Dáil Éireann díospóireacht -
Wednesday, 18 Feb 1942

Vol. 85 No. 13

Committee on Finance. - National Health Insurance Bill, 1941—Second Stage.

Parliamentary Secretary to the Minister for Local Government and Public Health (Dr. Ward)

I move that the Bill be now read a Second Time. This is a Bill to amend the National Health Insurance Acts 1911 to 1936. While it is a short Bill, containing no more than 16 clauses, the amendments which it proposes to the existing code of National Health Insurance are of far-reaching importance. Its object is to modify the financial system on which the scheme as at present operated is based in such a manner as to permit the release for expenditure on additional benefits of part of the income of the National Health Insurance Society which at present is carried to reserve. In order to explain to the Dáil the changes which are proposed it will be necessary for me to describe as clearly and as simply as is possible the rather complex and technical method of finance which was adopted in the first National Health Insurance Act and which, with some minor modifications, is still in operation.

The Act of 1911, which is the principal Act, provided that the scheme of national health insurance, so far as the payment of sickness, disablement and maternity benefits are concerned, was to be operated through the medium of bodies known as approved societies. The Act applied to what was then the United Kingdom of Great Britain and Ireland, and the particular form of administration which was adopted was largely determined by the conditions existing in Great Britain in relation to the development of the friendly society system. There was already in existence in Great Britain a long tradition of voluntary effort to secure by means of mutual insurance protection against loss of earnings through ill-health or unemployment and to provide for old age and death. A large number of friendly societies had come into existence, often associated with particular vocations or trades or with particular geographical areas such as villages and towns or sometimes with particular forms of religious, political or temperance affiliations. These were self-governing bodies, many of them carrying on their functions under a limited type of supervision exercised by the Registrar of Friendly Societies. Their existence naturally suggested to the persons responsible for the introduction of the National Health Insurance Act a method of administration which was not only convenient but well understood and eminently suited, so far at least as Great Britain was concerned, to the classes of persons to be covered by the scheme.

The Act, accordingly, provided for administration by approved societies and permitted those friendly societies already in being to be approved for the purposes of national health insurance. So far as Ireland was concerned, the friendly society system had not achieved a state of development at all approaching that in Great Britain. The system of approved societies, based largely on the friendly society model, was, however, also applied to Ireland, and many new bodies had to be brought into existence to operate the scheme. This is now only a matter of history because, as will be remembered, the National Health Insurance Act of 1933 abolished the system of separate societies and unified all societies then existing into one national society. It is necessary, however, to make this short historical survey, because the particular type of finance adopted in the National Health Insurance Act was largely determined by the method of operation through approved societies.

Each approved society was a separate entity and had its own separate benefit fund, represented by its own invested assets. While all persons coming within the scope of the Act were required compulsorily to be insured, there was no compulsion to join a particular approved society. There was complete freedom of choice in this respect, and accordingly a considerable degree of competition existed between many of the societies to secure new members. Societies with a policy of expansion could secure such expansion by intensive canvassing for new members. Societies confined to a particular trade might remain in a comparatively stable condition, while other societies, either through lack of efficiency or other causes, might suffer steady diminution in membership. No society had any guarantee whatever of continuity, and the method of finance had, therefore, to have regard to that fact. Their finances had to be arranged in such a way that the principles of actuarial valuation would apply to them as they apply in the case of private insurance bodies relying altogether on the voluntary payment of contributions by their members.

An actuarial valuation of this kind is a method of applying at regular intervals, usually not exceeding five years, a test of the sufficiency of the existing assets of the society to provide in the future for the society's liabilities towards all persons in the society on the valuation date. To describe the operation in its broadest outline, the procedure is to assess, as at the valuation date, on the one hand, the present value of the contributions which the society may expect to receive in future from these members, and on the other the present value of all the benefits (including the cost of administration) which the society may expect in the future to pay to these members. The excess of the present value of the future benefits (including administration) over the present value of the future contributions is the measure in present money of the society's liabilities to its members in the future. If this exceeds the amount of the society's assets, the society is in deficiency. If, on the other hand, it is less than the amount of the society's assets, the society has a surplus. It is important to note that account is taken only of persons in the society on the valuation date.

The valuation is thus, in effect, a measure of the funds which the society should have so that, if it never recruited another member, these funds, together with future contributions, would be sufficient to provide all the benefits to which members of the society would be entitled until, in the course of time, through death, transfer or lapse of members, the society had ceased to exist. This is a very simplified account of the meaning of an actuarial valuation, and leaves out of consideration methods of assessing appropriate rates of contributions and of determining the factors which have to be taken into account, not only in calculating rates of contribution, but in making the valuation; as, for instance, the probable future course of rates of sickness, mortality, marriage, widowhood, unemployment and lapse and of the probable future rate of interest governing the investment of funds.

When the scheme of health insurance was set up and the payment of weekly contributions was made compulsory in respect of all employed persons coming within its scope, the rate of contribution fixed was a flat rate. Although the contribution payable in respect of men differed from that payable in respect of women, principally on account of the different rates of benefit, the rate of contribution did not vary with the age at which insurance began. Since the incidence of sickness increases with age, it will be readily understood that the fixed weekly contribution required in respect of a boy of 16 should be less than that required from a man of, say, 30, and still less than from a man of 40 or 50. Though this is so, the scheme provided that the rate of contribution payable by all persons entering into insurance should be the same, distinguishing only between men and women, and this rate was fixed at the lowest rate, that is, the rate appropriate in the case of males to a boy of 16 and in the case of females to a girl of 16, which is the youngest age to which compulsory insurance applies. The original approved societies accordingly accepted all members at a rate of contribution which was sufficient to provide for the benefits of members who were aged 16 years at entry but was insufficient in the case of all older members and these were, of course, greatly in the majority. If an actuarial valuation were made of each society immediately after it was set up, a large deficiency would be shown. The societies had no invested assets and the commitments for the payment of benefit were considerably greater than the value of the contributions to be received in the future, because in the case of all members over the age of 16 the rate of contribution was too low. These deficiencies, therefore, would represent the capitalised value of the future liabilities assumed by societies in admitting members of all ages. It is not possible to state accurately the amount of these deficiencies which applied to the area now served by the National Health Insurance Society, because the system then applied to the whole area known as the United Kingdom.

It can, however, be said that, so far as Ireland was concerned, the amount was approximately £4,000,000 and that the increases of benefits and contributions made in the Act of 1920 had the effect of raising it to over £6,000,000. In order to deal with these initial deficiencies it was arranged that approved societies should be given book credits called reserve values, representing the capital value of the liabilities assumed by the societies in accepting as members persons over the age of 16. At the same time the Act provided that a proportion of the contributions paid to societies should be put aside to form a sinking fund, to provide firstly for interest at the rate of 3 per cent. on the reserve values and secondly for their redemption. This sinking fund was thus designed to convert the reserve values, which were in effect notional investments, into actual cash investments, over a period of years. The retention of a proportion of the weekly contributions to form this sinking fund was made possible by the assumption by the State of liability to pay a corresponding proportion, which is at present two-ninths, of the actual disbursements of societies in benefits and administration, until such time as the reserve values were redeemed and the income of the sinking fund became available for benefits.

The National Health Insurance Act of 1918 effected some modifications in the financial arrangements to which it is now necessary to refer, as certain funds set up by that Act are dealt with in the Bill. Experience of the working of the scheme had shown that the finances of societies required strengthening and this was achieved partly by the provision of additional State aid and partly by reducing the sums retained out of contributions for the service of the sinking fund to redeem reserve values and thus postponing the date of final redemption. The sums diverted from the sinking fund moneys were used to establish a contingencies fund for each society and a central fund for all societies. The object of the contingencies fund of a society was to provide a first line of defence against a deficiency on a valuation made on the principles to which I have already referred. During the five-yearly intervals between valuations, the contributions to the contingencies fund were carried to that fund and accumulated there. When the benefit fund of the society came to be valued, the amount of the contingencies fund was left out of account in the valuation, as it was in the nature of a contingencies reserve. If the society was in deficiency, the contingencies fund was used as far as available to make good the deficiency. In the case of a society which had a surplus on valuation, or whose contingencies fund was more than sufficient to make good a deficiency, the amount of the contingencies fund or any balance remaining after making good a deficiency was credited to the benefit fund and was thus available in that fund at the next valuation. For the ensuing five years a new contingencies fund was built up. In effect, the result of this operation was that a proportion of current income was temporarily reserved over succeeding periods of five years.

