Seanad Éireann díospóireacht -
Wednesday, 12 Dec 1956

Vol. 46 No. 15

Voluntary Health Insurance Bill, 1956—Second Stage.

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

Minister for Health (Mr. T.F. O'Higgins)

As a result of the implementation of the Health Act, 1953, and the removal of difficulties in the way of its operation in the past two years a fairly comprehensive measure of free or partially free health services is now provided for a substantial number of persons. It can be estimated that about five-sixths of the population are eligible for services under present legislation. This large section of the community is provided with free or partially free services on the assumption that they are unable to meet in part or in full their own health costs.

There remains, however, a substantial section of the community who at the moment must bear the full cost of their health services. This section probably numbers some 500,000 persons including wives, children and other dependents, and they comprise a group of our citizens whose yearly means exceeds £600 or, if farmers, whose valuation is over £50. Should illness requiring hospitalisation or extensive surgical or medical treatment befall such persons they may well be faced with heavy if not crippling expenses, difficult if not impossible to meet from income. Indeed their problem in this respect tends to increase in difficulty with the rising costs of hospitalisation, medicines and of medical treatment generally. It is clear that in these circumstances some means must be found to avoid or mitigate the inevitable financial hardship caused to these citizens as a result of serious illness.

It can be urged that the simplest way to meet this problem would be to extend the benefits of the Health Act to this section of the population. No great difficulty would be entailed in solving the problem in this way—a simple amendment of the Health Act would be sufficient to extend its scope to the entire population. The simplicity, however, of such a procedure is not, in my opinion, an argument in its favour. The adoption of the example offered to us by Britain where State medicine is in operation would in my opinion be a poor tribute to our ability in this country to solve our health problems by means more in accordance with our national traditions.

I believe that those citizens whom I have mentioned are people who would themselves wish to stand on their own feet and would desire to meet the costs of any illness they may encounter from their own resources. The vast bulk of them are persons accustomed and anxious to meet their various liabilities and in the habit of making provision for the various financial contingencies they are likely to meet. The average citizen balances his budget by foresight and good management and he has to lay out his income in such a way that he is enabled, not alone to meet his day-to-day expenses, but also to make reasonable provision for the future.

These commendable feelings of personal self-respect are not to be ignored and I do not believe that such persons would expect to have their natural obligation to look after the health of themselves and their families financed by the State or would wish to have no personal responsibility henceforth for the medical treatment and care of themselves and their families. In my considered opinion it would be contrary to our ideals and tradition that the State should in this manner supplant individual effort unless there are grounds for believing that the individual cannot himself meet his responsibility.

As matters stand, we in this country have not had at our disposal the means for making provision beforehand for meeting the expenses of ill-health in ourselves or our dependents. In many other countries this problem has been met successfully through schemes of voluntary health insurance and in order to establish how far we might proceed on similar lines I set up in January 1955 a widely representative body to advise me in the matter. I received the report of this Advisory Body in May 1956 and as Senators will recall I made copies of this report available to members of each House of the Oireachtas.

The Advisory Body in their excellently documented report stated that it would be feasible to introduce a scheme of voluntary health insurance in this country against the costs of hospital maintenance, surgical and medical services, and maternity. Amongst their other recommendations was one that the best type of organisation to administer such a scheme would be a non-profit-making company especially established for the purpose, exempt from the provisions of the Insurance Acts and with a Government guarantee at the commencement at least. The report was unanimous except in one respect to which I will refer later.

The Government has accepted the recommendation of the Advisory Body in regard to the type of organisation necessary to implement this scheme of voluntary health insurance and this Bill is designed to give practical effect to this recommendation. It is obvious that as this Bill is a Bill designed to create the necessary machinery it must be read in the light of the purpose it is designed to achieve. I have heard criticism to the effect that the Bill does not contain details of the benefits health insurance will offer, nor of the premiums likely to be charged. Any Senator who appreciates the background to this Bill will understand that it should be considered in the light of the Advisory Body's report and that it should be regarded as a Bill designed broadly to bring about a scheme of insurance providing benefits regarded by the Advisory Body as being desirable.

The Bill establishes a board to be known as the Voluntary Health Insurance Board whose functions will be to make and carry out schemes of voluntary health insurance. The board will in fact be required to carry out one particular scheme which the Minister will specify and will have in addition power to carry out such other schemes as they think fit subject to the sanction of the Minister in regard to the scope and extent of the benefits. The board will be required to conduct its business on a non-profit-making basis. This is secured by the provision in the Bill that the subscriptions payable must be determined in such a way as to balance incomings and out-goings, taking one year with another.

In order to enable the board to set themselves up in business and to meet their expenses until subscriptions commence to come in the Bill provides that the board may be given a loan from the Exchequer not exceeding £25,000 to be repaid on such terms and conditions as the Minister for Health, with the consent of the Minister for Finance, may determine. Provision is also made for a further sum not exceeding £25,000 which may be lent to the board to meet losses during the first five years of its operation. The board may not have to draw on this later loan but it is obviously necessary to make provision against possible losses. The Advisory Body in their report drew attention to the difficulties of estimating in advance the cost of benefits under the voluntary health insurance scheme and pointed out that practical experience is the only way of testing the adequacy of the premiums in relation to the benefits. In the event of a loss in the initial years the board must have the means to meet claims until such time as they can adjust the situation.

It is the normal practice when setting up statutory bodies of this kind to require them to make information on their activities available to the public. It is particularly important in the case of the Voluntary Health Insurance Board that that practice should be followed because of the interest which subscribers to the scheme will have in the value they are getting for their subscriptions. It is provided, therefore, in the Bill that the board must keep any accounts which the Minister for Health may direct them to maintain, and that they must send a copy of the auditor's report together with copies of their certified balance sheet and income and expenditure account to the Minister. These documents must be published and placed on sale and laid by the Minister before each House of the Oireachtas. Moreover, the board is required to furnish an annual report on its proceedings to the Minister who will cause it to be tabled.

The Advisory Body in their report estimated that a premium of the order of £1 15s. for each adult in the scheme would be necessary to provide a lump sum benefit of £20 for normal maternity. They considered that a substantial increase by this amount on the adult premium of about £4 estimated to be required to cover all other benefits under the scheme would discourage prospective members from joining the scheme. They suggested, therefore, that the State should make available a subsidy of £1 towards the estimated amount of £1 15s. leaving 15/- to be met by each adult subscriber. On this basis they took the view that it would be feasible to include cover against the cost of normal maternity. Two members of the Advisory Body dissented from this view in a reservation to this report.

While I agree that it would be most desirable to include a maternity benefit in a scheme of this kind I could not agree at this stage that the State should subsidise, even partly, such a benefit. I would in addition be concerned at the possible unfavourable consequences of loading the premium in respect of a benefit which many subscribers could not avail of. In the reservation to the report on this particular matter, the point was made that it is undesirable that any unnecessary obstacle should be placed in the way of persons who wish to join a health insurance scheme and that such a scheme should not contain provisions likely to discourage single persons and married persons beyond the child-bearing age from joining. The obstacle could be removed by subsidising the maternity premium in full, but since the idea of self-reliance is fundamental in this proposal that course does not commend itself to me at present. Moreover, a number of organisations representative of a large number of potential customers for the scheme have indicated to me since the report of the Advisory Body was published that they feel the ordinary prudent head of a family could himself budget for his maternity costs without recourse to an insurance arrangement.

However, this particular aspect is a difficult one upon which to form a clear judgment and the views which I have expressed here may have to be altered in the light of actual experience. The board will not be debarred from including maternity benefit in any scheme they carry out and it is my intention to consider this matter further in the light of such advice as the board may extend to me gathered from the actual experience which they will acquire from their initial operations.

I mentioned earlier that there are some 500,000 potential subscribers to a scheme including dependents, in the higher income group not eligible for services under the Health Act. I should like to make it clear at this point that it is not the purpose to design a scheme of voluntary health insurance solely for this group. I have every hope that numbers of persons eligible for the Health Act services at present will decide to cover their health risks by insurance when a scheme becomes available. It is noteworthy that the membership of the voluntary health insurance organisations in Great Britain has increased very substantially since the introduction there of the National Health Service. However, the actual number of persons likely to join a scheme at the beginning can be expected to be far less than the 500,000 mentioned.

There is little experience of this class of insurance in this country so far, particularly among the farming community which accounts for about 120,000 persons in the higher income group. One must expect that the market for this business here will be fairly small for some time and I do not think that there is room for more than one organisation to conduct it successfully. I consider it essential, furthermore, that voluntary health insurance should be developed in this country on a national basis and that the State should have some voice in its administration so as to ensure that the needs of the public are adequately met.

The public must have some assurance, too, of the continuity or permanency of any arrangement which is set up. Another important consideration is that this business which has the object of meeting what is undoubtedly a national need should be conducted on a non-profit-making basis. For these reasons, I am proposing in the Bill to give the board a virtual monopoly of health insurance business. This is done by requiring organisations wishing to carry on this business to obtain a licence from the Minister for Health. It is not intended to interfere with organisations offering, or intending to offer, health insurance to a limited membership or with a limited scale of benefits: generally speaking, organisations of this kind—trade unions, friendly societies and so on—are exempted under the Bill from the licensing requirements. It is intended, however, to prohibit any firm or organisation from continuing or entering into voluntary health insurance business to an extent which might prejudice the chance of success of the new board.

This Bill as I have indicated, is an enabling measure. Its importance is that it represents a new approach to a problem unsolved up to the present— the problem of those who are ineligible for benefits under existing health legislation. The idea of self-reliance is fundamental to it. Its eventual aim is to help people to help themselves. I am confident that most of those for whose protection the Bill is designed will welcome that principle of self-reliance. I trust that this House will accept the Bill as an endeavour to solve the important outstanding health problems and I commend it to the House for Second Reading.

Dr. ffrench O'Carroll

I see no reason whatsoever why we should not have a Voluntary Health Act in this country. The suggestion is not a new one. It has been considered by the Minister's predecessor and he took the same view—that there was no reason why we should not have a Voluntary Health Act in Ireland. He did add the provision, I believe, that such a Voluntary Health Act should be in addition to, and not instead of, the Health Act, 1953. There is no doubt about it that a Voluntary Health Act would be of considerable advantage to a large section of the community here. The present Bill, if it proves to be a workable Act, would be of considerable advantage as the Minister says, to at least one-fifth of the population and it would also be of considerable help to my profession who, like every other section of the community, find it much more difficult to live these days. It would, from a doctor's point of view, be of great comfort to know that as far as private and semi-private patients were concerned, or at least a good many of them, they found it easier to meet their medical expenses than they do to-day, but I think this one question of whether the Voluntary Health Insurance Act is in addition to, or instead of, the Health Act, 1953, must at this stage be very closely examined.

After the Minister took over the Department of Health he came to us in the Oireachtas and sought and obtained power to postpone the implementation of the Health Act, 1953. It was quite reasonable that he should do so at the time. He had just taken over the Department. There was undoubtedly a great deal of opposition to the Act as far as the medical profession were concerned. We will not at this stage go into the causes of that opposition. We regard that as past history. Many of us at that time, when the Minister came here, were rather worried as to what the future of the Health Act, 1953, would be. I can recollect Senators even on what we might call the Government side of the House, if one is permitted to say that here, saying that the Minister should be given six months or nine months to implement the Health Act, 1953.

The Minister did go on and he certainly did implement a considerable portion of the Health Act, 1953. On many occasions in public he reiterated his determination to implement the Health Act, 1953, in full.

I am not going into the workings of the Health Act, 1953, but I do think it is very important to consider it in relation to the Bill which is before us to-day. I should like to examine what I might describe as some of the evidence which is available to us here to-day so that we can make up our minds whether we will have a Voluntary Health Act in addition to, or instead of, part or parts of the Health Act, 1953.

I have here the Report of the Advisory Body on Voluntary Health Insurance Scheme, which is very interesting and very competently done. I think that people throughout the country generally do not appreciate sufficiently the work which people give to these voluntary bodies. I had the privilege on previous occasions of being on one or two of these Government councils or committees and I think that very few of the public realise the valuable work which is done by these committees. This report is an excellent one and, unlike those of most committees, was presented very quickly.

On page five of the report the Terms of Reference which were given by the Minister to this Advisory Body are shown. Paragraph six, page seven of the report, speaks about the Health Act, 1953, and towards the end of paragraph six the report says:—

"We understand that it is not the present intention of the Minister for Health to bring these provisions into operation. Hospital and specialist services are free for all children for defects discovered at health examinations in national schools."

They are referring there to what we would describe as the mother and infant services of the Health Act, 1953.

Mr. O'Higgins

It has reference only to the higher income group.

Dr. ffrench-O'Carroll

They were given to understand that at least portion of the mother and infant services of the Health Act, 1953, were not to be implemented.

Mr. O'Higgins

If the Senator reads the entire paragraph it will be made clear. That has reference to dental, ophthalmic and aural services to persons in the middle income group and to the provision of a maternity service for persons with a higher income on payment of contributions.

Dr. ffrench-O'Carroll

Yes, but it is remarkable that as far as the higher income group is concerned the Minister does not intend to proceed with that part of the Act, so that I might cite that in passing, at this stage, as at least some evidence that the full implementation of the Health Act, 1953, in respect of that particular section, as far as the mother and infant service is concerned, is not envisaged by the Minister.

The next thing that we might consider in regard to this question of whether we will have a Voluntary Health Insurance Act in addition to or instead of the Health Act, 1953, is some of the remarks which the Minister made in his speech in the Dáil. Many of them were repeated in his statement here to-day. In Volume 160, No. 6, column 827 of the Official Report of Dáil Eireann, he spoke of the Health Act and he said:—

"Some Deputies rather thought that this scheme was designed solely for the higher income group. May I emphasise that that is not so?"

