Health Insurance (Amendment) Bill 2014: Committee Stage

Section 1 agreed to.
Amendment No. 1 not moved.
Section 2 agreed to.
Section 3 agreed to.
NEW SECTIONS.

I move amendment No. 2:

In page 4, after line 42, to insert the following:

“Insertion of new section 7I to Principal Act

4. To insert a new section, after section 7H, of the Principal Act:

7I. Any medication which is available to a public patient, and is approved by the National Center for Pharmaeconomics, and is deemed necessary for treatment of a patient by a medical practitioner, must also be made available to those patients who hold a health insurance contract, the cost of which will be borne by the health benefits undertaking with whom the patient holds a health insurance contract.”.”.

I welcome the Minister and congratulate him on his speech last night. It was a rare example of clear political thinking and leadership and he deserves great credit for it. He managed to take a complex issue, distil away a lot of the emotion and talk about the hard issues we will have to discuss without bowing to the whims of extremists on either side. I salute him for it.

I will slightly disagree with the Minister, however, when he said that clearly something would be necessary to replace the eighth amendment. The Constitution ticked along very nicely for 46 years or so before the eighth amendment to the Constitution was introduced. My own belief is that if the will was there and if the will of the people was simply to remove it from the Constitution, to repeal it, there would probably be some fine-tuning with certain aspects of legislation which were formatted after the amendment came into effect and reflecting the strictures placed on them by the amendment, but in general these should be legislative rather than major constitutional issues. This does not mean that I am pro-abortion, anti-life, pro-choice or anything of the kind. It merely states the appropriate form for very nuanced, often technically, scientifically, medically and ethically complicated issues is in well contrived legislation. I do not feel there is any reason that should not be the goal for which we are aiming and people of goodwill who are occupying what I believe is the genuine middle ground on this issue would actually see this.

With respect to the business at hand, it is one of those funny things that people say not to be too personal when doing stuff in the Chamber, but because of my day job, I do actually see examples of things which I have the opportunity to highlight in a legislative forum and this is one of them. It has become apparent to me that there has been an appropriate and increasing scrutiny of the cost of drugs used for various illnesses, not just drugs but also treatments and tests, and an appropriate degree of scrutiny of things like cost-benefit analysis, quality, adjusted life years, incremental costs and effectiveness ratios. I totally understand this. I have written on health economics. I am not one of these naives who believes doctors operate in an economic vacuum and that there is not an opportunity cost on some other part of the health service for every penny that we spend on care for cystic fibrosis or cancer or diabetes.

That said, I do believe there are a number of remediable dysfunctions in the way the private insurance market is interacting with the question of procurement of drugs. I have seen it most specifically in cancer drugs, but I believe it happens in other areas also. There are certain drugs which are approved by some companies and not approved by others. One could state that in a competitive market, with a truly informed class of customers, this should not be a problem. People will elect to purchase product A versus product B. The reality, however, is that this is not the way these things are decided. People do not know in advance that a particular cancer drug, cystic fibrosis drug or drug for macular degeneration may not be available to them on the insurance. As a result, it is a distorted market. Completely distorting the market is the reality that there are two public entities which, in effect, become competitors of some of the private companies in this respect. One of them is their obvious competitor, Voluntary Health Insurance, which is basically back-stopped by the State and for which the Minister acts, as he pointed out the other day, as the sole shareholder. As well as that, there is the State, because the companies can withdraw from the emotional aspects of the debate about a potentially life-prolonging and life-saving drug by stating they will not get it, often in situations where the State will do it.

My own sense is that when people pay extra money for health insurance in addition to the money they pay in their taxes which subsidise the general health system of the entire country, perhaps they should expect that they will be given at least the same standards of care and the same access to newer treatments and technologies as they would have if they were to go through the public system. This strikes me as being an extraordinary example of the ability of the companies to cherry-pick in a very subtle way. They have these two distorted competitors who act at a certain disadvantage to them because they, unlike the private insurance companies, will have a degree of public accountability and public answerability. For that reason, I ask the Minister to consider this amendment. This is not carte blanche for any doctor to prescribe any drug to any patient. This is very specifically an attempt to make sure there is an equal playing field on access to some of these new treatments and that there is not, in fact, an incentive on two companies to decant patients' demands back either to VHI, if it is a non-VHI policyholder, or to the State.

