Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein) | Oireachtas source

I am all surprises. The system requires regulation, monitoring, enforcement and penalties for infringement as provided for in the Bill. Without legislation, the unregulated market would discriminate against the old, the sick and any other group or individual insurance companies decide are a greater risk. The Bill is, therefore, supposed to provide protection against the working out of the raw profit motive in the health insurance sector. It is supposed to be based on solidarity between generations and the healthy and the sick. That is welcome in so far as it goes, but we in Sinn Féin would go much further and extend the principle of solidarity to the way we fund, organise, structure and manage the entire health care system. I will return to this point in due course.

The Bill is before us at a critical time for the health insurance sector and in the midst of a crisis for the health care system. There has been a massive decline in the number of people with private health insurance. In 2008 there were 2.3 million people with private health insurance, but that figure has decreased to 2.1 million in 2012. Over 60,000 people have dispensed with private health insurance in the last year alone. Meanwhile, the cost of premiums is rising. People who have dispensed with insurance because they can no longer afford it are now dependent on a public health system which is under attack from the Government's failed austerity strategy. The State continues to heavily subsidise the private for profit health system with private beds in public hospitals, a fast track to treatment for private patients, while public waiting lists grow with the dual working of hospital consultants in the public and private sectors.

The Government's proposed solution is to move to an entirely health insurance based system of funding, managing and delivering health care. It is important to note that the health insurance policies of both Fine Gael and the Labour Party were conceived at the height of the Celtic tiger when record numbers had private health insurance. Perhaps it appeared to these parties that the ready-made solution for the State was to extend health insurance cover to everyone, while subsidising those who could not afford it. During and after the general election of 2011, Fine Gael and the Labour Party managed to paper over the differences in their respective models of universal health insurance. It is now clear, however, that the Fine Gael approach won out in the programme for Government and, subsequently, in the stewardship of the Minister for Health, Deputy James Reilly. In the now famous Dáil speech last September the then Minister of State, Deputy Róiin Shortall, who resigned a few days later, asked a number of pertinent questions, while failing to express confidence in the Minister. She asked:

Are we going to reform and strengthen our public health services, or privatise large parts of it? How do we ensure equity and access in the health service? What model of universal health insurance best suits the situation here in Ireland? Should it be a commercial insurance model or a social insurance model?

If one reads Fine Gael's FairCare policy, it is obvious that it favours privatisation and the commercial insurance model. It states with what I can only describe as overblown confidence that once universal health insurance is introduced "the insurance market will double in size. This will attract new entrants, increasing competition and driving down costs". This is a pure market approach which treats health care as a commodity and believes consumers will benefit from competition. However, the Bill highlights a contradiction in the approach. The Bill is based on the recognition that there has to be social solidarity in the insurance sector. The market has to be regulated to prevent price discrimination against the old and the sick. There cannot be normal commercial competition because otherwise we would have a US-style law of the jungle where the young and the fit would benefit from cut price health insurance, while the old and the ill would be fleeced or driven out altogether.

Given that the principle of social solidarity is recognised, why not extend it across the entire health care system? If one takes that concept of solidarity to its logical conclusion, one moves to a system of universal provision of health care based on need rather than ability to pay. The question arises of how one pays for such a system. Contrary to the frequent assertions of the Minister, we in Sinn Féin recognise that health care is hugely expensive and has to be paid for. The question is how to pay for it in a way that ensures the best possible health care for all who need it with the best achievable value for money. The Government is proposing to bring forward universal health insurance, with the State subsidising those who cannot afford to pay insurance premiums. Given that the State will still have a huge regulatory, managerial and funding role, why would it give private for profit insurance companies such a central place in the system? What contribution will they make? They are funded by the consumers who buy their products. The insurance companies, on behalf of policyholders, will buy services from private or public hospitals or other service providers and will have to make a substantial profit in the process. Why not cut out that profit for the privateers and keep the money in the health system and the pockets of citizens? The only possible reason for not keeping out the profiteers is commercial. In opting for the privatised insurance model, albeit including a slimmed down VHI in the mix, the Government is putting business before health. For citizens, the bottom line is that when they need health care, they need it promptly and they need the best care possible. That is why Sinn Féin advocates universal health care based on equal access for all. We want it to be State provided, funded from fair general taxation and free at the point of delivery. This would involve a higher contribution in tax from the highest earners than they contribute at present. How could this be wrong?

We do not favour the model of insurance based funding for the reasons I have outlined.

If health insurance is to be the basis for funding, then it should be a State insurance scheme. The Labour Party once claimed to be in favour of this, but its former policy has been suppressed in favour of that of Fine Gael in the authorship of the programme for Government and in the outworking of that over the period since. As far as Sinn Féin is concerned, the least desirable model is an insurance system based on competing private health insurance companies. In that case, the profit motive and the interests of shareholders become paramount, rather than public health. This is the Fine Gael model and it won out in the programme for Government.

On 8 November, the trade union IMPACT published an important paper, entitled The Future of Healthcare in Ireland. I commend it to the Minister of State if she has not already read it. It says of the Government's plans:

The Government model of competing private sector insurers has not been properly tested. Delays in its implementation suggest that Government plans for UHI have been poorly thought out. If implemented, the model is unlikely to deliver equity, value for money, quality or universal access. Quite the opposite: lessons from the Netherlands show that a profit-driven commercial model led to an inequitable and inefficient system of funding, different tiers of entitlement, rising hospital deficits and even bankrupt hospitals.

That is a very different view of the Dutch system compared to the glowing reviews of Fine Gael. The IMPACT paper recommends examination of what it calls a single payer social insurance model along the lines of those in France, Germany and the Nordic countries. It states, quite rightly, that the "competing insurers" model should not be adopted, at least and until all the options have been evaluated in terms of equity, quality, access to services and value for money. I appeal to the Labour Party Minister of State and her colleagues to be the brake on this runaway proposal with which the Minister, Deputy Reilly, is most comfortable.

At present, we have decreasing numbers of people with health insurance, rising premiums for those who have insurance, more pressure on the public health system from those coming off insurance and the persistence of the two-tier public-private system, with the struggling public system subsidising the private system. We have calculated, based on figures from Government, that if the Government applied the full cost of private beds in public hospitals, it would save €432.5 million - a sum that could then be spent in the public system reducing waiting times and overcrowding in our hospitals and on improving services. We must ask what is the real prospect of change under this Government, particularly if the Labour Party allows Fine Gael run away with the ball.

Already, the promised extension of free GP care has been postponed. The programme for Government promised a White Paper on financing universal health insurance early in the Government's first term. The Department of Health's recent briefing for the Joint Oireachtas Committee on Health and Children stated the White Paper will be published "as early as possible within the Government's term of office". We are still waiting. Going the insurance route is a mistake. It offers the increasingly remote prospect of reform, while the deeply flawed current two-tier system deteriorates, especially as a result of the austerity policy and health cuts of this Government that are undermining the public health system. We have ample evidence of this the length and breadth of the country.

This Bill is a necessary measure for the insurance sector as it stands and we will, accordingly, accommodate its passage. However, overall the future of health insurance and of the health system generally under this Government is fraught with uncertainty. I urge the Minister of State and her colleagues in the Labour Party to utilise their special place in the coalition to bring real consideration to the alternatives that have been documented by many voices, not only domestically but internationally, and to recognise there is international experience of the model being proposed, including that of the host country from which the idea has been borrowed. That experience is far from the picture painted by the Minister and other voices here over the past 18 months. It is time for a reappraisal.

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