This is, of course, referring to the proposed Voluntary Health Act.

"In fact, I should be profoundly disappointed if a number of persons now entitled to health services under existing legislation did not decide to avail themselves of this insurance. Deputies will appreciate that, under the Health Act, 1953, particularly in our country, it was not possible to arrive at a standard of means which would ensure that you were helping only those who, in fact, needed help."

Later on, in the next column, column 828, he speaks of the position in regard to semi-private patients under the Health Act of 1953 and those patients who, not being semi-private patients, would choose hospital accommodation other than that which the health authority offered them. He said:—

"Such a Health Act patient, going to a semi-private or private room in a hospital, gets nothing more than four guineas per week."

That is the contribution from the local authority under the Health Act of 1953. The Minister continued:—

"If, however, he decides to avail of health insurance, he will get, under the suggestion here, a contribution of £7 per week in respect of his hospital bill and full cover for surgical and medical fees."

Those two particular points make it quite clear that the Minister envisages that, as far as the Voluntary Health Insurance Bill is concerned, it will be in competition with many sections of the Health Act of 1953. Therefore, I do not think the Minister can claim in the first instance that it is his intention to implement fully the Health Act of 1953 or that he can assure us that this Voluntary Health Insurance Bill will be in addition to and not instead of the Health Act of 1953.

There is one other very important question to be considered. If the Minister really intended that the Health Act of 1953 should get a fair opportunity to go into full operation and smooth working, I do not think that he should bring forward further health legislation at this stage. As every Senator will know, there are complaints throughout the country at the moment about the difficulties of operation of the Health Act of 1953. It is only natural that there would be such difficulties. The commencement of every comprehensive health measure will have a good many difficulties. This measure of the Minister's will also have the same teething troubles. Apart from that, the Health Act of 1953 for various reasons is a very complicated and involved measure. It is by no means a perfect piece of legislation from the point of view of health services. Therefore, it was quite obvious from the beginning that there would be many years of trouble before the Health Act of 1953 would be working satisfactorily. I do not think any Minister who is sincere in regard to putting the Health Act of 1953 in full operation should come along with a further piece of Health legislation at this stage.

We have at the moment very considerable confusion between the various income groups under the Health Act of 1953. People do not know whether they are in the lower income group, the middle income group or the higher income group; many people do not know whether they are under the Health Act at all. Local authorities naturally, having a good deal of freedom in this matter, have thought to lay down different conditions as far as the qualifying or means test was concerned for the different groups. Now, on top of all this confusion, we are to have yet another group, the voluntary health insurance group; and on the Minister's admission there will be considerable interchange between various groups.

Let us look at the position from the practical point of view. We will put sick people in future, so far as health legislation is concerned, in the lower income group, the middle income group, the upper income group or now the voluntary health insurance group, with considerable interchange between various groups. As far as the Health Act is concerned, it will be administered locally by the local authorities— not all but many with different standards in regard to its implementations. The Act itself comes under Social Welfare as far as certain beneficiaries under the Act are concerned; we have the Department of Health and now we are to have another body, the board which will administer the voluntary health insurance scheme.

Therefore, this certainly is not the ideal time to bring in a Voluntary Health Insurance Bill. There is evidence, taking into consideration the time and some of the public statements of the Minister, which makes it quite obvious that this Voluntary Health Insurance Bill will not be operated in addition to the Health Act of 1953 but will be very much instead of part or parts of it.

There are various other points affecting this legislation which are particularly unusual. We have this rather strange position that the Minister is effecting special legislation to prevent any competition with this voluntary health insurance scheme. It is getting more or less a virtual monopoly of health insurance. That in itself we will discuss later, in relation to another part of the Bill. Leaving aside the position with regard to the Health Act of 1953, having read the Act carefully and having read the Bill, I ask myself quite honestly—the Minister may not accept that, but I did so without any prejudice whatever—is the voluntary health insurance scheme envisaged in this Bill a workable proposition at all?

Health insurance generally falls into one of two groups. It is either compulsory or non-compulsory, the latter being, for example, the type of insurance which commercial companies run. Where legislation is compulsory there is the advantage that everybody must join; and therefore, from an actuarial point of view, one is quite certain of getting a satisfactory mixture of good and bad risks to make the legislation a workable proposition in regard to profit and loss. I think Deputy Dr. Ryan has always taken the view that health insurance, to be workable on a large or comprehensive scale, must be compulsory. Personally, I think that is a sound view.

If health insurance is not compulsory and is carried on by the commercial insurance companies, it is voluntary but, of course, those companies are in a position to set quite a high standard for admission to the insurance. Although their insurance is a voluntary one, they do not carry the really bad risks. Therefore, to be commercially sound in general, it is more or less obvious that a scheme must be compulsory or, if it is not compulsory, it must at least be selective.

In this Report, there is quite an interesting summary or review of the position in other countries. It is notable from this Report that Belgium, Denmark, Norway and Sweden have compulsory health insurance. In Denmark I think it is only part compulsory. There are certain exemptions. In the United States and Britain there are schemes which are not compulsory and which are not State subsidised, but those schemes are run with the full advantages of ordinary commercial insurance practice; that is, the policies are not renewed if the claims are heavy. In the case of the United States, as far as the Blue Shield and others are concerned the Americans actually go in for what is called group insurance; that is, unless a certain number of applicants are forthcoming the insurance is not undertaken at all. There is in Australia—again according to this Report submitted to the Minister— voluntary insurance, but in that case there is a Government subsidy.

In the light of the evidence in the report, the Minister is bringing something before us to-day which is completely unique. It is not compulsory, yet it is not going to be run on ordinary commercial insurance practice. It is quite obvious that it will not be so run, because if a scheme could be run on ordinary commercial practice here, schemes would be available. We have the history in recent years of a commercial company which attempted to do this on a large scale here; the premiums were increased by 50 per cent., I think, after a year, and after two years they went out of business. Therefore, the scheme will not be compulsory. It will not be run on the lines of ordinary commercial practice and it will be lacking in the subsidy which is given, for example, to Australian health insurance. How the scheme is actuarially possible I cannot see at all.

In passing, I might mention that that is one part of the report with which I was rather disappointed. The actuarial evidence in support of the scheme submitted to the Minister is decidedly sketchy. It contains certain extracts from the recent census but, beyond that, there are no tables. As far as we are concerned we have no information—the Minister may have that information and, if he has, I would like him to give us a little more of it —as to how this scheme is actuarially possible from a purely mathematical point of view.

Again, looking at it from a purely practical point of view, there is another rather interesting aspect of the scheme. Under the Commercial Insurance Acts, 1909 to 1936, it is laid down that an insurance company must have £200,000 capital, of which 50 per cent. is paid up, and they must deposit £20,000 with the courts. The Minister has also relieved this proposed insurance body of that obligation. Looking ahead, I am extremely doubtful as to what will happen in practice when this board gets going. People will come along, they will be accepted and they will take out their premiums. It is obvious that their premiums will be renewed on far less stringent conditions than those relating to ordinary insurance with the ordinary commercial company. We have, then, this company which has not the advantage of being compulsory and has not the advantage of full commercial practice. It will have no subsidy from the State. Provision is made for two repayable loans. In addition, it has no assets. Suppose the scheme did get going with the Minister's assistance and had a couple of really bad years—I cannot exactly visualise in what circumstances that might happen but, let us assume for the sake of argument that it became fashionable for everybody to have their teeth and appendixes and gall bladders removed as a cure for something——

Professor Hayes

That would be a curious fashion, would it not?

Dr. ffrench-O'Carroll

It would but at one time it was suggested, as a cure for rheumatism, that everybody's septic fossa should be removed. People had that done. Suppose the company had a couple of very bad years and lost heavily, I presume they would then put up their premiums. Suppose they put up their premiums, an insured person is quite likely to say: "It was good value last year but it will not be good value this year and, therefore, I will not renew." Just like income-tax, the more premiums increase the more revenue falls off.

What will happen then? The company will have no Government guarantee and no assets. Will it be allowed to go bankrupt? Will members of the public rush in and put their money in a company which is in that financial position? These are just one or two points I do not understand in relation to this scheme. There are one or two somewhat similar points which I would like to mention at this stage. There is the question of domiciliary service. I fully appreciate that it would be impossible under a scheme to give a complete domiciliary service but, in practice, it is not helpful, to say the least of it, that the beneficiaries under this scheme should have to have all the services of the scheme in hospital. It would obviously be wasteful that anybody who requires minor surgical treatment, which could normally be done either at home or in the doctor's consulting room, should have to go to a hospital for that treatment. I am against the idea of this treatment being done in hospital though I admit it would be better to have such treatments done in hospitals rather than in consulting rooms because the facilities are better. But it does seem wasteful that these things which were normally done outside hospital should now under this scheme have to be done in hospital.

There is one matter in which I cannot see how we can avoid some domiciliary facilities and that is in the consulting capacity. The Minister is well aware that it is the practice for the family doctor to have the consultant surgeon or physician see the patient before he actually goes to hospital. It is not medical practice for the family doctor to admit a patient to hospital and then have the surgeon or physician come along and decide what treatment will be carried out. As a rule at least one consultation takes place in the patient's home or in the doctor's study before hospitalisation is decided on. So far as this scheme is concerned, provision should be made for at least one consultation in the patient's home per illness.

Mr. O'Higgins

I wonder would it assist the Senator if I directed his attention to paragraph 18 of the Report which is as follows:—

"As regards specialist surgical services, insured persons may be inclined to enter hospital for minor operations ordinarily performed outside hospital in order to qualify for benefit. To avoid unnecessary claims of this kind, the scheme should include provision for certain minor operations performed outside hospital."

Dr. ffrench O'Carroll

I knew that was in the Report but I did not know whether it was envisaged in the Bill. There are some things in the Report which are not in the Bill. There is only one other point I wish to raise. That is in relation to the actual scale of benefits as outlined in the Bill. I realise they are not final but there are one or two matters worthy of comment. The provisions for doctors' fees are in the main quite generous and adequate. The nursing home and hospital fee suggested would certainly be adequate also for any semi-private accommodation. I notice, however, that the grant for drugs and medicines is £5 in any one year. That figure is totally inadequate. Apart from the increase in the cost of living and rising prices, the increase in the cost of medicines is one of the biggest factors to-day in increasing the cost of medical and surgical services all round. It is quite common for drugs to cost anything up to £1 per day in the first few days of acute illness. Antibiotics will cost anything between 4/- and 5/- per tablet. Therefore, a figure of £5 in any one year is totally inadequate. It would be much better to provide that drugs would amount to at least 10 per cent. of the maintenance figure. I think that £5 per average illness might be much nearer the figure. I do not know for how many weeks in the year it will be possible for a patient to have hospitalisation. Ten weeks is mentioned. How many times that can be repeated, I do not know.

Mr. O'Higgins

Average hospitalisation works out at between two and three weeks.

Dr. ffrench O'Carroll

The figure so far as pharmacy is concerned is totally inadequate. In relation to physiotherapy, there again the maximum of five guineas is totally inadequate. Physiotherapy used post-operatively or in the treatment of rheumatism is essentially long-term. Treatment in these conditions is nothing like as dramatic as it is where you have drugs of a specific nature at your disposal and it is very rarely any patient has less than a dozen, or perhaps two dozen, treatments. Five guineas is quite inadequate there.

Generally speaking, the benefits are quite satisfactory. There is nothing more I have to say except to reiterate that I think it is a great pity that a Voluntary Health Insurance Act, which would undoubtedly be of considerable benefit to the country—I see no reason why in principle or practice we should not have it—should be introduced at a stage at which the Health Act is going through a very difficult period. It should be introduced in such a manner as to allow a deliberate overlap between many sections of the Health Act in order to bring about a rivalry between the two.

Dr. Sheehy Skeffington

I would agree with a good deal that has been said by Senator Dr. ffrench O'Carroll on the scheme that is before us now. I would also agree with the tribute he paid to the Minister who has quite obviously made a genuine effort, and a largely successful one, to implement his promises to us here when we first met him over the Health (Amendment) Act. I think we could all agree that he has been extremely active, and also obviously personally concerned with the health of the country and its health schemes. I think that is indicated by the speed with which, in general, he has introduced new measures and in this case the speed with which he sets about implementing the recommendations of the Report. I think he deserves full credit for all of these things; nevertheless, I am afraid that I shall be critical of this particular Bill.

I might state my major objection first. I think it is a very important objection. It is that the scheme will not work. Senator Dr. ffrench O'Carroll has indicated that he has some doubt as to whether it will be capable of succeeding. I do not think it will succeed. I would go further: I would say the scheme as envisaged here will prove itself, within a fairly short time, to be a disastrous failure, for reasons I propose to put before the Seanad. I doubt very much if it will attract, within measurable time, even as many as 50,000 subscribers but, even if it were to attract that number, I believe it would not be workable on that basis, for the reason that those 50,000, paying their premiums, would not provide enough money to provide the kind of benefits which could be regarded as adequate.

If, out of a potential consumer market, so to speak, of 500,000 people, we get only 50,000 who actually avail themselves of the voluntary health scheme, I think it must be recognised that the problem, even there, is not being dealt with in a way that satisfies the people. I mentioned 50,000 and I might be quite wrong in that guess, but my feeling is that, in practice, the number will be far less than 50,000 subscribers. I would like to ask the Minister, though it might not be fair to press him on the point, to indicate to us within certain limits, with what figure of subscribers he thinks it conceivable the scheme will work reasonably well, and below what figure it will be difficult. I hope that is not an unfair question and I think it is relevant to my contention that the scheme will fail because it will not attract enough support from subscribers, from policy holders.

