquiry about to be set up to inquire into the whole question of public health insurance administration. And what I would suggest seriously to the Minister is this: that, pending that inquiry, this proposal should be dropped and that he should await the decision and the report of that Committee of Inquiry before he proceeds to make a proposal such as this, a proposal which the societies themselves concerned say would be an unbearable one as far as their funds are concerned. If the Committee of Inquiry discover and are able to show that the 10d. burden would not be an unbearable one, if they are able to show that it would be a proper and a reasonable burden to be levied upon the individual members, or from the funds of the society, then the Government would be in a strong position, especially if they also had an actuary's report on the matter. They could then come down to this Dáil and say: here are our reports, both from the actuary and from the Committee of Inquiry, and they both say that this burden is a right and a proper one. Of course if, on the other hand, the Committee did not come to that conclusion, that would only be another justification for the amendment that I have placed upon the Order Paper and which I hope will be favourably considered by the Minister.

Mr. JOHNSON

I have put down an amendment in similar terms to this and I would like to supplement what Deputy Redmond has said in support of the proposal. He has indicated generally the reasons why he thought that this proposal to reduce the sum by 10d. is inequitable and much of what has to be said was said, or suggested, on Second Reading, but there is something more to be said. The proposals in the Bill are based, apparently, on the actuarial reports which were prepared for British Societies or, shall I say, for the whole of the institution, England, Scotland, Ireland and Wales, and the valuations that have been made, did not, even when they were made for the whole of these four countries I would maintain, and do not justify this reduction of the State grant and the additional charge upon the funds of the Societies. They are much less equitable when applied to Irish Societies. The burden of sickness is heavier in Ireland. The reports which were made for the last valuation period were made at a time when it was very unprofitable for a person to go sick and when it was easy in very many big establishments for a man to be allowed to remain on in work on pay while quite unfit for work, because employers said "we must not lose this man; we are being paid by the Government for public work according to a percentage over and above our output."

Anybody acquainted with industrial undertakings during that period knows that very large numbers of men were allowed to remain on the pay-sheets and in the case of shipbuilding centres, allowed to hide away and were for days and days, and sometimes for weeks and weeks, doing nothing, though on the pay-roll, and were told by the foreman or manager to get out of the way, not to show themselves, and to lie down. That sort of thing was very common and when people talk of the demoralisation of certain sections of the people they have to look to that kind of thing, for which the employer was responsible, as the explanation. That, however, is by the way. During that period there was the lowest possible rate of sickness and, therefore, the lowest possible charge on the societies. Since that period societies have had a very much heavier sickness rate and it is believed by those competent to judge that the great majority of societies—societies taking in all kinds and qualities of insured persons, not selected societies— will have to call upon the margins that were allowed under the scheme to meet their sickness liabilities.

Now, what is proposed is to apply these margins to pay those certifications. The Minister spoke of the 5d. which had been reduced from the administration expenses this year. That 5d. was originally set aside to make a contingency fund to meet possible defects, or possible deficits, in case of emergency—contagious diseases, infectious diseases, and any other abnormal liability—and it was to be put aside more or less as a reserve fund, to meet the abnormal costs of administration. Now that has been reduced. The societies contend, quite rightly, that it should go back to this emergency contingency fund because if it were ever required—it may well be required again—it ought not to be used for this medical certification. That is so far as the 5d. goes, but then we are asked to agree that another 3d. which is a margin also to meet extra liabilities, extra costs, should be taken from the societies health insurance and paid over to the cost of this medical certification. Now, what is going to be the effect, supposing the opinions and judgment of experts in health insurance are justified, and that the societies are not able, even the best administered societies, to bear this extra charge? It will mean that there will be a deficit on the next valuation, and that that will impose on every member of the societies the necessity for an extra levy to meet the deficit. We will have again the spectacle—without having had proper examination of accounts, without having had an actuarial certificate proving to us that the societies could bear this new charge—of the societies forced into a state of what you might call insolvency, throwing upon the insured person of two years hence, an added liability. Now, if it is the intention, as we understand it is, that there shall be a general inquiry into the health insurance scheme, then that inquiry should precede this change. This change should not take place until that inquiry has been carried through.

