Billy Kelleher (Cork North Central, Fianna Fail)
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I move:

That Dáil Éireann:notes that:

- there is an ongoing and persistent increase in the cost of private health insurance, with a crisis of affordability for both individuals and families developing;

- the increase in private health insurance premiums is significantly ahead not only of inflation generally, but health sector inflation as well;

- an average of six thousand consumers leave the private health insurance market every month;

- there is little incentive for younger people to take out health insurance;

- the haemorrhage of younger, healthier policy holders is threatening the sustainability of the private insurance market by generating further upward pressure on health insurance premiums for those who remain; and

- many of those who remain have downgraded their level of cover; and

calls on the Government to:

- act speedily to reduce costs in the delivery of both public and private health care as undertaken in the programme for Government;

- introduce lifetime community rating;

- revise the legal definition of non-advanced plans so that the 300,000 holders of lower level plans will not face a substantial rise in their health levy;

- defer the increase in the health levy which is scheduled for the end of March;

- remove children from liability to the levy;

- ensure patients who have private health insurance and pay their taxes do not lose their universal entitlement to public health care funded by the State;

- work with insurers to develop industry standard clinical pathways;

- permit public hospitals to negotiate with health insurers; and

- use its position and purchasing power as a VHI shareholder to negotiate a reduction in consultant fees.

Inflation costs in private health insurance are many multiple of the broader consumer price index inflation and health sector inflation. Health insurance premia have gone through the roof in the past number of years, and as a result it is critical that the Minister takes a hard look at policies and the legislative framework base in underpinning a move to universal health insurance. We have spoken about the issue on numerous occasions and the Government does not seem to understand the difficulties out there, with families dropping out of health insurance plans, as outlined by the Health Insurance Authority. Over 70,000 people left health insurance in 2012.

When 34,000 people left health insurance two years ago, the Minister described it as a crisis and was apoplectic with rage, frothing from the back teeth on a continuous basis about the need for strategic policies around the issue of private health insurance. Nothing has happened since except the opposite to what was required. The Minister of State is aware that there should have been non-advanced plans but none exist. All the people paying for lower benefit health insurance schemes will now subsidise those on more expensive plans. That was outlined at a health committee meeting some weeks ago by health insurers. The people who can only afford basic plans and cover will now subsidise those people with the Rolls-Royce of private health insurance, which is clearly unjust and unfair.

The Government must rethink the issue very quickly. When the Minister dealt with Second Stage of the risk equalisation Bill last year, he indicated non-advanced plans could be available and exempt from the higher levy. We were led to believe by the Health Insurance Authority that there would be approximately 47 non-advanced plans. The legislation has been passed but there are no non-advanced plans, which means we are asking people hanging on by their fingertips to private health insurance and are dropping benefits. That means they can no longer avail of day case procedures or MRI scans or will have to pay for them. Health insurers have indicated that benefits must be removed from plans to ensure they qualify for the non-advanced category.

We are asking people to choose whether to fill a tank with heating oil, pay a gas bill or pay for insurance. These people must now subsidise a person with a €4,000 premium plan and who is staying in five star accommodation. That is clearly unjust and the Government must examine it. If the Government does not understand the advice it gets from the authority and officials, it will be at clear odds with the facts in the market. The four insurers have indicated clearly that this will be a result of the risk equalisation levy and the lack of non-advanced plans available to the many families struggling on a daily basis.

Every party and Government over the years has encouraged people to take out health insurance. There was tax allowance for the VHI for many years and such incentives still exist. There has been a policy of encouraging people to take out private health insurance. We are saying to those who have been paying for private insurance for generations - since the foundation of the VHI - that because of the legislation to redesignate beds in public hospitals, if a person is referred through an accident and emergency department to any public hospital in the country, health insurance customers will foot the bill to be treated in a public hospital. These people would have already funded the hospital through general taxation but they would receive no extra benefits. It is completely unacceptable to ask a person who has worked and made sacrifices in paying health insurance and contributing to the Exchequer - which funds public hospitals - to accept an indirect charge when they are in an accident and emergency department and a private health insurance card is found in their pocket. As health insurance companies will foot the bill, the expense will be passed to private health insurance customers, which is an unacceptably low practice in funding the country's health services.

This is a form of double taxation and a mean attack on middle Ireland. The Government must examine the matter again. This year and last year it was factored into the Government's accounts and I ask it, at this late stage, not to go down the road of placing double taxes on people who work hard and try to lighten the burden on this State in providing health care. These people will now have to pay twice when they enter a public hospital. That arises from Government policy.

The Government's amendment contains a slap on the back for this double taxation on people who can barely afford health insurance as it is. It states that the Dáil "endorses the Government's policy of generating additional income for public hospitals, by addressing the present subsidy enjoyed by health insurers in respect of their private patients who occupy public hospital beds". This is not a subsidy as the health insurers must pass on the cost to those who are consumers of private health insurance. Health insurance companies are obligated to run a surplus and cannot run a deficit, as they work under regulations from the Central Bank. They are obliged to pass such costs directly to the consumers, or the basic policyholders who already find it difficult to hold on to the very lowest type of plans offered by health insurers. This is a nasty double taxation on middle Ireland and I urge the Government to revisit the matter as quickly as possible.

We have raised another issue on numerous occasions. The figures indicate that younger, healthier people are opting out of private health cover by no longer taking up private insurance or dropping plans. Demographics indicate that there is an increased number of people on the other end of the scale. If we are to have intergenerational solidarity, with one generation contributing to the welfare of another - the idea behind community rating, which we have all bought into - there must be some lifetime community rating to encourage young people into the private health insurance market. The figures, as published by the Health Insurance Authority, back this up.

In 2008, there were 334,000 people between the age of 18 and 29 with health insurance but last year there were 267,000 people in that group. It is a massive drop. On the other end of the scale, the group between 60 and 69 had 185,000 people in 2008, whereas in 2011, the group had 207,000 people. Such a dynamic is completely unsustainable. The Government is pretending there is a market that will provide vibrancy and competition when universal health insurance is imposed on the people.

There has been no great discussion so far because we are still waiting for the famous model and for the commission on universal health insurance to publish its findings. In the meantime, the laissez-faireapproach to encouraging people to take up health insurance is simply untenable. In the longer term, it will endanger elderly and sick people because there will not be a healthy swathe of young people taking up private health insurance to cross-subsidise those who most need it.

I ask the Minister of State, Deputy Alex White, to reconsider the three issues about which I have spoken. I will be elaborating on them in greater detail tomorrow evening. This amendment is an extremely farcical exercise in slapping oneself on the back for single-handedly destroying private health insurance and driving over 140,000 people out of the market since the parties opposite took up Government.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I welcome the opportunity to contribute to this important debate tonight on the spiralling cost of private health insurance. I commend my party colleague Deputy Billy Kelleher on tabling the motion. The high cost of health insurance is having a devastating and detrimental effect on households across the country. It affects both young and old, despite the commitment in the programme for Government that the Government would act speedily to reduce the cost of the delivery of both public and private health care. This simply has not occurred and circumstances have continued to deteriorate during the tenure of the Minister, Deputy Reilly, in the Department of Health.