The object of the central fund was to come to the aid of societies which on valuation showed a deficiency greater than could be covered by their own contingencies funds. It was a single fund for all societies in the United Kingdom and assistance was only given where it was clear that the deficiency was due to an abnormal rate of sickness arising from risks of occupation or unhealthy environment or resulting from small membership or other circumstances over which the society had no control. Its income was derived from a proportion of the moneys diverted from the service of reserve values, a fixed State grant of £150,000 and also certain moneys made available from the proceeds of sales of unclaimed stamps.

The Act of 1918, which set up the contingencies funds and the central fund, provided that of the money taken from the sinking fund for the redemption of reserve values at least seven-eighths should go to the contingencies fund and one-eighth to the central fund. It also enacted that regulations might provide that the proportion to be carried to the contingencies fund could be increased and the proportion to be carried to the central fund correspondingly decreased. The Act of 1921 provided that if such regulations reduced the proportion to be carried to the central fund, the State grant of £150,000 should be correspondingly reduced. Such regulations were in fact made in 1921 and provided that the whole moneys diverted from the sinking fund should go to the contingencies funds and accordingly the State grant of £150,000 ceased to be payable from that year. The position then was, and is now, that the central fund was supported solely by moneys credited to it out of the annual proceeds of unclaimed stamps.

In addition to the contingencies fund and central fund, the Act of 1918 also established a fund known as the reserve suspense fund, the purpose of which was to serve as a kind of clearing house for dealing with the reserve values of persons whose insurance was transferred from one society to another, or of persons lapsing from insurance, or of women who married and either ceased to be insured or continued after marriage to be insured, and required to be provided with a special reserve value. During the period following the 1911 Act, reserve values were gradually being redeemed, that is, if the reserve value of a particular person is considered, part of it had been converted into cash, and part of it still remained as an unredeemed book credit. When a person transferred from one society to another, the old society which held a reserve value for that person as part of its assets, ceased to have any liability for benefits in respect of him, and this liability was assumed by the new society. Similarly, when a person ceased to be insured, otherwise than by death or the attainment of age 70, part of his reserve value became available for the general purposes of the scheme.

The Act provided, accordingly, that where a society lost a member by transfer or lapse, the value of the society's liability thus cancelled—and called in the Act a transfer value—should be debited to the society and credited to the reserve suspense fund. On the other hand, when a society gained a member by transfer, or where a member who was over age 16 when he became insured, joined a society, the appropriate transfer value or reserve value, as the case may be, was provided out of the reserve suspense fund. Any cash balances remaining in the reserve suspense fund at the end of a year, so far as not required to provide reserve or transfer values from the membership changes occurring in that year, were made available to the sinking fund for the redemption of outstanding reserve values. That was the position at the time when societies were unified, and is still the position, with the difference that transfers of insurance are now practically confined to transfers between this country and Great Britain under reciprocal arrangements made with that country.

I have now given some account of these rather technical and complicated financial arrangements which are embodied in the existing National Health Insurance Acts, and which were necessitated mainly by a method of administration through a large number of approved societies. Some ten or 12 years ago, the financial position of many of these societies was giving cause for anxiety in my Department, and an examination of the question in relation to the system of separate societies was made. The conclusions arrived at were that a continuation of that system would result in further growth of the inequalities, anomalies and inequities as between different groups of insured persons which had already become apparent, and that no reconstruction or improvement of the scheme of health insurance on national lines would be possible until that system was changed.

These considerations resulted in the Act of 1933, under which all approved societies then in existence were unified into one national health insurance society. At the present moment, therefore, the position is that national health insurance in this country is administered by one society catering for all insured persons—with a few exceptions who are members of a special fund known as the military forces fund —but the financial arrangements under which the system is worked are still substantially in the form set up to provide for administration through a number of separate societies.

While the unification Bill was being considered, and after it had been passed, Departmental consideration and discussion with the Department's actuarial adviser was directed towards the question of what changes in the financial system were possible and desirable. It was recognised that the reserve value system was no longer appropriate, and that the principles of actuarial valuation hitherto applied should be capable of considerable modification. One of the first obstacles to progress in this direction was the absence of a reliable standard applicable to this country for the measurement of the fundamental factors affecting the actuarial basis of any scheme of health insurance. All successive valuations made since 1918 had been based (with some minor changes) on the rates of sickness, mortality, marriage and widowhood which had formed the actuarial groundwork of the scheme as originally adopted for the whole United Kingdom. These rates had been determined from British experience. No material was available from which rates applicable to this country could be determined although it had long been known that as a measure of the contingencies on which the finances of the scheme in Ireland should be determined, they were obsolete.

The first task following unification was to collect information on which a reliable standard of measurement of sickness liabilities of the scheme could be based. This was an undertaking of some magnitude which was readily undertaken by the new society, with the result that very full data covering the three years 1935-1937 were supplied from the society's records to the Departmental actuarial adviser and a report thereon was furnished by him in June, 1939. That report disclosed some unusual and disturbing results, which I will deal with later on. While this investigation was proceeding, consideration continued to be given to the financial position generally. A valuation of the society on the same principles as previous valuations, had been made as at 31st December, 1933. This valuation showed the result which would follow from combining into one valuation all the surpluses and deficiencies which would have been brought out from separate valuations of all the separate societies as at 31st December, 1933. It disclosed a deficiency of £46,700. There was, however, available in the contingencies fund a sum of £183,000, which was accordingly applied to cancel this deficiency and the balance, which was small in relation to the society's liabilities, was carried forward. It should be stated that this valuation not only followed in principle the methods of previous valuations, but also used in its measurement of future benefits and contributions the rates of sickness and mortality which had been used in previous valuations. The result of the investigation into the sickness experience of the Unified Society confirmed that the rates which had previously been used could not, in fact, provide a proper measure of the society's liabilities. The experience rates were considerably higher than the valuation standard, and it was clear that a valuation made on the basis of the society's own experience would produce a very large deficiency indeed which under the provision of the Acts would call for a substantial increase in contributions or reduction in benefits or both. This, however, was on the assumption that the principles underlying the valuations made of separate societies were also appropriate in the case of one national society, and this assumption was open to question. Instead of having some 85 different societies and branches of societies, ranging in membership from 100 to 90,000 competing amongst themselves in the recruitment of new members and with no one of them having any guarantee of permanency, there was one national society. Every person engaged in or taking up insurable employment in the country was compulsorily insurable, and the only body through which the benefits of the Acts could be obtained was the National Health Insurance Society. The society was, in effect, in the position that so long as insurance was compulsory it had a guarantee of the regular addition to its membership each year of persons entering into insurable employment.

The invested assets of the society as at 31st December, 1938, amounted to some £4,000,000. Each year its income from contributions, State grant and interest exceeded its expenditure on benefits and administration by amounts varying in recent years from £150,000 to over £200,000 and these sums were being applied to add to the reserves. Nevertheless, a valuation of the society made on the principles hitherto applicable showed that, even though this apparent surplus income existed and was being used to increase reserves, not only were these reserves insufficient but the rate at which they were being increased was also insufficient. On the surface, such a position invited adverse criticism, but in matters of this sort there is considerable danger that much of this criticism would be facile and ill-informed. The size of the invested assets of an insurance body is of itself no indication of its solvency, nor is the fact that income may exceed expenditure over a number of years any proof whatever that its finances are in a flourishing condition. It appeared, however, that in a national scheme operated through one society as distinct from a commercial scheme or a national scheme operated through a multiplicity of societies new considerations might probably be taken into account subject, of course, to the best expert opinion on the question that was available.

The Department's actuarial advisers were referred to on the matter and the result of that reference is contained in the very full and very informative report dated 28th March, 1941, which has been presented to the Oireachtas. That report is worthy of the most careful study and I will refer to it again later. For the moment, it is only necessary to say that broadly it confirmed the Departmental opinion that fundamental alterations were possible in the financial structure of the scheme and that an appreciable proportion of current income, instead of being placed to reserve, might be regarded as available for the provision of additional benefits.

The Bill now before the Dáil provides for the repeal of all those sections of the National Health Insurance Acts which deal with the crediting and debiting of reserve values and transfer values and with the provision of a sinking fund for the redemption of reserve values by means of a deduction from contributions. It also repeals the provisions relating to the contingencies fund, which, as already explained, is formed by placing to temporary reserve a proportion of the contribution income.

