Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)

I have no difficulty with the stated purpose of the Health Insurance (Miscellaneous Provisions) Bill 2008 which is to affirm the purposes of the previous Health Insurance Acts, ensure that access to health insurance cover is available to all consumers regardless of age and health status, to strengthen the legislative provisions to achieve this purpose, to enhance intergenerational solidarity and to provide for the implementation of related measures to achieve these objects. I am, however, no advocate of private health insurance.

There is clearly a need to protect our health system from a predatory approach by health insurers which would see older people and people with illnesses being forced to pay higher health insurance premiums. The most recent estimate has it that more than 50% of the population in this State subscribe to one of the private health insurance providers. That is an estimate published in 2008, presumably based on 2007-08 figures. I have no doubt that the figure for 2008-09 will show a significant fall in the number of people covered by private health insurance as a result of the recession. We are seeing an ebb and flow, with profound consequences for our health services.

During the Celtic tiger years, increasing numbers of people took out private health insurance, as reflected in the figure I have quoted. I believe this happened for two reasons. First, incomes increased and as a result many more people could afford, albeit with great difficulty in many cases, to pay for private health insurance. Second, and most important, the Government had allowed our public health services to deteriorate so much that many people believed they needed the added cover provided by private health insurance, despite its burdensome financial cost. I believe we are now seeing a turning of the tide.

The astronomical rise in unemployment is resulting in more people applying for medical cards, the cancellation of private health insurance and ever greater demands on the public health services. These services, because of the fundamentally flawed policies and disastrous mismanagement of our health service by successive Governments, are almost at breaking point. The cuts imposed since autumn 2007, and greatly increased cuts this year, are creating a crisis situation. While I accept the word "crisis" is often over-used, I challenge anyone to deny the crisis in respect of our health services.

Coupled with the cuts across all the health services, there is a concerted attack on the delivery of hospital services at local level. This week, the people of Cork and Kerry were shocked to hear what the HSE has in store for their local hospitals with Tralee, Mallow, Bantry, the South Infirmary and the Mercy Hospitals to be downgraded. The people of Monaghan warned people across the State what was coming down the tracks. We face the removal from 31 May, ten days from now, of all acute in-patient services from our hospital, Monaghan General Hospital. I take this opportunity to make a last minute appeal through the Minister of State, Deputy Brady, and her officials to the Minister for Health and Children to intervene to prevent this disastrous move which will have calamitous consequences for my community and the people of County Monaghan.

The great tragedy is that the period of the Celtic tiger presented successive Government with an unprecedented, and probably never to be repeated, opportunity to transform our health system. That transformation is still necessary and will have to be achieved but it will be done in much more difficult financial circumstances. Pending such transformation, this Bill is yet another measure to patch up the inequitable, ramshackle and inefficient health service in this State. Many years ago former Minister for Health, Deputy O'Hanlon, boasted that the system "with its integrated mix of public and private care, has served the nation well". Many years ago a former Minister for Health, my fellow Cavan-Monaghan Deputy, Deputy O'Hanlon, boasted that the system "with its integrated mix of public and private care, has served the nation well". He clearly admitted that it was a two-tier system. We do not get such frank admissions from Government these days. However, the two-tier system is more entrenched than it ever was. It is also more complex, more inequitable and infinitely more costly.

It is interesting to read the response of the Minister for Health and Children when concerns were raised in the Seanad last year about the prospect of VHI privatisation. She made the following statement: "If one has private health insurance, one has preferential access to diagnostics and facilities paid for by the taxpayer and for which a group of employees in this State gets a fee." The Minister appeared to speak disapprovingly of this preferential access, yet she has done everything to maintain it. This is the two-tier system. In 2005, the Minister said the fact that "more and more people are getting private health care is a good thing. It is a sign of increasing disposable income". The Minister did not say that the increasing number of people taking out private health insurance was also, as I have pointed out, a sign that people were moving away from the public health system because of long waiting lists and loss of confidence. A vicious circle was created. The public health system was allowed to deteriorate, which prompted more people to choose private care. The for-profit health sector grew richer as the Minister intended and the Government has fattened that for-profit health care business as never before.

