Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)

This Bill is necessary to provide, as the explanatory memorandum states, "a mechanism to support intergenerational solidarity" in the health insurance market. The memorandum also states that such solidarity is required because "there are incentives for insurers to design products that are attractive only to healthier lives, undermining intergenerational solidarity and the common good protections". Once again, the Oireachtas is being obliged to enact legislation in order to try to regulate the distortions and inequities brought about by the private health insurance market. Primarily, the latter is a market rather than a means of funding health care. In order to maximise profits, the private health insurance market often discriminates in favour of the healthy and against the aged and the ill. The State is then obliged to intervene - it has done so repeatedly - in order to try to redress the imbalance.

A question arises with regard to why the Government insists that the way forward for health reform in this State is by means of an insurance-based system. We are all of one mind with regard to the need for reform. It is the proposition of an insurance-based system to which the Fine Gael appears to be absolutely wed which gives rise to real concerns on my part. My remarks in this regard provide only a small insight of the range of concerns I harbour about the model that has been proposed.

It is interesting to revisit the programme for Government and the commitments it contains in respect of health reform based on insurance. The programme states:

A system of Universal Health Insurance (UHI) will be introduced by 2016, with the legislative and organisational groundwork for the system complete [that is, finished] within this Government's term of office.

That is a major commitment by any standard. The first step in implementing it is supposed to be a White Paper on financing universal health insurance. The programme for Government indicates that this White Paper will be published early in the Government's first term. Some time ago, the Minister for Health, Deputy Reilly, explained to me what constitutes such a term. When referring to two terms, he stated that the period involved was ten years. Therefore, the extent of one term of office is five years. So the White Paper is to be published early in this Administration's first term in office and, as the programme for Government states, it will "review cost-effective pricing and funding mechanisms for care and care to be covered under UHI".

On 14 September last, I tabled a parliamentary question in which I asked the Minister to indicate the timeframe for the publication of the White Paper. In reply, he made what I believe to be a considerable departure from the commitment provided in the programme for Government. The Minister stated:

The Government is embarking on a major reform programme for the health system ... While universal health insurance is the ultimate destination of this Government's reform programme, there are a number of important stepping stones along the way and each of these will play a critical role in improving our health service in advance of the introduction of universal health insurance.

In the reply, the Minister also mentioned the special delivery unit, strengthening primary care and repeated that oft trundled-out phrase to the effect that "money follows the patient". Furthermore, he indicated that the Government had given approval for the establishment of an implementation group on universal health insurance and stated that this will have responsibility for assisting the Department in preparing the White Paper. The Minister made a further significant observation when he said that the White Paper will be published within the Government's current term in office.

Given that I look at the responses I receive and I listen to what the Ministers state in reply to me here as a spokesperson on both health and children, I believe there is a big difference between that statement "within the Government's current term in office", within a five-year period, and the programme for Government commitment to publish "early in the Government's first term". Early, in my view, would be in the first couple of years. Now it seems, at least to me, that the timeframe is being extended all the time. We are always tempted to use the oft-used analogy of kicking the can down the road and I am tempted to apply it once again in this case.

That aside, and explaining my concerns, the Minister went further in that response and added an "However", stating:

[T]he precise cost of universal health insurance will significantly depend on the success of various reform measures ... over the next 3-4 years. This will influence the development of the White Paper and, as such, it is not possible to be more specific regarding its publication at this stage.

Something that is to expose itself in the next three to four years will influence the preparation and presentation subsequently of the White Paper that was definitely promised in the early stages. Whether it even presents within the so-called "five-year term" of the 31st Dáil is now a moot question.

Here we see a fundamental element, which is exactly as it must be seen, of the Fine Gael and Labour Government's health reform agenda being kicked years down the road. The White Paper would appear to be turning into a white elephant. The Minister, in his response, stated that he saw the delivery of all of this within a ten-year period but there is no guarantee that the Government will be back after this Dáil, whatever its duration. Every day we are here it becomes more interesting.

In the meantime, we have the continuation of the inequitable and inefficient two-tier health care system against which the Minister, Deputy Reilly, and the Ministers of State, Deputies Kathleen Lynch and Shortall, and all of their colleagues so strongly and correctly criticised when in opposition. I hope they have not changed their minds on that because the current system is abhorrent. It ill-serves us as a people and I do not believe that anyone could describe it in any international forum in a short couple of sentences. The type of system we have in this State would take some explaining in any language.

Worse is the continuing imposition of the health cuts imposed by the former Government partners, Fianna Fáil and the Greens. In my home county of Monaghan, I campaigned vehemently with colleagues across the political spectrum in this House in opposition to the removal of key services from our local hospital, Monaghan General Hospital. Never could I have envisaged the further loss of services from that hospital site following on the general election in February last. All of the acute services had been removed and none of us, including former Deputies of the main party in government with whom I developed a close and respectful working relationship that continues to this day, could ever have imagined that this new Government of Fine Gael and Labour would impose further cuts after all that over the proceding years to which those parties were witness and to which they were such strong voices in opposition, and yet that is what has happened.