The result of these repeals will be that the whole contribution income of the society, which hitherto has been apportioned between the benefit fund (including the administration account) of the society, the contingencies fund and the sinking fund for redemption of reserve values, will be credited to the benefit fund and administration account of the society. The Bill also provides for the repeal of those sections of the existing Acts governing valuation and the manner of dealing with a surplus or deficiency arising on valuation. Instead of these provisions, the Bill proposes that, as at the dates on which a valuation under the existing Acts would normally be made, there shall be made a comprehensive actuarial review by an actuary appointed by the Minister with the consent of the Minister for Finance. In his review, the actuary is to have regard to the amount by which the income of the society, other than that available for administration expenses, exceeded the expenditure on benefits, medical certification and the provision of transfer values during the preceding five years, and he is required by the Bill to report as to the amount of such excess that may be made available for additional benefits in the next succeeding additional benefit period. The type of report contemplated would correspond to the report to which I have already referred, and which governs the amounts which will be made available for additional benefits in the five years beginning 1st April, 1942. The Minister, after considering any such report, is to determine the amount which may be made available for additional benefits, and the society may submit for his sanction a scheme for the provision of such additional benefits.

The Bill proposes to make no change in the list of additional benefits contained in the existing Acts. Under Section 3 of the Act of 1911, two-ninths of the cost of the provision of additional benefits, including the cost of their administration, is borne by the Exchequer. It is contemplated that the amount to be made available for additional benefits in each of the next five years will be £175,000, of which, therefore, about £39,000 will be borne by the Exchequer. The central fund is to be reconstituted as the national health insurance reserve fund, and will in future be the only resources of the scheme held in reserve to meet adverse experience. It is of the highest importance that the existing capital assets of the society, which represent the investments of its benefit fund, should be maintained intact, and should not be encroached upon. They are under no circumstances available for distribution. They perform the function of producing by way of interest an income which is a supplement to contributions. If this interest income were to fail, then it would be necessary to replace it by an increase of contributions. If adverse circumstances were experienced in which the income of the society fell to a level lower than that necessary to provide ordinary benefits, or if the claim rate so increased that the income was no longer sufficient to meet it, then the proper procedure would be not to encroach on capital assets, but to increase contributions or reduce benefits in order to restore equilibrium. For this reason the new reserve fund is of importance. Its purpose is to perform the functions of a contingencies reserve fund, and it is proposed that it should be allowed to accumulate by its own interest and by the addition from year to year of certain moneys made available from the proceeds of unclaimed stamps, until, in the opinion of the actuary, it has reached a figure which will constitute a reasonable reserve. He will consider its position at each quinquennial review, and will advise as to the amount, if any, which may be transferred from it to the benefit fund of the society. Any amount so transferred will be taken into account in deciding the amount made available for additional benefits.

The Bill also deals with the disposal of moneys representing unclaimed stamps, and proposes that an amount not exceeding £15,000 of these moneys be paid each year to the Exchequer as an appropriation-in-aid of the cost of central administration, the balance being credited to the new reserve fund. Under the existing Acts, the State bears two-ninths of the expenditure on benefits and administration by the National Health Insurance Society. It contributes a substantial amount by way of State grant on contributions, provides the cost of the district medical referee scheme, and in addition the whole cost of central administration, including the cost of printing contribution cards, and of the printing and sale of insurance stamps. The present Bill will add to that expenditure by the State two-ninths of the cost of the additional benefits to be provided. In these circumstances it is not unreasonable that the State should seek some mitigation of a burden of cost which is already considerable, and the Bill proposes to do this to an extent not exceeding £15,000 per annum.

The remaining provisions of the Bill are rather technical in nature. They deal with the winding-up of the contingencies fund, the sinking fund and the reserve suspense fund; with the cancellation of reserve value; with the provision of transfer values in cases of transfers of insurance to or from Great Britain or to or from the military forces fund; and with the allocation of interest income amongst the various funds and accounts on which interest is earned.

Before I conclude I think it well to say that this Bill is to some extent experimental in character. The changes made in the finances of the scheme are fundamental, but it must not be taken that they permit of any loosening of supervision and control over the existing financial resources. Because the income of the scheme has regularly exceeded the expenditure, it must not be assumed that a satisfactory position exists, allowing of large extensions of the benefits, limited only by the amount of that excess. On the contrary there are indications that the position is far from satisfactory in certain respects, and the actuary in his report of 1939 dealing with the sickness experience and also his report of last year dealing with the general financial position has drawn particular attention to these.

It is clear from his reports that the rates of incapacity for which payment to members is being made by the society are exceedingly heavy, particularly in regard to disablement benefit, which are two or three times the corresponding British rates, and far exceed the amount of incapacity for which provision was made in the financial basis of the scheme in this country. He states that unless drastic administrative measures are taken successfully to eradicate the "claim habit" the incapacity experienced will have to determine the actuarial basis of the scheme. This is a question which is actively engaging the attention of the society and the Department.

The actuary also draws attention to the comparatively low proportion of persons of insurable age who are insurably employed in this country, while pointing out that in recent years a considerable increase in members has occurred particularly at the later ages and concludes that the insured population, both as regards numbers and age distribution, is not in a stable position. He adds that since changes in numbers and age constitution may have a marked effect not only on the capital liabilities of the scheme but also on the average cost of benefits, it must be remembered always that this instability in the insured population is a factor of fundamental importance in considering the effect of far-reaching amendments of the financial arrangements and enlargements of the scope of benefits. The need for extreme caution is evident. It must not, therefore, be assumed that because recent experience allows of a temporary enlargement of benefits there is a certainty of continuing these additional benefits indefinitely. Apart from the very important considerations advanced by the actuary, it may well be that an increase in the incidence of unemployment, due to present economic conditions, might have the effect of so seriously reducing the contribution income of the society, that expenditure on additional benefits might have to be curtailed.

General Mulcahy

I think it is about eight years since the unified society was formed, and, in regard to what might be said to be the first constructive proposal coming before the House after that, I think the Parliamentary Secretary must bear with us if we say we are disappointed. The Parliamentary Secretary introduced his measure as being far-reaching in a certain way, and he wound up by saying it was experimental. As far as I can see, the experiment that is being carried out is that it is proposed to expend about £175,000 in additional benefits every year, if I understood the Parliamentary Secretary properly, for a period of five years. That is a small financial experiment in times when our ordinary budget has risen to such enormous size and when so much financial experimentation is being carried out by other countries for various other purposes. What the Parliamentary Secretary's speech on the Bill brings to my mind is this, that really we have no national health policy at all. The Parliamentary Secretary indicated that the report of the actuaries and the report on the health situation generally was such that he feared that the additional benefits which were now going to be paid could not be continued, as it were, inside the present financial framework. When I come to think of the benefits provided by the national health insurance system here, I am forced to say that there is as little connection between the finances of the national health insurance system here and national health as there is, say, between the Post Office Savings Bank and national health. At the present moment, if a man with a family goes sick he gets 15/- a week from a scheme that calls itself a scheme set up for the purpose of improving national health. It brings us really up against the question as to what the national health scheme, as we are running it at the present time, is for at all.

I had occassion the other day to discuss some aspects of poverty and the relief question here in the city. I had a particular case before me. It was that of a man who was in good work and had been able to save a certain amount of money, so that when he went out of work he had a small sum of money as a kind of standby. He had seven children. Under the unemployment insurance scheme he was entitled to £17s. 6d., and he had about 13/- coming in from the earnings of one of his family. After six months' unemployment he found that he had eaten into his savings to the extent of something like 16/- a week, after he had cut off certain expenditure that he had to cut off because of the circumstances. If that man went sick, instead of his £1 17s. 6d. he would have 15/-. If he were a man who had a wife and seven children, none of whom was able to earn, and if he had no money put by, his position would be that he would have to maintain himself and his family on 15/- a week or go and look for outdoor relief. When we consider all the great financial bases, all the actuarial work, all the figuring out that has to be done, and the amount spent in the total administration of the scheme say in the year 1939, £201,000, and when we consider that inside a scheme which is so perfectly thought out on the financial side, and on the administration of which so much money is spent, a man with a wife and six or seven children or even with three children will get only 15/- a week out of it in present circumstances, or under this particular kind of scheme 15/- a week and some additional benefit of one kind or another, it emphasises the fact that this is simply handling a certain amount of money in a kind of savings bank way without any direction or application to the general question of national health at all. I am quite sure that the unified society have had their minds directed to the health side of things, but not at all to the same extent, apparently, as they have had their minds directed to their responsibility for guarding the finances of the society. I quite agree that one of the most important things that anybody in charge of any society has to do is to look after the finances of the society, but outside the society and helped by the society I think we here in the Dáil have to look at what is the real object of all this work and what is the real object of all this expenditure. It is to have a position here in which our people can be healthy, and we can not only avoid wastage of money but can have increased energy and increased production by our people because their health has been safeguarded.

