Louise O'Reilly (Dublin Fingal, Sinn Fein) | Oireachtas source

I do not think I will need the full 20 minutes.

We can all agree that the main deficiency in our health system must be the absence of universal health care. Unfortunately, this continues to be reinforced by the Government and its backers in Fianna Fáil. Despite the fact that my party colleague, Deputy Caoimhghín Ó Caoláin, has repeatedly raised the inherent inequality in our health system each year during debates on consecutive Health Insurance (Amendment) Bills. That inherent inequality has been allowed to flourish. This happened on the Government's watch and on that of Fianna Fáil. Rather than finding ways to navigate a way out of a reliance on a two-tier system, it appears that oxygen has been given to the private sector at the expense of vital investment in public health services.

This morning, the CEOs of the hospital groups attended the Committee on the Future of Healthcare and spoke to us about stretch targets. I was not exactly aware of the detail of these stretch targets but I was mostly interested in what the CEOs will do if they do not meet these new targets. In the context of cutting services and cutting back, I specifically asked how they will determine what will be cut. There is a target. The Minister has been very clear that he will set targets for hospitals. Those hospitals that do not meet their targets will have to face the consequences. In truth, the patients will face the consequences. I asked all the CEOs and representatives who appeared before the committee how they would determine what gets cut. One of the replies was that they would cut the fat from the system. There is no fat in the system. Fianna Fáil started cutting it a long time ago and Fine Gael has continued the process. There is no fat in the system to cut, so these stretch targets, when they fail to be met - as they very well might - will end up resulting in cuts to front-line services.

Successive Governments have failed to introduce universal access to our health service based on medical need rather than ability to pay. Many critics noted that the introduction of lifetime community rating in 2015 made the health system less universal. This was because penalising people over the age of 35 for not taking out private health insurance exacerbates the two-tier health system we have all apparently set out to dismantle.

During the course of the meetings of the Committee on the Future of Healthcare, we have had the benefit of listening to the expertise of some very eminent professionals, academics, researchers and practitioners in the health service. Having seen all the evidence presented to us, it is clear that those who will suffer will be the poorest, the sickest and those with disabilities. These are the people who find it most difficult to pay charges, no matter how small those charges may be, and who are obliged to wait longest to access care.

This leads me on to the market private health insurance market, which will continue the scandal of two-tier access to health care. The diminishing minority who can afford private health insurance get to jump the queue. That is a fact. That is why they buy it. They buy it because, as Deputy Kelleher rightly pointed out, some of them do not have confidence in the public health system. They do not have confidence that they will be seen when they need to be seen, so it is not selfish on their part. I think it is borne out of fear rather than anything else. They take out private health insurance because they fear that the public health system will let them down. That is very unfortunate.

Inability to pay continues to deny people access to the opportunity to lead full, long and healthy lives. That is a fact. We need to increase investment in the public health system and directly challenge and eliminate the structural inequalities in it. The current heavy reliance on private health insurance will not facilitate that. The Minister knows it will not. It cannot. As I read the transcripts of successive debates relating to health insurance legislation, it became strikingly obvious that the Government has no roadmap to address this inequality. It looks like more of the same: leave the private insurance market alone and retain two-tier health care access. This State, as a relatively high-income OECD country, is unique in having managed to marry private health insurance with its public hospital system. People who can afford to pay privately can get their diagnostic tests more quickly, get to see a specialist more quickly and, if they have the right kind of insurance, might even be able to get their treatment more quickly.

When she was before the Committee on the Future of Healthcare earlier this year, Dr. Sara Burke advised us that the policy analysis work undertaken by her and others, which was published at the end of last year, found that despite the rhetoric and the intention of increased universalism between 2011 and 2015, there is in fact less, not more, universalism now than there was in 2011. This is due to the further increase in drug charges for people with and without medical cards, the introduction of lifetime community rating and the failure to reduce waiting times for access for public patients. For individuals earning annual €17,000, €35,000 or €65,000, the purchase of an average private health insurance premium at the rate of €1,200 per annum takes up 7%, 3.4% or 1.8% of their incomes, respectively.

One of the most striking parts of Dr. Burke's presentation was her analysis of 2009-2010 data exploring the extent of affordability of private health expenditure and what proportion of Irish citizens is financially protected and what proportion is not when they access health care. The analysis found that the poorest 40% of the population spent the most on private health insurance, yet the Government has no plan to redress this. Universalism is regressing, but we see no roadmap. The Committee on the Future of Healthcare is tasked with designing one but, as I have said before - the Minister will be well aware of my comments in this regard because I have voiced them on a number of occasions - I fear that while we are in one room trying to figure out a ten-year roadmap for universal access to health care based on need rather than ability to pay, the Government is busy in another room actively undermining any hope we might ever have of achieving it.

The Minister can shake his head but we have seen this and other examples which repeatedly show that inequality will deepen while we are in a room talking to people and trying to work out a roadmap in order to resolve the position. It is a case of us perhaps taking one step forward but being dragged two steps back by the actions of the Government.