The sum of 2d. is put down rather because it is a certain margin that was calculated as being available for extras. That margin of 2d. per year is suggested as a sufficient contribution to make towards this classification, instead of the 5d. that is now suggested. The 10d. is entirely too much; 5d. has been deducted already, and this, it is contended and believed, would simply mean that it is not in administration that the loss will be. It can not be an actual saving to the State, because the effect will be that you are going to reduce administration. You are going to reduce the allowances for administration, which will mean a reduction in the efficiency of administration, which will mean an added charge upon the societies, or, alternatively, it will force the societies to cut down benefits, and the insured persons will probably have to seek Home Help. Sick people are either going to suffer, or get assistance from one place or another. There is no suggestion that anyone will get anything out of this amendment. It is simply affirming the belief that the scheme will not bear this charge, and if you are going to alter the scheme it had better be after full inquiry and any readjustments that an acturial report may involve, rather than to make your change now, and then have your inquiry. The societies, I think, are unanimous in their view in this matter. I do not believe that the Commissioners could tell us, through the Minister, that this will leave societies in a sound position. I believe it is against all expert advice and that it is simply a case of the Minister saying: "Well, we will not allow these various funds, this Contingency Fund or Unclaimed Stamps Account, to be drawn on, even for this year," pending this full inquiry even. We are going to make the poor pay. I suggest that that is not a position we ought to allow, and we ought to accept the amendment.

Mr. BLYTHE

I think that we must have regard to what the societies have escaped paying during the past couple of years owing to the fact that the Saorstát came into being and that the Exchequer bore the whole cost of medical certification. The expense of medical certification to the societies in Northern Ireland for the years ending in 1922, '23, and '24, all-told, will be £29.300. The amount that we are proposing to put on the societies this year will be £14,300. The number of members in the Saorstát is about 440,000, over whom the £14,300 will be spread. The number of members in Northern Ireland is 280,000, so that if this arrangement that we propose this year were to end with this year the societies here would get out of it very cheaply, indeed. Their total would be less than the total of Northern Ireland; it would only be half the total of Northern Ireland, with a great many more members. Even if it were to be continued for two years, and £14,300 were to be charged for a second year, the societies in the period beginning in 1922 would have paid less than the Northern societies have had to pay, and with a great many more members, so that it cannot be said that we are imposing an unduly heavy burden on the societies. If we take the question of the effect of this extra charge of 8d. beyond what the amendment suggests—the 8d. per member spread over a period of five years—I do not think it would be very likely to have any appreciable effect on the valuation. I should think that a society that would be put in a wrong position and valuation because of this 8d. per member must be conducted in a very unsatisfactory way, and must be very near the margin.

Mr. JOHNSON

Is it not 8d. per member per year? The Minister said spread over a period of five years.

Mr. BLYTHE

Yes, but I have stated that we have proposed to have this for this year only, or at most for two years, when we hope that the whole state of insurance can be looked into and dealt with. What is proposed in the Bill is simply a provision to meet the requirements for medical certification for the present until we can have an examination into the whole system of National Health Insurance, and until we can see what reforms can beneficially be carried out in the system. This is, as you might say, a stop-gap arrangement, and there is no intention of making it a permanent one because, as I have already pointed out in regard to one part of this proposal, it could not possibly be permanent. We propose to find 1/2 of the 2/- required for medical certification out of the Unclaimed Stamps Account. We could not, I think, take it from that account for more than two years in succession, and in fact it would be undesirable even to take an amount from that account for two years. At the conference to which Deputy Redmond referred the societies objected to the 5d. which was going to administration, not to the other 5d., which is made up of the 2d and the 3d. I do not think that they would have urged that the administrative expenses should be cut down and that the Benefit Fund or the Contingency Fund should have the advantage of the 5d. which is being saved on administration. I believe that that 5d. taken off administration is at the bottom of the objection of the societies to the proposal, and if the 5d. had been left them and they had continued to receive 4/10 for administration, and the other 5d. had been found as we proposed, there might not have been so much objection at all. There is no particular advantage in taking this amount required—supposing we are to take the 10d. from these funds—from the other funds rather than taking it directly from the Benefit Fund, because these other funds will have to be taken into account at a valuation, and the effect on the societies will be the same when it comes to a valuation, whether it comes from this particular fund or not. We do not desire to take more from the Unclaimed Stamps Account than we are already taking, because we are not able to estimate the precise amount of that fund. Of the £113,000 for all Ireland to which Deputy Redmond referred there must be a deduction for cards that have not come in and for stamps that are in the hands of the public and have not been affixed to cards. This is not the surplus fund. Even if we did know the exact amount that was surplus at present there is the fact that the fund has still to be apportioned between Great Britain, Northern Ireland and the Saorstát, and we do not know the precise amount of the fund.

