Catherine Connolly (Galway West, Independent) | Oireachtas source

I welcome the opportunity to speak on the Health Insurance (Amendment) Bill, which is legislation that is introduced annually. I thank the Department and the Minister for the work. That will be the end of my positive praise as I will now I go into the background as to why this is necessary. It is a short Bill of ten pages and seven sections. We go through this process every single year. What we have created here is a necessary mechanism to equalise the risk faced by different insurance companies.

The briefing paper has been very helpful. For anyone listening to this subsequently, it is important that it has been spelled out that the risk equalisation is a process that aims to equitably neutralise the differences in insurance costs that arise due to differences in the age profile and health status of the health insurers' customers. In the limited competition that we have, with a small number of insurers, VHI - which is non-profit - would be left unable to cherry-pick whereas the other insurance companies could cherry-pick who they decide to insure or not to insure, depending on age or vulnerability. In that sense, this is very welcome legislation because it equalises that risk.

However, when we look at why this legislation is necessary, the word "surreal" comes to mind with regard to it. I will go with facts first and then go into the surreal reason this mechanism and legislation are needed every year and also the hypocrisy of Government after Government with regard to the commitment to a public health system, while all the time promoting the private system, albeit on a non-profit basis with VHI. Due to pressure arising from EU free trade laws, the health insurance market had to be opened up. That was hailed as great progress, and it was if one takes a limited view of it because it opened up the sector to more insurance companies. The Minister of State may remember when BUPA came in. It was one of the first, and one of the first to leave when it did not get its own way on risk equalisation. It fought many court cases to stop that.

In the time I have, I will give some background and address why we are praising a scheme like this. We see what the naked market does when we look at what BUPA did in bringing the Government to court after court with regard to the equalisation scheme. If BUPA had won, it would have meant the insurance companies could have cherry-picked who they wanted.

Prior to the market being opened up 30 years ago, the VHI had a monopoly. In June of this year, we learned that 2.46 million people, almost 50% of the population, or 47.6% to be precise, have health insurance, the annual cost is over €1,500 per year and so on. In 2022, the total premium income was €2.93 billion. As Deputy Shortall mentioned, the actual money collected in premiums is tiny relative to the spend by this Government and other Governments on providing a public health system. Yet, that income, and the entitlement that goes with a premium, allows extraordinary leverage to consultants and patients and also a sense of entitlement, all of which I hope to come back to.

I am someone who has seen the system from both sides, having had the privilege, through family, of having VHI membership in the past. I am no longer a member. Interestingly, the size of the private insurance market grew by 3% in 2022 compared with 2021. There are 79,553 more people with health insurance, which, although it is a relatively small number, is an extraordinary increase at a time when the Government and its predecessor have committed to a universal public health system. There was cross-party agreement under Sláintecare that we would go down the road of public medicine, with equal access for everybody, and that insurance, and certainly the tax relief on it, would be phased out. People who continued to choose to have an insurance policy would do so in the understanding that they would be treated in a private hospital, full stop, with no more access to the public system. I am sure the Minister of State and a lot of his colleagues in Fianna Fáil agree with that. The problem is that Government policies have complicated matters no end and we now have a surreal situation whereby a State-owned company, VHI, is actively promoting private medicine. "Surreal" does not capture what successive Governments have done.

Looking back to 2004, which is almost 20 years ago, the ESRI's report, Health Insurance in Ireland: Issues and Challenges, stated in its conclusions:

Almost half the Irish population [at that time] now pay for private health insurance, one of the highest levels of coverage in the OECD. This is despite the fact that everyone has entitlement to public hospital care from the state, and hospital care is what private health insurance mostly covers. The insured can avail of "private" health care, although much of the private health care is actually delivered in public hospitals.

A scheme was set up to encourage people to take out a premium in order to be entitled to treatment in public hospitals by paying privately for the right to access.

