The object of this Bill is to introduce certain changes into the code of National Health Insurance which will make for simplification and economy. There is rather a large background to the proposals made in this Bill going back to a Committee dealing with the matter of National Health Insurance and Medical Services which sat in 1924 but did not definitely report until 1927. The Committee was appointed by the Minister for Finance and its terms of reference were (1) to inquire into and report on the advisability of the continued maintenance of the system of National Health Insurance in its present form and to make any recommendations which the Committee consider proper in that connection. (2) To consider whether it is desirable to institute a system of medical treatment on a contributory basis, and if so, to advise as to the form which that system should take. (3) To examine into and report on the question whether the Medical Services at present assisted and maintained out of State or local funds can be improved as respects efficiency and economy, and if so, in what manner, due regard being had to any recommendations made under the preceeding paragraph. Two reports have been published. On the general question of the continued maintenance of National Health Insurance the Committee reported that an overwhelming body of evidence was in favour of its continuance. The approved societies, the employers' representatives, the Labour representatives, the General Council of County Councils, and the medical profession, were all of opinion that Health Insurance had proved a real benefit to the working classes in the Saorstát. The Committee, however, recommended that certain changes could be advantageously made in regard to particular features of the Act, and the main object of this Bill is to give effect to these changes. It may be recalled that the effect of the Insurance Act has proved a real benefit to the working classes as borne out by statistics. The average weekly number of insured persons receiving sickness and disablement benefit during the year 1928 was 21,250, and the amount expended on these benefits during the year was £563,000. The amount expended on maternity benefit was £54,000. In addition, these societies which had surpluses at the last valuation were providing additional benefits such as dental benefit, hospital benefit, etc., involving expenditure of about £34,000 per annum.
In the Bill the first matter dealt with is that of exempt persons. It is necessary at the outset to distinguish between excepted persons arid exempt persons. Excepted persons are completely outside the scope of the Acts, while exempt persons are only partly out; they pay no contributions themselves but the employer has to pay the ordinary employer's portion of the contribution. The exempt class is composed of persons who are given a statutory right on certain conditions to apply for exemption, a right which they may or may not exercise at their own discretion. There are various conditions set out in the Acts which confer this right but the main grounds upon which exemptions are obtained arc (1) that the claimant has a pension or income of £26 per annum derived from sources other than his employment, or (2) that he is depending on some other person for his livelihood. Those who apply for exemption are in fact small in number — there were 726 exempt persons in 1928 — but they constitute a highly favoured class as they pay nothing themselves and yet they are provided with benefits out of the money provided by their employers and by the State.
As is usual in dealing with small classes of this nature the administration expenses involved are much higher than can be justified by the small amount of good effected. The Committee recommend that the right to claim exemption should be withdrawn and it is proposed to give effect to this recommendation, in the present Bill. Adjustments will be necessary so that such persons as are exempt at the present moment will not lose the rights they are entitled to as exempt persons until they become persons in ordinary insurance. There are certain statutory provisions dealing with Irish migratory labourers. As a matter of fact only two persons in 1928 applied to be regarded as in the class of migratory labourers and in fact provision dealing with Irish migratory labourers are no longer required in the Act.
With regard to the deposit contributors, the Committee unanimously recommended that if at all possible the class of deposit contributors should be abolished, and that all existing deposit contributors should be transferred to approved societies. While insurance under the Acts is compulsory, an insured person is not compelled to join a society, nor is a society compelled to take him as a member, and those insured persons who, for one reason or another, do not become members of approved societies constitute a class known as deposit contributors. The general principle of deposit insurance is that the contributors' right to benefit is limited to the contributions paid in respect of him increased by the usual State grant. A separate account is kept in the Commission for each deposit contributor. The benefits are administered by the Insurance Committees and are paid by the Commission out of the sum standing to the credit of the individual accounts. Insurance of this nature is obviously of very little use to the contributor, and in case of prolonged or serious illness his account is soon exhausted and lie is left entirely unprovided for. The weakness of the whole position is that a scheme purporting to be a scheme for National Health Insurance fails to provide for the insured person whose health is so indifferent that he cannot obtain admission to an approved society. There are only between 3,000 and 4,000 deposit contributors. Concurrently with a provision, of this nature doing away with the deposit contributor us a type of person recognised under the Act, it is obviously necessary that the existing rights of societies to refuse admission to members and to expel them should be withdraws except in cases where the constitution of the society requires that its membership should be limited to persons of certain classes. For instance, some societies have special rules limiting membership to men or women only, and to persons of a particular religion, or to residents of a certain area or employed in a particular trade. Such societies will continue to be entitled to reject applications for membership from persons who do not come within such category. Provision is also made for the transfer of existing deposit contributors to approved societies. A suitable interval will be given after the passing of the Bill to enable them to choose their own societies, but any who have not done so at the end of the period will be transferred en bloc to certain societies which will be selected by the Commission as suitable for the acceptance of such members.