The National Centre for Pharmacoeconomics, NCPE, carries out health technology assessments for pharmaceuticals in Ireland and aims to provide impartial advice to help decision-makers provide the most effective, safe and value for money treatments for patients. In Ireland, once a product is licensed for use in the public health system, the relevant company can make an application for reimbursement to the HSE. As part of the reimbursement process, the NCPE carries out an assessment and makes recommendations to the HSE. The NCPE report is an important input to assist the HSE in its decision-making process and informs further discussions between the HSE and drug companies. When considering any application for a new product on the reimbursable list, the HSE considers a wide range of criteria. In addition to the NCPE findings, the HSE will also consider the overall health needs of the public and the proposed benefits and risks of the product, as well as the resources available to the HSE.

Minimum benefit regulations made under the Health Insurance Acts ensure consumers obtain a minimum level of health insurance cover, regardless of what plan they purchase.

Beyond the minimum benefit, cover for medical expenses, including medication, under a customer's health insurance contract is a private contractual matter between the customer and the insurer. Any requirement for insurers to cover a particular medication could have the effect of increasing costs and premiums. It is not the role of the Minister to direct private health insurers as to which services or facilities they should cover. That is a commercial decision for the insurers themselves.

While I understand the Senator's point, it is important to bear in mind that the National Centre for Pharmacoeconomics, NCPE, can approve lots of different medicines, even ones that have a similar effect. It makes sense to allow insurers reimburse the cheaper one, not the more expensive one, if it is just as good. Alternatively, if there are several approved therapies available, it should be up to the insurers to tender and ask the different companies to tender for the supply of the medicines. This amendment would effectively require insurers to reimburse any medicine approved by the NCPE, even if it was a more expensive or less effective one.

I disagree with the Minister because there are situations where there is no other competing treatment. They make an arbitrary decision “we ain’t paying for this one” because they know that people will fall back into the arms of the State. In taking a global systematic view of health expenditure in the country, I understand this would tend to increase premia but not increasing the premia, if the drug is rejected by the company and is instead provided by the State, increases our tax. There is a very good argument to be made for enforcing a degree of compliance with the mandate. I can give the Minister specific examples - I have been somewhat critical of the methodologies used by the NCPE – of drugs that the NCPE has approved as being sufficiently cost-effective but that insurance companies have rejected. At the same time some of these insurance companies are paying for things like homeopathy.

I agree with the Minister that health insurance companies should be allowed to insist on people taking the treatment as sanctioned by the NCPE rather than spend excessive money. Senator John Crown’s case does, however, infringe the basic foundations on which this area operates, open enrolment lifetime cover and community rating. In the example he gave, somebody is refused cover and is, therefore, sent back to the State, if I interpreted what he said correctly. Do we have a mechanism that states one is entitled under those three criteria to purchase health insurance in the market and should not be turned down because there is open enrolment lifetime cover which covers people getting sick as they get older and community rating charging everybody the same price? If Senator John Crown has found loopholes where people are refused treatment and go back to the Exchequer for finance, the amendment might assist in that regard, within the context that health insurance companies should get the best bargain. The denial of cover in Senator John Crown’s example would contravene the basis on which policy in this area was supposed to operate.

I listened very carefully to the Minister and Senators John Crown and Sean D. Barrett and all have made strong cases. The one that wins is Senator John Crown’s point about the equal playing field. There is a need for an equal playing field which we will not have unless we go along with the amendment.

Amendment put:
The Committee divided: Tá, 12; Níl, 24.

  • Barrett, Sean D.
  • Byrne, Thomas.
  • Craughwell, Gerard P.
  • Crown, John.
  • Cullinane, David.
  • Leyden, Terry.
  • Mooney, Paschal.
  • Ó Murchú, Labhrás.
  • Power, Averil.
  • Quinn, Feargal.
  • Wilson, Diarmuid.
  • Zappone, Katherine.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • D'Arcy, Michael.
  • Daly, Mark.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Donnell, Marie-Louise.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • Whelan, John.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.

I move amendment No. 3:

In page 4, after line 42, to insert the following:

“Insertion of new section 7I to Principal Act

4. To insert a new section, after section 7H, of the Principal Act:

7I. Any health benefits undertaking may, if they decide that it is in their commercial interest, reduce the premium offered to any individual who avoids behaviours which are known to have negative health effects.”.”.