My own view, of course, is—I have stated this on many occasions—that an over-all free State scheme covering the last one-sixth of our population as well as the other five-sixths would be by far the best. The Minister has stated his view, and the Government view, that such a scheme would not be best suited to this country though he did admit quite frankly that it would be very simple to extend the present scheme to cover the whole country—every class, section and income group. It is obvious to us that not merely would it be simple as the Minister says, to extend the present scheme to cover everybody in the country, but if you were to do that, you would very considerably simplify the present scheme because a large number of the complications and the form-fillings which are associated in the public mind with the present scheme, derive from a concern on the part of the administrators of the scheme to find out how much money the people in question have.

In other words, a large measure of the complications in the present scheme derive, not from the essential complications of a public health scheme, but solely from our desire to apply a stringent means test. Six out of 10 of the questions on any health scheme form relate to finding answers to the questions: how much money has the patient got? What rent does he pay? What are his earnings? What are the earnings of his dependents? Does he own a dwellinghouse? Does he own any land? Does he own any other property of value more than £25 Does he get an old age pension, or unemployment assistance? In other words, not merely, as the Minister says, would it be "simple" to extend the provisions of the present Health Act to every section of the community, but things would become far simpler even for those to whom it now applies, because we would no longer be under an obligation to find out how much money they had. Six-tenths of the complications of the present scheme, with all its form-filling, results from our application of the means test; and the necessity for that, of course, would disappear if we were to apply the scheme to the other one-sixth of the population for which this voluntary health insurance scheme is intended.

The Minister has met that point, and he defends the present Bill by saying he hopes we will agree that it would be "a poor tribute to our ability to solve" our own problems, if we were to rely on provisions in the State health services for people in the income group of more than £600 a year or for farmers with valuations over £50 a year, and if we were to give them free medical treatment. On this question of income groups, I would say that I think we are all aware that the man who has an income of £600 a year to-day can hardly be said to be a very wealthy man or that the farmer with a valuation of £50 a year is a man with an immense amount of extra cash at his disposal for subscription to a voluntary health insurance scheme as well as for meeting the various other charges upon him. Six hundred pounds a year is the lowest limit and yet anybody with a few pounds more will have to provide for his health needs by voluntary insurance if we accept the Minister's view.

The Minister says it would be a poor tribute to our ability to solve our problems, and so on, if we were not to allow this upper income group to solve their own problems through a voluntary health insurance scheme which would pay for itself. Nevertheless, in many things in this State we do in fact help people by subsidies, by concealed subsidies, such as tariffs, and by all kinds of State protection, which prevent them from feeling the full cold wind of economic competition. Not only are some people in this State protected by subsidies, but they are given grants; you are now to get a two-thirds grant if you build a new factory under certain conditions.

An Cathaoirleach

Let us not widen the debate unnecessarily.

Dr. Sheehy Skeffington

I do not intend to do so, but I do not think it would be considered fair to say that it would be a poor tribute to the ability of our businessmen to say they must be helped in this way, that we must have a Welfare State for tired, sickly, feeble businessmen and that the helping of people by subsidies is sapping their moral fibre in any way.

Therefore, I do not accept the Minister's suggestion that if we were to adopt a similar policy, for a similar type of person in the upper income group in relation to health, we should be sapping their moral fibre any more in relation to their health than we are doing in relation to their business worth and initiative, by giving them these subsidies to which I have referred.

The Minister has suggested that these sturdy people, with wealth amounting to over £600 a year or with land the valuation of which is over £50, will thank us for insisting they shall not be deprived of the right to pay their doctors and hospitals themselves. I do not picture their indignation were we to say; "No, I am sorry; but we are going to deprive you of this right to stand entirely on your own feet in relation to the provision of health services." I believe they would accept our help gratefully, as people do in other spheres.

The Minister spoke about "self-reliance" which, I think, is a good translation of the original concept of Sinn Féin. Self-reliance is an excellent thing, but we have found in recent times in this State which we have been building up, that things do not work that way, and that in all kinds of other fields self-reliance is not recognised as being enough. I suggest that it is unfair, therefore, to ask this group of people, who are not in fact, in the main, wealthy people, to bear the brunt further of supplying their own health needs, in their entirety, by a scheme of self-help insurance to which the Exchequer is not going to contribute a single penny.

I think that the Minister's own case would be greatly strengthened if he came before us and said that whether these people liked to contribute something towards their health scheme or not, he believed the State should contribute, say, two-thirds of the premium just as it does contribute two-thirds of factory-building costs for new industrialists. The Minister has not said that; he has come before us and before the Dáil and said: "We do not intend to give a penny; there is to be no subsidy of any kind."

Part of my belief that this scheme is going to be a disastrous failure arises from my realisation that the potential consumer market, as is mentioned in the Report of the Advisory Body, is something like 500,000 people. I refer the House to page 24 of this report. In making this first reference to the report I should like to associate myself with what has already been said in praise of the people who drew it up. They were appointed in 1955 and it took them only about a year to make the report and to publish it. Now we find the Minister implementing the report in less than two years after the Advisory Body had been set up. I should like to see that imitated in other Departments, particularly in regard to the Report of the Council of Education, for instance.

This is a good report not merely for the speed of its compilation, but for the frank manner in which the Advisory Body go into the whole matter, not merely in relation to this country. We should, in praise of the report, add that it gives the figures for Denmark, Belgium, Norway, Sweden, Switzerland and Britain. That is an excellent thing because we should not make a move in such matters as this without knowing what is being done elsewhere. In paragraph 61, then, on page 24, we find the Estimate that:—

"the maximum number of the middle income group who would be disposed to become members of a voluntary health insurance scheme would be in the region of 500,000. One would have to assume, however, that the number who would be likely to join the scheme at its commencement would be considerably less than the figure mentioned."

I believe that, owing to the fact that it will be so "considerably less" at the commencement, premiums will have to be so high that they will reduce still further the number who would be likely to join the scheme. That potential number will again be reduced by two other facts, neither of which is stressed sufficiently by the report. One is that within this group of people for whom the scheme is devised, on the average it will be the older and more responsible members of that group who will be most likely to contribute and join it.

"Older and more responsible" is the phrase used in the report, I believe. It is legitimate to assume that will be so. The older members of that group are also likely to be ill more frequently, and more likely to make calls upon the benefits of the scheme than the younger group. If you compute the number of subscribers and say that a large proportion of the older people—who deserve praise for their contributing—will participate, you will have to push up the premium rates, because your benefits will be more frequently called upon. The second point is that among the younger people who will join, it will not be those in most robust health who will insure.

That again means that you will have an emphasis within that second group, among those young people, on those in ill-health, those who have been brought face to face with the facts of illness, and who have gained some knowledge of what it means and of what the cost is. It is the less robust, even among the young, who will be attracted to the scheme. By those two facts, the premium will have to be further considerably increased, if the scheme is to be self-supporting.

That is particularly so since this scheme will be getting no subsidy, since it must support itself entirely. I notice that this report, in referring to Denmark and Norway, in page eight, mentions conditions in those countries and in Switzerland, in which the State or the local authorities pay a subsidy towards such a scheme. I feel the value of that should be stated and realised, and I regret very much that the Minister has not seen the necessity to do this and to put up at least pound for pound with the subscribers if he wants the scheme to work, as I think he sincerely does.

All that he is doing is to put up two sums of £25,000—£50,000 in all—all of which must be paid back. None of that is a present from the Exchequer to the new scheme. The Minister did not tell us whether or not this is an interest-free grant. I should like to assume that it is, and that our new company will at least not be saddled also with the necessity of paying back interest to the State on these sums. That point has not been made clear yet, as far as I know. I think the Minister might advert to whether, as I hope, these grants are in fact to be interest-free. I do not think it is made clear in the Bill, either, over what period of years repayment will be spread.

It is made quite apparent, then, in the Minister's own words that this new company will have to "balance outgoings with incomings". The result, I suggest, will be to make premiums far too high and benefits far too low. I should like to quote the Minister, who rightly answered certain objections to this Bill by saying that we must remember that the Bill is based upon this Report, and that, by the nature of things, you could not have in the Bill details of premiums and benefits. I think he met such queries perfectly legitimately by saying that in general this Bill is to enable some such scheme as is adumbrated by the Report to be implemented. Therefore, we are entitled to turn to the Report and see what kinds of premiums and benefits are envisaged. I would refer Senators to page 16 of the Report. I will not read all of the rates of contribution. I will just select two. The first concerns a married couple with three children. The suggested premium rate will be £13 5s. a year. For a married couple with four or more children the premium rate payable will be £15 a year.

On page 13 of the Report we get some idea of the sort of benefits that will be derived from such a contribution. It is anticipated that for an adult the benefit rate will be up to £7 per week for hospital maintenance charges up to a maximum period of ten weeks, that is, a maximum of £70 in the year. For a child, the equivalent figure would be £25.

In the case of surgeons' fees, the benefit rates for an adult are £25 for a major operation, £13 for an intermediate operation and £7 for a minor operation. The maximum medical fees during in-patient medical treatment for an adult is £25. The maximum yearly fees for anaesthetic services for an adult in respect of a major or intermediate operation is three guineas, and so on. All these details are to be found on page 13 of the Report of the Advisory Body on Voluntary Health Insurance Scheme. I think they are worth fairly careful consideration. I want to come back to that presently.

At this point I should just like to say that it is quite apparent from these benefits that these people will also have considerably to supplement the benefit payments to hospitals and doctors from their own pockets, and that they will not be able to feel that, if they are covered by voluntary health insurance, that will cover all the cost of a major operation once they have given the surgeon £25. Those of us who know something about the fees of surgeons know that they range from nothing to a fairly large figure and that on the average for a fairly large operation, a sum of £25 will cover only a part of the surgeon's fee. So, too, with hospital costs—ten weeks at £7 per week. These are the kind of people who will be looking presumably for a private room in a hospital. How many of our hospitals in Dublin——

Mr. O'Higgins

Would the Senator have regard to paragraph 16 on page 10 of the Report in relation to surgical and medical fees in hospital? I would refer the Senator to the last sentence in that paragraph.

Dr. Sheehy Skeffington

The sentence reads: "We are of opinion that the benefit rates for surgical and medical fees as indicated at 2 and 3 in the Schedule at paragraph 28 should ordinarily be the maximum charges to a person covered by a scheme where accommodation is shared with one or more patients in a hospital or nursing home and we have, in fact, received a firm assurance on behalf of the medical profession that such will be the case." That partly answers my objection—in theory. I shall watch the practice with some interest. Of course, the phrase "where accommodation is shared with one or more patients" is slightly vague. You might be sharing with another patient, in which case it would be a semi-private room, or you might be sharing with 12 patients in which cases it would be a ward. Usually, I think the sort of person to whom this would be attractive would not object to a semi-private room, but would prefer not to get ward accommodation.

Of course, the semi-private room or the private room in most of our hospitals, does, in fact, cost more than £7 a week. I do not know whether hospitals will be as co-operative as all that with the Minister. Of course, he is in close touch with the hospitals. I am afraid it would be a kind of Pooh Bah situation in which the Minister, as Minister, desires that this scheme will work and so will favour low hospital charges, and, in another capacity as Minister, desires to cut down hospital expenditure and increase hospital income. Conceivably he will have a quarrel with himself as to how much should be charged for a private or a semi-private room.

If people are to be charged a maximum of £7 a week in private or semi-private rooms, the hospital's income will go down as compared with the present nine or ten guineas a week. In nursing homes, indeed, nine or ten guineas a week is a minimum figure to-day: you pay quite a lot more than that! Nevertheless, I am glad to see that, in theory at any rate, this objection has been recognised. I am afraid, however, that in practice you will find that the beneficiary under this scheme will have in fact to supplement these payments to hospitals, to doctors, for anaesthetics, and so on, out of his own pocket. That will be an additional charge upon his not so very big income.

I also notice that this figure of £7 a week for hospital maintenance bears very little relation, as the Minister knows, to the average weekly bed-cost to-day in any hospital. I have not got the figures at my fingertips but you will find many hospitals where the average weekly bed-cost over the year is £10, £11, £12, £13. Apparently it is a slightly varying figure, because it frequently rather artifically includes a large out-patient attendance. Nevertheless, I wonder if any hospitals at all in the country can really, without loss, keep a person for £7 a week.

Mr. O'Higgins

Certainly one hospital does it at less than that for a private room.

Dr. Sheehy Skeffington

Really— and not fictitiously and not by a clever adjustment of costings, and so on?

Mr. O'Higgins

No.

Dr. Sheehy Skeffington

I wonder what percentage of hospitals do it? I think, in other words, the benefit figures, as read out here by me, will in practice prove too small and will force the beneficiaries, who have been paying these premiums for voluntary health insurance, to supplement the benefits out of their own pockets, and sometimes to a considerable extent. Again, a maximum of ten weeks in hospital may seem a lot in a year, but a great deal depends upon the age of the patient and the nature of the malady. It is quite conceivable that that, in itself, would be exceeded, in which case the full brunt of the extra cost would have to be borne by the patient.

Reference is made in the report, on page 3 of the first appendix, to schemes in Britain where various provident societies indulge in this kind of insurance. It says that the three largest of these are the British United Provident Association, the London Association for Hospital Services and the Western Provident Association, which, between them, cover about 750,000 people and have a subscription income of nearly £2,000,000. This British United Provident Association does offer a similar scheme, but in fact if we examine what kind of scheme it offers, as we are invited to do, we find that it offers a much better scheme, with a far lower premium and far higher benefits. The Minister referred to the fact that in Great Britain, even since the introduction of the health scheme, the State medical services, membership of these associations has increased. The present membership, however, of the British United Provident Association is less than 240,000—and that is in one of the biggest such companies in Britain, in a country where the population is 15 times as great as our population and where people are being offered by this provident association, far better terms than it will be possible for us to offer. The three associations together in Britain attract a total of 750,000 subscribers.

