Dáil Éireann díospóireacht -
Wednesday, 2 Dec 2015

Vol. 899 No. 1

Health Insurance (Amendment) Bill 2015: Report and Final Stages

Bill received for final consideration.

Question proposed: "That the Bill do now pass".

Minister for Health (Deputy Leo Varadkar)

I welcome the wide support for the Bill across the House. Ensuring as many individuals as possible have access to affordable health insurance, regardless of their age, gender or health status, forms the basis of Government policy in this area. Particular attention is given to protecting the needs of older and less healthy policy holders. We all recognise the important role risk equalisation plays in protecting the solidarity principle in our community rated voluntary health insurance system. It ensures older people and those who have illnesses do not have to pay more than younger, healthier people and that is what the Bill is all about. It is not about promoting health insurance or guaranteeing profits for insurers; it is about social solidarity and equalisation.

The main purpose of the Bill is to specify the risk equalisation credits and corresponding stamp duty levels for March 2016. It also provides for an improvement in the health status measure under the scheme by expanding the setting in which a utilisation credit will be payable to include day cases. The expansion of the credit to include a lower payment of €30 in the case of all day cases to hospitals increases the support provided for less healthy people of all ages. The reduction in stamp duty for non-advance contracts supports the provision of affordable low cost entry products. Risk equalisation is a necessary support to community rated health insurance and I am committed to making the scheme as effective as possible in a way that promotes open and fair competition.

I thank all Deputies for their positive contributions to the debate and for facilitating the rapid passage of the Bill through the House.

Deputy Billy Kelleher

We had detailed discussions about this on Committee Stage. The Minister referred to the fact that this is about making sure risk equalisation is maintained along with the concept of community rating and intergenerational solidarity to ensure affordable health insurance. However, the biggest recruiter for private health insurance companies is the fact that our public health system is in chaos. Week in, week out people consistently experience delays accessing diagnostics and treatments and that is why people who are anxious, concerned and fearful are forced to take out insurance because if anything happens to them or their families, they simply could not access the public health system.

I have never said there is a quick-fix solution to the broader difficulties facing the health services but the notion that an 18-month waiting period is deemed acceptable for people to access diagnostics, consultants or treatment is wrong. That is why there is a change in the perspective of people taking out private health insurance. While the improving economy is a factor, the key factor driving people into taking out insurance is that companies are offering coverage for the basics, which they should be able to access in the public health system but cannot. Companies are not offering anything above and beyond basic coverage.

Until such time as there is a level playing pitch in terms of access based on clinical need, there will be a continual move of people into the private health insurance market, not because of what is being offered but because of what is not being offered in the public health system. What is not being offered in the public health system is basic access to basic healthcare. The Minister talks about the roll-out of universal health care, but in the meantime, while that grand plan is being announced and universal health insurance is being shelved, there are 400,000 people waiting for an outpatient appointment. There are tens of thousands of people who have been waiting for over one year for diagnostics and treatments. That is what is happening in the public health system. The Bill is about ensuring risk equalisation is maintained, ensuring the efficiencies of same, maintaining inter-generational solidarity and lifetime community rating and encouraging young people into the system. Private health insurance should offer something over and above what people should expect from the public health system such as private or semi-private rooms or other facilities. That is why people take out private health insurance. We should be conscious, however, that people are now taking out private health insurance not because of wonderful offers but because of the appalling scenario visited on people day in, day out in the public health system in accessing basic healthcare. Reference was made to the matter today during Leaders' Questions when Galway University Hospital and the incident in Cork in which a young child had to wait for an inordinate period on a trolley were mentioned. These are all things that put fear into people.

Until such time as we accept the roll-out of universal health care is welcome, we have a huge problem that is not being dealt with and we will see this problem escalate over the Christmas period. There will be further cancellations of elective surgeries and a back-up of outpatient waiting lists. That is what will happen again this year and the Minister will applaud himself because of his supplementary budget of €665 million, but the bottom line is that he has simply not got to grips with the overarching problems in the delivery of basic healthcare. When we talk about encouraging people into the health insurance market, it should be about encouraging them to lighten the burden on the public health system and it should not be done by forcing them to take out private health insurance because the public health system simply cannot deliver healthcare. That is the reason there has been an increase in the numbers taking out private health insurance.