That fund in any case is charged with other liabilities. The expense of keeping in benefit unemployed persons who are unable to stamp their cards, and whom it is not desirable to allow to fall out of benefit, is being charged to that fund. There are four years' cost of that service to come out of the fund, and, as a matter of fact, the bills are only falling due at present. Although it has been a couple of years in operation, we do not know the amount of the cost of keeping unemployed in benefit will be, and how much it will take out of the fund, and we do not think it is desirable to risk exhausting that fund competely, or to make it unable to bear the charge of keeping unemployed uninsured persons in benefit. The same consideration practically applies to the Surplus Interests Fund. The societies in this country which have British securities, owing to the fact that the income tax exemption for charities will not, I think, be extended a further year—certainly we have not on general grounds desired to extend that exemption to charities, and the British authorities I understand, are equally reluctant—will necessitate existing societies which have investments in England realising them. Some of these investments were bought when prices were a good deal higher than they are at present, and the surplus interest will probably be required to meet the loss on capital which will be occasioned by the transfer. As I say, there has been no apportionment of that fund, and we do not know what it is. We do not think it is sound and desirable to charge part of the cost of this to a fund about which, until an apportionment takes place, we know practically nothing. We feel that the best thing is to charge 10d. of the 2/- to the societies, and the other 1/2 to the unclaimed stamps account, which can bear that amount, but we do not wish to burden it further. The societies, taking an average of years, are coming out of it a great deal more cheaply than they would if they had been in the Northern area.

Mr. JOHNSON

Can the Minister tell us what has been the amount expended on medical certification within the last two, three, or four years?

Mr. BLYTHE

It was ranging around £51,000 a year. It was £51,000 last year for the Saorstát. Of course, the amount will be reduced in the coming year, because the amount paid to the medical officers is reduced from an average of 2/3 to 2/-.

Captain REDMOND

I am very glad to hear the Minister state that this is only a temporary proposal. He says that it may only apply to one year, and that at most it should only apply to two years, but, if he would only put that into the Bill, I think it would be a great advantage, because I have seen other temporary Bills brought in for temporary purposes that have been renewed again and again, and I cannot find it stated that this is only for this year.