I think I made it clear that I personally do not favour private enterprise in this kind of insurance, but if we do favour private enterprise, I think it is our bounden duty to get at least the best value that private enterprise, in this field, can offer. I should like to quote to the House the sort of benefit that is offered by the British United Provident Association. They have, I may say, a whole list of scales of benefit, five different scales at the moment and in January, 1957, they will introduce a further seven scales, premium and benefit. Senator Dr. ffrench O'Carroll has mentioned that the report did not give actuarial figures. I think it was his main criticism of the report. I think it is a pity it did not include, also, for the sake of comparison, the kind of premium and benefit that can be offered by a similar voluntary insurance scheme in Britain. I am not going to take the lowest scales because I think they are obviously too low. One can have a single man, without dependents, paying a premium of as little as £1 12s. 6d. a year and deriving benefit in hospital charges alone of £84, plus home nursing, plus surgeon's and anaesthetist's fees to the extent of £21 and for a major operation £31 fees for a specialist and so on. I should like, however, to quote what is more comparable with the sort of figure that the Irish equivalent will be asked to pay, the figure of the man who is in the age group from 35 to 64, under B.U.P.A. Scale 4. The British United Provident scheme would require a premium of £11 5s. That will be for a man with two or more dependents. It does not matter how many children are dependent on him, the premium does not go up. That is roughly comparable with the Irish subscriber with three children who will pay £13 5s., and with four children will pay £15. The benefit, however, is very far from comparable, because such a man, we find, will get in benefits for hospital maintenance alone, a grant at the rate of £14 14s. a week, to a maximum of £147 in the year—just about twice the figure which will be possible in Ireland. The figure will be £70 for home nursing; and for surgeon's and anaesthetist's fees: £31 10s. For a major operation £52 10s., and for an intermediate operation, the figure will be £28 7s. and for a minor operation, £13 13s., where the three Irish comparable operation figures will be £25, £13 and £7.

Mr. O'Higgins

Surely the important thing is that the Irish scheme is complete cover for medical and surgical fees and the British United Provident Association is not.

Dr. Sheehy Skeffington

The cover is not complete. It does not cover general practitioners' fees.

Mr. O'Higgins

I know, but all the Senator mentioned were surgical and medical fees in hospital. It does not matter much what the figure will be under the proposed Irish scheme; it is intended in the average case to give full cover.

Dr. Sheehy Skeffington

I see. Yet, in cases not involving an operation, there is a B.U.P.A. yearly maximum of £52 a year, but the Irish yearly maximum is £6 6s. A fifth case is the specialist's fees, in-patient or out-patient, to a maximum of £21 a year; and the Irish maximum is £5 5s. I quoted those figures in support of my view that we ought, if we are placing our faith in private enterprise, to insist that we get the best value and not the worst value.

The next question I should like to consider is what are going to be the administration costs of the scheme. I think it is fair to say that the actual figures are not yet known—we have not got experience in this country— but I rather feel that the administration costs also, as well as the premiums, are going to be too high, for some reasons which we cannot avoid, and for others which perhaps we might avoid. Part of the practice of the British United Provident Association, which I should like to quote, says: "The Governors who administer the association receive no remuneration and serve entirely voluntarily in the interests of subscribers." The Seanad will see that the word "voluntary" in the British scheme includes the governors. These receive no remuneration, and serve in an entirely voluntary capacity, in the interests of the subscribers.

I do not suggest that the remuneration to the directors of our scheme is going to alter the premium or benefit very materially, but I cannot help feeling that if we are going to pay for work done voluntarily in Britain, we are not doing justice to ourselves. In the Minister's words, I feel it is "a poor tribute to our ability" to run a voluntary scheme, that we have to pay people to do it.

The second point on administration costs is more important. The Report on pages 15 and 16 says:—

"Information made available to us in respect of certain existing voluntary health insurance organisations indicates that the administrative costs vary from 15 per cent. to 30 per cent. of premium income."

That information is not fully correct. I have a letter here from the general manager of the British United Provident Association in which he says:—

"As a large established organisation we are able to operate on the low expense ratio of 10 per cent."

Yet in the Irish Report here we are told that administrative costs elsewhere vary from 15 per cent. to 30 per cent.

I would refer you, again, to page 16 of the Report which says:—

"An allowance for administrative costs should be made at the rate of 30 per cent. of the premium income in the initial stages of the scheme."

That is very high indeed. It may be necessary, but it is part of the additional cost we will be paying for this kind of scheme in Ireland. In Britain for various reasons—some of them could not be paralleled here—they are able to run such a scheme with a voluntary board and with an expense ratio of 10 per cent. We will have a paid board and an expense ratio of 30 per cent. I would suggest that the administrative cost is another crippling factor which will make it very difficult for this new scheme to work at all.

Therefore, the best scheme in my view, would be a scheme, which the Minister told us in his opening speech would be quite simple, to extend our present services to everybody and cut out the means test and all this income interrogation. But if we are to have private enterprise in this field, private voluntary insurance, and so on, let us buy in the best market. Let us adopt a good commercial practice frequently praised in free enterprise circles: buy in the best market.

A lot of insurance in this country is already done by British companies, and very well done. In this field of voluntary health insurance I think it is fair to say that Irish companies actually found it impossible to continue operating such a scheme, and had to give it up a very short time ago. Consequently, we are not putting any Irish company out of business if we invite a British company to do this kind of business in Ireland. I would suggest that we should go either to the British United Provident Association, the Western Provident or to some other similar body across the way. They have a big potential market, consumer market, if you like. They have a far bigger spread, and are extremely well organised. I believe if we were to try to negotiate with them, we should get a scheme on far more favourable terms for the people involved, the consumers, the Irish policy holders, than it will be possible to offer them under the Bill which is now before us.

The question arises, would they do it? Would they be prepared to accept such a suggestion? I should like to quote for you a paragraph from the letter from the general manager of the B.U.P.A. in which he says:—

"We did some years ago consider operating in the Irish Republic, but were advised by the Department of Industry and Commerce that we were infringing the Eire Insurance Act. In consequence the enrolling of new members was stopped and the registration of existing members terminated."

That makes it reasonable to presume that if we were to approach them and to state that we found that Irish insurance companies have not been able to do this, and that we should like to invite them to make an offer in this field, I have no doubt that they would be prepared at least to consider such a suggestion.

My opinion on this question could be summed up in three points. (1) The scheme will not work. We are getting the worst of both worlds, a State scheme based on private insurance. (2) It will prove to be far too dear for subscribers, or potential subscribers, who on an income level of £600, £700 or £800 a year will have to pay out at least £15 yearly—I am thinking, of course, of the married man with three or four dependents; admittedly the single person will pay less—and will also find that he will have to pay considerable supplementary amounts for medical services to cover his health needs. (3) This scheme as adumbrated in the present Bill will not cover more than a small minority of these 500,000 people who need the benefits of such a scheme.

So we ought to negotiate a scheme with low premiums and large benefits with some such company as those I have mentioned, or if that does not appeal to the Minister or to the Government, better still, arrange now, after all the heart-searching we have gone into in this country, to have a free over-all State health scheme, cutting out from our present scheme all the niggling queries and interrogating forms whose main purpose has nothing to do with health but is concerned solely to apply a rigid means test.

I notice that, without loss of self-reliance or initiative, the Irish in Britain—there are now about 750,000 of them—use very freely the British national health service, and I would be curious, if the Minister has any figures to show me, among the 750,000 people using the voluntary insurance scheme in Britain, to know how many of them are Irish? I would hazard a guess that the Irish in Britain are quite happy to use the free health scheme, and do not find their moral fibre sapped or affected in any way by that.

I should like to ask the Minister three questions, in conclusion, in relation to the terms of the Bill itself. First of all, in relation to Section 6, can he assure the House that when it comes to the appointment of the members of the board he will not forget that half of the population, roughly speaking, are women? There ought to be some women among the five members of the board, and I should like to see a minimum of two women as members. The Minister, in appointing the advisory committee to draw up the report, appointed one excellent woman, but only one woman out of 20 members on the board. I do not think that is enough. A woman's opinion on such matters would be extremely useful, and I should like to hear the Minister give an assurance that he will bear that in mind in appointing the board.

The second question is in relation to the same section but it is in connection with sub-section (5) which says:—

"A member of the board shall be paid, out of funds at the disposal of the board, such remuneration and allowances for expenses as the Minister, after consultation with the Minister for Finance, determines."

What is the order of magnitude that he has in mind in regard to this remuneration? Is it to be a nominal figure which could be legitimately regarded as simply covering their out-of-pocket expenses, or will this be a paid job? It is important to have some information on that before we are asked to pass the Bill as it stands before us. I am not suggesting that the terms of remuneration of the board would significantly alter the benefits or the premiums, but I should like the spirit of voluntary service, about which so much is talked, to be incorporated in the view of what is understood by the remuneration and expenses account of the members of the board.

My third and last question is one which I have already put. It arises from Section 16, sub-section (2), which says: "Sums advanced by the Minister to the board under this section shall be repaid by the board upon the terms and conditions laid down by the Minister..." I want to know what kind of terms and conditions the Minister has in mind. How long a term; how long a period has he in mind? May we presume that he will not charge interest?

Professor O'Brien

I have very few observations to make on this Bill because I intend to raise my points on the Committee Stage. All I want to say is this. In order that the Bill may be a success, it must appeal to the widest possible class. If it simply attracts the hypochondriacs, the valetudinarians and the old people, it will fail owing to the high premium that will have to be charged. I want to make two very minor suggestions at this stage which I will put forward again on Committee Stage to endeavour to make the scheme attractive. The first is that if the premiums are found to be too high at first they should be retrospectively reduced. If on experiment it is found that the premiums can be reduced they should be reduced retrospectively so as to benefit the people who entered into the scheme at its beginning. I think nothing would be more calculated to keep people out than the thought that when they went in the premiums would be high, that they would then be lowered and that they would not get the benefit of the lower premium during their early years in the scheme.

Another thing I suggest is that a no claims bonus should be seriously considered. If the scheme is meant to embrace the healthy as well as the ailing, the young as well as the old, a no claims bonus might succeed in reducing the premiums in the future. In motor insurance the experience has been that the no claims bonus has been of the greatest possible value as it keeps down unnecessary and frivolous claims.

Finally, I would ask the Minister to consider the possibility of some small State subsidy for this scheme more than is provided in the Bill. The present Bill does not appeal to the rich or the poor. The rich are able to pay for their services while the poor are covered by the existing health schemes. The scheme is specifically meant to cover the white-collar middle class. With the cost of living rising all the time, the line of demarcation in the Bill is rapidly becoming inappropriate. Either the line should be altered to give a larger class the benefit of the health services or people should receive some sort of help to insure themselves against sickness under this Bill. A large number of the people affected are already paying heavy income-tax and rates and education fees for their children. They are the people who get a good deal less from the public services than other classes of the community and they have to keep up conventional standards. The premiums, at least in the experimental stages of this measure, may be rather high and prohibitive and might keep them out. There is a case for at least raising the ceiling on the sums which are mentioned in the Bill by way of loans in the early stages or turning those loans into grants right away. They will probably not be repaid in the long run. It would improve the popularity of the Bill if the sum were given by way of grant instead of by loan.

A strong case has been made for part of the administrative costs of this Bill being paid by the taxpayer. In the early stages these will be high, especially in the experimental period. There is a great deal to be said for that kind of State encouragement. We all agree that it is desirable that people should enter a voluntary health insurance scheme; but, in order to make the scheme attractive, it must be presented to them as something that is going to give them value and not impose too great a burden. I put forward three concrete suggestions—the retrospective reduction of premiums if they are being reduced; a no claims bonus and a small amount of State subsidy to float the scheme over its early experimental stages.

Mr. Murphy

I want to be brief in speaking on this Bill because I know that other Senators are anxious to contribute to the debate. I do not want to enter into the Report of the Advisory Committee but rather to deal with the Bill before us. In that Bill, we are asked to establish a board to provide insurance for health on a voluntary basis and in so far as we are asked to provide insurance for health, I welcome this measure because I think our experience under the 1933 Act has shown us that health on an insurance basis is far better than any free for all such as would be advocated by some Senators.

We should look at the Bill itself to see in what way it could be improved. In Section 6, sub-section (1), the Minister appoints the board and further down in that section it provides that the Minister, in consultation with his colleague the Minister for Finance, determines the remuneration and the allowances for expenses for the members of the board. When you see all that, you would naturally expect that the Minister or the State would pay the salaries and allowances to the people appointed to the board by the Minister.

We find, however, that even though the Minister appoints the board and fixes the remuneration, he does not in fact pay the board. The members of the board have to be paid by the people who join the voluntary health insurance scheme. If that is going to be the case, in order that there might be some method of reducing the administrative costs, instead of paying remuneration to these members of the board, particularly the part-time members, it should be possible to get people qualified and with an enthusiasm for the work to undertake membership of the board without any set scale of remuneration but rather being paid some expenses.

As I am on the subject of the board, I should like to make the further point that under Section 8 members of the Oireachtas are debarred from serving on the board. If my suggestions were accepted, that is, that the board should not be paid salaries but rather paid some expenses, I do not think there is good reason for debarring members of the Oireachtas. Might I make it clear right away, in case there should be any doubt in the mind of any member, that I would not consider myself a good member of such a board; but looking around here—and I am quite sure the same applies in the Dáil—I see people who would make quite good members of this board to administer the voluntary health scheme? It is a waste of talent that they should be debarred at once simply because they are Senators or, in the case of the Dáil, Deputies.

