Pádraig Rice (Cork South-Central, Social Democrats)

As in previous years, the Social Democrats will be supporting the Health Insurance (Amendment) Bill. Risk equalisation is necessary to ensure that older and sicker people do not face huge premiums because of their perceived risk. This modest measure also helps mitigate cherry-picking low-risk groups, such as younger and generally healthier people. In the context of our two-tier health service, where approximately 46% of the population have health insurance, the risk equalisation scheme is essential. Eight years on from the publication of Sláintecare, it is concerning that the private health insurance market continues to grow. That should give the Minister of State pause for thought, because it is hardly a ringing endorsement of his predecessor’s track records on reform.

A total of 2.5 million people in Ireland have health insurance. That is almost half the country. Last year, total premium income stood at €3.6 billion, up from €3.2 billion in 2023. According to the Health Insurance Authority, the average individual plan increased by 12% in 2024. As of June, the average premium stood at €1,830, an increase of €147 in 12 months. This is a huge expense for households, and it is way beyond the reach of many workers.

Even though almost half the country has health insurance, only 12% of overall health expenditure is paid for by private health insurance. In fact, despite some reform, there has not been much change in the last decade. In 2014, private health insurance accounted for 13% of health spending. However, we should, hopefully, see a more considerable drop in the figure in the years to come, as the process of disentangling public and private healthcare progresses. Ultimately, we cannot continue to stand over a system where the taxpayer is subsidising private healthcare. It is totally unjust and unfair that taxes pay for 77% of health expenditure, yet people with private health insurance have quicker access to healthcare compared to their fellow taxpayers without insurance.

Equally, those who have private health insurance should not feel the need to have it. They should not feel pressured into it, out of fear for themselves or their families failing ill. They should not feel obliged to dig even deeper every year to pay health insurance premiums, but the reality is that they do. This is not a European norm.

Ireland is an outlier.

Sláintecare recognised this dysfunction in our health system. In fact, it was the motivating force behind the setting up of the Committee on the Future of Healthcare. Sláintecare had and has cross-party support and remains official Government policy but momentum has undoubtedly stalled. Implementation has always been patchy but now more than ever, it seems as though the reform programme is being slow walked. I do not think that has been done consciously but I believe that a lack of political will has converged with a lack of institutional knowledge. On the latter point, I, like so many others, was not in the House in 2017 when Sláintecare was agreed. The membership of both Houses of the Oireachtas has changed considerably in the years since and just five of the 14 TDs who sat on the Committee on the Future of Healthcare are still in the Dáil. Of those five, not one is in the Department of Health, nor indeed is their party’s health spokesperson. I do not say this to suggest there is not an understanding of Sláintecare in this House, but we are, as Professor Steve Thomas has warned, in "danger of mission creep". To be clear, Professor Thomas is not just some commentator. He led the Trinity College team that supported the Committee on the Future of Healthcare in developing Sláintecare. He, like the Social Democrats, remains entirely committed to Sláintecare but I am not sure if the same can be said of all parties, particularly those in the Government. Everyone is still signed up to Sláintecare in principle but are they still committed to its vision or are they just paying lip service to the reform programme?

As Professor Thomas pointed out at a recent health policy conference, Sláintecare can mean almost whatever we want it to mean; therefore, it risks losing coherence. To emphasise his point, Professor Thomas pointed to the bizarre fact that eligibility and entitlement is still being debated. This is something I am particularly concerned about. Why, eight years into Sláintecare, is a review of the eligibility framework being carried out? Sláintecare was clear that an entitlement to universal healthcare should be provided to all, underpinned by legislation. In 2025, however, there are still virtually no universal entitlements to healthcare, only "eligibility" for some services. This point, while overlooked, is crucial - the distinction between "entitlements" and "eligibility". "Entitlement" means that a person has a right to something, while "eligibility" is defined as having the necessary qualities or satisfying the necessary conditions to qualify for a scheme. That is a very important distinction.

I accept that a review of the long-term illness scheme was needed and should have already taken place but this so-called strategic review of the wider eligibility framework concerns me. First, if it is anything like the long-delayed strategic review of general practice, it strikes me as a delay tactic, a way of doing nothing on eligibility under the guise of awaiting its findings. Second, there is no need for a review. What exactly is there to review? Yes, in the absence of clear entitlements, a complex system of eligibility has developed. There is no denying that but reviewing it is not the answer; undoing it is.

In a reply to a parliamentary question I submitted earlier this month, the Minister said that in order to achieve the goal of universal healthcare in line with the commitments made in Sláintecare, we must first review existing eligibility arrangements. This far into a ten-year plan to achieve universal healthcare, the Government wants to look at the existing arrangements now. This does not fill me with confidence. The focus is entirely misplaced.

The 2017 plan recommended legislating for a legal entitlement to healthcare. The proposed Bill would provide for a universal entitlement to a broad package of health and social care services. This universal entitlement for everyone living in Ireland was to be phased in over a five-year period and completed in 2023. I accept that Covid interrupted that timeline but that is not the real reason it has not progressed. Unfortunately, this Government has no interest in conferring any right to services on people. As usual, it is treating Sláintecare recommendations like a menu rather than a manual. That is not to say that every single word in the 2017 report must be accepted and that we cannot adapt to changing circumstances, but one cannot pick and choose from recommendations that are fundamental to delivering an integrated, universal, single-tier public health service delivered on medical need and not ability to pay.

Regrettably, I do not think there is an appreciation of the fact that the key recommendations in Sláintecare are interrelated and interdependent. Take for example one of the central elements of the reform programme, namely, integration. The recommendations related to delivering integrated care are particularly important. Why is this the case? It is because even if this Government were to make good on commitments related to entitlement to care, this would not ensure access. The integration section of Sláintecare is about improving access through a recalibration of our health system away from hospitals and towards the community, but integration also includes fundamental reform of HSE governance structures. It should be acknowledged that we are seeing some critical changes to the governance structures, most notably the phased implementation of health regions. However, I have concerns about the accountability mechanisms in place. It is deeply regrettable that the Minister has no intention of putting national and local accountability structures on a statutory footing.

I am also concerned about other key Sláintecare reforms, such as salaried GPs and a statutory right to home care. The latter is a long-standing commitment dating back to the Tánaiste’s time in the Department of Health. Since then, every target for the introduction of the statutory scheme has been missed. All the while, home care waiting lists have grown. This year alone, they have increased by 12% since January.

Looking at this year’s health budget, one would struggle to be optimistic. It is short on reform and even shorter on detail. Rarely has there been a more underwhelming budget for health. The Minister has shown limited ambition and limited commitment to change. It looks like Sláintecare has been put on ice for 2026. Why the standstill? In recent years, there have been some belated but encouraging signs of progress, such as the take-up of the consultant contact, the reduction in some out-of-pocket expenses and better access to community diagnostics, to name a few. However, since this new Government entered office, Sláintecare has been sidelined. I accept that a new action plan was published last May but that was two years overdue, and in those two years, the Department was unable to even come up with costings or provide a figure of implementation. The new plan lacks any substance. It is little more than a box-ticking exercise. Ultimately, the Social Democrats will always support genuine efforts to implement Sláintecare but I am afraid that those instances have been few and far between. That needs to change. Otherwise, people will continue to feel obliged to fork out almost €2,000 a year for private health insurance and that is not acceptable.

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