If the Minister could see his way to make that clear, that at any rate would dispel some of the fears the approved societies have given expression to. But apart from that the Minister has not quite answered one or two questions that I put to him, especially the question as to whether any actuarial report had been received by him, and whether he is acting on this report or not, and secondly, whether it would not be advisable, now that the Committee of Inquiry is shortly to sit—I think it is to sit within the next few days—to await the report of that inquiry, before proceeding as, indeed, he appears to be, without any expert advice upon the matter. It is perfectly true, as he said, that for a few years the approved societies in Ireland were not taxed to the extent that they were in Great Britain or Northern Ireland, but it is also true, I think, to say that the approved societies were taxed more heavily in Ireland on account of the calls upon them in the shape of disease and the general conditions that prevailed in the country. Therefore, I do not think it quite fair to compare the present position of the approved societies in the Free State with the position of societies in Great Britain and Northern Ireland. If the societies were, as he suggests, to be severely hit by this, it would show that they were existing upon a very narrow margin at present, and I do not dispute that statement at all. On the contrary, I should say that that was a fact, and that being so I would suggest that it would be wiser before proceeding with this proposed extra levy to stop until he had good grounds, whether from an actuarial report, or from the report of the Committee of Inquiry, which is about to go into the whole question. As to the Unclaimed Stamp Fund which I referred to, the Minister evidently cannot inform us of the extent of it at present. Well, I think it is about time we did know where we stand in that matter, and what the amount is that will have to be apportioned between Northern Ireland and the Free State. Would it not be wiser, if he does not know the exact amount of that fund now, to wait until he does and then perhaps he would have more at his disposal from that fund than he appears to think? That fund, as he has stated, will be drained for other purposes, but that fund was used as far as Great Britain and Northern Ireland are concerned, and is still used for this purpose. Taking all these things into consideration, later on I think that the Minister will consider this step to have been a hasty one, and that it would have been better in the interest of the National Health Commissioners, of the approved societies and of the country generally, if he was to stay his hand and await the decision and report of a duly qualified actuary and of the Committee of Inquiry, and also to await the time when he would be in a position to know the exact amount of this Unclaimed Stamps Fund—how much can be apportioned to this country, and what fund there will be to draw upon for this sum. I think these facts make a strong case why the Minister should not proceed, and I would strongly urge upon him to take these facts into consideration, and if he does not see his way to do so, at any rate, to make it clear in the Bill that this proposal is only for the present year.

Mr. BLYTHE

If Deputy Redmond would look at Section 4 he will see that this is only a temporary Bill: "There shall be paid out of the Medical Certification Fund—(a) such sums in respect of the year 1924...." To continue it even for another year will require a fresh Bill. In regard to getting an actuarial report, that would involve a valuation of the societies, and we felt that there was sufficient ground for holding that the societies could bear the small burden of seven-ninths of 10d. without crashing. We have not provided in the Estimates for this year for medical certification, and if this Bill, or something like it, were not passed, either the medical certification scheme would fall to the ground, or we would require to present a Supplementary Estimate to the Dáil to provide a sum of £35,000 to meet the costs of this service, which we do not feel we could well do in all the circumstances.

Captain REDMOND

Section 4 says: "There shall be paid out of the Medical Certification Fund—(a) such sums in respect of the year 1924...." That is, that there shall be paid out of the Medical Certification Fund. But then Section 2 provides for the method of forming the Certification Fund, and to make it clear, in that Section 2 there should be words to the effect that this method can only be adopted for this year. The fund may be made up as proposed in Section 2 from this on ad infinitum. It is in the actual compiling of the fund that I would suggest the method should be limited to this year. I respectfully put that to the Minister.

Mr. BLYTHE

My feeling is that the Deputy has not read the Bill very carefully, and might leave it at that.

AN LEAS-CHEANN COMHAIRLE took the Chair at this Stage.

Amendment put.

The Committee divided: Tá, 18; Níl, 46.

Tá

• Seán Buitléir.
• John Daly.
• Séamus Eabhróid.
• David Hall.
• Séamus Mac Cosgair.
• Tomás Mac Eoin.
• Risteárd Mac Fheorais.
• Pádraig Mac Fhlannchadha.
• Tomás de Nógla.
• Ailfrid O Broin.
• Tomás O Conaill.
• Liam O Daimhín.
• Eamon O Dubhghaill.
• Seán O Laidhin.
• Domhnall O Muirgheasa.
• Tadhg O Murchadha.
• Pádraig O hOgáin (An Clár).
• William A. Redmond.