I am most anxious indeed that this voluntary health scheme should succeed. If I criticise what is envisaged, it is not because I am against the scheme but because of my anxiety that it should prove a success. I do seriously consider that without some subvention the scheme which we now propose to launch will founder. I say that because it seems to me that the contributions which will be payable will be too high and too unpopular. You will get the bad risks joining the scheme and you will not get a wide measure of support for it. Eventually the bad risks would bankrupt the scheme, the premiums would continue to increase and in a few years would be priced out of the market. If that happens, and I would like Senators to bear this point in mind, there inevitably will be pressure for an extension of the 1953 Health Act, with consequent expense to the State and to the local authorities throughout the country. You are, in effect, spoiling the ship for a ha'porth of tar.

The Minister has used the phrase "self-reliance". That is all very well, but, more than that, we are anxious that the scheme should succeed. If it does not succeed, you will have that inevitable pressure—a pressure which really cannot be opposed—to extend the provisions of the 1953 Act. Then forever afterwards the idea or ideal of a voluntary health scheme in this country will be killed. But supposing some subvention was given to this voluntary health scheme, then you would have quite the opposite position. You would have a wide membership. The good risks as well as the bad risks would join and, as suggested by the Minister, you would have people joining the scheme who are at present covered by the 1953 Act, with a consequent saving to the State and the local authorities.

Apparently the Minister has set his mind against any subsidy, but I wonder could we get some compromise on this matter? I have in mind that, instead of this voluntary health scheme being set up as a separate organisation, recruiting and paying its own staff, the Department of Health itself should staff this insurance company or board, and should provide the officials, the manager, the assessors, and the clerks, to run the scheme. They should be seconded from the Department of Health and paid by the Department of Health. That would considerably reduce the administrative costs of running the scheme and would, in my opinion, enable a popular premium to be offered to the public.

In saying that, I have also at the back of my mind that there will be difficulty in recruiting the proposed officials in the early years of the scheme. For instance, I think it would be difficult to get assessors and to pay them. If there is a doubt about the success of the scheme, they would have no guarantee of employment and to get them at all you would have to pay them very high salaries. I suppose there are assessors employed already in the Department of Health. Surely it would be more economical in the long run, and more advantageous to the State and the local authorities, that the subvention should be given, and that it should be along these lines, namely, the Department of Health should man this board and provide assistance so that there would not be a heavy charge for administration in the premiums being offered to the general public.

I seriously commend this suggestion to the Minister. I would like Senators to express their viewpoints on it because, as I insisted at the start, I am most anxious that this scheme should be a success. I fear, however, that if we do not assist it in some way, it will founder and forever afterwards the ideal of a voluntary health scheme in this country will be finished.

Dr. McHugh

I think that perhaps too much attention has been devoted to discussing the comparative merits of this scheme and the 1953 Act, and also to approaching the Bill with Senators' minds made up that it is bound to fail. I would prefer something like the Danish system but I am quite certain we will not get that from the present Government and I am prepared to examine the Bill in the light of how far it is workable.

I have only one or two suggestions as to how it might be improved. I would like to congratulate the Minister on having accepted Deputy Finlay's amendment in the Dáil which makes it possible for the board to operate with a manager who is entrusted with carrying out a policy. I think a lot of the inefficiency of existing boards and institutions in this country very often derives from the fact that the managing director is a kind of colossus who bestrides the whole board and determines policy but shifts responsibility to the board when the policy does not operate properly.

The second point is this. In the Dáil Debates of 22nd November, column 1358, Mr. de Valera is reported as having asked:

"The board will probably employ actuarial assistance?"

The Minister replied:—

"Of course. From time to time, undoubtedly."

That seems to me to imply that perhaps actuarial assistance will not be there ab initio. As members of the Seanad are no doubt aware, costings are one of the necessities of a modern board, in fact, of a modern business, if it is to function efficiently. I would suggest that the Minister take note of that fact and arrange for actuary and costing accountancy help right from the beginning. These are the only two suggestions I have to offer.

Éamon Ó Ciosáin

Níl ach beagán le rá agam i dtaobh an Bhille seo. Cuirim fáilte roimhe. Braitheann an tslí ina n-éireoidh leis ar an méid daoine a bheidh páirteach ann, gan aon agó. Rud is ea é nár cuireadh i bhfeidhm anso riamh cheana. Tá sé i bhfeidhm i dtíortha eile ach ní fheadar an bhfuil na coinníollacha sna tíortha eile sin ar aon dul leis na coinníollacha atá sa tír seo—coinníollacha sóisialacha agus coinníollacha eacnamaíochta, agus mar sin de. Déanann na rudaí sin an-chuid difríochta i gcónaí agus, ina theannta sin, an dearcadh atá ag na daoine ar an saol, deánann sé sin difríocht leis.

Ach, maidir leis an mBille seo, caithfimíd ár ndícheall a dhéanamh chun é a chur chun cinn. Maidir liomsa, go háirithe, is dóigh liom gur cheart don Stáit teacht i gcabhair ar na ndaoine a mbeadh easláinte ag déanamh buartha dóibh ar feadh tamaill fhada, daoine a chaithfidh dul isteach in ospidéal agus a mbíonn ortha na costaisí troma d'íoc.

Sin iad na rudaí atá ag cur as do na daoine faoí láthair. Ní hé an méid a íocann siad leis na dochtúirí áitiúla a bhíonn ag déanamh buartha dóibh an oiread sin ach an trom-chostas a cuirtear orthu nuair a bhíonn orthu dul go dtí an t-ospidéal agus cúram speisialta d'fháil ó na daoine sin a bhfuil sé de chúram orthu é a thabhairt dóibh.

My observations on this measure will be brief because I realise that a good deal has been said already and, as it is, as the Minister stated, an enabling Bill, it does not lend itself to a long debate on Second Reading.

No doubt, in all considerations of social advancement, pride of place should be given to the health services, because, as everybody knows, there is no greater misfortune that can befall a family than to be visited by illness of a major kind, especially illness of a prolonged nature that necessitates hospitalisation and specialist treatment and the heavy expenses that go with that. That is one of the considerations that make it incumbent upon the State to do all it can for those who have the misfortune of having illness of the nature that I have described in their households. It is because of that, I must say, that some of us at any rate were enthusiastic about the 1953 Health Act, although I saw by Senator McHugh's opening remarks that he was not so enthusiastic about it.

Dr. McHugh

Oh, no. I am quite enthusiastic about it, but I think this is not the place to make a lengthy comparison between the present Bill and the 1953 Act—not on this Stage.

Mr. Kissane

In any case, the 1953 Act makes it possible for those in the middle income groups to avail themselves of hospital treatment and specialist treatment without being crushed by the financial burden that would otherwise be placed upon them. It has done that and the only thing about it is, of course, that its provisions have been delayed, and that is a pity.

This Bill is, I take it, designed to cover the 500,000 or so people who are above the middle income group and, no doubt, its success will depend on the number of people who avail themselves of it and the number of people who participate in the scheme. That is my opinion. I hope that it will be a success but it is very difficult to know. Some Senators are rather sceptical about it, but I think it is better to take the other view in a case like this and to say to ourselves that it will be a success and that we must make it a success.

Mr. Hickey

You cannot make it, if it is voluntary.

Mr. Kissane

It is the people themselves who will make it a success, but, as Senator Murphy observed, its success would be more assured if the State would give more financial assistance than it is giving under this measure. In fact, it can be said that the State hardly enters into it at all from the point of view of giving a subvention to the scheme.

As regards the board to be set up to administer the scheme, according to Section 5, it is to consist of the chairman and not more than four members and, of course, there will be a certain amount of administrative expenses, as has been referred to, connected with the board's administration. The administrative expenses will not be confined to the board. If one turns to Section 13, one sees the provision that the board shall appoint such and so many persons to be officers and servants of the board as the board from time to time thinks proper. Not alone will there be administrative expenses in connection with the activities of the board, but there will be other administrative expenses incurred by those officers who are provided for in Section 13. Unfortunately, it is the contributors to the scheme who will have to bear all the costs of this and, as somebody has observed, it would be better and more equitable if the State were to play some small part in bearing some of the financial burden of the scheme. At least, the State should bear the administrative expenses of these people—the members of the board covered by Section 5 and the officers who will be appointed by the board, covered by Section 13. I offer that as a suggestion to the Minister.

Senator ffrench O'Carroll mentioned that it was to be feared that certain sections of this Bill would cut across certain sections of the Health Act. I, too, am afraid that that is the case. As Senators will remember, there is provision in the 1953 Act that, even though a person's income is over £600 a year and his valuation over £50 a year, if he can prove a case of hardship, he will come under the terms of the 1953 Act. Now it appears that this present measure will do away with that completely. I would like to know from the Minister if that is really the case; it appears to me that it is. Of course, you could have a person with an income of £600 a year, with no family responsibility and you could have a person with an income of slightly over the £600 with a large family and yet the latter person would not qualify under the 1953 Act; but, as I said, there was provision in that Act to meet just such a case. I would like to know from the Minister whether that provision is being negatived by this Bill.

There is another point I want to make. I suppose this measure applies to people who are healthy and to people who are not so healthy. I would imagine that those who are not so healthy would be anxious to avail themselves of these provisions, while those who are healthy would be rather reluctant to become contributors to the scheme. The question is: will there be an initial medical test? Will people who wish to participate in the scheme have to submit themselves for a medical test before they are admitted to this insurance society, as I might call it?

I express the hope that the measure will succeed. As has been pointed out, there is a scheme such as this in operation in other countries, but the point is that what may succeed there may not succeed here. There are different social and economic conditions here from those in many other countries and probably people have a different outlook on life, and so on. All these things come into the picture. It is worth while giving this measure support; it is more or less of an experimental character as far as this country is concerned and I hope it will succeed.

Miss Davidson

I welcome the Voluntary Health Insurance Bill as giving an opportunity to people who so desire to make arrangements to meet expenses arising from unforeseeable ill-health. I would, however, like to refer, if I may do so at this stage, to what I think is a serious omission in the scheme. I am assuming that the scheme will follow largely on the lines of that outlined in the Report of the Advisory Body.

On page 9, paragraph 14, the report states:—

"Hospitalisation arising from mental disease or mental deficiency or from chronic senile diseases should normally be excluded from benefit."

While agreeing that mental deficiency and chronic senile diseases would have to be excluded, I do not think that all psychiatric illness should be excluded from the scheme.

The stress and strain of modern life have increased the incidence of mental upsets which, if they could receive early, skilled treatment, would disappear and certainly not deteriorate into a permanent or a serious state requiring long periods of hospitalisation. I would like the Minister to give us his views on this problem or to say if he would have the matter looked into with a view to having included in the scheme certain types of psychiatric illness.

The complete exclusion of hospitalisation for mental diseases is a serious weakness and is, first, a hardship on the mentally ill; secondly, it is perpetuating the stigma which prevents people seeking early advice; and also it is based on the false assumption that mental illness is always chronic and that treatment is long and tedious. The new approach to mental illness and its treatment has been revolutionised through modern techniques and the use of the new tranquillising drugs. Quite recently, the Board of Grangegorman Mental Hospital received a report from their Chief Resident Medical Superintendent that very gratifying results had been obtained from the use of these drugs.

Experts in the treatment of mental ailments say that under modern treatment patients can usually be relieved of their symptoms within a reasonable time. In view of the opinions of experts in the treatment of mental illness, on the shortening of the period of hospitalisation necessary for treatment and cure, I would ask the Minister to review the subject with a view to bringing at least certain types of psychiatric illness within the scope of the voluntary health insurance scheme.

Mr. Crowley

There are one or two aspects of the debate on which I should like to comment. I think it is very important that the House should bear in mind that if we pass this Bill in its present form we are putting an absolute obligation—make no mistake about it—on the board envisaged in the Bill to make absolutely certain from the beginning that the rate of premiums to be charged will be sufficiently high to cover the entire cost of the scheme itself. It is paramount that the House should bear that in mind.

It can be said with equal safety that the board for its guidance must turn surely to the Report of the Advisory Body as to the probable rate of premiums which they must seek in order to implement the scheme. I should like to emphasise this point, as I am satisfied that it is correct, that if any scheme involving a rate of premium such as that suggested in the Report of the Advisory Body is put into operation, it will be inevitable from the beginning that the selection of risk will be totally against the success of the scheme itself. That will follow automatically, because already there is sample evidence to prove that the class of people to whom this scheme might be said to make any appeal at all have already condemned the rate of premiums suggested by the Advisory Body, as being both unattractive and too high.

We should also remember that the particular class to which this scheme will appeal is, in fact, the class which is now contributing very substantially to the existing health services through rates, taxes and so on while they are debarred from any benefit from those services. Mark you, they are debarred. The House will agree that it is simply absurd to suggest that because a person has an income of £601 a year, or something above that figure, he is so well-off as to be rendered independent of any need for assistance. Quite obviously, the vast majority of such people need some little encouragement towards helping themselves in a scheme such as this.

I do not suggest there is any widespread demand or clamour for heavy subsidies or subventions from the State to provide benefits such as this scheme envisages for such people but, if we expect them to co-operate in helping themselves by making a success of the scheme, we certainly have on us an obligation to make some small contribution towards ensuring that the scheme will be workable. If we are satisfied, and I am afraid we must agree that it is so, that the rates of premium and the benefits offered by the proposed scheme are unattractive —I am certainly aware of the fact that they could be better and that quite a number of people at the moment are receiving better benefits for lower rates of premium—then surely we ought to recognise the fact that we must do something to make the scheme more attractive than it appears to be under this measure.