Many uninsured people also abandoned the public system and went into debt to pay for private care in order to avoid long waiting lists. Credit unions reported growing numbers of people taking out loans to fund health care. For example €30 million was lent in this way in 2004. However, as I have said, the tide has turned. Now the price is being paid in a sub-standard public health service on which growing numbers of people are becoming totally dependent.

The reality is that we do not know the total amount of money we spend as a society on health services. The Minister and her Department seem to be as ignorant about this fact as everyone else. We know that the best use is not being made of this money because it is being applied inequitably and inefficiently in a two-tier system. Approximately 70% of the population have long been paying for their health care twice - once through taxes and again through personal health insurance or direct user fees for GP services, medicines and hospital care. This complex and inefficient funding system has been used by successive Governments to underpin the grossly inequitable two-tier public-private system.

We in Sinn Féin have called for the establishment of a health funding commission which would assess all the money being spent on health services both by Government and by citizens in the form of health insurance premiums and user fees. This commission would not be engaged in a statistical exercise. Its purpose would be to plan the transition to a truly fair and efficient system. Surely that must be the shared objective of all who believe in health care justice on this island. In our strong view the way forward is a universal, single-tier system of health care accessible to all based on need alone and regardless of income or where we live. Such a system would be funded from general taxation based on the principle of ability to pay. It would protect the most vulnerable and ensure that there was no fast-track to better care for some while others languished on waiting lists. The best care should be available to all on the basis of need.

There are very few winners in our current inequitable health care system. The exceptions are those who profit from the increasingly lucrative private health business. Overall, our population suffers an inequitable and inefficient system. Its fundamental structure is flawed and it is plagued with bad political and bureaucratic management. A new beginning is needed and health funding is central to that. We need a much wider debate than can be facilitated by this Bill. The Celtic tiger is dead and we are now facing a devastating recession with health services that are still organised on the basis of an inequitable and inefficient, two-tier, public-private system. If this does not change then recession will greatly increase that inequity and inefficiency. Those with wealth will be looked after by the private system which the Government has built up, while the majority dependent on the public health system will face longer waiting times, fewer hospital beds, staff cuts, closure of local hospitals and reduction of services in the community. We are seeing that happen every week.

Sinn Féin has a different vision. We believe that health care is a fundamental human right. We need to ensure that everyone has equal access to health services that are both equitable and efficient. We also need to ensure that factors which lead to poor health for many people, including social and economic inequality, are tackled effectively. Studies in Ireland and worldwide have shown that those with less wealth are far more likely to suffer illness and premature death than more privileged sections of society. Therefore, Sinn Féin views health not just as an absence of illness but, in line with the World Health Organisation, as "a state of complete physical, mental and social well-being" and the enjoyment of health "is one of the fundamental rights of every human being without distinction".

We translate our vision for the health services into three key proposals: a new universal public health system for Ireland that provides care to all free at the point of delivery, on the basis of need alone, and funded from general fair and progressive taxation; fundamental re-orientation of the health system to adopt a central focus on prevention, health promotion and primary care, including mental health care, and on ultimately eliminating the underlying social and structural causes of ill-health and premature death, such as poverty and inequality; and immediate establishment of a health funding commission to report within a reasonable timeframe on the projected costs of the transition to an all-island system of universal provision, taking into account all spending on health services under the current systems, including direct Government spending and spending on health insurance.

Clearly, our key funding proposal requires a fair and progressive taxation system based on ability to pay. We seek a single-tier system and this would mean that State funding for the private for-profit health sector would be ended. I commend these proposals to the Minister and I recognise that the path to achieving each of these goals, which will be clearly in the interest of all citizens throughout the island of Ireland, will take time. In the interim I use the opportunity today on behalf of everyone in communities throughout the State who are afraid, deeply concerned and worried facing the loss of critical services from our network of local hospitals to appeal the Minister to take the appropriate action to ensure that these services will continue.

On behalf of my community in Monaghan, which was selected many years ago as the first test case for the reduction of services in hospitals throughout the State and is now facing the loss of the last acute facility in Monaghan General Hospital by the end of the month, I appeal to the Government once again to pull back, to have sense and to recognise that the people of the county, small in number though they may be, are entitled to equitable access to the critical services on which I, as but one citizen among their number, have depended for my life and to be able to participate today. In God's name, do not proceed with the closure of acute medical services at Monaghan General Hospital.

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