I propose, on the Committee Stage of this Bill, to put down an amendment to the effect that the increased benefits will be applied to married members of the society, and that they be applied in cash payments, because I think that if we are going to safeguard the health of the nation at all we have to direct as much effort as we can to the family side of it. If a man who has been in reasonable employment, and has been able to maintain his family reasonably well, is laid up for two or three months and is driven to exist on 15/- a week from national health insurance, in addition to whatever relief he gets, during that two or three months are sown seeds of ill-health and seeds of problems for future years for the national health society. Those seeds are sown during the months when the family are ill-fed and badly cared for, and will be a great source of additional expenditure and additional wastage of money in the years afterwards. I feel that the whole of our health position from the schools onward has to be considered. I feel that the members of the unified society, who are standing over the experience of the society, have a contribution to make by way of suggestion and by way of exposure of fact that we should have the benefit of, and that we will not have the benefit of unless we here declare in some way that we want a policy which will reach out in every way to improve the general national health position. You have a system in the schools under which there is dental treatment for the children, and under which they have their tonsils removed, but on the other hand nothing has been done about the recommendation of the primary programme conference that there should be a systematic system of physical training introduced throughout the whole country to set up the children and keep them set up. It is much more important I think to set up the children physically than it is to do some of the medical work that has been done in the schools. That is important, but, having gone to the extent of setting up the great organisation that we now have for dealing with the medical side of the schools, why the really important side of setting up the children has not been attended to I do not know.

I am quite sure a lot of the troubles that are causing heavy expenditure here, as viewed through the National Health Insurance Society, come from the fact that a little training and a little attention is not given in schools to the proper physical training of the children. There is a thing that has to be borne in mind, when we consider what the financial side of the national health insurance scheme does for the people. As I say, it gives a man, whether he is married or single, 15/- a week. There has been a very considerable amount of examination recently regarding family budgets on the one hand, and what it costs or would normally cost to maintain a family above the poverty line, on the other hand. The most recent and exhaustive report is based on 1936, when Mr. Rowntree, in investigating the position in York, indicated that, from his examination there, it would require 43/6 a week at the price level of 1936, to maintain a man and his wife and three children. The cost of living has gone up in such a way here that the average in, say, 1941, has increased price level, it would require £3 a week to keep a family of that size on the basis that Mr. Rowntree laid down for York. I have given a case where a man, his wife and seven children here in Dublin, cutting things down almost to the bone, found it took them £3 a week over six months' unemployment to maintain that family. Their savings were eaten into to do that, but the figure worked out at that. Where you have these facts so readily available, there is a definite challenge to our minds, as to what the national health insurance financial scheme—if we consider its cash benefits—is really doing for the health problem here.

I raise this matter in order to draw attention to the fact that we are really handling a financial problem and we are handling it as a financial problem under our present scheme; so far away from really effective treatment is the treatment we are giving that the challenge is very definitely there, and is particulary definite under present circumstances. When financial matters and national matters are being handled in such a gigantic way for purposes that are not less important and not less clamant to our attention here than the general purposes of national health, I propose to introduce an amendment that will be along those particular lines, because I think that medical attention can be organised without giving additional benefits. We have throughout the whole country the dispensary system in every country and there is not a single county which has not an ophthalmic organisation under the board of health perfectly capable of looking after eye treatment. In the same way there is provision for dental treatment under every county council in the country.

I think it would be a very grave mistake to utilise additional moneys for duplicating any services of this particular kind. The ophthalmic and dental services and the general county services should be raised to real public services, and the dispensary system should be brought much more definitely into the general medical scheme for national health. We are not able to provide money enough to have a separate scheme set up, so that if we can bring ourselves to look on national health in a really objective way, we will see that the real thing we want to do in all these Acts is to get a system by which our people will be secured in their health and will have good machinery for cure when they fall ill. If we could get our minds properly directed at this, we would look differently at the finances and the national health insurance scheme and look differently at, and get a lot more from, the medical services that we have in the country.

Mr. Norton

In certain directions I welcome this Bill as an advance; but my complaint against the Bill is that it is an advance of a crab-like variety. If the Minister's mentality is reflected in this Bill, I am afraid we are going to wait a very long time before getting a Minister of this Government to face up to the obvious necessity for a drastic overhaul of that thing that is masquerading as national health insurance in this country. It is neither a health scheme nor an insurance scheme in any sense of the term. I am particularly glad about one feature of this Bill, that we have at last abandoned the old method of valuation. That method of valuation was conceived in Britain and may have suited a scheme of organisation such as you had in Britain, with 2,500 separate societies, as against possibly 80 societies here, but it seemed to me never to be suitable to a scheme of organisation where you had one society to which every person was obliged by law to belong.

The old system of valuation gave us most amazing results. It was designed to provide for a theoretical "last man" who may join a particular sectional or territorial society. While you may have a theoretical last man— though the proposition would not be such as to disturb anybody's slumbers —there was no case whatever for the maintenance of a scheme of valuation of that kind once you got rid of the separate societies and created one single organisation, as every insured person was obliged to be a member of that organisation. If you assumed the continuance of the Irish race, then you were brought face to face with the position in which the insurable section of that race had to filter itself through a single national health society, and on the assumption of the continuance of the race there was no theoretical last man to be dealt with. The abandonment of that scheme of valuation, of an anachronism of that kind, is something that I welcome; but my complaint is that, while the Minister has abandoned that method of valuation, he is still trying to cling to the evils which flowed from that method of valuation.

When the old system of valuation was applied to the valuation of the assets of the national health insurance societies and to the assets of the new unified society, we had a periodic screech about the insolvency of the societies—a screech which was quite undeserved and quite unjustified on the financial facts and which was only possible because of the application to their valuation of a scheme of valuation which had no relationship to the facts of life in this country and which had no relationship whatever to the scheme of organisation of national health insurance here. While we had these periodic screeches about insolvency of the national health insurance society, the outstanding fact was that, during the quinquennial periods when this insolvency was accumulating, the society was in fact giving away over £200,000 a year. If any business firms in the country were making a surplus of over £200,000 in the year, one would regard them in these circumstances as doing extremely well; but when the National Health Insurance Society made a surplus of ever £200,000 the actuary apparently felt obliged to issue a solemn warning that the society was heading straight for bankruptcy and its future was such as to cause grave alarm to those responsible for its administration and supervision.

I never had any use for these valuations based on the scheme applied to our unified society here. Any society which could show a surplus of over £200,000, and has assets to the extent of £4,500,000, obviously is in a very flourishing position, notwithstanding the cautious advice one can get from actuaries from time to time on the necessity of making provision for the distant future. I always felt the society's position was such that it could afford to spend much more money in benefits, and that the departure from the old method of valuation would enable a substantial sum to be released for the provision of new additional benefits. But I am not sure that the departure from the old method of valuation has, in fact, produced any great change in respect to the benefits to be made available under this Bill.

The actuary, in his recent report, in timates that a sum of £500,000 might be released for expenditure on the enlargement of existing benefits or the provision of new benefits. He recommended that that sum should be spread over five years, and it would provide an annual sum of £150,000, allowing for interest and State grant in the provision of such benefits. The Parliamentary Secretary now intimates that the additional sum available will be approximately £175,000. Even if we take it at £150,000 or £175,000, it works out roughly at 5/- per insured person per year. That is, in effect, what this Bill is doing—it is going to make available for insured persons a sum of approximately 5/- per year, or little more than a penny per week. That sum will be aggregated in such a way that perhaps one person may get a substantial amount of benefit, but, when you want to ascertain to what extent benefits will be spread over insured contributors, that is the national average. And the Bill does not do more than that, apart from breaking away from the old system of valuation.

I agree with Deputy Mulcahy that we have really no scheme of national health insurance in this country. What masquerades as a scheme is neither a scheme for the preservation of health nor the provision of insurance. It is a purely anæmic system, and those charged with its administration will have to recognise that it bears none of the features of national health insurance in operation in progressive countries in Europe; that it is a long way behind the scheme operating in Great Britain, and far behind the schemes in operation in certain European countries. In fact, the present scheme makes no effort to treat a sick person or to provide adequately for the sustenance of that person if he is afflicted with infirmity. There is no medical service whatever under our scheme. A person goes to a doctor and, as most people are perfectly well aware, all that person gets is a medical certificate. Some of these certificates are signed and left on the doctor's hall table, and the insured person, the disabled receipient, is expected to call round on certain days.