Now, if this scheme fails there will automatically be a very urgent demand for an extension of the existing health services under the Health Acts. That will be inevitable. Apart from anything else, there will be a demand for raising the upper income level. We should, therefore, take cognisance of the fact now that any extension of the Health Acts will unquestionably cost substantially more than a nominal subsidy or subvention to make the proposed scheme a real success.

There is ample evidence available to the Minister to show that he can be assured of the active support and cooperation of organised groups, largely representative of the classes to whom this Bill will appeal. These organised groups would be only too glad to help in this scheme. They would be only too glad to put the benefit of their experience, and it has been a very wide experience in the administration of schemes of this kind, at the disposal of the Minister and his Department without, in fact, adding substantially to the cost of the administration of the proposed scheme. I warmly support the suggestion made by Senator Murphy that even at this late stage the Minister should consider some alternative means of control and administration. That aspect of the matter should receive some further consideration from the Minister. Surely if the Minister claims and insists on retaining the right to appoint the members of the board and the right of complete control over the board—incidentally, of course, complete control over the scheme—it is not unreasonable to suggest that he ought to be prepared to pay at least portion of the cost of the scheme.

We can be satisfied that the difference between making a success or failure of the scheme seems to hinge on whether or not we can put something by way of practical help and encouragement and something by way of State subsidy or subvention at the disposal of the board to enable the board to produce a scheme whereunder the rates of premium will be attractive to a sufficient number of people to ensure the ultimate success of the scheme. If that cannot be done, then it would be better for the Minister to withdraw this Bill now. The Minister has no right to come in here seeking the powers he is seeking under this Bill while, at the same time, he is not prepared to contribute as much as one penny towards the scheme. In addition, he is demanding a complete monopoly of this type of business. That is unreasonable and unfair. Even at this stage, the Minister should be prepared to reconsider these aspects of the matter.

Mr. Hartney

I do not deny for a moment that the principles underlying this Bill are laudable and praiseworthy. As against that, however, and looking at the grave realities and at conditions as they are at the moment, I ask myself is the time opportune for the introduction of a measure such as this? There has been no general demand for it. The existing health services are providing a very serious problem not alone for the Department but for the local authorities as well. Indeed, the time has possibly arrived when it may be necessary to ask for more State assistance if the existing health facilities and services are to be continued and maintained. Local authorities are discovering to their dismay that their costs continue to mount no matter how they try to keep them down. Every letter that reaches local authorities from the Department is a request that they will do something which will cost more. In the light of that situation and because of the things for which money is badly needed by local authorities and cannot be found, is it wise to introduce this measure now? This is definitely a Bill which could afford to wait. In view of that I see no reason why the Government should seek to bring it into immediate operation.

That is one aspect of it. The cost of establishment of the new body is something that we cannot exactly forecast. This will be a new State body, which is to be set up, and straightaway headquarters must be found for it and maintained. Definitely, the managing director will be paid and, I presume, on a whole-time basis. He must be provided with staff and while that staff, I presume, will be small at the outset, it will probably grow and possibly become enormous as many of these staffs do. At any rate, the £25,000 that may be made available at the beginning will not, in my opinion, last very long because such a sum at present-day values will not go very far in the case of a body like this. These facts have to be borne in mind.

Regarding the running costs, if the scheme is not a success, what will happen? If, in three, four, or five years' time, the Minister has to admit that the scheme is not working, what will be done with the staff? If we have to carry on a branch of insurance at all, the way I look at it is that the Department of Social Welfare should be able to take on this job. There should be sufficient civil servants in Government employment to enable this experiment to be tried, and if it is not found successful, the staff can be reverted to their former posts and will not have to be maintained where they may have nothing to do. On the other hand, if a staff is established to work the scheme, there will be a liability on the taxpayers and the ratepayers even though the staff has no work to do.

All these are points that should be considered and I think it would be soon enough to introduce a measure of this kind when the various people it is supposed to serve make, through their organisations, a unanimous appeal to the Minister for such a scheme. I think the Minister will be doing well if he listens to that appeal then.

Another aspect of the matter is that the new group must apparently have a monopoly of this type of insurance. Assuming the scheme is working for a few years, and assume that in the meantime a body of people get together and organise a scheme giving better service at lower cost, would one not think that the Minister's attitude would be to say: "Private enterprise has come in and has beaten State enterprise, and I am now prepared to give way to them and let them cater for those whose needs we have been endeavouring to meet"?

Definitely if the premiums are to cover all the costs, the scheme will not succeed because the premiums will be too dear and the body will have to come back to the Minister for Health or the Minister for Finance for a subsidy. This will be a very dangerous point, because, as I said, ratepayers and taxpayers will be put to the pin of their collars, so to speak, to maintain health services already in existence or about to come into existence.

The Minister is correct when he says this will not be a profit-making body, but he should also have mentioned the extent to which it will look to the State for subsidy. I am fully convinced as a member of a local authority that, with things as they are at present, the time is highly inopportune for the introduction of such a measure. This is going to mean more expense on the people who are ill-prepared to meet any further rise in costs, especially in rural areas, where falling prices for their products every other day provide sufficient problems for them. If any help can be given to them, it should be given them to maintain existing services, if these are to be maintained, because I know the burdens that at present lie on the local and central authority.

Mr. S.T. Ruane

I consider this Bill is necessary because, notwithstanding the amount of enthusiasm and energy expended in putting over the 1953 Act, people did not have to wait very long to find out that its defects were far more evident than its effects. Those who advocated the principles of that Act on the score that it would not put more than 2/- extra in the £ on the local rates had only to wait for the first estimate after the first year during which the Act, or in fact part of the Act, was in operation to find out how much they were disillusioned.

Since the Act came into operation, local representatives in several parts of the country have been persistently pestered by people who have got green cards and are not satisfied with the treatment afforded and by people who have not got green cards and who cannot see why they have not, since they consider they are as much entitled to them as the people who have them. In many cases farmers with a P.L.V. under £10 have been for one reason or another, refused green cards.

An Cathaoirleach

This is not a discussion on the 1953 Act.

Mr. S.T. Ruane

This Bill will, however, be welcomed by many of these people and notwithstanding the fact that quite a big section in the country are always on the lookout for something for nothing, there is a large number who still feel that the best way of getting efficient service is to pay for it directly. This Bill will enable them to do so, if its terms are made sufficiently attractive for them to come in. I can say that after 30 years as a representative in an electoral division and long before health legislation was so much in the public eye, I never heard or knew of any case requiring institutional or domiciliary treatment and being denied it. It is only fair to mention that I know of several doctors who visited cases and refused fees because they felt, in the circumstances of the patients they visited, they could not afford to pay a fee. During those 30 years I have not issued 20 red tickets.

I agree with Senator O'Brien that if this Bill is to be successful its terms must be made sufficiently attractive to bring in the largest possible number. He instanced the manner in which the terms could be made attractive, namely, to have the premiums reasonable, to have a no claim bonus and to ensure that, as the Bill would operate and as the terms might be reduced, those who came in initially would be placed in no worse position as to premiums than those who came in latterly.

I believe also that provision should be made in the Bill for domiciliary treatment. In many cases, patients can be more successfully treated in their homes than in institutions. One of the complaints with regard to the 1953 Health Act was that in some cases where doctors came to attend patients on green cards, they sent to institutions those who could be successfully treated in their homes, thereby taking up hospital accommodation needed for more acute cases. I believe also that maternity benefits should be included in this Act. Even though many people who might be inclined to avail of the provisions it offers for medical treatment might be in a reasonable position to pay premiums, they should not be expected to pay separately for maternity treatment which for evident reasons they would not avail of. I feel it would not be difficult to devise ways and means whereby such people could be brought into the scheme at lower premiums.

Of course this Bill is an experiment as the Minister pointed out in introducing it; it is an enabling measure and it is only from the experience gained during the years in which it will be in operation that it can be improved to a greater extent. For all those reasons, I welcome the Bill. I trust it will be made a success, that it will be made sufficiently attractive to bring in the number of people to make it self-supporting in the shortest possible time.

Mr. Walsh

In these days of more enlightened social security and of a higher standard of living generally, it it only proper, in my opinion, that all classes of the community should be permitted to avail of the modern methods of science now available to alleviate suffering and prolong life. While the lower and middle income groups have these services within their reach, I fear that many in the so-called higher income group, who have numerous dependents and an income of between £600 and £1,000 per annum, are unable to avail of the specialised services now available because these are beyond their means. For that reason, many people of that class are living in constant dread of becoming ill and requiring hospital treatment or specialised services.

Frequently many of these people would like to have medical examinations, and because they cannot have these, the treatment they need is not given in sufficient time. This is particularly so in view of the heavy and, as the Minister has said, almost crippling expenses involved in getting hospital treatment or surgical and medical care which is not normally provided for the higher income group by local authorities.

Since the Health Act was introduced some three years ago, quite a number of people who were then in the middle income group, because of inflation since and because of the fact that their wages have increased, have moved out of the middle income group and are now in the higher income group so that the Health Act does not apply to them. For that reason, I feel this Bill is good social legislation and should be commended by the members of this House.

I trust that a sufficient number of people will avail of its provisions. Like Senator Sheehy Skeffington and others, I feel somewhat pessimistic about whether or not sufficient numbers will participate in the scheme. I fear that on the average the people in this country are not sufficiently insurance minded, that they are more individualistic than in other countries. I note from the Report of the Advisory Body that in the United States and in many European countries, more than half of the population are insured under voluntary schemes. These countries are more materialistic and less improvident than we are and for that reason I feel that a considerable amount of propaganda and advertisement will be required to make a success of this scheme, to put it across to the people.

People in good health often fail to realise that they may require medical and surgical treatment within a short space of time. It is the duty of these people, both for themselves and their dependents, to avail of such a voluntary scheme as is suggested here. They would also in that way be helping their fellow-men because they would be contributing to making the scheme a success.

No doubt the cost of administering this scheme will be high. It is suggested the cost will amount to 30 per cent. of premiums. Like all such schemes, the cost of administration will be high because of the fact that there is no proper incentive to work and that the staff are inclined not to work sufficiently hard or to be too extravagant in the sense of devoting too much time to paper work. Apart from the Minister, there appears to be very little check on the activities of the board under the provisions of this Bill. The Minister specifies the extent of the scheme under Section 4. He has the job of appointing the members of the board and under Section 6 has power to lay down the terms of appointment and remuneration. Under Section 7, he may at any time remove a member of the board, and under Section 15, the board, with the Minister's approval, may provide pensions and gratuities for the staff. Section 22 empowers the Minister, at his absolute discretion, to grant or refuse a health insurance licence to any other person.

Does the Minister feel that healthy competition is bad, even though the board will have the advantage that they are not out to make any profit, which would not be the position in regard to any corresponding concern that would attempt to run such a scheme? When there is no proper competition, there is no real standard of efficiency. I have been wondering why the Minister should exercise all this control, seeing that there is to be no loss of public funds through the operation of the scheme. Surely those who pay the piper are entitled to call the tune. Would it not be fair that the subscribers to the insurance fund should have some direct representation on the board? Would it be wrong that members of the subscribers should be entitled to be elected to the board, say, in a voluntary capacity? Senator Murphy has already made some reference to that in his speech in connection with voluntary members on the board. I feel it would be a further desirable check on the activities and the finance of the board. It might help to give the subscribers more confidence in the scheme and to prevent any ill-informed criticism of the board at a later date.

Like some of the other speakers who have contributed to this discussion, I feel it is not unreasonable to suggest that the Government should contribute something towards the administration costs, particularly if the costs are going to be as high as 30 per cent. I feel that because they may be under the control of the Comptroller and Auditor-General and that there will be ministerial checks, the costs of supervision of the scheme will be greater than if it were run by a private company. I do not see anything wrong in the State contributing towards the subsidising of health, in view of the fact that the State already contributes towards subsidising people in the higher income group—say, in the case of children's allowances and subsidies on flour and possibly by the allowances which are permitted in respect of dependents under the income-tax code.

The Minister has stated that the number of people in the higher income group amounts to only 500,000. In view of the fact that some of these people are already permitted by the county managers to avail of the Health Act, because of hardship, that would reduce the numbers who are still outside the Health Acts. Considering that quite a number of people will still refuse to join this scheme, and that the local authority will in many cases have to come to the rescue of these rather improvident people, I wonder if it would not be wise to consider permitting the higher income group to have hospital and specialised services provided under these Acts? It would save a considerable amount of investigation of means and it should not involve a very large increase in the expenditure under the Act, in view of the fact, as the Minister states, that five-sixths of the population are already being provided for. I feel that eventually the State will have to come to the rescue of this fund because too few people will, at least for some time, join this scheme and because the administrative costs will possibly put up the premium.

Mr. Burke

In this Bill, the Minister has tended to outline what many people, particularly that group which is described as "the middle class", have been looking forward to for a considerable time. They have always felt that those in the lower and middle-income groups have been helped and assisted. These higher income groups do not require assistance nor do they wish to have assistance, but, in modern times, and in view of the advances in medical science where sometimes the costs of treatment are enormous, the cushion of an insurance policy would be a decided advantage. Senator ffrench O'Carroll referred to the cost of treatment with modern drugs. That alone—apart from surgical and medical treatment—can be very expensive and can often be well-nigh crippling.

Senator Walsh's suggestion that the Minister should have the Bill adequately publicised is a very valuable suggestion. It is only when illness attacks us that the benefits of a scheme of voluntary health insurance are brought home to us. A long illness or a series of family illnesses can cripple most well-to-do people and the most resolute sections of the community.