The statistics are stark and cannot be defended by the Government. According to the Health Insurance Authority, 2,099,000 people had inpatient health insurance plans at the end of December 2012. This represents a reduction of 64,000 policyholders in 2012. This followed a reduction of 65,000 people in 2011. According to the CSO data from April 2012, the percentage of the population with inpatient insurance has fallen from a peak of 50.9% in 2008 to 45.8%. These alarming statistics are compounded further by the staggering lack of progress of the Minister for Health on his trophy policy, the introduction of universal health insurance.

When the Minister had an opportunity to support the measure that would have extended free general practitioner care to all newborn children in 2013, as outlined in Fianna Fáil's pre-budget submission, A Fairer Way to Recovery, he declined it. This policy would have gone some way towards meeting the Government's long-delayed commitment to providing free general practitioner care. This was a missed opportunity.

The number of policyholders with private health insurance is falling continually. A more worrying trend concerns the high proportion of young people and families who have been priced out of the market and who have abandoned their health insurance cover. This is the core demographic that health insurance providers should be targeting to ensure their own sustainability and the very future of the industry. For the period 2008 to 2011, the number of those over 50 with inpatient health insurance increased by a further 50,000, while the number of policies for those under 50 fell by 122,000. The main reason is that young people and families, who have suffered greatly in the recession, can no longer afford to purchase health insurance. The four insurance providers operating in the market, VHI, Laya, Aviva and GloHealth, have all increased the costs of their policies over the period such that there has been a never-ending series of price hikes. For example, GloHealth, which has been in the market for only less than a year, increased the premiums for its core plans, outpatient-only plans and cash plans on 30 January and 2 February this year.

Young people with families have been left with two choices, that is, to give up health insurance entirely or downgrade their health insurance cover. The knock-on effects have resulted in health insurers increasing their prices for loyal customers to cover the gap, in effect pricing a second group out of the market. Despite this, the Minister for Health seems unconcerned and indifferent to this growing crisis. How can consumers realistically shop around when the four insurers in the market continually hike their prices? This position is simply untenable and the Minister will have to intervene. The lack of concern shown by the Minister is in sharp contrast with the criticisms he levelled at the former Government in 2011 over the then price increase. He spoke of the last straw for struggling families and claimed it would lead to increased demand on the public hospital system. Now, when the Minister has an opportunity to do something, he does not even consider the proposal that his Department research the impact of patients who have previously held private health insurance presenting in public hospitals.

This is not the first time that we have seen evidence of the Minister's dramatic transformation from his time in opposition to when he entered government. The concern remains but inaction is the adopted policy approach. A policy of "wait and see" is simply not good enough from the Minister for Health. Instead of stopping the haemorrhaging of consumers from the health insurance market, the trend has actually accelerated during the Government's term of office.

This trend can be reversed if the Minister for Health takes on board a number of recommendations. First, he needs to protect the 330,000 health insurance customers with lower levels of cover from another increase in the Government's health insurance levy in March. He needs to renew his commitment to adopt a two-tier levy system for those with advanced and non-advanced cover. The Health Insurance Authority, having examined the Health Insurance (Amendment) Act 2012, has classified all of the plans on the market as not conforming to the Minister's definition of "non-advanced". As a result, all policies are now categorised as advanced and subject to the higher rate of levy. The Minister needs to revisit urgently and revise the legal definition of a non-advanced plan. If the current situation is not rectified, an individual paying €500 for a lower-level plan, a very basic plan, will pay the same levy as someone who can afford to pay €4,000 for a Rolls-Royce plan. This raises fundamental questions with regard to equity and fairness since those on lower levels of cover are being asked to subsidise those with higher level health insurance policies.

The Government needs to defer the increase in the health levy due at the end of March until a new definition for non-advanced plans is agreed. The health insurance levy has already increased by nearly 80% since its introduction four years ago. The CSO reports that health insurance premiums have risen by 60% over the same period.

Children should be removed from the health levy criteria as a matter of priority. Young families who are hard pressed during this recession need a break. Intergenerational solidarity should be confined to those of 18 years and over. Only last year the referendum on children was passed to strengthen children's rights in the Constitution. How is it fair or equitable for the Government to expect children to support older and single people's health insurance costs through paying this levy? Simply put, the levy on children needs to be abolished urgently.

The Government needs to tackle the VHI and how it operates. The Government, as its senior shareholder, has an important say in how it operates. In 2005, the VHI had 1.7 million customers; today, the figure is 1.2 million, yet the number of staff has increased. If it were a private company, it would have gone bust.

The Government needs to ensure that patients who have private health insurance and pay their taxes do not lose their universal entitlement to public health care funded by the State. Increased public hospital charges, including the proposed additional hospital bed charge, and their impact on the cost of private health insurance need to be addressed. If the Government ignores the concerns of the insurers and the industry, it will, in effect, undermine the sustainability of the health insurance market.

The phased introduction of lifetime community rating ought to be considered. Such a move could be used to encourage younger people to purchase health insurance.

The prohibition on insurers negotiating with public hospitals must be lifted. At present insurers can only negotiate a package price with private hospitals. There is also a discrepancy between the five days and seven days in private and public hospitals, respectively, in the length of stay for VHI customers, which must be addressed.

Surely greater savings could be achieved if insurers could negotiate with public hospitals? As a means of lowering costs in the industry, insurers must work together, with the support of the Department of Health, to develop industry standard clinical pathways. Such a move would lead to the delivery of quality health care to customers in the most efficient manner.

This Government and the Minister for Health need to address the issues set out urgently to ensure the sustainability of private health insurance market in this country. The people deserve better than the level of incompetence evident in the Department of Health and displayed by this Minister.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I join Deputy Troy in commending Deputy Kelleher for putting forward this motion tonight.

Health insurance is one of the payments that families have struggled to keep up at all costs as finances have become tighter. Like many Deputies, I have come across many families who have explained to me that their mortgage and health insurance are the two bills they struggle to keep on top of. For many, however, that struggle has become too difficult. Since the Government has come into office, although the trend had already started, many people have stopped their health insurance.

Unfortunately the Minister and the Government have failed miserably so far to grasp this issue and put a halt to the slide in the numbers with health insurance. We now have a Minister who promised that, if elected, he would deliver universal health insurance.

Alex White (Dublin South, Labour)
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By 2016.

Charlie McConalogue (Donegal North East, Fianna Fail)
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Instead, during the first two years in government, we have seen more 1,000 people leaving private health insurance every day and coming back into the public system. Instead of those who need insurance getting public insurance and the services that would go with it, the opposite has been the case. We have seen a real lack of leadership to bring our health services around and changing their operation. Unfortunately, the Minister underwent a change of personality after the election. When he was on the Opposition side of the House, he would solve it all but now he is in government, he is creating more problems than he can solve.

We saw that with his ministerial team. Instead of going from strength to strength and getting a handle on what was happening, we have seen one Minister of State leave the team to be replaced by Deputy White. I wish Deputy White well in his role and I accept that the challenge of health service reform is very difficult and will take some time. Unfortunately, from what we have seen up to now, there is little cause for confidence that the Government will reach that target.

