Billy Kelleher (Cork North Central, Fianna Fail) | Oireachtas source

If universal health insurance was the utopian model, as we were being led to believe, I see no reason that the Government would not be moving full steam ahead with it. The contrary is the case in terms of the Minister's commitment to universal health insurance. It has actually been dropped from his lexicon and his vocabulary. He never speaks about it anymore. Instead, he speaks about universal health care. There is a fundamental difference between care and insurance, in terms of how we fund the health services in the years ahead. We will continue to pursue this issue to find out exactly what is the position of Fine Gael and the Government as a whole on the universal health insurance model that was proposed in the programme for Government.

Any society would judge itself on how it looks after those who are most vulnerable and most in need of our support. The Minister's party has had a latter-day conversion to the risk equalisation model, which is a critically important component in ensuring we have a vibrant health insurance market. More importantly, it helps to ensure people are not penalised as they get older and sicker and therefore have a greater need to draw on health insurance. A central tenet of any modern society is to ensure people are not penalised as they grow old. We should not uphold this tenet because it makes us feel better - we should do so because the people in question deserve it. They have served this country well. Many of them have been paying private health insurance for many years. The idea that they should be penalised as they grow older is simply unacceptable. That is why my party has always supported the concept of risk equalisation. If I wanted to look at how it evolved, I would mention that the opposition to it in this House was quite dramatic for many years. We were led to believe it would force families to abandon health insurance. Of course if there was no risk equalisation, older people would be forced to abandon private health insurance. That is the concept we endorsed and put through. Thankfully, most parties now agree to that very civilised principle.

Reference has been made to the impact of the Australian model of lifetime community rating in that country. I think it is a good idea. We called for it for a long time. It is quite clear and evident that since 2008 there has been a steady decline in the number of people taking out private health insurance. The primary age cohort that has been dropping out of health insurance comprises those under the age of 35. To put it simply, as the number of people taking out private health insurance has been decreasing, the burden that needs to be carried has been falling on fewer and fewer people. As a result, the spiralling cost of private health insurance has further exacerbated the problem of people dropping out of such insurance.

Government policies that added dramatically to the cost of private health insurance are a hidden part of this problem. The Minister said in his speech that "these measures, combined with the recent decision by my colleague, the Minister for Finance, not to decrease tax relief on health insurance premia and the freezing of hospital bed charges, all aim to support a competitive health insurance industry". That seems to be an indication that the policies pursued by the Government when it capped the tax relief on premiums and its policies with regard to hospital beds did not add to the competitiveness of the market. If the Government wanted a more competitive market, it should be going further by rowing back on the decisions it has made to date.

There is no doubt that last year's decision to cap tax relief was announced without consultation. The previous Minister for Health looked quite shocked when the Minister for Finance announced in this Chamber that he intended to cap tax relief on gold-plated health insurance premiums. By any stretch of the imagination, the measure that was introduced was not confined to gold-plated premiums. I think there is now an acknowledgement that the average premiums which families try to maintain on a yearly basis were also affected. Hundreds of thousands of people were directly affected by the increased cost that was imposed on health insurance premiums.

Many people are making great efforts on a continual basis to provide for their own health cover. Obviously, there are ideological arguments inside and outside this House about whether private health insurance is acceptable. When we consider whether it is right that private health insurance forms part of how we fund our health services, we must admit that people who take out such insurance are doing the State a service. They are alleviating the burden on the State, which is obliged under legislation to provide health care for everybody. People are willing to forgo certain luxuries, or have no luxuries at all, and to make huge sacrifices in order to pay for private health insurance. I find the idea that it is somehow wrong for them to do that very distasteful.

We have the system that we have. Following the abandonment of the universal health insurance model, it looks like we will have it for a while. Therefore, we should encourage people to take out private health insurance. We should not penalise them. This Government has consistently penalised ordinary families when they take out private health insurance. As I have said, last year's budget, which was a direct attack on families that pay private health insurance, is a case in point. We need to make it clear that if everybody decided to withdraw from private health insurance, the public health system would be lumbered with the cost and would, in effect, collapse as a result. Private health insurers pay out €1.8 billion in respect of health care each year. If that money was no longer available, the Government would have to put an equivalent amount of extra capacity into the public health system. Everybody should accept that the public system simply could not cope in such circumstances.

The attraction into private health insurance of young people must be a critical component of any effort to develop a sustainable private health insurance market. Competition, encouragement and social and inter-generational solidarity must also be features of such a market. We need to make sure the young subsidise the old. This straightforward and simple concept should be encouraged rather than discouraged. It has been quite evident for the last three or four years that something needs to be done to stimulate the uptake of private health insurance among younger people. Nothing has been done for a number of years.