There is no hospital treatment for insured persons. It is harder to get into the hospitals to-day than ever it was, notwithstanding the bed bureau and the other types of propaganda so prevalent. It is harder for a poor person to get into hospital to-day than ever it was before. There is no dental treatment provided under our insurance scheme, no optical treatment, no treatment for tuberculosis in the incipient or the advanced stage, and no surgical or convalescent treatment. What simply happens under this so-called code of national health insurance is that when a person gets sick he goes to a doctor, gets a certificate, which is given to him very hurriedly because of the bulk of cases; he sends that in to the society, loses the first three days and, after another seven days, he gets a cheque for 15/-, with the best wishes of the architects of national health insurance that he will get well as quickly as he can or, if he cannot get well, that he will die as soon as he can. The longer he lives and draws benefit, the greater the liability of the society.

I do not want to charge the society with desiring any man's premature death, but every responsible person knows that the scheme now in operation simply empowers the society to give a man 15/- a week as the maximum. After that, the society has no more concern about the application of curative treatment. They have no means of providing any type of treatment, and they are simply confined to the expenditure of 15/- a week for six months, while the man is drawing sickness benefit. On that miserable sum of 15/- a week a man is expected, while ill, to maintain himself in a debilitated condition and also maintain a wife and perhaps three, four or six children.

Take the case of a man living in a corporation house at Drimnagh, Whitehall or Kimmage. His rent is approximately 15/- and, therefore, his whole benefit goes in paying rent. There is no other income for the family. He might tell the corporation that he could not pay the rent for certain weeks, but, if he wanted to pay the rent and be a solvent tenant, then his whole income by way of insurance benefit goes to pay the landlord and there is not one halfpenny left for the maintenance of his family, not to speak of providing himself, as a sick man, with nourishment. Yet we call this scheme of ours a scheme of national health insurance.

What do we insure for? Obviously, we do not insure for the purpose of preserving health. The society cannot be concerned with the preservation of health, because there is no money to spend on that. The society has no function in that matter because it has no money. The structure of the society did not in the past permit it to be concerned, according to its rules, whatever it may have been concerned about in conscience, with curative treatment. Any tontine society would provide the same benefit as we are providing in our national health insurance scheme. In tontine societies, which function in a rather small way, persons contribute a weekly sum and they get certain benefits. Those societies adopt modest titles; they do not arrogate to themselves the title of national health insurance, but they do just the same kind of things as our national health insurance society.

While we know that to be the position, apparently we are quite content to let that unsatisfactory state of affairs drift. To-day, when we endeavoured to have the social activities of the different Departments coordinated in such a way that they would be administered by one Department, we were told by the Taoiseach that, in fact, the existing social services ran very smoothly in connection with the Departments that administered them, that there was no lack of co-ordination and, apparently, no incongruities in the administration of the different social services. Now, let us examine that position for a moment in relation to this Bill. Under the National Health Insurance Acts the maximum benefit that a man will get is 15/- a week, and he is required to pay a weekly contribution towards that. Supposing that a man were idle and lived in the city, he would get, under the unemployment assistance scheme, if he had a wife and five children, 23/- a week, although he is not required to insure for national health insurance benefit. A man in receipt of unemployment assistance benefit would get 23/- a week from the labour exchange. If, on the other hand, he has been working all the time, if he has been a hard-working, industrious and conscientious man, and is suddenly struck down by illness, and if he has a wife and five children, all he will get from the National Health Insurance Society is 15/-, and he only gets that because he has paid for it, whereas, under the Unemployment Assistance Act he will get 23/-. I do not know on what grounds you can justify the payment of 15/- to a sick man with a wife and children to maintain, while at the same time an idle man, with probably less children, will get 23/-.

I think that one of the blemishes associated with this whole Bill is its complete failure to make some provision for the payment of an allowance to dependents of sick persons. If, for instance, a man in receipt of unemployment assistance benefit can get an allowance for his wife and children, or if a man in receipt of unemployment insurance contribution benefit can get an allowance for his wife and children, why is it not possible to provide a similar allowance for the wife and children of persons who are unfortunately afflicted with illness? I think that that is one of the serious blemishes in our scheme of national health insurance, and I wish the Parliamentary Secretary had been removed definitely. But there is no indication that it is being removed, unless it should happen to get accidentally into the scheme which the society is to submit to the Minister for his approval.

The actuary, in his recent report, is again worried about the high expenditure on national health insurance. Well, the actuary can be absolutely certain of one thing, and that is that nobody in this country will get rich through drawing either sickness or disablement benefit from the national health insurance fund. Nobody will become a millionaire on that income, and most people would prefer to get work at decent wages rather than be dependent on the miserable pittance that they get from that fund. One of the direct causes of the high expenditure in this case is our complete inability, apparently, to provide medical treatment and to look after the health of the insured persons. So long as we fail to do that, then we are going to have persons in a state of health which will make them a continuous drain on the society and will ultimately transfer them to the books of the society as, virtually, pensioners dependent for the rest of their lives on disablement benefit because they are unable to resume duty.

I think it will be admitted by those administering the affairs of the National Health Insurance Society that, probably, rheumatism is one of the most frequent causes of absence from work. In fact, rheumatism in this country has become a national disease and its effect upon the finances of any National Health Insurance Society in this country must be very serious indeed. Bearing that fact in mind, and also bearing in mind the ravages of that disease on the limited man-power we have available, one would imagine that some effort would be made, either through the existing society or on a national basis, to establish clinics for dealing with that disease which exacts such an enormous toll in inactivity and idleness from our people. No effort whatever is made to deal with that problem at all. I should like to see statistics from the National Health Insurance Society testifying as to the number of persons who are absent from work, and the number of days they are absent, as a result of certificates that they are suffering from some kind of rheumatic disease.

I am sorry that this whole Bill has such a limited scope and that it does not deal with this question of national health and national health insurance in the only way in which it can be dealt with in this country, and that is by the inauguration of a comprehensive scheme which will provide adequate cash benefits, medical, surgical, convalescent home, optical, dental, T.B. treatment, and every other type of medical attention which is necessary to keep the insured person in a state of good health. If you can create a scheme or organisation which will do that, then you solve for all time the periodic screech about the insolvency of national health insurance in this country, and you will enable money to be devoted in increasing measure to those few people who would still fall ill notwithstanding the most perfect scheme of health services that we can devise.

This whole question of national health insurance has been huckstered ever since the first National Health Insurance Act was introduced in this country. There has been practically no advance in national health insurance legislation in this country since the first Act was introduced. There have been cash adjustments in expenditure due to the fact that living costs are much higher now than they were then. But on the whole that particular type of legislation has been more stodgy than any other type of legislation that has been introduced in or applied to this country in the last 25 years. There is a good deal of thoughtless moaning indulged in by some persons who talk about the loss of days by strikes. These persons are all worried if the workers, as a result of economic injustice, are compelled to withdraw their labour, and they talk about the loss of days due to strikes of that kind. If one were to take the trouble to ascertain, again from official statistics, the number of days lost through strikes and the number of days lost through sickness, one would get a very staggering comparison and it would be shown quite clearly that the loss of days through sickness is probably 200 times greater than the loss of days through strikes, even if you took a year in which there was an abnormal number of strikes and of a prolonged character. That ought to set us thinking and it ought to induce us to realise the necessity for dealing with this whole problem of national health insurance in a much more thorough and comprehensive way than we have so far dealt with it. Even as it is, we do not know from the Parliamentary Secretary what type of benefits will be provided under this Bill. We do not know whether the benefits will be in cash or in the form of an additional service. The only one thing that we do know is that the expenditure under this Bill will be, approximately, 5/- per insured person per year, and that limited additional benefit, I suggest, will not make any great difference in the state of health in this country, nor will it contribute in any substantial way to the mitigation of the ills of insured persons who are obliged to exist on the small allowance that they at present receive under our national health insurance legislation.

Since there was so much delay in introducing this Bill, I thought that its introduction would be accompanied by a manifestation of the Government's determination to deal with this whole question of national health insurance in a big and comprehensive way, but instead of that we get this Bill. It makes an advance, a very small advance, and apparently we will have to leave it to some other Government to deal with this problem in a much more comprehensive way if we are ever going to see a solution or to see any improvement of our puny health services in the lifetime of anybody now living.

Mr. D. Morrissey

I think the Minister has tried to add to this piece of deception that we have been trying on ourselves and on the insured population of this country over a number of years.