The report goes on, "The resulting two-tier system is now widely regarded as problematic from an equity perspective, but there are also serious efficiency issues to be faced because of the incentive structures embedded in this particularly close intertwining of public and private." This was written 19 years ago. It points to the incentives in place to attract more private patients to public hospitals in order to gain income. The report further concludes, "The recent introduction of competition in the health insurance market, in a tightly regulated setting, has led to the introduction of a wider range of insurance products." The Government, ostensibly, was doing something good in opening up the competition. However, as the ESRI clearly sets out, this did not address the fundamental problems of inequity. The report states, "The Irish experience shows that a structure designed to take advantage of possible benefits for the public system of close interaction with private care can create perverse incentives, be inequitable in terms of access and utilisation, and undermine the public system. The political economy of reform is however highly problematic."

That report was written 19 years ago. I can go back further. In 2001, the national health strategy stated openly that the public-private mix of beds in public hospitals was intentional, in order to ensure the two sectors could share resources, clinical knowledge, skills and technology. However, the overlap also gave rise to complex incentive patterns and concerns about equality. In 1989, the Commission on Health Funding recommended the introduction of a common waiting list. We had got to the point in this country, which had been declared a republic in 1949, that we needed a commission to tell us that a common waiting list was required, that we should not be distinguishing between private and public patients and that service should be prioritised according to medical need. It goes on and on.

I spent ten years of my life as a member of a regional heath forum, which I have referred to many times in this House, as did other councillors. I watched the systematic undermining of the public health system and, simultaneously, the promotion of the private system. I was a member of a city council that took a majority decision to rezone land to allow a second private hospital to be built in Galway on the basis, the councillors agreed, that 20% of the beds would be reserved for public patients. We often talk about misinformation. This was a total fallacy, a total lie and total misinformation. It has never been the case that 20% of beds were kept for public patients.

What happened was that the National Treatment Purchase Fund was set up 21 years ago. Many of us are old enough at 21 to have a sense of reason and to realise our mistakes. The fund was established in 2002 to treat patients who had been longest on public hospital waiting lists. It should be remembered that the Government was actively promoting the private system while this was being done. Twenty-one years ago, when the fund was founded, it had an allocation of €5 million. In 2023, a total of €150 million was allocated to the fund. For what has it been used? Where the public system had failed to treat patients, funding was being provided for treatment in one of the two private hospitals in Galway city or the one in Kilkenny, for example, the North or abroad. What kind of a farcical, surreal system is that?

In the meantime, while that is happening, there are cases such as one to which I will refer without naming names. A person came into my office who was waiting for a hip operation. I never like anecdotes but this case goes to the kernel or heart of what we are talking about here. The person was on a waiting list in the public system. The wonderful consultant, who has both public and private patients, offered to do this person's procedure privately for €12,000. The person went off and got a loan for €12,000 to get the hip replacement done. This patient is in limbo now, needing a second operation. Using the private system will require payment and the person has been taken off the public list. A payment of €12,000 is being asked for by the same consultant who has stood over a long list building up in the public system. I do not hear voices raised in outrage about that.

As background to all of that, we have 588,813 people on outpatient waiting lists nationwide, of whom 81,356 are children. These figures have been stated here repeatedly. I will be parochial in referring specifically to the orthopaedic service in Galway, where there are 6,694 adults on the outpatient list, of whom 1,230 have been waiting 18 months or more. We should remember that we have a thriving private system in which patients who have €12,000 can get the job done. In the meantime, 1,230 adults are waiting 18 months or longer in Galway. There are 622 people on the UHG orthopaedics outpatient list, of whom 261 have been waiting 18 months or more. On the inpatient lists in Galway, 118 adults are waiting 18 months or more. According to Trolley Watch, on Tuesday, 22 November this year, 562 patients were on trolleys nationwide, of whom 428 were in emergency departments and 134 closeted away on wards. There were 39 patients on trolleys in Galway, 31 of them in the emergency department, which is not fit for purpose and is currently operating in temporary accommodation, and eight in wards elsewhere.

In this scenario, the Government announces a recruitment freeze that, it tells us, will apply only to management and not to consultants, nurses or midwives. Then a little more information comes out from the head of the HSE, whom I admire as an honest and straight person. I have heard him speak at the health forum in an absolutely blunt and straight manner.He tells us the recruitment freeze is not exactly what we have been told it is; it is more than that. In the meantime, we get letters from clinical psychologists and speech therapists telling us the recruitment ban will affect them.