In the case of married women, at present an insured woman who marries and remains in employment continues to pay the ordinary contributions and to be entitled to the ordinary benefit. If, however, being a member of a society, she ceases to be employed for a certain period she is transferred to a special class, called Class K, in which no contributions are required and benefits are payable on a special scale. The transfer takes place at the date of unemployment, that is, at the end of eight consecutive weeks of unemployment, excluding unemployment due to incapacity for work, terminating within twelve months of her marriage. If, however, she had completed eight consecutive weeks unemployment on or before the date of the marriage the transfer takes place at that date. The special scale of benefits applicable to Class K is:—(a) sickness or disablement benefit of 7/6 a week for a maximum period of eight weeks in the period between the date of unemployment and the date of the completion of the second year of marriage (not subject to reduction for arrears): (b) maternity benefit of £2 in respect of the first confinement after the date of unemployment and within two years of the date of her marriage (subject to reduction for arrears, but not below one pound); and (c) sanatorium benefit until the end of the half-year next following the completion of a year from the termination of eight weeks unemployment.
At the end of two years from the date of her marriage a Class K member ceases to be insured and her membership of a society ends. If she again becomes unemployed while still a member, that is, before the end of two years from the date of marriage, she is treated as a new entrant into insurance and is required to requalify for benefit, retaining the right to any Class K benefit to which she would otherwise have been entitled until she requalifies. Administration of the insurance of this particular class, which came into existence in July, 1918, has proved to be troublesome and difficult, and the Committee recommended a simpler method. namely, that marriage should terminate the woman's insurance and that if she continued to be or again became insured after marriage she should be treated as a new entrant and, further, that in lieu of the present benefit a cash endowment should he paid to insured women on on marriage. The Bill makes provision for this. The matters of the greatest importance arc the abolition of sanatorium benefits and the abolition of insurance committees. Both of these changes have been unanimously recommended by the Committee of Inquiry. The Insurance Act of 1911 set aside 1/3 per insured person out of insurance funds for the treatment of tuberculous insured persons, and the administration of the scheme for such treatment was entrusted to the County and County Borough Insurance Committees. In 1912 grants became available which enabled local authorities to obtain recoupment from State funds of one-half of their net expenditure on the treatment of tuberculosis. There is, therefore, in existence a dual system by which responsibility for treatment rests partly on insurance committees and partly on the local authorities. In actual fact what has happened is that the great majority of insurance committees have entered into agreements with the local authorities by which they transfer their funds to such authorities in return for treatment for their insured persons so far as moneys are available for the purpose. In all these cases the work of the insurance committees is mainly limited to recommending certain insured persons for treatment to the local authorities.
The system gives rise to two serious complaints, firstly, that insured persons not only have to pay for sanatorium benefit under the Insurance Acts but have also to contribute is taxpayers and ratepayers for the moneys expended on tuberculosis under the local authorities schemes; secondly, that in some areas the money available for insurance funds is not sufficient to meet the number of cases requiring treatment with the result that insured persons although they have already contributed for sanatorium benefit are sometimes called on to pay part of the actual cost of treatment provided by the local authorities if their means enable them to do so. On these grounds the Committee recommended the abolition of sanatorium benefit and suggested that the treatment of tuberculosis should be left entirely in the hands of local authorities. As deposit contributors whose benefits were administered by insurance committees are also being abolished there is no further work for these committees to do and their abolition is consequently also recommended. The abolition has been recommended unanimously by the Committee and provision is now being made to deal with it.