This Bill is described as a National Health Insurance Bill. The Parliamentary Secretary might have described it more correctly as a very small amendment to the National Health Insurance Act. It is nearly nine years since we set up the unified society and I am rather sorry that a former Minister for Local Government, who was responsible for putting that measure through the House, is not here now. I know that he is a very busy man in his present position but I should like him to read some of the speeches he then made and consider the rosy future he held out for the society and the benefits which were to accrue to insured members. Some of us are not disappointed at what has happened. The bringing in of this Bill now seems to me like taking a nine-year-old motor car into a garage and getting it tightened up here and there. A few new parts will be supplied but it will go out of the garage with as many rattles and as many weaknesses as it had when it came in. The fact is, as has been so well stressed by previous speakers, that there is no such thing as insurance or national health covered by these Acts at all. Deputy Norton said that we had made no advance so far as national health insurance was concerned. Of course, we have not. From the point of view of the city man, the position is far worse than it was at any time since national health insurance was introduced when one has regard to the purchasing value of the cash benefit which he is paid. So far as a large number of insured persons are concerned, it would be far better if we had no so-called national health insurance at all because then they would get far more benefit from other sources. Many of them were assisted by their employers, particularly during short illnesses, before the Act was introduced. Nowadays, one of the benefits supposed to be enjoyed by workers is State insurances when sick. Many employers, and many of the workers' neighbours, think they are far better off when they are ill than when they are working.

Deputy Mulcahy and Deputy Norton have painted a picture for the House of what a payment of 15/- a week means to a person in the City of Dublin. What does it mean to a man in any part of the country—a man who has been in fairly constant employment in a small country town and who has kept his family together on a wage of from 30/- to £3 a week? He has barely been able to make ends meet and has been unable to save anything. He has no money in the Post Office or thrift association. Suddenly, he is stricken down and he is given 15/- a week. He may have four or five young children. Rents of workmen's houses in country towns are far lower than in the city. Let us assume that that man is living in a house at the low rent of 5/- a week. That is the first charge on his 15/-. At the very lowest fuel will cost him 5/- more. I shall not speak of the cost of milk, butter, or any other item. Is it any wonder that, as year succeeds year and as each five-yearly period comes round, the actuaries become more nervous of this national health insurance system? Is it not quite evident that, when a man is thrown back on 15/- a week during illness, when the outlay should be greater than when he was well, the children in the house will be undernourished during that period? Their health is undermined to such an extent that it is easily impaired throughout their lives.

National health insurance and not one word about medical benefits or curative or preventive treatment! A dole of 15/- a week is handed out as a maximum. Why do we want this expensive system to hand out 15/- a week? Why do we not deal with it through the Post Office, as we deal with old age pensions, or through the labour exchanges? The sole function of the unified society to-day—I know very well it is not the wish of those responsible for administering the society —is to dole out 7/6 a week or 15/- a week. That is the beginning and end of their work. Nothing the Parliamentary Secretary or anybody else can say can get away from that. This Bill should not be called a National Health Insurance Bill. This is a deception practised on the insured population for a great number of years, and it is time to put an end to it. Nine years after the setting up of the unified society, with all the investigations, and the reports made to the Minister and the section of his Department concerned, something more comprehensive and far-reaching than this measure should be forthcoming.

The Parliamentary Secretary referred to additional benefits. We do not know exactly what the benefits are to be. As Deputy Norton said, we have some idea of their limited nature by the amount of money mentioned. It was very popular 14 or 15 years ago to abuse and throw scorn at the approved societies. The actuaries sent in reports somewhat similar to the reports they have sent in regarding this unified society.

The fact is that many of the approved societies were paying benefits to their members which apparently the members will never enjoy again. That was not confined to societies dealing with members living in sheltered occupations, and who were favoured with continual employment. I myself was associated for a number of years with an approved society in an agricultural area whose members were drawn very largely, if not altogether, from agricultural labourers, domestic servants, and town workers, and I am glad to say that that society was so well managed that we paid at least amongst the highest and most varied additional benefits in Ireland. Prior to this unification, our members were getting 18/- per week cash benefit; the maternity benefit was considerably more than the statutory benefit, and the disablement benefit slightly higher. We could have paid still higher cash benefits, but, having regard to the rate of wages being paid to the bulk of our members at the time, we did not think it was desirable to do so. We had a system of dental benefits whereby we paid five-sixths of the cost of dentures. We paid for full dental and optical treatment. We paid the full price of optical appliances, and for full hospital treatment for members, whether in a local or Dublin hospital. All that was wiped out, and they now get 15/- per week as a maximum.

I do not expect miracles from the unified society; I did not expect them before it was set up, because I knew the unified society would not get a fair chance. It never did get a fair chance, and the Parliamentary Secretary is not giving it a fair chance under this Bill. So far as the insured person is concerned, this Bill practically makes no difference to him. I believe it will make certain aspects of the administrative system easier. Like Deputy Norton, I do not think it is any harm to have the old system of valuation done away with. The Parliamentary Secretary, in introducing this Bill, has not faced up to the main factors affecting the financial structure of the national health insurance scheme as it has been in operation or as amended by this Bill. There are three big outstanding factors. The Parliamentary Secretary stressed them, and said that the actuary had dealt with them in his report in 1939, as if it were the first time we had heard of them, namely, compliance, malingering and loose certification. Anybody who knows anything about the administration of national health insurance in this country knows that the two main things that affected the whole financial structure of the unified society, as in former years they affected the financial structure of the approved societies, were malingering and loose certification. One went, I might say, hand in hand with the other.

Then the old question of disablement benefit comes up again, and again the Parliamentary Secretary refers to the actuary's report in 1939, as if it were the first time we had heard of it. Is it not that that was responsible for the grey hairs in the head of the secretary of every approved society in Ireland, and that is turning the hair of the administrators of the present unified society grey? Is there anything in this Bill which will deal with loose certification or malingering or the disablement position? Nothing whatever. The Minister would get far better results, both from the financial point of view and every other point of view, if he would get those in his Department to devote half their time to those three points of loose certification, disablement benefit and malingering. As a matter of fact, they all hang together; they are just as united as the shamrock. If he could deal with these and have them put right, he would have gone a long way, a far longer way than this Bill will take him, towards setting the finances of the society at rest. There is nothing in this Bill or in the Government's mind that will make the system a national health insurance system. It has not been, and, so far as we can see, it will never be a national health insurance system.

Mr. Byrne

With other speakers, I wish to express my keen disappointment at this Bill. It would remind you of a great big fat hen cackling a lot and laying a bantam egg. After nine years, I cannot see that this Bill will effect any great improvement. I had expected to see outlined in the Bill that dental benefit, hospital treatment, optical benefit and convalescent treatment would be provided; that sick persons, whom convalescent treatment would help to improve, would be paid for in a convalescent home. Rheumatism has been referred to. The failure to provide adequate treatment for rheumatism is nearly as bad as the failure of the Government to provide adequate treatment, equipment and accommodation for tubercular patients. The lack of adequate provision for the treatment of tuberculosis and the indifference of those in authority to the suffering of people afflicted with that disease is a scandal. Unfortunate persons suffering from that disease are waiting for treatment and appealing for treatment and cannot get it.

Deputy Morrissey and Deputy Norton have referred to the fact that before the setting up of the unified society some societies provided the benefits I have mentioned, namely, dental and optical treatment and in some cases hospital treatment. Until these benefits are provided we cannot call the system in vogue at the moment a national health insurance system. It is just a method of collecting moneys and paying out small doles. The maximum amount at present, I believe, is 15/- per week. With the maximum allowance these unfortunate people, in most cases, are receiving outdoor relief from local authorities. That is a new sort of way of covering up our difficulties from a national point of view, to throw the burden on the local authorities. I was under the belief from what I heard that this Bill was going to be a vast improvement on the existing legislation, but I cannot see anything in it which anyone could enthuse about even for a few minutes. I hope that the Minister and the Government will go further towards what is required. I appeal to the Parliamentary Secretary to take an earnest part in facing this big problem, especially in Dublin, of providing for the proper treatment of T.B. cases.

As I understand, the National Health Society have substantial reserves. I wonder if it would not be advisable for the society to contribute, not meanly, but on a large, scale, to some institution that would deal with those already drawing benefit, who would pay if they got treatment, as that would take them off the pay roll of the society at an earlier date, and at the same time safeguard their health for the future. I must say that I am keenly disappointed at the Bill that has been introduced.