Our minor injuries unit has been reduced from a seven-day to a five-day, Monday to Friday service, and from 9 a.m. to 9.30 p.m., as it was, to 9 a.m. to 5 p.m. It is a major loss of critical access for those in my home county and the Minister's response to me time and again is that they can now go to North East Doctor on Call at Castleblaney or to the emergency department at Cavan General Hospital, both of which are at their wit's end in trying to cope with the current footfall and throughput. It is making situations even worse. All of this is excused on the basis of savings. The previous Government at least tried to paper it over with the argument of patient safety, but this is nakedly about money. It is not about patient service in any shape or form.

The Bill has been introduced in that context and in the context of a declining health insurance market. VHI has stated that it expects up to 200,000 people to give up private health insurance by the end of 2012 as a result of rising unemployment. The proportion of the population with health insurance declined from 49% in 2007 to 47% in 2010, and the numbers qualifying and receiving medical cards have increased. Some 30% of the population have a medical card, while 23% have neither medical card nor health insurance, including myself, on principle, and must pay as they go through every stage of the health care system. Thus, 53% of the population depend entirely on the public health system, from which the other 47% also benefit significantly, for example, from the use of private beds in public hospitals, but data from the OECD show that the largest proportion of funding for health care in the State comes from the public finances, at 80.7%.

When we debated the predecessor to this Bill, the Health Insurance (Miscellaneous Provisions) Bill 2008, I stated that we were seeing a turning of the tide. I stated that the astronomical rise in unemployment was 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 the disastrous mismanagement of the health services by previous Governments all of which were led by Fianna Fáil, were almost at breaking point. I stated that the cuts imposed since autumn 2007 and greatly increased cuts in 2008 were creating a crisis situation, and that is what we have lived with since. Regrettably, my words have proven correct. Two years on, we see the ramshackle structure of the health services under even greater pressure than at any time previously.

This Bill simply addresses one aspect of that structure, the need for what is called societal and intergenerational solidarity in the health insurance sector. It does this by continuing up to the end of 2012 the arrangement whereby the burden of the costs of health services are shared by insured persons through a cost subsidy, an age-related tax credit funded by the collection of a levy on all insured lives.

There is a need to protect the health system from a predatory approach by health insurers which would see older persons and persons with illnesses being forced to pay higher health insurance premiums, and this Bill seeks to achieve that for another year. How long will we have to depend on such stop-gap measures?

The Minister's back-tracking on the programme for Government commitments on universal health insurance does not augur well. I will argue for a very different approach, namely, universal health care delivery, delivered to all on the basis of need, and need alone, and paid for through direct and progressive taxation.

If the Minister's promise is fulfilled within the term of the Government, then clearly the whole legislative and funding framework around health insurance will have to be changed. As I pointed out earlier, the can is being kicked a long way down the road - conveniently, I add. All of this points to the need for a new direction, and the direction that I believe is best suited to our needs is the one I and my colleagues in Sinn Féin, and other voices, have long advocated. Real inter-generational solidarity and social solidarity are needed across our health care system, not just within a private health insurance market. For this, we require a single-tier public health care system, funded by fair and progressive taxation, with access to every citizen based on need, and need alone, and without any relation to the balance in one's bank account, the money in one's pocket or one's geographical location.

Why complicate matters by creating a separate health insurance system that requires a huge battery of legislative and regulatory checks to make it work? The only logic for the course being proposed by this Government, represented and spoken for by the Fine Gael Minister, Deputy James Reilly, is to benefit the private health insurance industry - I say this to the Minister of State, Deputy Shortall, as a well respected Labour Party representative of long standing.

Here we are, on the cusp of yet another budget, budget 2012, which will be announced next week. As we face into this new budget and all that will entail, there is no sign of any kind of fundamental change in the thinking of the Government or that any new direction will be presented for our health system by the Government for the future. Fine Gael and Labour, which made so much of the health care system in the lead-up to general elections over recent years, very particularly under Deputy James Reilly in his Opposition position, facing off with the former Minister for Health and Children, Deputy Mary Harney, have given rise to a sense of expectation among the wider electorate. None of it even presents on the horizon at this point in time. We are faced with the continuation of the dreadful system we have but with no prospect of real address, let alone reform.

My appeal, as it is on so many issues in regard to the Government, and to those in the Labour Party in the first instance, with whom, on the basis of their proclaimed position on many issues, I would find comfort and common appreciation, is to use their very important and valuable access to the decision making process in the Government and in the Cabinet to ensure that new directions are found, that new models are mooted and that we have the implementation of a system of which we can all be proud. That is within their gift. It is within the timeframe of a five-year cycle - a term of Government. In looking back, would that not be a proud legacy for their involvement in this 31st Dáil?

See this speech in context