Róisín Shortall (Dublin North West, Social Democrats) | Oireachtas source

Insofar as the purpose of the Bill is to get the approval of the House to establish the risk equalisation mechanism in order to support community-rated health insurance, and the decision must be taken on an annual basis, I have no difficulty with it. I recognise it for what it is. In the context of a private health insurance market, it is better that there is risk equalisation, lifetime community rating and so on, in order that people who have certain illnesses or are of a particular age that would make them more likely to develop illness are not penalised. The principles underpinning that are good. They were agreed many years ago, in 2013. In the context of the private health insurance market, risk equalisation improves it and makes it fairer and better.

From that point of view I do not have a difficulty with the Bill, nor do I have a difficulty with the additional provision in this year's Bill, which specifies the amount of risk equalisation along with a high-cost claims credit to enhance the risk equalisation. This credit will assist people of different ages and those who are unlucky enough to have serious illnesses and end up in hospital receiving very expensive treatment and staying for long periods of time.

The original risk equalisation was to provide something of a level playing pitch among different insurers and ensure the VHI in particular, which had a greater proportion of older members, would not be disadvantaged relative to other newcomers to the market. Just as risk equalisation was agreed, it is also important that there is equalisation to address a situation where an insurer has a disproportionate number of people with serious illnesses and therefore much higher claims. That is a positive development in this year's proposal. Insofar as it goes, I agree with that in the context of the private health insurance market.

I made the point on the previous occasion we dealt with such a Bill that we are having the wrong conversation. The conversation should be about how we run and fund the health service. At the moment, for many historical reasons, including undue influence of business and significant vested interest within the health service, we have a two-tier health service. It is a totally dysfunctional health service that achieves neither the best health outcomes nor the best value for money. That does not make any sense.

We have never had a properly functioning public health service, going back to the establishment of the State. In the 1950s, there was the mother and child scheme and all that flowed from that in terms of the political opposition to it. That is sometimes underrated. We hear a lot about the religious objections to the mother and child scheme, but the objections from the medical profession were just as strong, if not stronger, and they were supported and, let us say, indulged by the political system at the time. It is incredible that we still have not achieved proper, free public healthcare for mothers and children. It is outrageous.

We are a complete outlier when it comes to the rest of the Europe. We are the only European country that does not have a single-tier universal healthcare system. We are also the only country in Europe where a large majority of the population must fork out the full fee to see a GP. That is just unheard of anywhere else. In most European countries, primary care is free at the point of access. There are other countries where there is a nominal or small charge to see a GP, but we are the only country where large numbers of people must fork out €60 when they want to see a GP. That makes no sense at all. We should be encouraging people to get early access to healthcare so that when they have an ailment they get it seen to and treated at an early stage, rather than having a situation where an awful lot of people simply cannot afford to visit a GP because the cost takes too much out of their family budget. As a result, people leave conditions to fester and get worse and often end up having to go to accident and emergency units or being admitted to hospital for much more serious treatment.

Early diagnosis and intervention are key in healthcare. For this reason, rather than being scared of people visiting their GP too much, we should be encouraging them to avail of primary healthcare at an early stage to ensure there is early intervention, which is very important, and they are enabled to return to full health as quickly as possible and make a full contribution to society. That is not the attitude that is taken.

The very fact that nearly half of the population feel they have no choice but to take out private health insurance is damning of the State and successive Governments. Ireland, alone in the European context, has utterly failed to introduce a modern, universal public healthcare system. It is an absolute tenet of any modern democracy that there is a properly functioning public health service. We have utterly failed to provide that since the State was founded.

We are told that this legislation is about achieving equity and equity of access to private health insurance. I accept that is what it does, but the other issue of equity - equity of access to healthcare - is much more important. Private health insurance enables people to buy access. That means skipping the queue and going ahead of other people. We must consider why people do that. The reason is that it enables them to get early access to healthcare. We all want that. We have such a dysfunctional system. People on very low fixed incomes, who cannot afford private health insurance, will sacrifice many other things to be able to pay a health insurance premium.

It is such an appalling reflection on the state of our health system that people have to scrimp and save and make all kinds of sacrifices in order to achieve the kind of assurance that when they need healthcare, they will get it. We should not be putting people in that situation.

Others have spoken about other countries where, even with a properly functioning public national health service, people still take out private health insurance. Yes, they do and that is fine and they are welcome to do that, but the state is not promoting that, nor is the state subsidising it - that is the whole thing. In the UK, there is the NHS and it was originally very good, although starved of funding over recent decades, undoubtedly. However, even in that situation, almost 90% of people in the UK are more than happy to use the NHS. These include people on good incomes, high incomes and all of that and they are perfectly happy to use it because it is accessible, they can get seen to quickly and they are happy with the standard of the service. People talk about the NHS and the fact there are waiting lists and all of that, but it is a measure that the vast majority of people in the UK are happy to use it. They give out about delays and so on, but they are happy to use it.

That is not the case in Ireland. As I said, almost half of the population feel they have no choice because the public system is so unreliable. A Deputy spoke of a couple spending €3,000 on private health insurance and that is probably at the lower end of the scale. However, even where people fork out a number of thousand euro per year for private health insurance, and for the kind of peace of mind that gives them, it is still very bad value for money. They still have to pay to see a GP, they still have to pay to see a consultant, they have to pay to see a physiotherapist and they have to pay through the nose for diagnostic tests because these things, in the main, are not covered. It is about getting into hospital; it is about skipping the queue and getting early treatment in hospital.