Mr. Hickey

The proposals in the Bill indicate the conservative mind of the Government when dealing with the social services. After waiting so long some of us had hopes that we would have a better Bill than the one now before the House. In my opinion this is an enabling Bill for the expenditure of a small sum of money on national health services. At Question Time to-day the Taoiseach was asked if he could state when there would be a recasting of the whole social services, and he expressed the opinion that the time had not arrived for such a measure. The social services concern national health, home assistance, unemployment insurance, unemployment assistance, widows' and orphans' pensions, old age and blind pensions, free meals for children of the unemployed, free school meals, and last, but by no means least, workmen's compensation. All these social services are operating under different Departments.

I pointed out to the Taoiseach that workmen who are looking for compensation are thrown back on the national health benefit. A man, drawing unemployment assistance, who goes to the labour exchange on a Friday morning to draw 14/- or in some cases where there is a family 23/-, has to go the following day to the home assistance office for vouchers, or maybe 4/6 in cash. In other words a man has to deal with two Departments in the one week in order to get a maximum of 30/- to maintain the health of himself and his family.

I should like to see the Government dealing with national health in another way than what is proposed in the so-called National Health Insurance Bill before the House. I listened to Deputy Mulcahy talking about the necessity for physical training, but surely we could not talk about that until children going to school have been properly fed. We read in the newspapers that teachers have urged the drinking of more milk. Parents are prepared to give their children more milk but where is the money to come from to buy it? We are dealing always with effects rather than with causes. If a workman who earned £3 5s. or £3 12s. every week is idle he will only get 15/- while he is sick, so that his wife has to go to the home assistance officer to supplement that sum. I know a person who returned from a sanatorium, whose allowance was reduced to 7/6 weekly. Boards of health estimate that they will require a certain sum to meet their requirements for the year, and when allowances of 15/- weekly are reduced to 7/6, the difference has to be made up by grants of home assistance. I could mention another case, that of a man drawing a pension from the English Government, who has been in this country since 1915, and after spending nine months in a sanatorium he had the weekly allowance for the support of himself, his wife and four children reduced to 7/6. Nobody can estimate the cost of poverty and malnutrition that falls on the social services with which we are dealing. I agree that there has been some step forward, but I look upon this as being an enabling Bill for the purpose of spending a certain sum of money.

When we consider how easy Governments spend millions upon war and that here we propose to spend £8,000,000 on the Army, how is it that when we come to deal with public health we are told that we cannot spend millions to improve it? The report of the medical officer of health in Cork was a most depressing document for anyone to read, all due to poverty and malnutrition amongst the people. The death rate of infants amounted to 16 per thousand more than in 1919. Comparative figures for the two previous years were 96 as against 73. Tuberculosis cases have increased.

I appeal to the Government to take another step forward and to bring in a really unified social scheme to be operated by one State Department—if you wish by a Minister for Health.

I think it is waste of money to send people to santaoria, as when they return home after six months they find that their income, instead of being increased in order that they may improve their health, is reduced. I know one sad case in Cork where a man spent a couple of months in a sanatorium and when he came out found that owing to the war his occupation was gone. He has been residing for 29 years in the same house, and now he has been served with notice to leave it. How could that family live on 7/6 weekly? Every one of the social services is concerned with national health. I am aware of another case where a man who was drawing unemployment assistance injured himself while breaking wood, and as he had no stamps on his cards for two-and-a-half years he is now compelled to rely on home assistance.

I would suggest to the Parliamentary Secretary and to the Government as a whole that they should cease trifling with national health by schemes such as have been put forward here and try to formulate a scheme under which all these services will be operated from one definite source. On the question of malingering, I do not agree with Deputy Morrissey that it prevails to any serious extent although I agree that the present social system induces men and women to malinger. We know that when a man who has reached the age of 45 or 50 finds that he has no chance of procuring work, his inclination will be to try to obtain a certificate that he is unfit for work. It is well known that firms in this country are not prepared to employ men except they are under 30 years of age. What then do you except from a man of 45, 50 or 55 except to malinger so as to get money somehow? The fact that such attempts at malingering are made, merely emphasises the necessity for having a unified social insurance scheme, covering all these various forms of insurance—unemployment insurance, national health insurance, workmen's compensation, widows' and orphans' insurance, etc. I believe that if all these various forms of insurance were centralised and were covered by one common contribution, instead of its being necessary to look for increased contributions from workers and from the unemployed, it is likely that there would be a big saving and that the scheme would be operated with some sort of humanity.

I should like to emphasise again the need for this change because I repeat that the drawbacks of the present system are largely due to the fact that it is bound up with the money question and that national health takes second place to monetary considerations. There is no use in talking about what the insurance society and the committee of management can do. They are simply there to dole out whatever money is at their disposal. No matter what they may feel on questions of national health, the fact is that they are bound down by the money system and they cannot go beyond a certain limit. I suggest to the Parliamentary Secretary and to the Government that one of the lessons they should have learned from the present war is that money should not take precedence of national health. I hope that they will give effect to that lesson in the future.

Mr. Hurley

I just want to say that I have very much sympathy with the unified society because of the position in which they are placed under this Bill. The Parliamentary Secretary told us that the purpose of the Bill is to release part of the income at present carried to reserve. That I think gives point to the criticism offered to this measure by Deputies who have spoken, that the object of the Bill is not so much to extend the society's scope to deal adequately with the health of people who are insured as to deal with money. The society has been, as I say, unfairly treated. The Bill allows a certain sum, £175,000 each year for five years, to be set aside, and the society are asked to draft a scheme to absorb that. I have followed very closely the work of the society, limited as it is, and I have read some of their reports. They are reports which deal with the question of national health from the real standpoint of the health of the people concerned, but the society are handicapped by financial limitations. I could never understand why it is that, although the society has made for some years a profit of £250,000 and has a reserve of £4,500,000, even the Minister cannot touch that money to bring about the necessary reforms that the society has suggested.

This Bill, as has been rightly said, does not deal with the question of national health at all. If it dealt with the question of national health, the case that has been made surely should strike the Parliamentary Secretary, who is a medical man himself, and should strike the members of the Government generally. It should surely strike them as ridiculous that a man with family responsibilities, when he becomes ill, has to try to exist, to get nourishment and improve his health on 15/- a week. The amount that is provided in this Bill will certainly not give any kind of additional benefit to that man. It will not in any way relieve his position when he falls ill again because the amount is not sufficient to finance a comprehensive scheme to deal with national health, as I am sure the Parliamentary Secretary himself realises, and as numerous speakers already pointed out. There is no provision under the national health insurance scheme for the dependents of a person who falls ill. Surely if you have a comprehensive scheme of national health insurance, it should deal with the needs and the health of the dependents of the person who has the misfortune to fall ill.

In other words, is it not as necessary to guard the health of the rising generation as it is to give the miserable amount that is provided for under the principal Act, 15/- a week to the person who falls ill? No provision whatever of that kind is made in any of the Acts from 1911 to 1936. The insurance code takes no cognisance of the position of the dependents, the wife and children of the man who is ill.

Of course, I shall be told that the money is not available, that it cannot be got and that it is not possible under the present system to provide such money. That is the rather peculiar mentality of peace-time finance. That point was very well exemplified in a lecture which I attended at the Mansion House recently at which a member of the audience pointed out that an unemployed man gets 1/- per head per week for his children now but if bombs were dropped on Dublin he would get 5/- per week. He asked where was all this money to come from and wondered if it would come down in the bombs. The fact remains that when there is anything like a serious disturbance, things will be done that would not be attempted in peace time. The same remarks apply to this legislation. We are now asking the society to provide a scheme but we are limiting the expenditure to not more than £175,000 per year. I think it was Deputy Norton pointed out that that represented only about 5/- per year per insured person. Surely that will not be a very great contribution to the present scheme of national health insurance. As I stated in opening, I have sympathy with the society which has to try within those limits to provide a scheme that will in any way bring any amelioration to insured persons. Deputy Hickey has made the point, and I think it is a point worthy of consideration by the Government, that the proper way to deal with this question is to formulate a comprehensive scheme of social insurance. There are so many different services associated with national health that the provision of insurance or any kind of financial help should be dealt with comprehensively.

The only pleasing feature of this Bill is that the Parliamentary Secretary and the Minister have got away from what I would term this antiquated actuarial investigating system. That system which has been in operation since the Act was passed should surely also change with changing world conditions and the fact that we are getting away from that system is the only hopeful feature in the Bill. As for the benefits that can be provided, I am afraid they cannot be very great. That work will be left to the society and I repeat that I have sympathy with the society in that task, in view of the limitations imposed on them. While the Bill makes an advance in the direction of breaking the manacles of the actuarial investigation, and does something which will probably be of use in the future, as it stands, it does not mark any great advance so far as national health insurance is concerned.

