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

The Bill is a follow on from the Health Insurance (Amendment) Act 2012, a very important piece of legislation which significantly updated the regulatory regime for the health insurance sector in the State. The 2012 Act introduced a permanent risk equalisation scheme from 1 January 2013. Risk equalisation makes possible the scheme of community rating, which ensures all consumers are charged the same premium for a particular health insurance plan regardless of age, gender or health status, thus preventing price discrimination against those more likely to require medical treatment.

The Health Insurance (Amendment) Bill 2013 has as its main purpose to specify the amount of the hospital bed utilisation credit and the amount of risk equalisation credits in respect of age, gender and level of cover that is payable to insurers from the risk equalisation fund from 1 March 2014. It makes amendments to the Stamp Duties Consolidation Act 1999 to revise the stamp duty levy required to fund the risk equalisation credits for 2014.

As I stated on Second Stage of the 2012 Bill, as long as we have the type of health insurance market and the type of health funding that exists in the State, the regulatory regime provided for in the Bill will be necessary. It involves a complex system of risk equalisation to support the community rating principle. This entails the transfer of compensation from insurers who carry lighter risk burdens to those who carry heavier risk burdens. All this requires regulation, monitoring, enforcement and penalties for infringements. Without such legislation the unregulated market would discriminate against the old and the sick, or any other group or individual insurance companies decided were a greater risk.

The legislation is, therefore, supposed to be a 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 between the healthy and those who do not enjoy good health. This is welcome, in so far as it goes, but time after time I have indicated to the Minister that we in Sinn Féin would go much further, extending the principle of solidarity to the way we fund, organise, structure and manage our entire health care system. The cost of health insurance premiums is rising and there is real concern this legislation will inevitably lead to further rises, by as much as 15%. In an article in The Irish Times on Tuesday the Minister for Health, Deputy Reilly, stated the stamp duty increases provided for in the Bill do not have to be passed on to customers by the insurance companies. He stated, "I would also remind everyone again that insurers do not have to pass on the cost of the changes we have had to make. As I have said many times, they must look to their own cost base.” The Minister states it is up to insurers to decide their own pricing plans and insurers can reduce their outgoings under the scheme by taking on a fairer share of older customers, but he admits this is not happening. It is clearly not happening when we see the statistics cited by the Minister. VHI holds 89% of the market share of those aged over 80, compared to only 6% held by Aviva and Laya. For the 70 to 79 age group the equivalent figures are 78% for VHI and 9% and 12% for the others respectively. Clearly this is an unsustainable situation.

The Minister reminds us he has commissioned an independent report on the high costs in the health insurance industry and he expects to receive it soon. Whether he will be able or willing to do anything about these costs is another matter. The Minister also stated in the article: "The last thing we want is for health insurance to become a luxury that existing customers can’t afford.” The Minister can write this, but where is the evidence this is something believes or intends? He certainly is not adhering to it. The option of health insurance has become a luxury that is no longer affordable to many thousands who previously held it. I am not an advocate of private health insurance and I do not hold it on principle. In 2008 2.3 million people had private health insurance. In 2012 this figure had dropped to 2.1 million and more than 60,000 people dispensed with private health insurance in that year alone.

People who have dispensed with health insurance because they can no longer afford it are dependent on the public health system, which is under attack from the Government’s failed austerity strategy which it happily embraced when it took over from the previous Government. The State continues to heavily subsidise the private for-profit health system with private beds in public hospitals, a fast-track to care for private patients while public waiting lists grow, and the dual working of hospital consultants in the public and private sectors.

The Minister claims that the Government is making progress towards its ultimate goal, which he describes as a single tier patient-centred system of universal health care for all. This is what I want, but the Minister states this is to be achieved by a market-based universal health insurance system, and here is where the big gap presents. The Minister states the maintenance of a healthy and functioning private health insurance market is an essential step in the transition to this goal. The Bill before us is, presumably, one of the steps he deems necessary in this transition.

The Government wants to move to an entirely health insurance-based system of funding, managing and delivering health care. As I have noted here previously, the health insurance policies of Fine Gael and the Labour Party were conceived at the height of the Celtic tiger, when record numbers of people had private health insurance. Perhaps it seemed to be a ready-made solution for the State to extend health insurance cover to everyone, subsidising those who could not afford it or who made the choice not to take it.

During the general election campaign in 2011 and following the election itself, Fine Gael and the Labour Party managed to play down the differences in approach in their respective models of universal health insurance. Let there be no mistake; the Fine Gael approach won out in the programme for Government. When one reads the Fine Gael FairCare policy, it is obvious that said party favours privatisation and the commercial insurance model. The policy states that once universal health insurance is introduced "the insurance market will double in size". It also states, "This will attract new entrants, increasing competition and driving down costs". This is a purely market-based approach, treating health care as a commodity and believing consumers or customers will benefit from competition. The market basis for his so-called reforms was confirmed by the Minister in the article he wrote for The Irish Timesthis week.

