Brian Stanley (Laois, Independent)

I welcome the opportunity to contribute to this debate. The cost of private health insurance puts a huge burden on people. In particular, it puts a huge burden on pensioners, who feel they have no choice. People feel compelled to take up private health insurance because of the delays and inefficiencies in our public system. Some progress has been made in some areas. Some of the screening projects being run are very effective. However, we must do a lot better. It is another tax on people. That is the reality of it. I have dealt with pensioners who are on €280 a week who are paying €40 to €60 for private health insurance. We are seeing several hikes in the one year. There is not one increase but a number of them. Some of them are double-digit increases. We have a market model. While we are stuck with having to use private health insurance, the Government needs to address the charges put on public facilities by private companies such as VHI and Laya. There are flaws in this approach to private health insurance. It is based on profit rather than medical need. It is a two-tier system.

Every week, I see examples of people who urgently need medical care or surgery. I am sure it is the same for the Ministers of State. This surgery could be a hip replacement. The scandal of the two-tier system is that in spite of what the proclamation read out in 1916 said about treating everyone equally, these people are being told that, if they pay, they can be brought in next week but, if they cannot pay, they will have to sit there for two or three years. I have seen several examples of that. That is what we need to change.

There are those who profess that the private sector will sort everything. If somebody wants to operate a private hospital, that is all well and good. Good for them. It is okay if they want to do that but it needs to be separated out. I welcome the 80%-20% consulting model. That is a step in the right direction but we need to go the whole way on that. Mary Harney famously said that we could go with either the Boston model or the Berlin model. What she meant was that we would go with the American model. Previous speakers have said that we should go with the Thatcherite private model. That is the system in America. How has that worked out? You have to be a millionaire to get treatment. Are we seriously being told we should go down the route of the American model where you have to be a millionaire, or very close to it, before you can get your appendix taken out or something else done? That is not where we need to go. We need to look after people.

Let us look at the figures in this country. Some 2.53 million people have private health insurance.

A total of 1.57 million have medical card cover. This is based on figures from the start of the year, and they are probably still fairly accurate. However, we have 1.3 million who have neither - that is 1.3 million people without proper healthcare of any kind. Some of them may have a GP-only card, which I acknowledge is a help, but it is still a long way off. A small number of people have that card.

Let us look at this category of people for a moment. These are the same people who cannot get on a local authority housing waiting list. Many workers and their families cannot get on a local authority waiting list. They cannot get a mortgage - and if they do get a mortgage, they are crucified trying to pay it out of their wages. Most likely, they are paying for a car to travel to work. If they are in private rented accommodation, they are really at the mercy of a wild west system. Let us just think about these people for a minute. They are trapped in a very difficult place. On top of all of that, they do not have medical cover. I have met those people, as has the Minister of State. They ask me why they are being left out the whole time. They pay taxes. They get up every morning and drive their car to Dublin to work on a building site all day or they drive wherever elsewhere to work a ten-hour shift. They are doing the best they can and they do not even have basic health cover. That is what we need to change.

We are stuck with the current system. I accept that we have to do this every year and the risk equalisation fund is the only way it can be done. We are where we are. While we are here, we have to do this to spread out the burden. If we were to charge those who most need healthcare on the basis of their age and their health needs, they would not be able to do it. We would have people falling through the cracks. I recognise that the system has to be supported. That is recognising the real-world situation we are in now, but what I am saying is that we need to change the current model. The fact is that a lot of people do not have the option. Risk equalisation is based on having an annual adjustment. It is a logical approach, which spreads that burden.

I want to address value for money in the health system. We had the 100th anniversary of the Committee of Public Accounts today. As a former Cathaoirleach of the committee, I attended the celebration. There is no doubt that people in the health system are doing great work, but its finances are shrouded in fog. We put in a lot of money as a percentage of GDP. We are behind some other countries, but we have a high GDP, which is good. In terms of hard cash, we compare very well with other countries. We exceed the amount put in by most of them. I have no argument with that given where I come from on the left of the political spectrum. However, I question the value for money that we get and the gap between the money actually going over to Miesian Plaza - the headquarters of the Department of Health - and the actual services on the ground. It is a long and winding road. The one thing I would implore of the Ministers is that they would make sure that they can track where that is going. The Comptroller and Auditor General's office would have had difficulty at times trying to follow that route. In the five-year period I was there, I and the members of the Committee of Public Accounts had difficulty. We tried very hard at times and we made some progress, but it is a difficult route to follow. That route must be shortened. Money, budget and action need to be a straight line so that people can see exactly who is accountable along the way, that the route is the shortest possible one, and that there are not too many diversions. We must do that.

As I recall, the implementation programme for Sláintecare is a ten-year one. We do not have that much time left in it. I accept that Covid slowed it down. I also accept that that is the real world. I am not going to shout at the Government about that. That is something that we all had to deal with. We might have dealt with it differently if it came up now, but everybody did their best at the time and they did what they thought was right. We have to get Sláintecare up and running. We are an outlier in Europe. We do not have a national health system comparable to other north European countries. Per head of population we are counted as one of the richest countries. It is not a panacea for all. They have an NHS in the North, but that is not perfect. There are big long waiting lists. My niece works in it and I know all about it. It is a difficult system. If you put in the system and you do not put in the necessary checks, balances and procedures, you wind up with that result. We do need to move to a single-tier system to ensure the people I referred to at the outset do not feel compelled to pay €40 to €60 a week. We can work it out. The charges amount to €2,000 or €3,000 a year. If you are on a pension of €280 or €285 a week, and you have to pay €40 to €60 a week, that is the first thing that goes out of it. That is a huge pile of money, and a huge take out of the income of a pensioner. Even if they have an occupational pension of typically €80 to €120 a week, it is a huge pull on it every week. We must do better than that. We must try to move to Sláintecare.

I asked the Minister, Deputy Carroll MacNeill, before the budget if in the short term we could do something to help the 1.3 million citizens who do not have medical card cover. They are mainly workers and their families. It is unfair. The income threshold for the medical card has not changed for as long as I am here, and even before that. I am open to correction on this, but as I recall it is more than 20 years since the income threshold was increased. It is €186 for a single person. The lowest rate of social welfare for a single person is over €230. I know people automatically get a medical card if they are on social welfare, but they are not automatically entitled to it if they are working in a part-time job and that is their only income. That is an absolute scandal that we are ignoring that group of people. They are the people who cannot get a house. They cannot get a mortgage. They are paying taxes. They have to get to work. They have to make payments on cars and everything else, yet they and their children have no health cover.

I was challenged by a man while I was canvassing at this time last year for the general election. I know him and his wife, as she comes from the same area as me. He said to me that the people beside him have a medical card. He said he does not begrudge them it, but he does not have one. They had it by virtue of their status in this country. I do not like saying that. I do not want it to be taken off them either. The point I make is that the children in that family had been sick but they could not go to the doctor in the month of November. The Minister of State might recall how cold the weather was when she was canvassing last November. I remember the man saying that to me at the door one freezing cold night. It is not good enough that we do that. We must help those people. We must help the workers and their families in this country. We have had a lot of time to do it and we have made a lot of progress, but the one thing that has not moved, that is frozen in time, is the income thresholds for medical cards.

See this speech in context