On the financial side the Bill provides that 1/3 per insured person hitherto available for sanatorium benefit and the 4d. per insured person available for the administration of insurance committees should now be diverted to meet the cost of medical certification. This amount of 1/7 together with the 5d. already contributed by approved societies will provide the 2/- per insured person which is required to meet the cost of obtaining medical certificates for insurance purposes. Local authorities will be compensated for the loss of 1/3d. per insured person which they had been getting from insurance funds by an annual grant from State sources of £27,750. which will be provided for in the Vote for Local Government and Public Health. As the State has hitherto been contributing 1/7d. per head to the Medical Certification Fund which will now cease, there will be a net saving to the State of 4d. per insured person, the estimated figure being £7,400 per annum. These arrangements put on a permanent basis the provision of money for medical certification and Acts of a temporary nature such as have been passed each year since 1924 will be no longer necessary. The Medical Referee Service will still be provided from State funds.
A number of smaller matters are dealt with in the Bill. There has been difficulty in getting the terms of the Act carried out in regard to the stamping of cards for junior assistant mistresses. That has been due to the fact that while the Minister for Education was responsible For the payment of the employer's share of the contributions the manager was supposed to stamp the cards. It is proposed that in future the Minister for education will be regarded as the employer. That arrangement will save the trouble hitherto experienced both by the managers and the Commissioners. In accordance with the further recommendation of the committee an amendment is made in Section 112 of the Act of 1911 which will enable inspectors of the Commission to enter private dwelling houses, if necessary, at reasonable times to investigate cases of non-compliance with the provisions of the Act. There has been a rather widespread non-compliance on the part of persons employing domestic servants in respect of the Act. While inspectors have had statutory powers to approach employers in workshops and other places other than private dwellings, they had no power to approach private dwellings. It is now proposed to give them such powers.
It is proposed to extend the period within which an insured person is required to give notice of illness to his approved society from the present figure of three to seven days. A system existed up to now by which if it was found that a person was not complying with the Act the Commissioners took steps to get him to comply with it. They have no statutory powers to get arrears paid up except in respect of arrears for a period of twelve months. It is proposed to amend the position by which the Commissioners can recover all arrears outstanding. The National Health Insurance auditors are given a power of surcharge in regard to the accounts of approved societies similar to that which they already possessed in the case of insurance committees.
At present their power is limited to disallowing improper payments or payments for which there is no legal authority. The sums are not charted against any individual, and after investigation they are recharged to the societies' benefit fund or the administration account on instructions from the Commission. It is proposed to take stops to enable such surcharge to be levied against the particular individual who was responsible in the matter. The Bill also contains a clause which limits the rights of insured person to pay contributions in respect of periods of unemployment. Under the existing law they are not ordinarily allowed to stamp their cards themselves, but in the 1918 Act they were given a limited right to pay contributions in respect of periods of unemployment due to incapacity or inability to obtain work, in order to bring their total contributions up to the number of 104. This gave an opportunity to an insured person who fell ill or who became unemployed during the early part of his insurance and in respect of whom contributions consequently ceased to be paid, to pay contributions himself for the purpose of making up the number of contributions required before benefit became payable. Some limitation of this right now becomes necessary having regard to the fact that all insured persons will in future be members of approved societies, and if the existing provisions were not altered unscrupulous persons could become entitled to substantial benefit by entering into employment for a short period with the collusion of an employer — even a week or a fortnight would be sufficient — and then paying a comparatively small sum in contributions themselves.
The point involved will be made clear if we consider that a person going into employment gets a card stamped for three or four weeks and then leaves employment. He would have the right to pay contributions himself to bring the total number up to 104 and he would then become entitled to a payment of 7/6 a week disablement benefit which might last for the rest of his life. If we consider the liability involved in that way as distinct from a liability which would arise in a bona fide way it will be realised that some provision must be made to prevent fraud. Such persons, who would not ordinarily lie insured persons at could, if they found themselves in bad health or suffering from a serious disease which was likely to lead to continued incapacity, secure employment for a short period, pay contributions themselves up to the qualifying number and become entitled to benefit which might last continuously during their lifetime.