Since 2008, the number of people with health insurance has fallen from a record of just under 2.3 million to just under 2.1 million at the end of 2012. The worrying thing about these figures is the imbalance in who has left the health insurance market. If we look at the breakdown of age, we can see the problem. The over 80s category has gone from just over 36,000 in 2008 to 44,000. Likewise, the 70 to 79 age bracket has risen from 94,500 in 2008 to 110,000 in 2012. Similarly, in the 50 to 59 category, there has been a rise from 266,000 to 271,000. Once we look at the categories under the 50 age bracket, however, we see where the pain lies and where the imbalance is becoming pronounced in the health insurance system. In the 40 to 49 age bracket, numbers have fallen from 320,000 to 312,000, while for those in their 30s, the numbers have fallen from 367,000 to 339,000. The 18 to 29 bracket has seen numbers fall from 334,000 to 267,000 and further drop of 20,000 in the numbers who are 17 or under.

The problem here is that this places more pressure on the health insurers. Those who are continuing with their health insurance are older and perhaps more insulated from the recession, debt and family pressure compared with those under 50, and are therefore more able to sustain their health cover. It is also that category who will make greater use of health insurance products and have a more immediate need to keep it up. Those with families and who are younger might make less use of health insurance and have more demands on their weekly income, forcing them to drop out. As a result, the health insurers find it becoming more and more expensive to provide health cover because those who have kept their policies are using them. That is doubtless a factor in the increases in fees that we have seen.

This is something the Minister said he would tackle, saying he would bring a halt to increases in private insurance costs, but that has not been the case. At the start of the year, VHI announced further increases for 15 for their corporate plans and has now announced it will increase premiums on 50 plans by 4% to 8.5% on 1 March. The latest 6% increase means the costs of some the State's largest health insurer's policies, typically held by older people, have risen by almost 70% in little more than two years, a massive increase by any standards. The figures I outlined earlier show that older people have kept their health insurance up despite the 70% increase.

The VHI announcement is the fifth increase in just over two years. Last November it increased its prices by 3%, with similar trends across the other health care insurers, with Laya, Aviva and GloHealth also significantly increasing premiums in recent times. This means the cost of health insurance has doubled in four years at a time when health inflation has been low and there has been deflation in the general economy.

The latest evidence of the Government's failure to get a handle on the issue has been the breaking of the commitment to protect the 330,000 health insurance customers with lower levels of cover from another increase in the Government's health insurance levy in March.

These new problems arise from the Health Insurance (Amendment) Act 2012 and mean that everyone will pay the same additional levy regardless of what type of private health insurance policy they hold. During the debate on the Health Insurance (Amendment) Bill last year the Minister for Health made a clear promise that there would be a two-tier levy system for those with advanced and non-advanced cover so that those with more basic cover would not end up subsidising the holders of more advanced policies. It was expected that those on basic packages would face a €5 increase while those on advanced policies would face a €65 hike. However, following on from the recent review of all policies by the Health Insurance Authority based on the wording of the Minister's legislation, Laya found that none of the plans on the market conform with the Minister's definition of non-advanced. As a result, all policies are now categorised as advanced, meaning the same higher rate of levy will be applicable to all, making a mockery of the Minister's pledge here in advance of bringing in the legislation with regard to its impact.

The motion in the name of Deputy Kelleher, put forward on behalf of our party, asks that the Minister address the health levy, in particular, its impact on children. Parents, who have the additional cost of putting a student through college and raising a family, are finding it most difficult. If the Minister could address the levy cost on children, it would at least bring some relief to them.

Overall, we must see some meat on the bones of what the Minister is proposing in terms of universal health insurance. What has been delivered so far, two fifths of the way into the Government's term, has been the opposite - fewer people with health insurance rather than everyone with health insurance. That is a real failure and an indictment of the Government. I hope to see some sense of confidence that the Minister and the Government know where they are going on this and some sense as well that there will be real change and real movement on this. This will be a long-term project but it can only be a project if it gets moving and if we progress it. We have not seen that.

Michael Moynihan (Cork North West, Fianna Fail)
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I compliment Deputy Kelleher on putting down this motion and I thank him for the opportunity to speak on it.

There is a number of issues in this regard. First, before I go into the motion itself, there are anomalies in the system. As public representatives, we meet people who come to us who would have had paid up membership of VHI or other insurers who, because of one application or one day in respite, the two-week respite would not be granted under the cover. Also, recently there was a difficulty with the contents of a policy where a person under the age of 30 had been diagnosed with a serious cancer and, because of specific rules and regulations, was put outside of the insurance cover and was not able to benefit from it even though the person had paid it and the person's family had paid it right through from the time the person had been a young child.

The thrust of the motion relates to affordability of VHI cover and the situation families face who are making decisions on a daily basis as to whether they can continue with private health cover. The Government has flagged many policies on universal health cover but it remains the case that families throughout the country are making decisions on whether they will be able to continue with private health insurance. Those making that decision are predominantly within a certain age group. I refer to young families, those who have mortgage difficulties and those couples who would have lost one or more jobs and maybe have a significant mortgage commitment and have all the other add-on costs of children going to school, perhaps children going to college, etc. The families that are making these decisions are of the younger age group and are under considerable pressure.

There does not seem to be any urgency from Government on this issue. This affects entire sectors of the population, not only in the commuter belt but across the country. In my constituency, there are many families making these decisions for purely economic reasons in that they do not have the money to continue with the health insurance cover that they probably have had since they were born. The statistics on the numbers dropping out of the private health insurance market were quoted earlier. Throughout the past years the Government parties were telling us that they would have a detailed plan in place and that almost at the touch of a button there would be a solution to the issue.

The insurance companies, in particular, VHI, are preparing for more increases. As one of my colleagues stated, the numbers availing of VHI cover has decreased dramatically and the number of those working within that organisation has increased dramatically. There is no logic to it. The company has never been able to explain properly how this correlates. If the company operated in any other sector, it could not add up.

Some of the private health insurance companies have told us that they have achieved savings by negotiating with consultants and others but the bottom line is that when the renewal letter comes in through the post for ordinary families with children the premium has increased and they are faced with a difficult decision. This affects those families in terms of whether they can continue with health insurance cover.

I came from such a family which would have had private health insurance up to a point and had to discontinue it in the mid-1980s. That had significant repercussions down the line. I do not want to dwell too much on my family situation but merely wish to state that I would have experience in this area. If matters improve in ten or 15 years' time and it happens that the parents of those families will be in a position to get back into the private health insurance market, they will be penalised. It behoves the Minister and the Government to look at this in a logical and sensible way to ensure that there is a reasonable decision made on it.

The fact that families that have withdrawn from private health insurance is having a detrimental effect on others who want to continue in it in that there is a corresponding increase in the cost of cover. Nowhere over the past two years have we seen a robust defence of what will be done except what was outlined in the programme for Government. At this point, we need a clear indication that this will be tackled for the many families discussing their finances and looking at what they must cut back to continue providing for the children going to school, the extra-curricular activities and all the other associated costs. Such costs are not excessive because the vast majority are looking at them in a realistic fashion. What will the Government do from this point on? If the roles were reversed, outside the doors of the House and elsewhere there would be passionate pleas regarding what we were doing wrong. The reality is that there is nothing being done for the many thousands of people who are withdrawing from private insurance. It is having a detrimental effect on those who are remaining in private health insurance.