Dr. Ward

So far as the provisions of the Bill are concerned, there is no criticism to answer, inasmuch as the debate has been confined, not to what the Bill proposes to do, not to the terms of the Bill, but to the various desirable things which different Deputies consider should be incorporated in a national health insurance Bill. So far as the principle of the Bill, that is, the principle of changing from the capitalisation system of valuation to the assessmentism system, is concerned, it appears to meet with the unanimous approval of the House, so that, as I say, I have to make no defence of the Bill.

Mr. Hurley

There is nothing in it.

Dr. Ward

Deputy Hurley says there is nothing in it. Many other Deputies have conveyed the same kind of thought: that there is nothing in the Bill. In fact, it is almost suggested that it is a waste of time to discuss the terms of the Bill—so much so that they did not discuss the terms of the Bill at all—but surely in a matter like this we ought to be reasonable? Is it nothing to the insured population of the country that, by the terms of this Bill, we make available for additional benefits a sum between £150,000 and £200,000 per annum? Of course, it is not enough. I have never introduced a measure of social reform into this House which carried with it an additional burden on the finances of the State that I have not been told, in terms which could not be mistaken or misunderstood, that we were not going far enough. We never spend enough on our social services and our critics are never satisfied, but, yet, these very critics will attack us outside the House and will make political capital of the fact that, because of the increase in the cost of our social services, taxation is being increased.

In these matters of social legislation, it would be far better for all concerned if Deputies on the opposite benches did not play politics at all, but faced the realities of the situation. The realities of the situation in this particular regard are that if we are to evolve the comprehensive health insurance scheme about which Deputies on the opposite benches talk—I am including the Labour Party, of course— additional money must be found, and a very large sum at that. If additional money has to be found, we have to ask ourselves straight away: Where are we going to get it? Increased taxation? If there is unanimous support in the House for increasing taxation for the purpose of extending and amending the National Health Insurance Acts, and all members will defend the Government for such expenditure, the Government might be found in a receptive frame of mind, but do not ask us to keep on expanding our social services, if, at the same time, we are attacked from Press and platform for the consequential increase in taxation which that brings about.

Deputy Mulcahy says that there is little connection between the health insurance scheme and national health. I will not pretend to be satisfied with the health insurance scheme from the national health point of view, but I do say that the provisions of this Bill are a very considerable advance, in so far as £175,000 will go to provide additional benefits, whether dental, medical, hospital, optical, etc.

General Mulcahy

There is no restriction on their being additional cash benefits?

Dr. Ward

The list of benefits from which a selection must be made by the society is set out. The society will prepare a scheme and that scheme will embody the additional benefits which this sum of £175,000 is calculated to provide. Discussions will take place between the society and the Ministry as to whether the society's proposals show the best possible expenditure of the moneys available. Additional benefits must be selected from the following: (1) medical benefit; (2) medical treatment for dependents; (3) dental benefit; (4) increase of sickness and disablement benefit for all members or for such as have dependent children; (5) payment of sickness benefit for first, second and third day of incapacity; (6) disablement allowances for members not totally incapacitated; (7) increase in maternity benefits; (8) allowances during convalescence; (9) building or leasing of premises and their maintenance as convalescent homes; (10) superannuation allowances; (11) payment of contributions to superannuation funds; (12) payments to members in want or distress, including remission of arrears; (13) payment to a member who, being in an institution, is not in receipt of benefit; (14) payment to members not allowed to attend work on account of infection; (15) reduction of contributions. The following are prescribed under the Act of 1920: hospital treatment; cost of medical and surgical appliances; optical treatment; cost of nursing; hospital treatment for dependents; specialist services; increase of marriage benefit. That is the entire list of possible additional benefits, and, within the scope of that list, the society will prepare their scheme.

General Mulcahy

Is that list taken from an Act of from regulations?

Dr. Ward

The last seven mentioned benefits are prescribed by regulation under the Act of 1920. Up to "hospital treatment", the benefits are set out in the Act of 1911. Deputy Mulcahy has stressed the inadequacy of benefits of 15/- per week. Personally, I have a good deal of sympathy with that point of view, but, at the same time, if I had a limited amount of money at my disposal tomorrow for the purpose of national health insurance, I would prefer to expend it on treatment: on trying to make people fit to work rather than on increasing cash benefits which might, in certain cases, be an inducement to people to remain idle. The real fundamental defect, in my judgment anyhow, in our national health insurance system, is in the lack of treatment.

Deputy Mulcahy has suggested the possibility of co-relating the medical charities services with our national health insurance scheme. When we talk here, as many Deputies have this afternoon, about the lack of treatment, and the absence of treatment we ought to bear in mind that our insured population get treatment under the Medical Charities Acts. I do not think any Deputy will suggest that our dispensary system is not, on the whole, a good and efficient system. If we are to provide medical benefits for the insured population, we are going to superimpose another form of medical treatment on the provision that already exists for medical treatment. In the larger centres of population it is quite possible that the insured person may have a different doctor under a medical benefit scheme, but certainly, in the rural areas, the only difference that an insured person will experience when ill, is that he will not have to go to a guardian or warden for the issue of a dispensary ticket. It is the same doctor that will be available because, in most rural areas there is only one doctor available for the treatment of such classes of people. But, apart from that, it seems to me that medical benefits for an insured person will get us nowhere unless we can provide medical benefits for his family as well. The bread-winner, the insured person, when he became ill would, under the medical benefit system, call in his insurance doctor who would, I suppose, be in much the same position towards him as the panel doctor is in England, but when his wife or children became ill he would have to avail of the Medical Charities Acts and call in the dispensary doctor. Such a system has not any attractions for me. If we found ourselves in a position to finance a medical treatment scheme, I should like to see it applied not only to the insured person but to his family and dependents.

Deputy Norton referred to the ravages of rheumatism in the insurance population. The sickness experience of the National Health Insurance Society has established this fact: that rheumatism is a greater cause of sickness than any other two or three illnesses taken together. Deputy Norton says we are doing nothing about it. Well, we are. Deputy Alfred Byrne mentioned the same point. The Deputy may or may not have heard that we have in fact acquired premises and are at present engaged in equipping them for the establishment of a rheumatism clinic in Dublin. It is true that it may not, just at the very outset, contribute very largely to the solution of the problem, as the National Health Insurance Society see it, but, like the provision of the additional benefits to which I have referred, it can, I think, be claimed as an advance, and an advance in the right direction. Perhaps, from the rheumatism clinic that we establish in Dublin, we may be able to develop out into the provinces and provide a more extensive system of clinics for its treatment. We feel conscious of the ravages that are being made by rheumatism, and, in so far as we are able to deal with that position, we are providing a clinic in Dublin as a start off. As I have said, if we meet with an encouraging measure of success in the Dublin area, we may extend.

Deputy Morrissey referred, amongst other things, to loose certification and lack of compliance as being the main causes of the financial drain on the funds of the society. That is an old complaint with the Deputy. All I can say is that the position would appear to have substantially improved in regard to compliance and certification. As regards loose certification, many substantial fines have been imposed by the Minister on certifiers who were guilty of what appeared to be gross carelessness. I do not think loose certification is as extensive as it is represented to be. I do not think there is any other point that calls for reply. As I have said, most of the discussion has centred round matters that are not in the Bill rather than on what it contains.

Mr. Hurley

Will the Parliamentary Secretary say what amount of additional taxation will be required to implement the financial provisions of the scheme?

Dr. Ward

Of what scheme?

Mr. Hurley

This scheme.

An Ceann Comhairle

The Deputy may raise that question on the next stage of the Bill or on an Estimate.

Question put and agreed to.

An Ceann Comhairle

When is it proposed to take the Committee Stage?

Dr. Ward

This day week.

Mr. Cosgrave

That does not give very much time.

Dr. Ward

There is this degree of urgency about the Bill, that if it be possible we want to have the scheme in it operating by the 1st April. It is only an enabling measure. There is nothing contentious in the Bill itself unless the fact that it does not contain lots of things that many people would like to see in it.

General Mulcahy

There is not much amendment to be carried out?

Dr. Ward

It is not open to much amendment.

Mr. Hickey

If it is not capable of much amendment, I suppose we had better give it to you.

Committee Stage ordered for Wednesday, 25th February.