As is well known, probably since before the Minister was in medical school, I have been an advocate for a model of universal insurance in this country with competing companies, most of which, I hope, would be not for profit. I am a great believer of models such as the ones in place in Germany, Israel and several of the other countries of north-west Europe of dependence on a model of social insurance where the profit motive is not what drives the insurance companies but where there is a more efficient link between activity and reimbursement. It is called money following the patient.

As a society we are all in it together and I believe people should have a level playing field when it comes to accessing health insurance. For that reason I am a major supporter of community rating. We should not be able to charge people more if they are older and less if they are younger. We should not be able to charge people differentially according to their family history. People cannot pick their genetic background. These are the cards one is dealt by genetics and chronology. However, there are some things that people can pick regardless of any other circumstance in their lives. The very extreme example is smoking. People can choose to become smokers or not to become smokers. People who choose to become smokers overwhelmingly become addicted as children if they remain smokers during their adult years. I believe there are very few rational adults, armed as we are with the health risks associated with smoking, who would make a decision while adults to take up the habit for the first time, although it does happen. However, I do not believe it is contrary to the spirit of community rating to allow health insurance companies to analyse, perhaps with some type of ministerial oversight or some type of commission oversight the issue of wholly avoidable bad health behaviours. It should allow people to be incentivised. It would not only make sense from the companies' point of view but would also make sense from society's point of view to allow people to be incentivised by giving them a smaller health insurance premium if, for instance, they were non-smokers.

I know that with some of the other risk factors that are avoidable, it is a little trickier and that there are nuances in it. Certainly, if the principle were introduced, it would not be contrary to the principle of community rating and it would allow us to have a powerful tool in the public health sphere and also one that would be rational from the point of view of health economics.

I second what Senator John Crown has said. The medical argument against smoking is unassailable at this stage. All recent Ministers for Health have endorsed this. The amendment attaches a penalty to a health damaging factor. It is easily verified as people on renewing their premium can show that they have not been smoking.

It tackles the moral hazard problem that if one does not smoke, one will save on tobacco and health insurance. As Senator John Crown said, the principles of open enrolment, life time cover and community rating stand, but it is legitimate in the current economic climate that we nudge people towards conduct which will reduce demands on the health insurance company and the health service. There is much merit in the amendment and I am honoured to second it.

I add my voice to those of Senators John Crown and Sean D. Barrett. I mentioned on Second Stage that I was aware of two large companies, one in the United States and the other in South Africa, which had policies that their employees could influence, one of which was smoking. Therefore, they were able to give a reduction in their insurance charges for those people who had ceased smoking. There were other steps in regard to obesity and those who joined health clubs. In other words, there are aspects of our health that we can influence ourselves. While community rating can certainly be accepted in regard to age and other areas, in regard to items that we can influence, particularly smoking, an exception should be made and I urge the Minister to accept the amendment.

While I agree with my colleagues on the principle, it is a case of over-regulation through legislation at this stage. There is the argument that people who smoke make a contribution through a level of taxation on cigarettes. There are a huge number of programmes in place which are doing everything possible to encourage people to move away from smoking. I do not think the insertion of a regulation such as this would assist in these programmes and on that basis it would not be appropriate to amend the Bill going through the House.

I thank the Senator for his contribution. Community rating is a fundamental cornerstone of the health insurance market. Everyone is charged the same premium if he or she has a particular health insurance plan, irrespective of age, gender, genetics or the current or likely future state of his or her health. This means that the price of health insurance for all persons reflects the principle of intergenerational solidarity that the entire community of insured persons should contribute towards the higher cost of claims of older and less healthy people.

In a risk-rated market which is being suggested, at least in part, insurers would charge higher premiums to higher risk individuals and lower premiums to low risk individuals. To adopt an approach along those lines whereby insurers could reduce premiums for some people who avoid certain activities, with known negative health affects, would undermine and dilute the existing system of community rating. I appreciate that all Senators spoke in favour of community rating in principle. It is worth pointing out that, in so far as I understand it, South Africa and the United States do not have community rating; it is very much risk-rated. I think I am correct in saying the Senators are not proposing that model but are proposing that premiums should be higher for certain modifiable behaviours and so on such as smoking, taking exercise or obesity. There may well be some merit in it, but I would be very careful about departing from community rating in any way without thinking it through and knowing exactly how we would do it.