We are now very much in a crisis situation. The age profile of people in private health insurance is exceptionally worrying. As I have said, the burden is falling on older people to subsidise older people. That is simply not sustainable. I hope this legislation will address this key area, which needs to be addressed. The prevarication that continued for three and a half years, when there was a pretence that universal health insurance would be introduced, has come to an end. The introduction of this legislation is, in effect, an admission that the Government is not going to go down the road of universal health insurance. The problem is that the unsustainable model which prevailed in recent years discouraged young people from coming into the health insurance market.

I would like to comment on the age structure of the market. There has been a significant ageing of the insured population. In 2003, the percentage of the insured population over the age of 60 was 13.3%, but this had increased to 19% by the second half of 2012. There has been a dramatic increase in the age profile of the insured.

If it is not underpinned by a continuous flow of younger people into the market, the sustainability of same is undermined.

The Minister referred to the advice of the Health Insurance Authority, HIA. That he has taken it on board is a welcome departure. The previous Minister for Health never took the HIA's advice. He continually dismissed logical advice on how to contain the cost of private health insurance for families and how to ensure a basic model of risk equalisation, which was important for social and intergenerational solidarity.

For all of the reasons I have listed, trying to provide cover proved difficult for families. The increases in premiums ranged from 7.3% in 2011 to 12.1% in 2012. In 2008, the average premium per insured person was €729. In 2013, it was €1,250, representing a dramatic increase in the cost of health insurance. There are many reasons for this, but Government policy and its neglect of the private insurance sector have been contributory factors. Introducing the instability of not knowing whether people would need to take out mandatory health insurance undermined people's initiative to join. Why would anyone have taken out health insurance in recent years if stated Government policy was to force people to do so in 2018 or thereabouts? In such circumstances, it was illogical to believe that anyone would take out insurance for the next six years. Thanks to the Government's policy, we are still in a vacuum. Sometimes, its policy may be at variance with the Minister's policy, but we need to know what the Government intends to do with universal health insurance. That insurance would be compulsory in a couple of years' time contributed to young people in particular not taking out insurance of their own. This Bill is an indication that the situation may be changing.

Health insurers and providers have an obligation to try to curtail costs. Much work remains to be done in this regard. There will be occasional clinical audits of payments, but people still hold the view that the level of service increases above what is necessary once a private health insurance card is shown. People are concerned about supplier-induced demand. We must aggressively ensure that an auditing system to prevent this is in place. We do not want clinicians and other medical professionals to cut corners, but people must not be incentivised to provide unnecessary diagnostics or other forms of care just because patients have private health insurance. That the system might contain such incentives is wrong, including ethically. The Minister should consider this matter.

In September 2013, VHI insured 54% of the market, Laya insured 23%, Aviva insured 15% and GloHealth insured 4%. One could argue that it is competition that will sustain the market, in that insurers and health service providers will compete with one another to get market share, but I wonder whether that is really the case. We have a dominant insurer in VHI. In terms of the cost of care for private patients, I wonder whether service providers are negotiated with aggressively. This matter should be also considered. Private health service providers are under financial pressure, but an upturn in the economy, more people entering the market and proper clinical auditing of treatments might help.

Turning to the question of how we will fund the health service in the years ahead, the Minister and others have often accused me of not having a determined health policy. Whenever I open the pages of a newspaper, though, the Government seems to be reverting to the policies that we would have pursued, namely, a publicly funded health system with the option of private health insurance. Pitting one against the other or removing private insurance entirely would disadvantage others. If no one took out private insurance, we would all be disadvantaged because the public health system would not be able to support everyone. It is fine if people take out private health insurance and the insurer has a contract with a health service provider, but the difficulty with this is that the public health system is underfunded. There is no point in trying to deny it. Consider the recent and alarming figures detailing the number of people awaiting inpatient and outpatient appointments. That the previous Minister scrapped the National Treatment Purchase Fund, NTPF, and pretended that the special delivery unit alone would address the underlying issue, namely, the capacity of the public health system to deal with the throughput, was farcical. This must be realised at some stage.

A patient who is in the public system should not be penalised by having to wait for a long time. If the public health system does not have sufficient capacity to ensure this, the patient's care should be contracted out to a private provider. This is not an irrational thought. It worked well in the case of the NTPF. There is no reason that the fund cannot be resumed. Under its guidelines, if someone was waiting for a certain period of time and the public health system could not deal with him or her, the patient's care was contracted out to a private provider. People were dealt with in a timely fashion.

In the tail end of 2014, we have reached crisis point. We are awaiting publication of the HSE's service plan for 2015. The figures are alarming. Judging by the amounts announced in the budget, the public health system will not be able to deal with those figures in 2015 alone. Something will have to be done to alleviate the pressure of patients who wait inordinate and unacceptable lengths of time for procedures.