In ten or 15 years' time, this will have a bigger effect on the health service of this country.

We have seen what is likely to change in the demographics, but if we are not able to maintain the people in middle Ireland, who are working to sustain families, in the private health insurance market in the immediate term or in the next four, five or ten years when they will come to rejoin it, it will have a huge effect on it. If they cannot rejoin, it will have serious consequences for the public purse and public policy. Not alone for the families who are leaving now but for the people in ten, 15 or 20 years' time, and for society as a whole this is a most fundamental decision to make. I appeal to the Minister to respond to the motion and outline what will be done in the short term to rectify the situation. I commend the motion to the House.

James Reilly (Dublin North, Fine Gael)
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I move amendment No. 1:

To delete all words after “Dáil Éireann” and substitute the following:

“strongly endorses the principal of community rating, whereby people can buy health insurance for the same price irrespective of their age or health status;

acknowledges with satisfaction the passing by the Oireachtas of the Health Insurance (Amendment) Act 2012, which introduced a permanent scheme of risk equalisation effective from 1st January, 2013;

commends the Minister for Health on the measures he is taking to protect community rating in the private health insurance market and recognises the support that risk equalisation provides to maintaining community rating in the market in helping to ensure the affordability of health insurance for older people;

supports the work of the Minister for Health to ensure a sustainable private health insurance market in Ireland;

welcomes:

— the success of the Minister for Health in securing the approval of the EU Commission for the new Risk Equalisation Scheme as a vital means of protecting the affordability of private health insurance for older and less healthy customers who are most likely to need it; and

— the notifications by insurers for categorisation of another 30 plans as non-advanced by the industry regulator, the Health Insurance Authority, to be made available to customers, with a corresponding lower rate of Stamp Duty, from 31st March, 2013; after that date new products can be introduced at any time subject to meeting a 30 day notification period and requirements for classification;

notes that there is no need to amend the legal definition of non-advanced plans since they will be readily available to customers under the current definition;

supports the work of the Minister for Health to make private health insurance affordable for all who wish to purchase it;

welcomes and supports:

— the Government’s continuing work to address unacceptably high costs in the private health insurance market and shares the Minister’s concern that increases in private health insurance premiums are not justified in all circumstances; and

— the actions of the Minster for Health in requiring the VHI to address its cost base immediately, including action on the fees it pays to health professionals, auditing the volume of treatments it pays for and clinically reviewing the appropriateness of these procedures;

endorses the Government’s policy of generating additional income for public hospitals, by addressing the present subsidy enjoyed by health insurers in respect of their private patients who occupy public hospital beds;

further supports the continuing work on the Health Service Executive National Clinical Programmes in developing effective clinical pathways for patients that can be utilised by all health insurers; and

further endorses the actions of the Minister for Health designed to ensure a strong and competitive health insurance market as a key building block in the Government’s commitment to implement Universal Health Insurance.”

Tom Hayes (Tipperary South, Fine Gael)
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Is that agreed? Agreed.

James Reilly (Dublin North, Fine Gael)
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I welcome the opportunity to participate in the debate in order to set out some of the progress achieved to date by my Department which underpins the development of universal health insurance by 2016. The preparatory legislative and organisational groundwork for the UHI system currently in progress will be put in place and completed within the Government's term of office.

The Government is the first in the history of the State that is committed to developing a universal single-tier health service, which guarantees access to medical care based on need, not income. We will, unlike the failed policies of Fianna Fáil, introduce UHI with equal access to care for all. Under this system there will be no discrimination between patients on the grounds of income or insurance status. The two-tier system presided over by Fianna Fáil for decades will end. Contrary to Deputy Kelleher's suggestions, no one on this side of the House ever suggested that the mess left by Fianna Fáil could be fixed at the press of a button. On the contrary in opposition at the time, we were the first to be honest and mature enough to say it would take two terms of Government to fix this and put in place an equitable system.

Billy Kelleher (Cork North Central, Fianna Fail)
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Honesty and the Minister's policies are an oxymoron.

Brian Hayes (Dublin South West, Fine Gael)
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Please-----

James Reilly (Dublin North, Fine Gael)
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When I was listening on the monitor earlier, I did not hear anybody interrupting Deputy Kelleher.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Minister is being argumentative.

James Reilly (Dublin North, Fine Gael)
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Nobody likes to hear the truth, but as an old lady once said to me "The truth is not fragile, doctor, it won't break." The truth is that the Government of which Deputy Kelleher was part had the power for 14 years and did nothing to address this issue. I wish to correct the record of the House because all sorts of outlandish claims have been made from the far side on increases in insurance. In 2009, health insurance increased by 11%; in 2010 it increased by 7%; in 2011 it increased by 10%; and last year it increased by 12.1%. The trend started in 2008 and for more than three of those years the Fianna Fáil-led Government had responsibility for it. It sold our financial sovereignty and left us with the biggest debt the country has ever seen, and Deputy Kelleher wonders why some of the costs of living have to increase. His vision of reality is quite remarkable.

There are a number of other important stepping-stones to achieving the goal of universal health insurance. Good progress is under way in the strengthening of primary care services to deliver universal primary care, as well as ongoing work in tackling waiting times and establishing hospital groups. When I came into government I set up a special delivery unit, SDU, in my Department. The SDU started a major national programme aimed at helping hospitals to tackle the problems associated with delays in accessing care. Hospitals were set ambitious targets and in the main they met them. Through meeting them, clinicians adopted new ways of working.

During 2012 there have been significant improvements in hospital access targets, including a reduction of 23.6% in the number of patients waiting on trolleys in 2012 compared with 2011, which equates to 20,352 fewer patients waiting on trolleys. There are still too many people waiting on trolleys, but already in the first two months of this year we have seen a further reduction of 10% on 2012. I remind the Deputy - his memory seems to fail him sometimes - that the month before the general election that saw the removal of his Government had the highest number of patients on trolleys since records began with 569.

On scheduled care we set a nine-month target and the number of adults - excluding endoscopy - having to wait more than nine months for inpatient and day-case surgery was down to 86 at the end of December 2012, from 3,706 in December 2011, which is a 98% decrease. The target for 2013 is a maximum wait-time guarantee of eight months. In the paediatric area we set a 20-week access target and the number of children - excluding endoscopy - waiting over 20 weeks was down to 89 at the end of December 2012, from 1,759 in December 2011, which is a 95% decrease. The number of patients waiting over 13 weeks for a routine GI endoscopy procedure reduced from 4,590 in December 2011 to 36 at the end of December 2012 representing a 99% decrease.

All this was achieved despite having to remove more than €3 billion from the health budget in recent years and despite several thousand people - most of them in February 2012 - leaving the health service. We are trying very hard to ensure that by 30 November 2013 no patient will be waiting more than 52 weeks for a first-time consultant-led appointment. I heard Deputy Kelleher say that he would cover more of this in his wrap-up speech tomorrow night. Perhaps he would be good enough to tell us why, despite all its years in power, Fianna Fáil never even bothered to count the number of people waiting on an outpatient waiting list. This is the first Government to do so and we are not afraid to admit there is a problem and to say we will address it. We have said we do not want any patient waiting longer than 52 weeks for a first-time consultant-led appointment by the end of this year. That is a very ambitious target and we will seek to meet it.