Deputy Caoimhghín Ó Caoláin

As I indicated on Second Stage, I will not be opposing the passage of the Bill. I have to accept it in the context of the reality in the provision of healthcare and its funding. I am a strong opponent of private health insurance and I object to it on principle. At its core, it is immoral that people can buy access to healthcare on the basis of the strength of their income stream or net wealth, while others must languish in long waiting queues, many of them in agony and some with their lives in suspension, waiting for the opportunity to even have a first consultation, never mind access to a treatment programme.

The Minister has moved the Government's focus from the former Minister, Deputy James Reilly's and the Taoiseach's favoured model of a multi-tier system of private health insurance in the context of universal health insurance. The central plank of the Minister's party and the Government's policy position outlined in the programme for Government after the February 2011 general election has moved to the language of some Opposition voices who for many years have championed universal healthcare on the basis of need alone, irrespective of one's ability to pay or geographical location. That is where I hope the Minister will bring his party's thinking. Rather than parking this issue and commissioning further consideration, reviews and reports on a single health insurance model to fund universal healthcare, I hope he will come to accept that what we need is healthcare paid for by progressive taxation which will be available to all on the basis of need. That is the goal my party and I have and there are other voices in this House who mirror that objective.

It is very important in the last weeks of the Government for the Minister, as a medical practitioner and someone whom I believe cannot be unaware of the inequities in the current system and how wrong it is to perpetuate a two-tier health system, to demonstrate favour to the idea and ideal of universal healthcare paid for through progressive taxation and available free at the point of delivery for all on the basis of need. It is achievable; it is not a pipe dream. It is an ambitious goal but one that can be achieved. We could present ourselves in a country with a small population on the western seaboard of Europe as having one of the foremost healthcare delivery systems anywhere in Europe and beyond. This is achievable with the good will not only of political voices but also of practitioners at every level within the healthcare system. I have noted in my engagement with consultants, doctors, nurses, midwives, therapists and a range of other healthcare professionals that there is nothing like the opposition some would suggest. The concept has found favour. We need it to be laid out in clear and understandable language in order that people can buy into the objective and ideal. I hope to be able to help progress this in the time ahead, but it cannot be done and will not be achieved from a single voice perspective. It will need the support of more and more voices across the political spectrum if it is to have any prospect of realisation. It is worthy of the Minister's best consideration and the consideration of all others who truly believe in equality and the right of every citizen to equal treatment to meet their healthcare needs and increase their life expectancy. I have no fervour for the basis of the propositions contained in the Bill, namely, the extension of the transfer from overnight inpatient care to inpatient services on a day care basis and all of the other allied elements of the legislation, but accepting the situation as it is, I will not oppose the Bill.

However, I will use this opportunity to again articulate the importance of looking at a completely new approach, one in which the overwhelming majority of the people would not only buy into but would view in the future with confidence while eliminating the need for so many to have private health insurance. For those who make that choice, they can have their private hospitals and private clinics but they can no longer piggyback on the public health system.

Deputy Dan Neville

I welcome the passing of this Bill. I want to use the opportunity to briefly raise an issue I raised previously, namely, the cover provided by the health insurance companies for mental health inpatient services. There seems to be discrimination in the approach of the insurance companies to coverage for mental health inpatient services. For example, the Voluntary Health Insurance, VHI, covers 180 days for general health issues and hospitalisation while its psychiatric policies vary from 100 days to 180 days, depending on the plan. Likewise, GloHealth has no time limit on physical health cover but has one of 100 days for mental health inpatient services. Laya Healthcare has coverage for hospitals of 180 days but the coverage for psychiatric inpatient treatment is 100 days. Why are there different kinds of coverage under the same plans? Everyone will agree this is discrimination in an age when we see mental health inpatient and outpatient treatment as based on a recovery approach, as described in A Vision for Change.

Deputy Fergus O'Dowd

I welcome the changes made in this Bill. I listened carefully to what my colleagues opposite said. The fact remains that everybody should get the medical care they need at the point they need it, regardless of income and family circumstances. There is a progressive taxation system in this country where the more one earns, the more one pays. Nevertheless, as has been pointed out, a significant number of people are paying for private health insurance. Whether we are getting value for money or not, the more competition there is in the marketplace, the more companies will enter and offer choices to patients at different stages.

People seek medical help and attention at an acute point in their life cycle, such as when they are seriously ill, have to go into hospital or into a nursing home when they can no longer continue living at home. We need to examine not just health insurance issues in these cases. It would be far cheaper on the State to invest in continuing care in the home so as to keep people in their homes as long as possible. The first option on the fair deal scheme is to go into a nursing home when it should be the last.