One Senator said that it would be easily verified. I am not sure how easy it is to verify it. For example, what test would the insurer perform on its customer to see if he or she is not smoking? Would it carry out alcohol-blood level tests? Would it take hair samples to check what drugs a person might have taken? Would the insurance company start weighing people and compiling a BMI and call people back a few months later to check whether their BMI had gone down a little? Would it put pedometers or some type of electronic tag on customers to check whether they are getting the right type of exercise? I am not sure it is verifiable and, therefore, it is an issue that needs to be thought out much better before I could it. The nature of insurance is that the premiums that come in have to slightly exceed the claims. Therefore, any proposal to reduce premiums for anyone must also mean an increase for others.

I thank the Minister. I also thank the most thoughtful legislator on the Government benches, Senator Colm Burke, for his contribution, although I politely disagree with him. We are not proposing additional regulation by legislation. We are looking at existing regulation by legislation and proposing to loosen it because under the interpretation of the strictures of community rating, the Minister could not do what we are proposing. My sense is that we are loosening the thoughtless bonds of unthinking unnuanced regulation and allowing something which makes economic sense and which would be socially productive.

In terms of the verification question raised by the Minister, there are ample precedents for this in life insurance where there are all types of loading based on people's life insurance policies and whether they smoke. I am sure there are methodologies to determine whether people were compliant with assertions made by them when applying for life insurance that they were or were not smokers. In a hypothetical scenario, somebody who came into the hospital having benefited from a lower premium because he or she maintained that he or she was a non-smoker but was found to be a smoker would not lose his or her cover, but he or she might be asked to pay back the difference during the years when he or she was misrepresenting himself or herself as a non-smoker.

In terms of the issues across generational solidarity, I stress I am a huge believer in community rating. If there was not a large element of personal choice in continuing to smoke - I firmly believe this is a personal choice which is heavily modified by addiction, tragically addiction which usually occurs before people have come to the age of reason - in terms of intergenerational solidarity, old and young people are just as entitled to smoke or to give up smoking and this is in no sense undermining any aspect of community rating. Where community rating is critically important is on age and secondary issues such as genetics. One cannot change one's family, although I must admit that in the event that Senator Feargal Quinn wished to adopt me, I probably would not say no. The reality - I mean no disrespect to my mother - is that one cannot change one's genes or age, but one can change whether one smokes. This is a very powerful message and I urge the Minister to accept it. I understand he will not do so, but we will press the amendment.

Does the Minister wish to add anything further?

I wish to make two points. I do not have an entirely closed mind on this issue. It is something I would like to have examined for my own interest.

(Interruptions).

Doctors are always on call.

As it is a call from the Labour Relations Commission, I am not going to answer it.

That is modern technology, but once it is turned off, we will accept that.

Somebody must be agreeing some deal.

It is an issue on which I do not have an entirely closed mind. It is something to which I would like to give more consideration, but there are two difficulties that arise. There is exactly the issue of insurance fraud, of somebody coming into hospital and the hospital discovering that the person is obese and having to get back payments because the person did not admit to being obese or something similar when it comes to tobacco, where a person is diagnosed with COPD but did not tell us the truth. We are not going to refuse cover, but we will make them pay some loading. However, what happens if they do not? Does one then refuse a person cover? It is the kind of issue that needs to be thought out. I think the amendment is flawed in the sense that it states:

Any health benefits undertaking may, if they decide that it is in their commercial interest, reduce the premium offered to any individual who avoids behaviours which are known to have negative health effects.

No insurance company will ever reduce a premium; it will have to be able to increase it also. It is not workable on that basis because the whole point of allowing loadings and risk is that they can increase, as well as decrease. The amendment would only allow them to decrease.

Amendment put:
The Committee divided: Tá, 13; Níl, 25.

  • Barrett, Sean D.
  • Byrne, Thomas.
  • Crown, John.
  • Healy Eames, Fidelma.
  • Leyden, Terry.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • Norris, David.
  • O'Brien, Darragh.
  • O'Sullivan, Ned.
  • Power, Averil.
  • Quinn, Feargal.
  • Walsh, Jim.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Cullinane, David.
  • Cummins, Maurice.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Neill, Pat.
  • van Turnhout, Jillian.
  • Whelan, John.
  • Zappone, Katherine.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.
Sections 4 and 5 agreed to.
NEW SECTIONS

I move amendment No. 4:

In page 6, between lines 9 and 10, to insert the following:

“Amendment of section 21 of Principal Act

6. To insert a new subsection after subsection (1) of section 21 of the Principal Act:

“(2) To analyse and review the health insurance contracts which are offered by the various health insurance undertakings to ensure than there exists no anti-competitive behaviour in the market place, and to notify the Minister, and the Competition Authority, if they form the opinion that any such, or any other cartel-like behaviours are likely to be present in the health insurance contract market.”.”.