On access to GPs more than 1.8 million medical cards - the highest number in the history of the State - have been issued to individuals. That is the highest in percentage and absolute terms. The Bill to allow for the extension of free GP care to persons with prescribed illness will be published this year. I am the first to acknowledge that we have been delayed in that regard, through a combination of very serious technical issues and the volume of legislation to go through the Oireachtas. Progress continues to be made in building primary care capacity and in chronic disease management particularly for the management of diabetes. Funding has been approved for the appointment of 17 clinical nurse specialists whose role will include supporting health-care professionals involved in the provision of care to their diabetes patients in both the primary and secondary-care settings.

In moving towards universal health insurance, community rating is a fundamental cornerstone of the Irish health insurance market. This means that the price of health insurance for all persons should reflect the principle of intergenerational solidarity, that is, that the entire community of privately insured persons should contribute towards the higher costs of claims for older people and less healthy people. Under community rating, everyone is charged the same premium for a particular health insurance plan, irrespective of age, gender and the current or likely future state of his or her health. Community rating therefore means that the level of risk a particular consumer poses to an insurer does not directly affect the premium paid. I know the Deputies on the far side of the House agree with that principle.

The pricing of risk across the community of insured persons clearly requires robust mechanisms to share costs when there are several insurance companies in the market. The standard transfer mechanism to support community rating is called risk equalisation. The aim of risk equalisation is to look at the market as a whole and distribute fairly some of the differences that arise in insurers' costs due to the differing health conditions of all their customers. Community-rated health insurance systems across the world use this as a means of providing the necessary support for the market.

An effective risk equalisation scheme creates an incentive for insurers to focus on innovation, greater efficiencies and improved customer service rather than on selecting customers based on risk. This is the type of competition that is best for consumers. In this context, I am pleased to note that two major reinsurers are now involved in providing underwriting services in the Irish market. In the lead up to the introduction of universal health insurance it is critical that private health insurance remains affordable and that the market is competitive.

Jerry Buttimer (Cork South Central, Fine Gael)
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Hear, hear.

James Reilly (Dublin North, Fine Gael)
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I welcome that there are now four insurers competing in the Irish market. If our policies were erroneous and misguided further insurers would not be coming into the market. What they value is certainty into the future. Insurers see risk equalisation for what it is. It gives them the sense of certainty they need to compete in that market.

The Health Insurance (Amendment) Act 2012 which I introduced last November provides for the introduction, for the first time in this country, of a permanent risk equalisation scheme in the private health insurance market with effect from 1 January 2013. I was gratified that the legislation was strongly supported on all sides in the Dáil. This support was a clear recognition of the vital part risk equalisation plays in maintaining stability in the private health insurance market. The scheme provides that health insurers receive higher premiums in respect of insuring older people but that older people receive risk equalisation credits equal to the amount of the additional premium so that all people continue to pay the same amount for a given health insurance product.

The risk equalisation scheme encourages efficiencies as it compensates insurers for only a proportion of the higher costs of insuring older and less healthy people. Insurers should then compete for market share by providing better services rather than competing for younger, healthier lives. The risk equalisation scheme also provides for a cost subsidy from younger, healthier people to older, less healthy people. The compensation is provided in favour of the individual consumer rather than any particular insurance company. A company with a worse than average risk profile and, therefore, higher claims costs, will be a net beneficiary from the scheme while a company with a greater proportion of younger and healthier people will be a net contributor to the scheme but will benefit considerably from having much lower claims costs.

In setting the rates for risk equalisation credits, following consultation with the Minister for Finance I had particular regard to the principal objective of the Health Insurance Act, which is to ensure that access to health insurance cover is available to consumers, with no differentiation between them, in particular as regards the cost of health services based on health risk status, age or sex. I also had regard to the aims of maintaining the sustainability of the market, having fair and open competition in the health insurance market and avoiding the risk equalisation fund having a surplus or deficit from year to year. If the risk equalisation is set at an appropriate rate, it should meet its costs, and no more.

In operating the risk equalisation scheme it is important to ensure that those who purchase the more basic plans, with lower levels of cover, do not effectively subsidise customers who decide to purchase plans that provide higher levels of benefit. With this in mind, the Health Insurance (Amendment) Act 2012 distinguishes between non-advanced and advanced plans. The non-advanced or entry level plans will have a lower rate of stamp duty payable. In addition to avoiding any unintended subsidisation of advanced plans, they also help to make the entry level plans as affordable as possible. I am conscious of the concerns that have been expressed regarding the absence to date of any non-advanced plans which would attract the lower level of stamp duty. It is important to note that the new stamp duty rates will come into effect for policies taken out from 31 March 2013 onwards. While currently there are no non-advanced plans in place, the focus will be on availability of such plans from 31 March, when they can start benefiting from the lower levy.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Minister is making it up as he goes along.

James Reilly (Dublin North, Fine Gael)
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That was the policy of Fianna Fáil. The Deputy should not confuse this Government's policy with that of Fianna Fáil.

It is open to insurers to introduce new non-advanced products at any time, subject to meeting the qualifying criteria and adhering to a 30-day notice period to the Health Insurance Authority. I understand - I am sure if the Deputy is not interested in this that his constituencies will be - that insurers are currently engaging with the authority in this regard and that more than 30 products are expected to be available to consumers from the end of this month.

Billy Kelleher (Cork North Central, Fianna Fail)
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With lesser benefit.

James Reilly (Dublin North, Fine Gael)
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I want now to turn to the issue of costs, an issue fundamental to the Government's programme of reform. I do not accept that medical inflation is in some way special or should be allowed to jeopardise affordable health care. I have emphasised to insurers to do everything possible to keep down the cost of health insurance so that it is affordable for as many people as possible. I have consistently raised the issue of costs with health insurers and I am determined to address costs in the sector in the interests of consumers.

Last year, I established the health insurance consultative forum, which comprises representatives of the country's main health insurance companies, the Health Insurance Authority and Department of Health. This forum was established to generate ideas which would help address health insurance costs, always respecting the requirements of competition law and giving a voice to insurers in the development of the new universal health insurance model. I have made clear to the health insurers that I believe that significant savings can still be made, the effect of which can be to minimise the need for increases in premiums. I have requested the VHI to address its costs as a matter of urgency. In particular, I have asked it to focus on auditing the volumes of procedures it pays for and to audit, from a clinical perspective, the appropriateness of procedures carried out before funding them. I have also stressed to the VHI that it should critically examine the actual prices its pay to health professionals and to private hospitals. I have emphasised the steps that I expect to be taken across the private health insurance industry so as to keep costs and resulting premia down.

Just over 2.09 million or 45.8% of the population currently has private health insurance. The number of people insured has fallen by 63,700 or 2.9% in the 12 months to end-2012, which is a continuation of the declining trend since the peak of 2.2 million, or 50.9% of population, at the end of 2008. This reflects the general economic downturn Ireland is currently experiencing. For those who have been insured on the same plan for a number of years, it is important they review their level of cover to ensure that their needs are being met, without being over-insured. Consumers have a legal right to switch between or within insurers to get better value and to reduce their premium costs. The Government would strongly advise consumers to shop around for the health insurance plan that best suits their needs. The Health Insurance Authority, HIA, provides information to consumers and its website, www.hia.ie has a useful plan comparison tool which assists in finding suitable and competitive health insurance plans.