I welcome the increased packages of home help care and other support services provided by the Minister. However, they do not go anywhere near far enough. As our financial position improves, I would welcome increased support services to people in their homes, increased home help hours and increased care from public health nurses, who do a fantastic job. The level of investment in community care is important. One of the significant issues we have not addressed as a society is the question of dementia care and dementia-friendly towns and cities. Will the Minister take on board the examples of many other cities and countries which are looking at caring for people in their communities while keeping people at home who would otherwise be in long-term care? We need to have a proactive approach in care for people with dementia in particular.

Concerns were raised about patients on hospital trolleys. We all encounter such cases every day. In Drogheda, I have not heard anything but the highest of praise for the nurses and doctors in the Our Lady of Lourdes Hospital. There is a significant appreciation of the professional care which people receive, notwithstanding the fact that it is on trolleys, which nobody wants.

If there is one significant inequality in the way the State's finances are organised and care is provided, it is in the area of prescription charges for those on medical cards. The sicker one is, the more medication one needs and the more one will pay on prescription charges. For those on medical cards, they must pay for prescription charges up to a maximum of €25 per month. It is wrong that medical cardholders on low incomes continue to pay prescription charges. As our economic situation improves and as we face into the general election, this should become an important issue to be addressed.

I welcome the Bill as well as the significant changes the Minister has made in difficult times in our health system. I hope this work continues.

Deputy Richard Boyd Barrett

I will be brief as we have had this discussion at length on earlier Stages. As I said before, I fundamentally reject the basis on which this entire Bill is constructed and the emphasis of this Government's policy on the private health insurance industry playing a useful role in developing a universal health system. The reason the Government used the term “universal health insurance” prior to the last general election is because it knew that is what people wanted. People want something that is available to everybody. Whatever about our ideological and philosophical differences on a range of issues, such as markets and whatnot, everybody believes health care provision should be universal. Everybody should get the same treatment because they need it as human beings, particularly when they are ill, disabled or whatever. That is what the majority think and Fine Gael used that term prior to the last election because it knew that is what everybody wanted. Everybody rejects the two-tier health care system. If we listen to what people say they want and if we are moving towards providing quality health care to everybody, regardless of income, position in society or whatever, then we must move to a universal system.

The Minister has now acknowledged that trying to deliver universality, while incorporating the private health insurance industry, just does not add up.

After five years of saying we will have universal health insurance, what the public heard was "universal" but what the Government smuggled in was "insurance". The second bit undermines the first. We all know it. The international evidence is absolutely clear. Once private health insurance companies are brought into the equation, hierarchies come into play straight away. Some people can afford to buy better packages than others. We do not get equality or universality. We get something else.

We also get a massive waste and drain on resources. Money which is paid out of the Exchequer and the pockets of those who take out health insurance is wasted on things which have nothing to do with health care. Millions of euro are wasted on advertising. On a worldwide scale, billions of euro are wasted on private health insurance companies competing with one another. It is not spent on nurses and doctors or on building hospitals or primary care centres but on advertising and it is a waste. We see and hear the advertisements every day on the television and the radio, including one telling people to go to the Blackrock Clinic as it is much better in an emergency. People should know that there is an accident and emergency department nearby which they can access on a 24-hour basis, that they will not be left for days on trolleys and that money is not an issue. It should be paid for through central and progressive taxation. That is what people want.

I have made the point before but there is something wrong when a debate on health starts with phrases such as "risk equalisation" and "lifetime community rating" and lots of technical babble which has nothing to do with health. When we hear these terms, we know we have done something wrong and are on the wrong track because that is not what health care is about. That is not what hospitals and sickness are about. It is techno babble and it arises from the fact that there are external, profit-seeking bodies that have nothing to do with delivering health care thrown into the mix. Massive billing operations, administration and all that kind of stuff has nothing to do with health care. The cost of providing health care is greater wherever this model exists. It will always be greater because it is necessary to add profit-seeking, advertising, administration, billing costs and all the rest of it into the equation.

The Government has sort of had to acknowledge that those are the facts because it has more or less abandoned a promise it made on this issue. The Government should listen to what people are saying and what all the evidence is saying. Let us have a national health system and let us fund and finance it because in the end, it will be cheaper, more efficient and fairer.