Even more bizarrely, a speech therapist tells us that she is working through an agency, which is costing the health executive more money. I will not use up my time in reading out the letter but I am sure we all got these letters spelling out clearly what is happening around recruitment.

On top of that, when I was on the health forum I was told there was no money and that there had to be cutbacks, refurbishment of beds, and that people could not be employed. Since I came to the Dáil I am being told that money is not a problem and it is just that staff are not available. As I stand here I know there are five empty beds in the nursing home in Carraroe. Tá cúig leapacha folamh i gcroílár na Gaeltachta mar níl siad in ann foireann a fháil. They cannot get the staff. Now we have a staff recruitment freeze. Honestly. I have used the word "surreal" and I do not use it easily. I really have a difficulty in fathoming what is going on here in relation to a freeze on staff recruitment.

We have delayed discharges in the hospital in Galway. Some are for years because there are no nursing home beds. We have privatised the whole nursing home sector. I believe it is 17% that are public nursing home beds now. Can one imagine that it is 17%? Yet, on any given week when we open the newspaper we see another private company in trouble. The Minister of State's colleague, Minister of State, Deputy Butler, has acknowledged it - and it has been in the newspaper - about the nursing home company Aperee Living which owns a company in Galway as well. There are huge problems there in relation to governance, fire safety and so on. Who will pick up the pieces? It will be the public purse. It has happened repeatedly. It has happened in Galway, in Oughterard, where it was necessary to send in public nurses to operate the private nursing home. Most of the nursing homes now are huge companies.

I will now turn to primary care. As of the end of 2022, there were 160 primary care centres open nationwide. What is happening in relation to those? The vast majority are owned by companies. Indeed one of the company directors was the former head of the health executive who saw the gaps and the opportunities. The private companies are now providing the primary care centres and we lease them back. Does that make sense? Does it make sense that while we are ostensibly going down the route of Sláintecare and public medicine, at the same time we are promoting private insurance and private primary care, which is supposed to take the pressure off the hospitals? We have privatised it almost completely.

Does the Minister of State have any idea what analysis or risk assessment has been done on the move by this Government and the previous Government to provide health centres that are all owned by for-profit companies? What happens when they get into trouble? What happens when they fold? What do we do then?

There was an options appraisal in Galway back in 2019 on what was the future for Galway hospital services. We have the regional hospital, the Merlin Park hospital, and two private hospitals. I foolishly relaxed when I saw the options appraisal going for a brand-new hospital in Merlin Park to be built for purpose. Nothing happened. When I asked lately, I found out there was a second options appraisal carried out few years after that and suddenly they said they would keep building up the congested site and would put up a few little places in Merlin Park hospital, so the new elective hospital would be in Merlin Park and a new surgical hub. The original plan for a brand new hospital went - I was told by the clinical director - because the Government failed to act or give them the thumbs up for that options appraisal. We are now, therefore, down the road of a different options appraisal that is leading us to build on the congested site, build in a jigsaw manner without an overall picture for Merlin Park hospital, and constant delays.

Consider the accident and emergency capability. The then Minister for Health - the current Taoiseach - said that a new building was the only solution to the problems in University Hospital Galway. In 2015, Enda Kenny said that the ED was not fit for purpose. The 2016 programme for Government committed to looking at it and so on and so on. We got an interim ED - I believe it was for €15 or €16 million - which opened in October 2022.

It is hard not to despair. How can the Government not see that a public health system with equal access for everyone is the most fundamental requirement of a republic, as is housing that gives shelter, in order that people can then participate in society on an ongoing basis? The kernel is to have shelter and access to public health. Instead of that, we have privatised in every way we can from the diagnosis to allowing doctors have a private building in Merlin Park for diagnoses.

I will finish on osteoporosis. There is a fantastic public service but not enough equipment. Everybody is directed out to the private clinic for osteoporosis scans.

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