Since coming into office I have made some significant improvements to the measures in place to ensure that private health insurance remains affordable for older and less healthy people. To keep down the cost of health insurance for older people, I increased significantly, with effect from 1 January 2012, the age-related income tax credit for insured persons aged 60 years or older. Without this support, health insurers would have had an even stronger financial incentive to segment the market by offering policies targeted at young people, to the disadvantage of older customers. With effect from end March 2013, the risk equalisation credits will increase substantially over 2012 levels for higher risk groups, particularly men aged 70 and over. For example, the risk equalisation credit for a 75 year old male with advanced cover has increased by €400 or 20% and for an 85 year old male has increased even more, by €675 or 25%. The Health Insurance Authority has confirmed, based on market average claim costs for prescribed benefits, that the 2013 scheme compensates for 75% of the higher claims costs for those aged in their 70s and compensates for 83% of the higher claims costs for those aged in their 80s.

An additional consideration regarding the cost of health care delivery concerns the charging for public bed occupancy. Under the current legal framework, private inpatients who occupy public beds in public hospitals are not levied the daily maintenance charge which in most public hospitals ranges from €586 to €1,046. The Comptroller and Auditor General reported in 2010 that 45% of inpatients treated privately by consultants were not charged maintenance costs because they were not occupying designated private beds in public hospitals. I have previously announced my intention to bring forward legislation to address this.

As part of Budget 2013, I announced further details on legislation to provide for the charging of all private patients in public hospitals. Primary legislation will be introduced during 2013 to provide for charging of private inpatients in public hospitals, where they are not in a designated private bed. On that basis, budget 2013 provides for additional patient income of €60 million in 2013. This measure is designed to recoup some of the cost of treating private patients in public hospitals. The current system, whereby private patients are charged only €75 per day when they occupy a public bed, represents an unsustainable subsidy to health insurers.

Billy Kelleher (Cork North Central, Fianna Fail)
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They are all taxpayers.

James Reilly (Dublin North, Fine Gael)
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It is not fair and I am committed to addressing it by charging a realistic amount for this service.

The recently published money follows the patient policy paper proposes the introduction of a new model of funding for public hospital care.

It involves changing from the current inefficient system of block grant budgets to a new approach where hospitals are paid for the actual level of activity they undertake. This will be facilitated through the introduction of a prospective case-based payment system using diagnosis related groups. The changes will effectively mean that hospitals will be funded on the basis of the quantity and quality of the services they deliver to patients and not the size of last year's budget. This move is in line with the recommendations of a value for money and policy review which previously examined this issue. It means if there are no patients, there will be no payment.

With regard to the national clinical programmes, it is in the interests of all patients, public and private, that effective clinical pathways are in place throughout the health system. National clinical guidelines will help to improve further the quality, safety and cost effectiveness of health care throughout Ireland. In the public health system, the HSE continues to work on national clinical programmes to improve and standardise patient care throughout the system. The stroke programme has saved one life a week since its introduction and pre-empted the necessity for three patients a week to go into long-term care. We also have a new early warning score card which will make a huge difference throughout the system. We are the first country to put it in place nationally. It will mean doctors and nurses in Tralee will operate on the same value set as doctors and nurses in Letterkenny, Beaumont Hospital or St. James's Hospital.

As I stated earlier, the Government is embarking on a major reform programme for the health system, the aim of which is to deliver a single-tier health service, supported by universal health insurance where access is based on need, not on income. I have already outlined the number of important stepping stones which are under way to pave the way for the introduction of universal health insurance.

Contrary to the claims made by the Opposition, I believe we are taking the right steps to achieve a sustainable and robust private health insurance market. The risk equalisation legislation is a key element of this. Taken with the actions on addressing costs in the market, I am determined to ensure that private health insurance remains affordable. My concern is to ensure the private health insurance market is ready to form a key building block for universal health insurance. In the meantime, the Government will work intensively to ensure a well-functioning insurance system for our people. I urge insurers to take all appropriate means to address their costs and to keep premium rises to the absolute minimum. There is much room for improvement.

Michelle Mulherin (Mayo, Fine Gael)
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I welcome the opportunity to speak on the motion. Health insurance is a vicious circle as the more people who leave it, the more expensive it becomes and then more people leave it. It is an issue for lower income families, not least on account of the fact that those on higher incomes get tax breaks on their health insurance premium. The measure of the cost of cover, perhaps €3,000 or €4,000 for a family, is not based on one's income but on risk. Any steps which can be taken for those who genuinely want health insurance but find it is outside their grasp should be pursued. We must also recognise the tax break is not as attractive or significant for lower income families.

I very much welcome the concept being pursued by the Minister of money following the patient. It makes sense that hospitals and health services are paid on the basis of the service they provide and are not blindly given a block grant, the details of which can lead to inefficiencies. I welcome the development of a more efficient system as we move towards universal health care, which will be very much welcome.

Sometimes we forget the onus is on health insurance companies to challenge the costs charged by hospitals and consultants, and in doing so reduce the cost of health cover. In some cases insurance companies are handed a bill and very little checking is done to see what they get for their money. They simply pay. They have a role to play in demanding efficiencies in hospitals, including the use of step-down beds. We must think outside the box. Perhaps a patient having a day procedure but who needs to be seen the following morning could be put into a hotel at a much lower rate, depending on medical requirements. We must examine the costs and be creative in how they are reduced. At all times we should look towards reducing costs and making health care and health insurance affordable.

While I have the opportunity to do so, I wish to raise briefly the problems being encountered with the fair deal scheme, whereby older persons experience inordinate and excessive delays in having their applications processed. Not only does this mean they remain in local community hospitals where they take up what should be step-down beds, but in some cases they are in acute hospital beds, which means other patients are on trolleys. Money is being put towards caring for the elderly in long-term residential care, with approximately €1 billion being invested last year and more than 22,500 people being provided for through schemes such as fair deal and subvention. None the less this problem prevails and is a real issue for hospitals which experience blockages. People cannot leave hospital because they cannot get approval under the fair deal scheme. I am not sure how it can be addressed because properties secured after someone's death cannot be sold. The question is what is the market value of a property which cannot be sold. There inherent problems are caused by the economy and the property market. With regard to efficiencies and expensive hospital beds being taken up, something must be done to allow the more rapid processing of fair deal scheme applications.

John O'Mahony (Mayo, Fine Gael)
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I am glad to contribute to the debate on this Private Members' motion. I acknowledge it is an issue for the public and I thank Deputy Kelleher of Fianna Fáil for raising the matter. It is also important to point out this has not just become an issue in the past two years. The price of an average private health insurance policy increased by 11% in 2009. We are aware of the declining trend in membership from a peak of 2.3 million to 2.1 million people and 67,000 people gave up their policies last year. This problem is exacerbated by the fact it is younger people who cannot afford it because they have so many other issues such as unemployment or mortgages. Once they opt out it puts pressure on the health service and this increases membership prices because under the schemes we have and the method used, there is less money to subsidise older people, 12% more of whom have taken out health insurance.