Minister for Health (Deputy Leo Varadkar)

I thank the Deputies for their comments. I thank Deputy Kelleher and Deputy Ó Caoláin for their support for this Bill. I note there are reservations and caveats attached to it. I also welcome their support for universal health care and agree with their objective in that regard. In the next few weeks, we will be moving into an election phase and there is an obligation on the Opposition not just to offer criticism but to offer alternatives as well. Given Deputy Kelleher's words and commitment to universal health care, I look forward to reading his detailed and costed proposals to bring it about and his transition plans showing how to get from where we are today to where we all want to be. I look forward to reading his detailed policies or manifestos, when published.

Deputy Billy Kelleher

I read the Minister's.

Deputy Leo Varadkar

Fianna Fáil has an opportunity to show how much better it would be than any other party in government by producing a detailed and costed plan on bringing about universal health care in the first term of a Fianna Fáil government with Deputy Kelleher as Minister, presumably, and how he would achieve the transition. Perhaps I could learn from it. I look forward, therefore, to reading his manifesto and policy and hope it will be as good as he promises it will be.

Deputy Neville asked about mental health cover. Every health insurance policy must offer minimum benefits. After that, it depends on the particular policy. Any policy must offer at least 100 days inpatient care. Other policies offer more. I take his point that there should not be a distinction between a person availing of inpatient mental health care services and a person availing of any other inpatient service. It is a well-made point but to address it, changes to the minimum benefits would be required and that is beyond the scope of this Bill.

Deputy O'Dowd made a number of comments which I also welcome. He mentioned prescription charges. They are set at a maximum of €25 per month for a medical cardholder. The sum of €25 is still the maximum for a person on a large number of medicines. I would like to reduce the figure in the term of the next Government, if I am part of it, but it would be expensive. Those prescription charges bring in more than €100 million in a year and the money does not go into the general Exchequer pot but directly to the health service. A reduction in half of the sum would require €60 million or so to be found either from another source or from cuts to services and we are not in a position to do so at the moment, for reasons the Deputy will understand.

Even in a utopia with the best public health service in the world, we would still probably have some form of supplementary health insurance. The NHS, or national health system, as Deputy Boyd Barrett referred to it, performs extremely well in terms of rapid and timely access to health care on an equal basis. It does not perform as well in terms of patient outcomes. We do better than that system in terms of many patient outcomes. A system might do well on access but it may not necessarily do as well on morbidity, mortality, outcomes, cure rates and survivor rates. However, even in a socialist national health system, no matter how one designs it, by definition, one will run into certain issues. There will have to be some degree of rationing. Even in the wealthiest, most socialist country in the world, the health budget is always finite.

A finite budget requires rationing and queues. People have to wait because someone else's case is more urgent. It requires the removal of choice. People may want to see a particular consultant and not another one but if one is going to have a socialist national health service, that choice has to be taken away. If everyone wants to see a particular guy, the waiting list will be very long. People will have to be split up and told where they have to go. Just as we do in a public education system at the moment, everyone cannot go to the school of his or her choice. It would not be possible for everyone to go to the hospital or doctor of his or her choice either.

There would have to be a degree of rationing when it comes to treatments, which is exactly what happens in the NHS. Certain treatments are not available because they are not considered to be cost effective on a population basis and that is increasingly the trend across the world in those public health systems. Unless we ban people from spending their own money on their health so that they can skip a queue, see a consultant or go to a hospital of their choice or get a treatment the Kremlin or whatever system is running the show does not consider to be cost effective, there will be some sort of private health insurance system.

Once there is a private health system, albeit perhaps a supplementary one, it needs to be regulated. We regulate health insurance in this country because we do not want to have a system like that in America. We want a system that says whether a person is old, young, sick or healthy, he or she pays the same amount for the same policy. That is what this legislation is about.

Even if he were elected with an overall majority tomorrow and he decided to raise taxes by €8 billion to introduce his socialist national health service system, it would still take Deputy Boyd Barrett time to do it. It would take him five or ten years, if not 15 years, to do it. In the meantime, he would need to have some sort of health insurance system in place. If we stopped health insurance tomorrow morning, our public hospitals would immediately lose €800 million. Those hospitals get €800 million in income from the health insurance system. Deputy Boyd Barrett would still need to have this Bill during the transition period. I, therefore, ask him to support it because so long as health insurance is not illegal, this Bill will ensure that in Ireland, the old pay the same as the young and the sick pay the same as the well for the same product. If Deputy Boyd Barrett votes against the Bill, he votes against that principle.

Question put and agreed to.