Níl

• Earnán de Blaghd.
• Seoirse de Bhulbh.
• Séamus de Búrca.
• John Conlan.
• Máighréad Ní Choileáin Bean Uí Dhrisceóil.
• Patrick J. Egan.
• Osmond Grattan Esmonde.
• Seán de Faoite.
• Darrell Figgis.
• Desmond Fitzgerald.
• John Hennigan.
• William Hewat.
• Connor Hogan.
• Patrick McGilligan.
• Risteárd Mac Liam.
• Eoin Mac Néill.
• Seoirse Mac Niocaill.
• Liam Mac Sioghaird.
• Liam Mag Aonghusa.
• Pádraig Mag Ualghairg.
• Martin M. Nally.
• John T. Nolan.
• Peadar O hAodha.
• Mícheál O hAonghusa.
• Criostóir O Broin.
• Próinsias O Cathail.
• Partholán O Conchubhair.
• Conchubhair O Conghaile. Eoghan O Dochartaigh.
• Séamus O Dóláin.
• Tadhg O Donnabháin.
• Peadar O Dubhghaill.
• Eamon O Dúgáin.
• Donchadh O Guaire.
• Fionán O Loingsigh.
• Risteárd O Maolchatha.
• Domhnall O Mocháin.
• Séamus O Murchadha.
• Pádraig O hOgáin (Gaillimh).
• Patrick K. Hogan (Luimneach).
• Seán O Súilleabháin.
• Caoimhghín O hUigín.
• Seán Priomhdhail.
• Patrick W. Shaw.
• Liam Thrift.
• Nicholas Wall.

Amendment declared lost.

Question—"That Section 2 stand part of the Bill"—put and agreed to.

Section 3 added to the Bill.

SECTION 4.

There shall be paid out of the Medical Certification Fund—

(a) such sums in respect of the year 1924 as the Irish Insurance Commissioners with the approval of the Minister for Finance may determine to be payable to medical practitioners for medical certification, and

(b) to each approved society such sum calculated at a rate not exceeding one penny and one halfpenny per annum in respect of each member of the society as may be required to meet any sums sanctioned by the Minister for Finance for payment in the year 1924 to that approved society in respect of the cost of obtaining second medical opinions.

Mr. JOHNSON

I move:—

To add at the end a sub-section as follows:—

(2) The sum due to any medical practitioner in respect of medical certification shall not be paid in full unless and until the Insurance Committee for the area has notified the Irish Insurance Commissioners that it has no objection to final payment or that, having raised objection, it has, after consultation with the medical practitioner, agreed to withdraw its objection.

This amendment is an attempt to secure that Insurance Committees will have some kind of control over medical certification. I gather that there has been a considerable amount of dissatisfaction with medical certification, and local Insurance Committees—that is County Committees—should have some check upon medical practitioners who are directly responsible to the Commissioners. It is only when specific complaints may be made to the Commissioners that any action can be taken. It is alleged that in many cases perhaps, here and there, medical practitioners are not—shall I say—very honest in their issuing of certificates, and that there is a good deal of dissatisfaction. This is an attempt to give the local Insurance Committee some kind of suspensory veto upon the payment of the sums due to the practitioners. It ought to be, I think, acceptable. If the Insurance Committees are to be given any rights or authority at all, this certainly should be included. Therefore, I move the amendment.

Mr. BLYTHE

I think this amendment arises from some idea of an analogy with conditions in Great Britain, where there is medical certification, and where the local societies keep registers not only of the insured people in their area, but also of the medical practitioners, and pay out the funds to the doctors. Now there is no such arrangement here. The duty of the Committees has been confined practically to sanatorium benefit. They have had nothing to do with this matter and to make any change would involve some increase of staff to the Committees at a time when we are about to consider the whole system. I do not think that extra burdens of a type of work that has not existed up to this should be thrown on Committees or that committees should be compelled to employ new staffs and to undertake new duties. Then there is the question of our arrangement with the doctors. We have arranged with them to undertake the work at a certain fee under certain conditions. If we impose new conditions, that bargain will have to be re-opened and I do not think that that should be done when we are dealing really with an interim arrangement. There are means of inquiring into the conduct of a medical certifier and I think that on the whole those means are working reasonably well. Certainly there has not in my time come to my knowledge any considerable number of complaints and I think that the system that exists at present for inquiring into the way that the certifiers do their work will serve for the interval that will elapse before this and other questions can be considered. I do not think it would be desirable at all to make this amendment, and I think there is no particular demand for it.

Amendment put and negatived.

Sections 4, 5, 6, 7, 8 and Title put and agreed to.