The need for community rating and the concept of risk equalisation is accepted by and large. This would mean everybody would be charged the same premium for a particular health insurance plan irrespective of age, gender and current and future likely risks to health. This can lead to anomalies. A male constituent of mine recently asked me why he must pay for maternity cover when he does not expect to get pregnant any time soon.

Why can private health insurance not provide a range or menu of packages from which people can pick what they want? It would be a bit like car insurance, which can be third party, fire and theft or comprehensive. We need to look at health insurance in new ways.

There are benefits to be had from shopping around, but until recently members of the public did not take advantage of the competition between various companies. There is a tendency, especially with the older generation to stay where they always have been. Nonetheless there are large savings to be made by shopping around and comparing the various health premiums.

It is important to review the level of cover and ensure that needs are being met without being over-insured. In the past, some people have spent money on being over-insured. The message should go out that people have a legal right to switch between or within insurers to get better value and thus reduce costs.

I would like to comment finally on the pace at which private health insurance companies pay hospitals for procedures. I was astounded at the end of last year to find that €47 million was owed to hospitals in the HSE west region. Some €4,208,000 was owed in the case of Mayo General Hospital. That is a huge figure which is simply not acceptable. I commend the Minister for the efforts he made to reduce that. Galway University Hospital and Merlin Park Hospital were owed over €10 million. At a time when hospitals are trying to meet budgets they need to get the money they are due.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Amendment No. 2 in my name reads:

To delete all words after "calls on the Government to" and substitute the following:"- in the interim, ensure the proper working of the system of risk equalisation to support the community rating principle, entailing the transfer of compensation from insurers who carry lighter risk burdens to those who carry heavier risk burdens, preventing unregulated market discrimination against the old and the sick or any other group or individual that insurance companies may decide are a greater risk;

- take measures to improve access to healthcare for all who need it;

- abandon its plan to base the health system on the discredited model of competing private health insurance companies;

- adopt a new approach based on universal access to equitable and efficient public health services based on medical need alone, funded from fair general taxation."

The first part of the motion describes the situation as it is and is not objectionable. The second part is not acceptable to me and my colleagues in Sinn Féin. It supports the maintenance of the current two-tier, public-private system that is at the root of the crisis in our health services. This is not surprising. More than any other party, Fianna Fáil is the architect of the grossly inequitable two-tier system that has afflicted the delivery of health care in this State for decades. A former Fianna Fáil health Minister said that the two-tier system had served us well. At least he acknowledged it was a two-tier system but his successors pretended that health care apartheid did not exist.

We saw the private health care system piggy-backing on the public system at huge cost to the State, the taxpayer and, above all, at the expense of the public health system. Citizens were paying for health through taxes, through charges and, in many cases, through health insurance premiums. That situation still maintains.

When in office, during the Celtic tiger period, Fianna Fáil, under health Ministers Deputy Micheál Martin, former Deputy Brian Cowen and former Deputy Mary Harney, boosted the private for-profit health sector as never before. Property-based tax breaks enriched the privateers. Private health insurance was encouraged. The failure to properly reform and resource front-line health care services - as distinct from the HSE bureaucracy - led many citizens to conclude that private health insurance was the only guarantee of decent health care. All of this has, of course, been followed by the inevitable collapse.

There has been a massive decline in the number of people with private health insurance. In 2008, there were 2.3 million people with private health insurance. In 2012, that has dropped to 2.1 million, while the cost of premiums is rising. People who have dispensed with insurance because they can no longer afford it are now totally dependent on the public health system which is under attack from this Government's failed austerity strategy.

The State continues to heavily subsidise the private for-profit health system with private beds in public hospitals, a fast-track to care for private patients while public waiting lists grow, and the dual working of hospital consultants in the public and private sectors continuing apace. As I said in the debate on the Health Insurance (Amendment) Bill 2012, that legislation is supposed to be a protection against the working out of the raw profit motive in the health insurance sector. It is supposed to be based on solidarity between generations and between the healthy and the sick. That is welcome, in so far as it goes but we in Sinn Féin would go much further, extending the principle of solidarity to the way we fund, organise, structure and manage our entire health care system.

The Health Insurance (Amendment) Bill 2012 is based on the recognition that there has to be social solidarity within the insurance sector, that the market has to be regulated to prevent price discrimination against the old and the sick. Given this, normal commercial competition cannot exist, otherwise we would have a US-style law of the jungle where the young and the fit would benefit from cut-price health insurance and the old and the ill would be fleeced or driven out altogether. Instead, the principle of social solidarity is recognised. That is a very welcome position from which to start. Why not then take the next step and extend social solidarity across the entire health care system? That is my appeal to the Minister.

If one takes that solidarity to its logical conclusion then one moves to a system of universal provision of health care based on need, and need alone, and not on ability to pay. The question then is how to pay for such a system. Contrary to the frequent assertions of the Minister and others, we in Sinn Féin recognise that health care is hugely expensive and has to be paid for. The question is how to pay for it in a way that ensures the best possible health care for all who need it, and which does so with the best achievable value for money.

The Government is proposing to bring in universal health insurance with the State subsidising those who cannot afford to pay insurance premiums. The State will still have a huge regulatory, managerial and funding role. Why then give private for-profit insurance companies such a central place in the system? What contribution will they make? They are funded by consumers who buy their products. The insurance companies, on behalf of policy-holders, will buy services from private or public hospitals, or other service providers. They will have to make a substantial profit in the process. Their shareholders will expect it and demand it. Why not cut out that profit for the privateers and keep the money in the health system and in the pockets of our citizens?

The only possible reason for not keeping out the profiteers is not a health care reason but a commercial reason. In going for the privatised insurance model, albeit including a slimmed-down VHI in the mix, the Government is putting business before health. For citizens the bottom line is that when they need health care, they need it promptly and need the best care possible. Everyone is exactly the same in that regard. This is the reason Sinn Féin advocates universal health care based on equal access for all. We want that to be State-provided, funded from fair general taxation and free at the point of delivery. This would involve a higher contribution in tax from the highest earners than they contribute at present. Sinn Féin does not favour the model of insurance-based funding for the reasons I have outlined. If health insurance is to be the basis for funding, then it should be a State insurance scheme. The Labour Party once claimed to be in favour of this but their former policy has been suppressed in favour of Fine Gael's stance on this matter. The least desirable model, as far as Sinn Féin is concerned, is an insurance system based on competing private health insurance companies. In that case, the profit motive and the interests of shareholders become paramount, rather than public health. This is the Fine Gael model and it won out clearly in the negotiations on the programme for Government.

I have referred this to the Minister previously but on 8 November 2012, the trade union IMPACT published an important paper entitled, The Future of Healthcare in Ireland. I make no apologies for again putting on the record its observations on the Government's plans:

The Government’s model of competing private sector insurers has not been properly tested. Delays in its implementation suggest that Government plans for UHI have been poorly thought out. If implemented, the model is unlikely to deliver equity, value for money, quality or universal access. Quite the opposite: lessons from the Netherlands show that a profit-driven commercial model led to an inequitable and inefficient system of funding, different tiers of entitlement, rising hospital deficits, and even bankrupt hospitals.