Like its 2012 predecessor, the Bill is based on the recognition that there must be social solidarity within the insurance sector and that the market has to be regulated to prevent price discrimination against the old and the sick. As a result, normal commercial competition cannot exist because we would otherwise have a US-style law of the jungle where the young and the fit would benefit from cut-price health insurance and the old and the ill would be fleeced or driven out altogether. Instead, the principle of social solidarity is recognised. I never give up hope that the Minister might go that extra mile. In that context, why will he not extend social solidarity across the entire health care system? If one takes that solidarity to its logical conclusion, one moves to a system of universal provision of health care based on need alone and not on ability to pay. The question that then arises is how to pay for such a system.

Health care is hugely expensive and must be paid for. The question is how to pay for it in a way that ensures the best possible care for all who need it and achieves the best value for money. The Government is proposing to introduce universal health insurance, with the State subsidising those who cannot afford to pay insurance premiums. The State will still have a huge regulatory, managerial and funding role. Why, then, 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. In addition, they will have to make a substantial profit in the process in order to satisfy both their hunger for such profit and the interests of their respective shareholders. The Minister has already recognised the failure of the insurance companies to reduce their outgoings and address their cost base. We await with interest the report he has commissioned in that regard. Perhaps he might inform us as to when he expects to receive that report and indicate when he will bring it before the House.

Why not cut out private profiteering from the entire equation and retain that money in the health system and any surplus thereafter in the pockets of citizens in order to give them greater potential to succeed in life and to enjoy the comforts that life has to offer? The only possible reason for not keeping out the profiteers does not relate to health care. There can only be a commercial reason in this regard. In opting for the privatised insurance model – albeit including a slimmed down VHI in the mix – the Government is putting business before health. The Government should re-examine its position. Does the Minister also subscribe to this position, or are there other influences at play here? We need to remove business from the equation when considering health care because the latter is not about profit. People's ill health, the requirement to provide real health care and the protections that are necessary against the challenges that can present in the course of one's lifetime are not the bases on which profits should be made.

The bottom line for citizens is that when they need health care, they need it promptly. They also require the best care possible. I am a recent service user and wish to acknowledge that when one is in the system, it generally performs very well. Most people acknowledge having undergone a positive experience once inside the system. It is because of the need for greater urgency and the best care possible that Sinn Féin advocates universal health care based on equal access for all. We want that truly reformed system to be State-provided, funded from fair general taxation and free at the point of delivery. It will not actually be free because people will have already paid for it as part of their general taxation contribution. Such a system would involve a higher contribution in tax from the highest earners than they contribute at present. I make no apology for that at all. Such a system would give rise to comprehensive savings on costs, such as medicines and excessive top salaries, which we have set out in successive alternative budget documents, and would end the State subsidy of private health care. We do not favour the model of insurance-based funding advocated by the Minister for the reasons I have outlined, not only today but on many previous occasions.

If health insurance is to be the basis for funding, then it should be a State insurance scheme. Labour once claimed to be in favour of this, but its former policy has been suppressed in favour of that advocated by the Minister's party. The least desirable model, as far as we are concerned, is an insurance system based on competing private health insurance companies. In that case, the profit motive and the interests of shareholders, rather than public health, become paramount. This is the Fine Gael model and it is clear that it won out in the programme for Government.

I make no apology for once again citing the important paper, The Future of Healthcare in Ireland, published by the IMPACT trade union a year ago. I remind the Minister that, in the context of the Government's plans, this document states:

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.

The IMPACT paper recommends examination of what it describes as a single payer social insurance model along the lines of the systems in place in France, Germany and the Nordic countries. It states the competing insurers model should not be adopted before all of the options have been evaluated on the basis of equity, quality, access to services and value for money. I have no doubt the competing insurers model will not tick the boxes in relation to any of these factors.

The number of people with health insurance is decreasing; premiums for those who have health insurance are increasing; the public health system is under greater pressure as people leave the private health insurance system and the two-tier public-private system persists, with the struggling public system continuing to subsidise the private practice of many consultants.

In the programme for Government a White Paper on financing universal health insurance was promised "early in the Government's first term". Two and a half years later, we are still waiting. I doubt if the first page of the White Paper has been written, not to mention agreed. I do not believe there is a White Paper in the offing and it will come as one hell of a surprise if the Minister is able to tell me-----

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