It is bad value all round but it also creates that dysfunction within our two-tier system. There are all kinds of perverse incentives within our two-tier system so there is a huge pull factor for people to buy private health insurance and there is also a huge pull factor for staff to work in the private sector. The bottom line in all of this is that the better the public healthcare system is, the less profit there is to be made in the private sector. Equally, one would say that the worse the public healthcare system is, the more money there is to be made in the private healthcare system. There is never money made out of people being well. There is money made out of people being sick. If the public healthcare system does not work properly, as ours does not, if it does not meet the needs of the people, then it provides that huge incentive for the private sector to profiteer from the provision of healthcare.

That has been aided, abetted and facilitated by successive Governments down through the years. There are moral questions about that. It is a fundamental failing of government that the Government is incapable of providing a public healthcare system where equity of access to healthcare is guaranteed. Access to healthcare is fundamental to our existence for all of us.

That was where Sláintecare came in. It was to achieve the kind of universal public healthcare system that, as I said, every other country in Europe has. There was cross-party agreement on that. Regrettably, the progress on implementing it has been desperately slow. Successive Ministers have been happy to wrap the Sláintecare flag around them and talk the talk of Sláintecare, but not actually deliver the fundamental reforms that are contained in it. Unfortunately, earlier this year, we had the very high-profile resignations of two key people who were charged with leading out the Sláintecare programme. Again, that is absolutely damning of this Government and the last Government and their failure to give political commitment to the implementation of the universal public healthcare system.

We are told that those two people have been replaced by the Secretary General of the Department and the chief executive of the HSE. It is a very disappointing move because if the Department of Health and the HSE were capable of reform, they would have done it long ago. They are not capable of reform. There is institutional resistance to reform. The idea of putting the two senior people there in charge of the rollout of Sláintecare is laughable in many ways. We need political courage and we need political commitment to the principle of equity of access to basic healthcare. That is what has been lacking, that is what we need to see the Minister doing and we need the full Government behind that. Implementing fundamental radical reform of the health service is something on which we must have cross-government support. The Taoiseach has been running away from this, as have the Ministers. It is the responsibility of the entire Government to deliver on Sláintecare. This Government will be judged on its failure or otherwise in respect of that, rightly so.

It is also important to acknowledge the principles that were identified in terms of the emergency response over the last two years to the dire situation we face in the context of the pandemic. At an early stage, it was recognised that we have to treat everybody the same on this. Because there was a complete lack of capacity within the hospital system, the private hospital system was brought in and created that additional capacity in terms of hospital beds generally, of staff, of ICU beds and of high dependency unit, HDU, beds in particular. We could not have survived without that. However, in terms of accessing those, there was a very important principle, which was that access would be on the basis of health need. To a large extent, that is how the country has survived the full impact of the pandemic because the healthcare system became a single-tier system, so access to healthcare was on the basis of need, not ability to pay.

Imagine that through the big waves of Covid, and we are currently on the fourth wave, we were saying to people they could only get treatment for Covid if they could afford to pay. It would be totally intolerable. Imagine if we said to people they could only get access to vaccines if they were prepared to pay and if they were not able to pay and could not afford it, tough luck, they go to the back of the queue, they do not get the vaccines and they do not get the protection. That is exactly what we are saying to people who need other life-saving care. We are saying it is available to them if they can afford to pay, but tough luck if they cannot because they go on a long waiting list. We have to realise that this is such a basic thing for people and that the Government has such a responsibility in regard to ensuring proper access.

There are a couple of further points that need to be made. The first is in regard to the understanding about Sláintecare. Some people think they will not be allowed to have private health insurance under Sláintecare. That was never the case. If people want to buy private health insurance, they are free to go and do it. However, the whole approach in Sláintecare was that we would develop a high quality, universal healthcare system so people did not feel they had to take out private health insurance, irrespective of whether they could afford it or not, and I have used the example of the NHS.

We know, of course, that the Exchequer directly subsidises private health insurance to the tune of €377 million. However, that is only the topline figure that we are aware of and in a whole lot of other areas where tax relief is allowed for healthcare, the figures are not even collected by Revenue in such a way that they can be reported.

There is a huge element of hidden cross-subsidisation by the public purse of the private system, which again is bad value.

The other thing provided for in this Bill that I cannot understand is in section 4. The Bill proposes to increase what is referred to as the benchmark of reasonable profit from 4.4% to 6%. I do not know what the justification for that is. Health insurance companies are profitable and we know that when people get their annual notice to tell them what their premium is, many do not just accept that. Rather, they pick up the phone and tell their health insurer they have received a better quote and ask if it can do something about that. Within seconds the company agrees to drop the premium by 5% or 10%. We should encourage everybody to do that when renewing their insurance and people get that immediate reaction if they ring up, say they got a better quote and threaten to leave. If companies can drop their premiums in an instant then why are we saying their reasonable profit levels should go up? I ask the Minister of State to explain that. We know the health insurance sector was worth €2.64 billion last year so it is a massive market.

Some 47% of people in Ireland are paying for expensive private health insurance. What does that contribute to the overall health spend in the country? It is an amazing figure. It only contributes 13% to the overall health spend in the country. The public purse, which is funded from people’s taxes, funds the health service to the tune of 69%. There is massive cross-subsidisation from the public purse to the private sector. That figure tells it all and it is quite startling. We need to start making progress on this. What we have done on Sláintecare so far is not good enough; the public deserves better.

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