Tom Hayes (Tipperary South, Fine Gael)
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The Deputy's time is up now.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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May I conclude on this point?

Tom Hayes (Tipperary South, Fine Gael)
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Very well.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It states, quite rightly in Sinn Féin's belief, that the "competing insurers" model should not be adopted before all the options have been evaluated in terms of equity, quality, access to services and value for money.

As I understand my time has concluded-----

Sandra McLellan (Cork East, Sinn Fein)
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The Deputy may have another minute of my time.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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May I take a minute?

Tom Hayes (Tipperary South, Fine Gael)
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Yes, Deputy McLellan has given a minute to the Deputy.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I thank Deputy McLellan. It is good to have friends in the House.

At present we have decreasing numbers of people with health insurance, rising premiums for those who have, more pressure on the public health system from those coming off insurance and the persistence of the two-tier public-private system with the struggling public system subsidising the private system. Sinn Féin has calculated, based on Government figures, that were the Government to apply the full cost of private beds in public hospitals, it would save €432.5 million. This sum could then be spent in the public system to reduce waiting times and overcrowding in hospitals and to improve services. One must ask what is the real prospect of change under the Government. Already the promised extension of free GP care has been postponed. The programme for Government promised the White Paper on financing universal health insurance early in the Government's first term. The Department of Health's recent briefing for the Oireachtas Joint Committee on Health and Children states it will be published as early as possible within the Government's term of office. Members are all still waiting.

In conclusion, I believe choosing the insurance route is a mistake and this private insurance mix certainly is. It offers the increasingly remote prospect of reform while the deeply flawed current two-tier system deteriorates, especially as a result of the Government's austerity policy and health cuts that are undermining the public health system. Accordingly, I urge support for the Sinn Féin amendment to the motion.

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the opportunity to speak on this motion and thank Fianna Fáil for giving Members the opportunity to discuss this important issue. Like my colleague, Deputy Ó Caoláin, in theory I do not have a problem with the first section of the Fianna Fáil Private Members' motion. However, in keeping with Sinn Féin policy and my views on this subject, I have serious concerns, both politically and ideologically, regarding the second part of the motion. Therefore I support my party's amendments and concur with the view that this motion should be about health care and not, as Fianna Fáil would have it, private health insurance. Any discussion on the issue of health insurance, no matter how politically progressive and socially enlightened, carries with it a sub-text in respect of issues of access, management and profitability. In other words, it raises questions regarding who can afford to pay, how much it will cost and how efficient it will be. In planning or imagining a decent health care system for a modern state in the 21st century, these questions merely serve to reinforce both in material and ideological terms the system of apartheid that currently exists in the provision of health care in Ireland. That Fianna Fáil would wish to perpetuate this system should come as no shock because when in office, Fianna Fáil, under the ministries of Deputy Micheál Martin, Brian Cowen and Mary Harney, vigorously pursued a policy of vulgar privatisation of the State's health service that Members now know has had a devastating impact on the provision of public health care in this country.

Today, our public health care system is essentially broken, and this is in spite of the gallant efforts of the medical, nursing and domestic staff who work tirelessly, day in and day out, to keep the system going. The appalling situation has arisen whereby the working poor and the under-employed will delay going to the doctor due to the high cost associated with such a visit. Many people cannot afford to pay for medication because they simply do not have the money. Seriously ill people wait for months if not years to see a specialist. The free dental scheme, which is so important for the disabled, the poor and the vulnerable has been all but dismantled. This unfortunately is the reality of health care in today's Ireland. We have a dysfunctional public health care system, which in large measure is a legacy of Fianna Fáil's love affair with privatisation. In many ways tonight's Private Members' motion reflects this distorted thinking about health care. Any discussion about the provision of health care must begin from the premise of universal access. For-profit models do not belong in this discussion as they serve to reproduce a system that is inherently unequal and seriously disadvantages the working poor and the vulnerable. Sinn Féin is committed to building a universal public health care system that is found in most modern advanced states.

Tom Hayes (Tipperary South, Fine Gael)
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The next slot is for Deputies Healy and Pringle, who have two and a half minutes each.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The private health insurance industry is in crisis. As Members are aware, almost 70,000 people have left the sector in the past 12 months, having been simply unable to afford the premia, which have been pushed up year after year by huge levels of inflation. The latter have been far in advance of the normal rates of inflation and far above health sector inflation. Young people simply are unable to afford the premia now and this is pushing up the payments and insurance premiums for the remaining people, who mainly are older people. It simply is unwise and unsustainable to hand over the public health service to competing health insurance companies. I believe this to be unacceptable and unsustainable. A public health service must be provided in which access is based on medical need alone, which is funded from general taxation and which is operated by a body that is transparent, publicly accountable and widely representative of all stakeholders, including patients and staff. Furthermore and importantly, it must be legally obliged to consult stakeholders prior to any decisions being made. This brings me to an appalling situation that arose in south County Tipperary last week, in which a decision was made to transfer a rehabilitation unit from St. Patrick's Hospital, Cashel, with absolutely no consultation with patients, their representatives, staff, medics or any stakeholders. Staff and stakeholders were treated with absolute contempt.

The HSE sent an official to announce this decision and gave no details about it whatsoever. This is deeply traumatic for patients and staff and is completely unacceptable. If the Minister would listen to me, he should instruct the HSE to consult stakeholders in future and immediately prior to making decisions, and introduce legislation that would give them an entitlement to be consulted prior to the making of any decisions. The conduct of the HSE in South Tipperary over the past week has been absolutely appalling. It shows absolute contempt for all stakeholders, including staff, and that must stop.

Thomas Pringle (Donegal South West, Independent)
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I do not support either this motion or the Government amendment. This Fianna Fáil motion is a total contradiction, calling on the Government to reduce both the cost of health provision and of private health insurance premiums. There are many reasons for the increases in the premiums, mainly that 70,000 people have given up their health insurance in the past year due to the effect of the recession and the fact that they can no longer afford it, leading to a cycle of increased premia. Part of the reason for this increase has been a welcome move to reduce the subsidy that the health service gives to health insurance companies. Making private health insurers pay for the actual cost of the health care that many who have insurance cover receive from the State is the right thing to do. Fianna Fáil want the cost of insurance and health care reduced. Do they want this to be achieved by including a reduction in the wages of health care workers in the Croke Park extension? I do not see any other proposals here.

In its amendment the Government claps itself on the back about the changes it is making in the health services. We will hear the rubbish again about how universal health insurance will solve all the problems in the health services. It is interesting to note that the Labour Party has dropped all its talk of universal health care, which is completely different from insurance, but Labour has been captured by Fine Gael and will go along with the universal health insurance model.

The Government plans to hand the health services over to the private sector and give control to the insurance companies, a system that has seen the cost of health insurance in Holland treble since the introduction of universal health insurance, which the Government says is the way to go. Holland is the only country in Europe where hospitals are going bankrupt because universal health insurance has made sure that the money for health care goes to fewer and fewer hospitals. The Government plans will ensure the health insurance companies will make all the gains. They will dictate the price in the future and the Oireachtas will not be able to do anything about it. Almost €2 billion is paid in health insurance premia in this State. If that money was raised in taxation on those who can pay it and put into a health service, there would be no need for private health insurance.