Those in the public system see private insurance policyholders receiving treatment quickly. This is unfair, but it is not the fault of the private insurers. Nor is it the fault of families that, having worked hard and saved money, take out private health insurance. The unfairness lies in the State's failure to provide adequate resources to the public hospital system. We should not demonise people who slave continuously to retain their private health insurance for "jumping the queue".

It is the public health system, because of the lack of funding, that is delaying people's timely and speedy access to diagnostics and to care. This is where the fault lies and I reiterate that Fianna Fáil intended to go for a seismic shift over to a new system of funding the health services. Everybody would be assessed in a timely manner and everybody would get treatment based on their clinical need. However, the same principle should apply as it is. People should get their treatment based on their clinical need and if one is a public patient, one is entitled to treatment as quickly as a person who has private health insurance. The delay is not the fault of the person who takes out private health cover. The delay and the fault is with the Minister, the Government and the Health Service Executive, HSE, in providing sufficient resources to ensure that public patients are not waiting an inordinate length of time. Members would then not be having this debate because the system would be fair and equitable in the sense of access to health care, be it public or private, in a timely manner. This is the Minister's difficulty.

Obviously, on the broader issue of the insurance market itself, Fianna Fáil also examined some of the insurance models and while we did not send off teams of officials to examine the various models, we were able to get information from around the place and universal health insurance is far from being a utopian model. The Minister should fight tooth and nail for adequate funding and resources to be put in place to ensure the public hospital system has the resources to deal with patients in a timely manner. If this means being obliged to transfer some of them into the care of private health service providers, this should not be a difficulty. I note this is being done on an ad hoc basis and from time to time is done in a panic mode. The pressure comes on, waiting lists lengthen and the special delivery unit then makes a few telephone calls and acquires treatment. However, what really should be done is to put in place a proper structure whereby the State, through the HSE, could put out to tender a number of procedures in areas such as orthopaedics and ophthalmology or whatever are the areas in which there are inordinate waiting times. That work should be contracted out in order that people are dealt with quickly, effectively and in a timely manner. I am quite definite that in terms of value for money, this approach is worth re-examining because regardless of whether people had an ideological objection to it or otherwise, the National Treatment Purchase Fund was addressing the waiting lists. It was able to refer people into private health care in a timely manner and that capacity in the private hospital system has grown in recent years with the opening of other facilities. I assure the Minister that nobody minds where they are treated, albeit not in the geographical sense but in the context of public versus private, as long as they are treated quickly, efficiently and in a timely manner in a safe environment. This point should be reiterated through all Government policy in the short to medium term.

Thereafter, in the run up to the next general election, Members will have a broader debate on how the health services will be funded in the years ahead because the people have a right to know. The people in general have a right to know what precisely the Government intends to do. This will take into account both the funding of the health services and broader taxation policy, the question of who will pay, how it will be paid and who will own the health service. As matters stand at present, I am unsure who will be the final arbitrators in the delivery of health care in Ireland. If one goes down the universal health insurance model, coupled with the hospital groupings themselves in a scenario in which they are all bidding and tendering against one another, it quickly will become evident that the insurers will be the ones that will dictate the amount of care provided to people. The Minister can talk about all the baskets he likes in the context of universal health insurance cover but financial realities will dictate quickly. This has happened in the Netherlands and elsewhere where the various fruits slowly were taken from the baskets and only extremely basic cover was left. If one then broadens this out to the issue of primary care, I note it is under huge pressure in some countries that have the model until recently was being espoused or promoted.

Overall, Fianna Fáil welcomes this Bill. It is urgent because the prevarication over the past three years has meant there has been a weakening of the health insurance market in terms of the age profile of those taking out private health insurance. One cannot sustain a position in which one now is asking older people to support older people, as was the case with regard to the age profile of those who had private health insurance and the fact that nobody was being encouraged into the market for many reasons. I accept the downturn in the economy obviously had an impact on the number of people taking out health cover. However, there also was no incentivisation and with the other issue of compulsory health insurance hanging over people's heads, there was no incentive for people to even consider private health insurance. For all these reasons, I would appreciate an expeditious passage of this Bill to ensure that Government policy retains a vibrant health insurance market and does not overburden it with costs, as has been the case with the policy decisions of the Minister for Finance and the previous Minister for Health, which lumbered additional funding costs onto those who already were hard pressed. More importantly, Members must get a clear and concise statement from the Minister or somebody in government outlining precisely whether the Government intends to proceed with the pretence of a universal health insurance model or whether Members will revert to having a genuine discussion on how the health services will be funded in the years ahead.

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