We know, internationally, that insurance-based systems are more expensive and cause inequalities. In Ireland, 45% of our population has private health insurance but it contributes less than 10% to the overall health budget. This matter was raised at a committee meeting with representatives of the Economic and Social Research Institute. In the explanation as to how 45% of the population has private health insurance when it only contributes to 9% of the cost, Dr. Burke explained it is because private health insurance in Ireland largely insures someone for inpatient or day-case elective procedures. It does not cover most other issues. For example, it does not cover outpatient care generally, outpatient appointments with specialists in the first instance, the cost of drugs or most primary care payments. In effect, what we have seen is that this insurance is inpatient hospital insurance that people are scared into taking because it gets them faster access than they fear they will get via the public system.

Nobody could disagree that this is a blatant example of very poor value for money. It indicates that the public system is subsidising the private system because 45% of the population has private health insurance but the majority of the expense of health care is not paid for by private health insurers. Nowhere near 45% of the cost is paid by private health insurance. So why are we perpetuating this? Why has the Government not made any moves to break this self-fulfilling cycle of failure? I do not know.

Nine years ago, Ms Susie Long died from bowel cancer after a seven-month delay in getting a colonoscopy because she could not afford private health care. Before her death, she was very brave. The Minister is aware of the case, as I was, and I happened to listen to her on the Joe Duffy show when she spoke. It would have broken anybody's heart. She was very critical of the politicians in charge of the health system at the time and stated, "all they can think to do is put resources into privatisation". How far have we come in the intervening nine years? Honestly, how much progress has been made and how sure would we be, sitting here this evening, that there will not be another example like Susie Long? How is promoting private health insurance a step towards universal health care? How is perpetuating this market and subsidisation of private insurance in Ireland benefitting the public health services? It is not. It is exactly the same principle as the argument we had here when we discussed pay increases for Deputies. Out one side of the mouth comes the wish to prioritise low to middle income workers but this is done by giving people who earn €87,000 per annum a €5,000 pay increase. It is counter-intuitive and we are not fooling anybody if we think people cannot see that.

Our public services are underfunded and we cannot retain or recruit staff. The Minister may quote all the statistics he likes but the chief executives this morning stated they cannot retain or recruit staff. Even the staff they can manage to entice to work here do not find the Irish health service an attractive place to work. That is a fact. Although part of the issue is money, it is not all about funding. The Minister knows that. We cannot attract and retain the bring young people we should be. Most of these people want to work in the public health service. I visited student nurses in universities who wanted to stay here and work but they felt they could not do so. The issue is not just with nursing as there is a crisis throughout the health service with staff. There is also a crisis with waiting lists. This morning there were 528 patients on trolleys or awaiting admission to our hospitals. That is just unacceptable.

Before I conclude, let me respond to the much-publicised measure in this Bill, the introduction of a 10% increase in health insurance stamp duty levies, a move likely to lead to further price hikes for subscribers. In the media at the weekend, the Minister was reported as saying companies should "think carefully" before passing on these increases in stamp duty and that the legislation was "necessary to maintain a stable and sustainable health insurance market ... This is the way in which we ensure that everyone pays the same for their particular plan, regardless of age, health status or gender." If the Minister really believes that increases are not going to be passed on to consumers in some way, he is being somewhat naive. The reality is that when one does business with private companies, profit is their underlying motive and a few well-meaning words will not cut it. A private company exists to make money and any opportunity to make more of it will be grabbed with both hands. I am sure the Minister's intentions are good but asking people not to do something will not have the desired effect. I hope it will but it will not.

I was struck when the Minister indicated the need to maintain stability in the health insurance market. We have an ailing public health system, massive public waiting lists, repeated trolley crises, failures to recruit and retain staff and primary care that leaves a lot to be desired, yet we are concerned with the stability of a for-profit, private market. That is unbelievable and not what people want the Minister to do. They do not want him to spend his time worrying about providing stability for private health insurance companies. Good luck to them but they are private companies. Let them off. The Minister should be worrying about the public health service and the people depending on it.

If we want to ensure equality in our health service and that people get access to health care based on need, we need universal health care. Sinn Féin is committed to the realisation of a world-class system of universal health care, accessed on the basis of need, free at the point of delivery and funded by progressive taxation from the Irish State. This Government clearly is not so committed. In a short period, the committee on the future of health care will report. I do not yet know the blueprint that will be proposed or if consensus can be reached. I genuinely hope we can reach that consensus. I have heeded a great deal of advice during the course of the proceedings and much of this points to the need to disentangle the private activity from public health services and invest in our public services rather than relying on the private sector. I hope that next time we come to this House with a Bill of this nature, we will have such a plan. It is counter-intuitive to say we want to disentangle private involvement in our public health service while saying we are very concerned about the stability of private companies.

Despite the rhetoric of universal health care, the reality is that the Government's measures are mitigating against universalism. In its Better4Health document launched last year, Sinn Féin recommended an end to the special treatment of private patients in public hospitals by incrementally eliminating private activity and replacing the revenue lost with increased public funding to their core activity budgets during the lifetime of a Government. The HSE estimated, in its 2014 submission to the consultative forum on the health insurance review group, that, "the private health insurance market generates roughly €500 million per annum for the statutory and voluntary hospital system". Sinn Féin would make an additional investment of €100 million, rising to

My party and I are serious about ending the two-tier system of health care access that is currently in place. This Government, backed by Fianna Fáil, clearly is not as serious.

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