I must admit I am enjoying having a lot of quality time with the Leas-Chathaoirleach this afternoon.

This amendment is borne out of personal experience. In comparatively recent history, I approached a company concerning treatment for a patient and was told it was waiting to see what a rival company was doing. I will not be specific and believe this matter is probably in the realm of sloppiness rather than malfeasance. I actually used the "C" word when I spoke to the company representatives in that I said it sounded like a cartel to me and that it struck me as intrinsically anti-competitive if the company was deciding whether it would make a potentially expensive service available to one of its customers or members depending on whether a potential rival organisation would do so. It struck me also that there was a little trend for this to happen sometimes across the various strands of the relatively small private health insurance market. By introducing this amendment, we are hoping to ensure scrutiny in order that this behaviour could not happen.

The Health Insurance Authority is the independent regulator of the health insurance market and performs a range of specialist functions, as set out in the Health Insurance Acts. These include monitoring the market, advising the Minister, operating and managing the risk equalisation fund, providing consumer information and maintaining registers. In carrying out its monitoring role, the authority is cognisant of competition issues. It is also mindful of the role of the Competition and Consumer Protection Commission which was established in October this year following the amalgamation of the Competition Authority and the National Consumer Agency. The commission has statutory responsibility for enforcing Irish and European competition law in Ireland and bringing anti-competitive behaviour and practices that are harmful to consumers to an end. This would include any anti-competitive practices in the health insurance market. Charging two regulatory bodies with overseeing anti-competitive practices would create confusion in the market. I am satisfied the function rests appropriately with the Competition and Consumer Protection Commission.

Amendment put:
The Committee divided: Tá, 14; Níl, 25.

  • Barrett, Sean D.
  • Byrne, Thomas.
  • Craughwell, Gerard P.
  • Crown, John.
  • Cullinane, David.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • Norris, David.
  • O'Brien, Darragh.
  • O'Donovan, Denis.
  • Power, Averil.
  • Quinn, Feargal.
  • Walsh, Jim.
  • Wilson, Diarmuid.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Cummins, Maurice.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Kelly, John.
  • Landy, Denis.
  • Mac Conghail, Fiach.
  • Moloney, Marie.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • van Turnhout, Jillian.
  • Whelan, John.
  • Zappone, Katherine.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.

I move amendment No. 5:

In page 6, between lines 9 and 10, to insert the following:

“Amendment of section 21 of Principal Act

6. To insert a new subsection after subsection (1) of section 21 of the Principal Act:

“(2) Where a complaint is made to the Authority by a medical practitioner, to review whether any changes in coding, or payments structures, used by any health insurance undertaking, has the effect of restricting access to care for those who have health insurance contracts, or whether such changes result in services no longer being provided outside of the public system, and to notify the Minister, and the Competition Authority, if they form the opinion that any such change is likely to have such a consequence in the health insurance contract market.”.”.

This is a very particular issue brought to my attention. I do not wish to personalise the matter or make it too readily identifiable but an entire category of medical treatment has effectively become unavailable throughout the private sector in Dublin recently because of a decision made on reimbursement for a group of procedures by one of the major players in the insurance market. It is a little hard for me to escape the conclusion that a major engineering decision was made by the company in an attempt to corral this particular treatment back into the public sector and deciding that this is not a treatment to be covered in the private sector. This has the potential to cause chaos for the solitary unit in Dublin which provides this type of treatment, as there will be a major increase in demand and waiting lists for a procedure that is already over-subscribed and under-provided. It is very neatly allowing the insurance company off the hook in this regard. It has struck me that perhaps a little Government oversight of some of the secondary and unanticipated consequences of certain reimbursement procedures could be brought to bear.