Senator Sheehy Skeffington dealt with many matters. He described the Bill as private enterprise in health services. He went on to say that we should have an overall State-supported scheme. The particular reason he gave for that suggestion was that all other sections of the community, such as industrialists farmers, and so on, are being subsidised. I do not propose to deal with that because I think it would be out of order on the Bill, but I disagree even with his contention with regard to the subsidy. In many cases, what is called a subsidy to people engaged in industry is the fact that there are proposals to allow them to retain some of the money which they themselves earned for the benefit of that industry and the benefit of the people working in the industry and the benefit of the community at large. The introduction of a Bill for voluntary health insurance is most important. It encourages people to do something for themselves and it points out their responsibility to them. It is an act of faith in our people that they will do these things for themselves rather than expect the State to do them for them. The most important thing which anybody who has to bring up a family can have is a sense of responsibility and a sense of self-reliance. I understand that the modern State is called a paternal State. If it is in the true sense a paternal State, it ought to encourage these desirable traits which are good in the individual.

The Minister has turned complete face to the modern trends. The modern trend is all towards a self-reliant State. It has been found in many respects that the State is not even competent in the economic sphere. When little chinks occur in the Iron Curtain, many of the economic ventures of totalitarianism are shown to have been very futile. I think it will also be demonstrated by a Bill of this type that if this large section of the community of at least 500,000 people can be encouraged by the payment of a premium to provide health insurance for themselves, the Minister will have done a lot for the people of this country and he will have done a lot that we may in future years wish to thank him for.

Senator Kissane referred to persons with incomes over £600 a year and farmers with poor law valuations in excess of £60 and said that it looked to him as if this new Bill, when it became an Act, would exclude them from the benefits which they enjoy under the earlier Act, and that if these two categories were able to show that owing to the length of illness, or any other reason, the charge in full or in part, the cost of hospital and other services, was an undue burden, they could ask that the local authority help them either in part or in full. Senator Kissane was of the opinion that the new Bill would deny these people that benefit. I cannot see anything in the Bill that would suggest that, but I ask the Minister to clarify that when he is replying because it is very important, and I believe that if it went abroad that that section of the community, with, say, £600 to £800 a year, or a poor law valuation of £60 to £70, are to be denied benefits, which they enjoyed under the earlier Act, it would make this measure very unpopular. I do not believe that is so.

In conclusion, I want to say that everybody should appreciate what the Minister is doing in regard to voluntary health insurance and particularly those sections of the community who have been able to make a success of free enterprise in many other respects, and will be encouraged to look after their own interests.

Mr. Bergin

I find that I have no welcome whatever for this Bill. I do not believe that a Voluntary Health Insurance Bill will go any way at all towards lessening the amount of preventable suffering in this country. I believe the only way we can prevent it is by having a State health scheme similar to that in operation in the north eastern part of our country. The Minister has said in the Dáil that to bring in such a State scheme would be to belittle our people. I do not hold with that view. We do not seem to belittle our people when we have local authorities providing such things as sanitation and it does not seem to belittle us in any way if we avail ourselves of the free State primary education. It does not seem to affect us if we avail of the completely free T.B. services. I would like the Minister to explain, if he could, why it is all right and not unethical and not belittling for persons who are unfortunate enough to contract T.B. to go into a sanatorium and be treated free of charge for their cure, and why a person who is more unfortunate and contracts cancer, is left, in a lot of cases, dependent on his own resources for any hope of a cure.

I know that this business of health has been made the subject of a lot of heated discussion and was discussed from the financial and ethical points of view for a long time. I think all of us would be happier if we could be certain that there was nobody in the country suffering materially and I think the only way we can bring about that situation is by having a State scheme. I think a country such as England, which has a State scheme, a country which taxes its citizens in accordance with their wealth or lack of wealth, takes more from the wealthy and less from the poor, but gives back to all with a completely free scheme and affords the same treatment to its visitors, gives an example of Christianity in practice that we could well follow.

The case may be made that we cannot afford a health scheme on the same lines as in England. I do not believe that either. If a person is sick, he pays either directly, if he has not got the benefit of a State scheme, or indirectly, if there is a State scheme. In this voluntary health insurance scheme, we are asking a particular section to pay for their hospitalisation after they have already contributed to provide hospital services for other sections of the community.

I would like to say that the terms of reference of this Advisory Body, as a result of which we now have this Bill, are important because the body were not asked to advise whether or not the voluntary health insurance scheme was good but only to say whether or not it was possible. They were not asked to advise whether it would be better than a State scheme or whether we could get a better scheme. They have only told us that we can have a voluntary health insurance scheme and that it could be worked in this way. I would suggest that the Minister should set up a further advisory body and ask them to advise him whether or not a State health insurance, free for all, would be possible and whether or not it would be better than the one proposed and whether we could work it here.

Mr. O'Reilly

Many members of this House have expressed agreement with this measure, in so far as they saw in it an attempt to make as many people as possible self-reliant and provident in regard to this question of providing a health service by way of contribution. In so far as it can be admitted that that principle is enshrined in the measure, I would welcome it also. It is a good thing, in my opinion, that people who can be self-reliant should be self-reliant and not rely on the State or local authority or on anybody other than themselves for providing services which are fundamental. There is a moral responsibility, on people who can, to provide such services and that can also be said in regard to education and many other services. It is not a very good principle that people should rely on their poorer fellows, or weaker brothers, to help them provide something which they should be able to provide themselves.

I wonder how far is that principle being achieved in this measure? After all, there was nothing to prevent people in this country in the past from entering into a contract with some insurance society, and there are such societies doing that business in this country, to ensure that, by paying an annual premium, they would cushion themselves against the effect of sickness. This measure proposes to enshrine this grand principle and I wonder will it achieve it in fact? I hope that it will, but I doubt it.

This Bill has up to 24 sections devoted to setting up a board, outlining its powers and functions, and outlining the officers of the board and the power of the Minister to borrow money, either as a moneylender charging interest or without charging interest, as the case may be. The rest of the Bill is devoted possibly to denying to people who may have been provident in the past the right of insuring with an insurance company against sickness or accident or against both, unless that company is pleasing to the Minister or to the board. When the machinery is set up under this Bill, if it does appear that certain insurance companies doing this business can give better terms and better service at the same premium or at a lower premium than the board, what will happen?

There was no great effort made by the Minister or by anybody else to lead the people to the mental condition in which they would realise that it would be a good thing for them to pay a little as they went along and protect themselves against the impact of sickness or prolonged illnesses, either on themselves or members of their family towards whom they have a moral responsibility. Very little was done along those lines until a controversy arose and a professional group, a trade union, if you like, claimed that was the line along which health services should be organised. We had a group of people whose interests were involved pretending to act on a major principle. Every time I hear people talking about principle, particularly when their own interests are involved, I always think of the comment made by the late Senator Colgan, who said, when he heard a man talking about principle, it reminded him that it was against the man's interest to pay the principal since it was against his principle to pay the interest.

As I say, it was only when that viewpoint was put forward by a group of people who had a definite professional interest that this idea was promulgated. It was promulgated only when there was an attempt being made to provide minimum health services for the weaker sections of the people. That service was being attacked and statements were made that should not have been made. While it might be in order to go into that, it would not be a good thing to go over that same ground again. However, there are people and I know there are members of this House, who have, over a long period, paid into insurance companies to cushion themselves against sickness or accidents, or against both.

Consequently, I am somewhat worried about the provisions of Sections 25 and 26 of this Bill. I should like the Minister to give an assurance that the people who have been paying premiums to insurance societies will not find themselves in a worse position as a result of this enactment. They should be free to pay into any business organisation they think fit to protect themselves if they so elect. I am worried in case that section operates against such business concerns if it appears that their service is as good as or better than that of the institution being set up under this Bill. I am brought to the conclusion that it is felt, even by the Minister, that this measure cannot operate too well, that he does not want competition in this field and that as far as possible competition will be limited. I hope I am wrong, but I fear I am right. I would be very happy if the Minister would give an assurance that I am wrong.

There are many insurance companies operating every branch of insurance in this country, including cross-Channel companies. So long as they comply with regulations laid down by the Department of Industry and Commerce under the Insurance Act, they are entitled to operate along these lines. If they are allowed to operate in other fields of our commercial life, I do not see that it is logical to debar them from operating in this field, just as I understand the Western Provident Society will be debarred in this respect.

There is no compulsory insurance under this Bill, whereas under the health scheme there is compulsory insurance. The State under the Health Act compels people through rates and taxes to cushion themselves against the impact of prolonged illnesses. Everybody has a responsibility to his fellow-citizens. We are our neighbour's keepers, so far as this is concerned. The people who come under this scheme have to pay substantially through rates or taxes for the operation of the Health Act and they are being given the choice of protecting themselves through a State run voluntary society. It is a compulsory voluntary society, if one could reconcile one term with the other. It is compulsory in so far as the Minister has certain powers under the Bill when it is passed, and it is voluntary for those who elect to join and pay their premiums. The Minister, while he has absolute power in the running of the scheme, through the board which he appoints, is protecting himself and the taxpayer by ensuring that he will not contribute in so far as he may lend money with or without interest at certain times, either in the initial stages or when the board requires money to discharge their responsibility.

Although the Minister is not a man who is easily frightened, he does seem to have got a bit scared by the pressure exerted by a certain professional society, and, in order to meet the wishes of that society, we have this measure. That is a view I cannot help coming to. If I thought the scheme would work, I would welcome it, but I cannot see it working. The cost in regard to the servants and officers of the board would also be a drain on the financial resources of the association. Having regard to the fact that this type of insurance was never developed in this country in the past, I cannot see a large number of people joining in the scheme at this stage. Also, terms as good as can be provided by other societies cannot be given at the same premium cost.

The Minister may regard me as a pessimist, but I am, indeed, worried about the attempt that may be made to prevent competition and I know there are other people who are worried about what will happen in that regard. If it is a success, I will be pleased because it will have the effect of making people more self-reliant and more provident in ensuring they will provide for the day when they themselves, the members of their families or their dependents, are visited with sickness. In that respect also they can feel consoled because they will not have to call on their poorer fellow man to pay in taxes or rates towards protecting them against sickness. I hope the scheme will be a success but I have grave doubts.

Mr. Cogan

I think the Minister will agree that the House has not received this Bill with very wild enthusiasm. That is understandable because it is rather difficult to be enthusiastic about a measure which to the ordinary man whom it affects means paying an annual premium. The most he can hope to gain by way of return for that premium is that he may be lucky enough to have a series of major operations and, as a result, may recover a substantial amount of money. At the same time, I think most people will acknowledge that it would be an advantage to have at least a scheme which would protect people from a very severe cost. As we know, the type of person affected by this Bill is the person with an income of £600 or over £50 valuation. That type of person could meet the smaller liabilities of illness and take them in his stride, but what he would fear most is a very severe illness which would involve a prolonged period in a hospital or institution with high surgical and specialist fees and which might lead him to poverty. That is what I think most people would have in mind when thinking of a scheme of this kind. To meet that demand, it is desirable that some kind of a scheme of this nature should operate. At first glance, it would seem that the best way would be to have the premium as low as possible and only meet the more severe charges, but in practice that might not work out because if a person would only receive benefit, where the expenses would be very high, a lot of people would feel they would never derive that benefit and might not be inclined to insure at all.

That is why the maternity benefits were suggested by some as being an advantage to the scheme in making it more popular. That is a question about which there could be a good deal of difference of opinion. If the number of people who would benefit under the scheme is enlarged by making the benefit more widespread, then there is a likelihood that a greater number will be inclined to insure.

What strikes me is this—it is a question which I have risen to ask— has every alternative been considered? There are a number of alternative methods by which this protection could be provided. The method embodied in this scheme is the establishment of a State non-profit-making company specially for the purpose. There are a number of Irish insurance companies who are not prepared, it has been proved, to take up this type of insurance. If they had been given encouragement by the State and if they had been given some little financial backing, would they be prepared to take it up? If they were, it would seem to me to be a better scheme than this, because if the ordinary commercial insurance companies were to take up this matter, at least we would be relieved of the high administrative costs which are involved in the scheme embodied in this Bill.

Moreover, a commercial insurance company could offer a more varied type of benefit. They could offer a more attractive type of policy which might attract more subscribers. I should like to hear from the Minister if that alternative was considered or if there were any negotiations with existing Irish insurance companies to see if they would be prepared to handle this matter. It would be very bad from every point of view if, having enacted this legislation and put this scheme into operation, it were to collapse through want of support or through the draw on the fund being greater than the subscription.

It is almost inevitable that, in a voluntary insurance scheme of this kind, the type of people who would be attracted to subscribe are the type of people who expect that in a very short time they may need benefit; people who are health conscious, perhaps because of the condition of their health, would be the most likely to subscribe. In that way the draw on the fund would be greater than its income.

I cannot say, however, that I would be attracted by the idea of making insurance of this kind compulsory, because that in itself would carry with it a number of other evils which we would like to avoid. I do not hold the view that insurance makes people more self-reliant or independent or anything like that. Compulsory insurance is very much on the same lines as compulsory contribution to general taxation. Once people are compelled to pay their share, they all vie with one another at the same time to get all the benefits they can. They all join together to draw upon the funds of the State or of the statutory body concerned. It would have been far better if the commercial insurance companies could have been induced or encouraged —or even, in regard to this particular service, subsidised—in order to get them to carry out this scheme.

Senator Crowley, I think, made the statement that if the rates of premium are found to be inadequate they must be increased and in that way insolvency can be prevented and the scheme can be kept going. I would not be as optimistic as that. I think there is a real possibility of this scheme breaking down. An increase in the premiums would not keep it going, because the net effect of such an increase might be to reduce the number of subscribers and the last state would be worse than the first.

One of the features of this scheme is that the administrative cost will be rather high and will eat up a considerable amount of the income of the fund. That is why the Minister is taking a risk and has taken a risk in bringing in legislation of this kind, because if it fails, the condition will not be better than it was before the scheme was introduced, but will be worse.