The Bill, therefore, limits the existing rights as regards two classes — first, women, who have gone out of insurance on marriage and have re-entered employment within twelve months, and, second, employed contributors who are over eighteen years of age on entering insurance, and who fail to prove that they are normally insurable persons. The great majority of insured persons enter insurance before the age of eighteen, and if a society finds that the first insurable employment of an applicant for membership commences after that age, they will be entitled to satisfy themselves that such employment is genuine and not taken up for a short period merely for the purpose of being able to qualify for benefit before they allow him to pay contributions himself during periods of unemployment or incapacity. The Bill also contains provisions bringing the terms of National Health Insurance for soldiers more into accord with the present regulations for recruiting in the Army.
It will be seen from the terms of reference which I mentioned in the beginning that there were two matters of considerable importance which the Committee of Inquiry dealt with. One was the unification of societies. That does not appear in the terms of reference, but in fact the unification of societies and the introduction of medical benefits were two very important matters dealt with by the Commission. I did not introduce into this Bill anything dealing with medical benefits or the unification of societies. It was the opinion of the Commission that the unification of societies, that is, the bringing about of a condition of affairs in which the large number of approved societies that we have at the moment would be amalgamated into one unified society, was the most satisfactory way to deal with the National Health Insurance scheme, so that there might be a possibility of giving better benefit to insured persons and of economy in administration. At the time that the Committee was inquiring into the matter there were eighty separate approved societies and one approved society with twenty-five branches. At the present moment there are sixty-five approved societies and one approved society with nineteen branches, so that during the period that has elapsed from the time the Committee sat a reduction has taken, place in the number of societies.
The Committee, while stating that unification of the societies would be the best possible way for organising the National Health Insurance system, were not prepared to say that that was feasible. The Executive Council, on considering the matter, were not prepared to say either that it was feasible, but I propose, on the Committee State, to put an amendment before the House that would provide an opportunity of discussing what can be done to improve the position from what it is at present. I said that the number of approved societies has been reduced from eighty to sixty-five. In my opinion, a very considerable reduction is desirable, and I propose to put before the House an amendment somewhat along these lines — giving the Commissioners power, in the case of voluntary amalgamations of societies during the next two years, the plan of amalgamation being subject to the Commissioners, to give a certain amount of compensation to those employees of the approved societies whose services will be dispensed with as a result. That is, in cases where voluntary amalgamation takes place within the next two years, provided that after two years the Commission may compulsorily bring about the amalgamation of societies down to a number not greater than twelve or fifteen, and giving, at the same time, a certain amount of compensation to the employees of the societies whose services will be dispensed with. When I say compensation, Deputies must put out of their minds that in such amalgamation as might take place in that particular way, anything like pensions will be available, because the organisation of the societies from a financial point of view would not make that in any way possible. There has been no compensation in any of the amalgamations that have taken place up to the present. The amalgamations have been amalgamations of weak societies, and in the great majority of cases the Commissioners had to step in and compulsorily carry out amalgamation. However, I will put an amendment before the House that will enable that matter to be discussed.
On the medical benefits aspect of the question, while the majority of the Committee considered that there should be a scheme of medical benefit and suggested that a medical benefit scheme could be arranged by increasing the contribution by twopence, nevertheless Deputies will find that there were three minority reports.
What, operated most in the minds of the minority reporters, and what operates in the minds of the Executive Council is the fact that it is shown that a very large proportion of insured persons are already treated free by the dispensary system throughout the country. It was felt, following the change that had taken place owing to the setting up of Boards of Health throughout the country — a change that had taken place comparatively recently — that we would require further time to judge what kind of a scheme of medical benefits should be introduced as well as to satisfy ourselves that the present system did not meet the needs of the situation. Personally, I am agreed that the system of medical benefits is very desirable, but we have not come to the time at which we can say what lines the finances or even the organisation for granting medical benefits to insured persons should take.