I will follow Senator John Crown's comments, although not on the same issue. I know of a case in which a specific procedure can only be undertaken in a hospital and GPs are not allowed do it. This is specifically when people have very high iron levels in blood and blood must be taken once every three months. My understanding is that insurance companies would pay out approximately €300 every time somebody would go to hospital for this procedure but the same cover is not given when a GP is prepared to perform the procedure for €100. An advantage in using a GP is that people can access somebody at a local level rather than clogging hospital services. In Cork we proposed that UCC, University College Cork, conduct some research on this issue with the Health Service Executive, HSE, and GPs. The total cost was €25,000, but the HSE will not come on board. I know it is a slightly different issue from that raised by Senator John Crown, but the amendment highlights what happens with insurance companies when they give cover but only if certain procedures are followed. In many cases, there is a far higher cost. Therefore, the issue should be examined.

Similar to other non-life insurance contracts, health insurance contracts generally have a duration of 12 months and the insurer cannot alter the terms and conditions of the contract during that period. Consumer protection measures in existing private health insurance legislation provide that insurers must notify the Health Insurance Authority, HIA, of variations to existing product benefits and any new product being offered on the market.

Consumers are also protected by the minimum benefit regulations, made under the health insurance Acts, which require insurers to offer a minimum benefit to every insured person. These regulations help to ensure consumers obtain a minimum level of health insurance cover, regardless of what plan they purchase. Currently, the minimum benefits cover access to a semi-private room in a public hospital, including inpatient consultant fees, and a wide range of acute treatments. This represents the minimum level of cover that must be offered to every insured person. Where services are not provided outside the public health system, insured members will continue to have cover for those services as private patients in public hospitals. The HIA is specifically charged with ensuring compliance with the health insurance Acts. The Competition and Consumer Protection Commission ensures commercial decisions about the type of cover provided by health insurers under their various plans are in compliance with Irish and European competition law.

It is very difficult for me to escape the conclusion that a very deliberate decision was made that a particular service should in the future become a public service. It had been safely, adequately and efficiently provided in the private sector, fulfilling all the requirements one would have for private insurance. These are that it would provide an appropriate level of care and reduce the burden on the overly stretched public service, while giving individuals a degree of choice. All of these beneficial effects have been lost. It is not a small or rare procedure; it is common. I do not wish to say too much more about this under Seanad privilege, but I may discuss it with the Minister in the future. A real problem will arise, specifically in a place that is traditionally a catchment area for greater south Dublin, with respect to a broad range of services that will no longer be available, except following referral to a national referral service.

The Senator may have raised the issue before. It relates to a specific procedure that was covered by health insurers and now it is not. I do not really understand how that pertains to this amendment. The nature of health insurance is that there is a minimum level of benefits that every package must cover, with anything beyond that being a variable. Anybody who has tried to get health insurance can see that some hospitals are covered with some packages, but others are not. If the procedure is not covered in the minimum benefits package, I am not sure how the amendment would achieve anything.

This is my fault as I am not communicating the issue well, perhaps due to opacity. By arbitrarily fixing a reimbursement level for a group of procedures which are below that which can be sustained with malpractice insurance premium costs, persons providing the service suddenly have indicated that the numbers do not add up. In one very sad case, a person has packed bags and emigrated from this country, removing his expertise from the country, as well as his service, and placing an extra burden on the public system. This will save money for the insurers in question but increase the spend by the public health system. It is very hard for me to believe this was not done rather deliberately.

It is not that there is an indication that the service will not be provided, but these folks who are aware of the prevailing macroeconomic circumstances and the specifics in the likes of insurance premia for certain high tech surgical specialties readily realise that it is to be rendered extinct as a private service.

Amendment put:
The Committee divided: Tá, 13; Níl, 24.

  • Barrett, Sean D.
  • Byrne, Thomas.
  • Craughwell, Gerard P.
  • Crown, John.
  • Healy Eames, Fidelma.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • Norris, David.
  • O'Brien, Darragh.
  • O'Donovan, Denis.
  • Power, Averil.
  • Quinn, Feargal.
  • Wilson, Diarmuid.

Níl

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Cummins, Maurice.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Henry, Imelda.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Kelly, John.
  • Landy, Denis.
  • Moloney, Marie.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Donnell, Marie-Louise.
  • O'Neill, Pat.
  • van Turnhout, Jillian.
  • Whelan, John.
Tellers: Tá, Senators Sean D. Barrett and John Crown; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.
Progress reported; Committee to sit again.