I would be in wholehearted agreement with what Senator O'Brien said about the reduction of premiums for people who do not make any claim against the fund. It is always desirable to encourage people who pay into a fund of this kind, to keep on paying even though they are not getting any benefit from it. The type of subscriber who pays in and who avoids making claims as far as possible—it may be through good fortune, but even in regard to minor illnesses, he may not make a claim—should be recognised by having his premium reduced. The Minister and the House are taking a certain risk in regard to this measure. It may be that the possibility of failure is fairly high and it is not going to be a benefit to the community, if it does fail. In matters of this kind, particularly in a democracy, you can always revise and readjust any scheme from year to year. The operation of this service will have to be kept under very close observation and if it is found not to be working out satisfactorily, the Minister should be very ready to come back to the Oireachtas and seek to have it revised rather than allow the whole thing to collapse after it has been established.

Mr. O'Higgins

The position, with regard to this proposal, appears from the discussion here to be that most members of the House, with one or two exceptions, recognise that there is need to provide some form of help for that section of our community who at the moment can depend only on their available income to meet the expenses attendant on illhealth.

I would like to emphasise to the House, as the Minister responsible, that, in my opinion, that need cannot be over-emphasised. I think it is true to say, irrespective of how fortunate one may be in the possession of this world's goods, that to-day a serious illness may constitute such a serious financial blow as to cause anxiety to anyone at all. With increasing hospital expenses, with growing surgical and medical techniques, the attendant cost and expenses of illness are rising every day. Accordingly, this problem must be very present to the minds of most people who have to look after themselves and look after their families. It is true that, particularly in the last decade or so, most States and most Governments have become conscious of the anxiety caused to citizens by the increasing expenses attendant upon illness. Most States have felt that there is some responsibility on the State to help; others have felt that the responsibility should be that of the State to take over the whole burden.

In Britain, as has been mentioned, the view was accepted that the State should supplant completely the individual's obligation to look after himself and his family. In Britain, as a result of that decision, from the cradle to the grave, every man, woman and child is assured by the State that they need have no fears, no worries, no responsibilities and no obligations. That is the working of the Welfare State and I have no doubt that it is an easy way of doing things and that it makes the lot of the individual probably more careless and gay.

Here in this country in recent years, we had to look at precisely the same problem. Prompted undoubtedly by developments in England, there was a more general public consciousness here of the need for some form of help by the State in relation to individual health problems, but having looked at the question, we did not come to any clear decision. We came to the compromise decision and decided to introduce a form of State medical scheme for a section of the population, and, of course, the section concerned was the majority. That was no doubt an element in the decision. But we left completely unaided many thousands of citizens and I do not think we could have regarded ourselves as facing up to this problem if we did not take some step to meet their case.

Senator Hartney has suggested that there is no demand for this measure dealing with that section of the population. I could not accept that. I feel that there is a demand, a very definite, pressing demand for the State to provide this or some form of help for these people. The way proposed here is not an easy way. It cannot be put forward with any certificate as to its simplicity or possible success, but it is put forward by me, as the Minister responsible, in the firm belief that it will succeed because I believe that our people will see that it will succeed.

Senator Sheehy Skeffington has given his view that this proposal will be a disastrous failure. I would rather put it this way: if it is a failure, it would be disastrous. I do not think it will fail. I feel that more and more people now realise that these responsibilities must be faced by each individual in accordance with his means. If a man cannot look after his family, if he cannot provide for himself, then it must be the concern of the State to provide for him fully and adequately. If he can meet his own responsibilities, then he is less than a man if he does not do it. Over the years we have had a plethora of different countries, with different welfare schemes and the different Ministers have come forward with wonderful schemes designed to provide free this and free that for different sections of the people. They were doing that largely in order to curry public favour and in order to get the public to believe that there was some limitless well from which money could be provided for a variety of different purposes. There is no such limitless well in this or any other State, and I believe there will be a growing appreciation of the fact that in relation to many of the individual responsibilities people will have to stand more and more on their own feet.

Senator Cogan said it was not surprising that this House, or the individual Senators, might not be enthusiastic with regard to a scheme under which a person could only derive a benefit when he undergoes a major operation or series of operations. That, of course, is a point of view which might have been advanced originally as an argument against insurance. Each person—Senator Cogan included, I assume—who has regard at all for the value of his property or his land or his business, his house, or his own material possessions, is prudent enough to provide against the risk of fire, or burglary or loss, and he pays fire insurance, under which, of course, he will only benefit if a fire breaks out or if a burglar comes in, or if he loses the articles insured, but that is the prudent thing to do and people have been doing it for years.

They have been doing it in order to preserve the goods they possess, the things they own, and in order to ensure that if an accident happens, they will be in a position to replace what is burned or restore what is stolen or lost. Is it too much of a stretch of one's imagination to apply precisely the same ideas of prudence to the preservation of one's own personal health or that of one's wife and family not on the basis that one pays for the pleasure of hospitalisation or operations or anything of that kind, but because it is prudent to ensure that if these things happen, one will be in a position to meet one's responsibilities on such a sad occasion? I would like to believe that people who through the years have availed of insurance for a whole lot of other purposes would be determined to ensure also the gift of health.

Senator ffrench O'Carroll and some other Senators suggested, or rather posed the question, here as to whether this insurance proposal was intended to be in addition to, or in substitution for, our present health services. I should like to remind this House—I think I am entitled to do so—that when I became Minister charged with responsibility for these matters, I did not have an easy problem facing me. I found in relation to health services conditions approaching chaos. So bad were those conditions that it was necessary for the Government to authorise me to seek certain powers to deal with the problems which then confronted me.

I never made any secret of the fact that, under the Health Act, in my opinion, it was inevitable that a number of people who could well afford to pay for themselves were being subsidised in their health services by the ratepayer and the taxpayer; but I was not so much concerned with regard to those people as I was concerned with the many thousands who were intended to benefit under the Health Act and who were unable to provide for themselves. I told this House, as I told the Dáil, that it would be my concern, although the problem was obviously difficult, to provide the services under the Health Act as quickly as I could. I think I can assert now, some 18 months later, that it has been possible to do precisely that.

To-day, the services intended by the Health Act of 1953 are in operation. When I say "the services", there are some small services which, for obvious reasons, could not be provided at the moment, but the substantial portion of the services under the Health Act are fully in operation now. When, therefore, I come forward with a proposal of insurance such as is envisaged in this Bill, it is clear that this form of insurance will and should exist side by side with the present services under the Health Act. People should have available to them a free choice, if they are eligible for services under the Health Act, to avail of present services or—and I am going to encourage them —if they prefer to make their own arrangements under health insurance they are free to do so.

Quite obviously, those who would prefer to make their own insurance arrangements will be that fortunate section of eligible patients under the Health Act who, in fact, are able to pay something in relation to their own health services. It was never intended under the Health Act, though it was impossible to provide a ready means of excluding them, that those who could afford to meet their own health costs should, in fact, be subsidised in that regard by the taxpayer or the ratepayer. Those people will now have an opportunity of availing of health insurance, but they will not be compelled to do it. If they prefer to continue to avail of existing health services, those services will be available to them at as high a standard as I and my Department can ensure. The matter then will be entirely one for the individual himself—namely, whether he prefers to continue to avail of services, in the knowledge that he himself could make his own arrangements in a simple way.

Senator ffrench O'Carroll and others joined with Senator Sheehy Skeffington in doubting whether this proposal will succeed. Whenever any new proposal is made, there are those who sit back and "tut, tut" and wonder if it is wise. Of course, it is never wise to move out on the streets because you might be knocked down by a car. It is never wise to take a risk. But, if one does not take risks, then, in fact, no progress is ever made. I do not know whether or not this will succeed: I believe it will. I am fortified by the views of the very representative body that I asked to consider this matter— a body which comprises amongst its members those expert in insurance, at least one person prominently identified with this form of health insurance in Britain, another person who is an actuary of considerable standing, also trade union personalities, doctors of considerable standing and persons representative of different sections of our people here. That body was unanimous in its view that this form of insurance would succeed in this country. I hope Senator Sheehy Skeffington and Senator ffrench O'Carroll will pardon me if I prefer to act on the view of those people rather than be depressed by the pessimistic views expressed here.

I can well understand the suggestion that has been made by different Senators that this insurance proposal, in order to succeed, must be as attractive as possible. That is so fundamental that I do not think it needs much discussion. I feel that Senators who have that in mind fall into the sort of mistake into which I fear Senator O'Reilly fell. At the moment, just to make things clear to members of this House, there is no form of health insurance such as is envisaged in this Bill available to our people, none whatsoever. One Irish company some years ago pioneered in this direction and offered a scheme of health insurance to the people. That company, in the middle or the end of its second year, discontinued this form of insurance. The position, therefore, is that there is a void and there is no means whereby any person can cover himself or his family against the risks of ill-health in the manner suggested by the Advisory Body in its report.

It is true that some of the bodies at present operating in Britain have investigated the possibility of offering their schemes to our people here and, in fact, one such organisation, I think, has actually sold policies to persons in this country. May I make it clear that each of these organisations, the British United Provident Association, the Western Provident Association and these other similar bodies are not, under existing law, entitled to engage in this form of insurance in this country? They are prohibited in accordance with the provisions of the Insurance Act of 1936 and I would like to say that the prohibition in that connection is perhaps fortunate for the British associations themselves because they could not possibly—and I want to say this cincerely—sell the kind of policy in this country that they can offer successfully to people in Britain, at similar premiums. Our conditions are quite different.

Remember that in Britain, first of all, the average size of families is less than half the size of families here. That is a very important element in relation to the size of premiums. In addition in Britain, with State medicine available, it can be understood that people taking out health insurance for a variety of minor ailments and minor difficulties avail of existing health services and it is only in relation to the more serious illnesses that they avail of their insurance scheme. The result is that quite a lot of expenses are saved through the operation of the National Health Service.

Information on the size of premiums on offer in England and the experience of the British companies was available to the advisory body. In fact, as I indicated, they had the services of one of the British experts on this matter and having availed of actual experience in Britain and having carefully considered our circumstances here, the advisory body's report on premiums represented their considered view as to the kind of premium that would have to be charged here.

Again, one can only refer, if anyone is in doubt, to the experience of the Irish company which engaged in health insurance in this country some two or three years ago and which offered policies at much the same premium rates as those offered by these British companies. Very quickly, that company had almost to double its premiums and in fact could not continue. I think it would be foolish to assume that because in relation to British circumstances a premium of a particular size can be offered there it can also be offered here. It is my view, and I can say it definitely now because I do not believe it can ever be tested one way or the other, that if some years ago the prohibition in the Insurance Acts 1936 did not operate and these British companies offered health insurance in this country, they would have found very quickly that they could not continue unless they substantially increased their premiums.

I have been told that some of these schemes are in operation in certain parts of the city and I am also told that those associations which operate them find that their outgoings far exceed their premium income because the premiums are too low. Having said that, just as background to the question of premiums, I would not like it to be accepted as definite that the premiums suggested in the Advisory Report will in fact be the premiums charged by the Health Insurance Board. One must remember that the premiums in this report are based on each individual subscriber and if the report were to be criticised at all, I think it could be criticised on the side of caution. They have been cautious in their approach and they have taken, in considering the premiums, merely the individual and, as Senators have pointed out, they have taken a very high percentage for administrative costs. Certainly in relation to the premium that they have suggested it cannot be said that every element which should be considered has not been considered.

I would imagine that the Health Insurance Board, when they come to put their scheme on offer, may be able to consider the facility whereby premiums can be collected from a large group of persons and they may be able in many cases to offer premiums substantially lower than suggested in the report. Even assuming that the premiums remained at precisely the level set out in this Report, remember that the maximum premium is £15 per year. That represents about the price of two packets of cigarettes a week and I do not think that for a payment of that size, the individual, the family man, is getting a bad bargain in relation to the insurance he will have with regard to the health of himself and his family. In addition such a person paying a premium of £15 per year will also have available, under the Finance Act of 1955, an income tax allowance in relation to his health insurance premiums. These are matters which I think should be considered in assessing the size of the premiums and whether they are too high or not.

I can understand the case made by Senators that there should be some form of subsidy made available by the State and the Government. In fact, of course, the financial provisions in the Bill do provide what I regard as the necessary help from the State in the initiation of this scheme. The two sums of £25,000 should, in my opinion, be adequate to tide the Health Insurance Board over the initial difficulties they will encounter in offering this scheme to the public.

I would not under any circumstances say that this measure is in any way perfect. Of course, it is not. It may be necessary, in the light of experience, to have regard to whether certain modifications or amendments might have to be made, but it is a start, I believe, on a good road. I think that if the people appreciate the purpose behind this form of health insurance, it will be availed of.

The present health services will continue and their standards will in no circumstances be reduced, but I do not believe that the continuation of our present health services will in any way militate against the success of health insurance. As I say, it is an experiment. I believe it is a worth while experiment. I believe it will succeed, but it will only succeed if people generally throughout the country realise that under health insurance they have an easy and attractive way of facing up to their own personal responsibilities for themselves and their families.

If they approach it from that point of view, surely we in this country will make a success of a form of insurance which is strictly in accordance with our traditional views as to the individual dignity and feeling of self-respect. I have the greatest possible hopes for the success of this scheme. I believe that people generally will co-operate with it and in that sense I commend the Second Reading of this Bill to the House.

Question put and agreed to.

Acting-Chairman (Mr. Kissane)

Next stage?

Professor Hayes

The first sitting day after Christmas. We cannot decide on that until we see what happens to the Finance Bill next Tuesday.

Committee Stage ordered for the first sitting day after Christmas.