James Reilly (Dublin North, Fine Gael)
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I move: "That the Bill be now read a Second Time."

It is my pleasure today to introduce the Second Stage of the Health (Amendment) Bill 2013 to the Dáil. The Bill amends both the Nursing Homes Support Scheme Act 2009 and the Health Act 1970, and has completed all Stages in the Seanad with no amendments. The main aim of the Bill is to facilitate the announcements made in budget 2013 with regard to public acute hospital in-patient charges, the charging of private in-patients in public hospitals, and the nursing homes support scheme. The Bill also amends certain charging provisions under the Health Act 1970 and enables the outsourcing of functions under the Nursing Homes Support Scheme Act 2009.

It was announced as part of budget 2013 that the asset contribution under the nursing homes support scheme would be increased from 5% to 7.5% and that the entitlement for State support to be backdated to 27 October 2009 for people who were in nursing home care prior to the scheme commencing, would be abolished. I wish to clarify from the outset that the increased asset contribution will only apply to new entrants to the scheme after the enactment of the Bill. Individuals who are already in receipt of financial support under the scheme will not be affected by this increase. I am aware there is concern about the asset contribution being increased. The reality is that the funding available for services for older people is not increasing at the same rate as the population. The budget for the scheme this year is €974 million. The HSE's 2013 National Service Plan sets a target of 22,761 people to be in receipt of financial support under the nursing homes support scheme at end-2013.

Given the extreme pressure that now exists on HSE funding across the full range of its services, it is necessary to increase the asset contribution. Importantly, however, contributions will continue to be based on applicants' means and on their ability to pay. Furthermore, even after the increased asset contribution comes into effect, the HSE will continue to meet the greater part of the cost of an individual's nursing home care. In that regard, it is worth noting that the average weekly contribution by the individual in receipt of care under the scheme is currently about €280. Despite the asset contribution being increased, it should be noted that the scheme contains several safeguards which ensure that both the person in the nursing home and their spouse or partner, if applicable, are adequately provided for. These are unaffected by the provisions of the Bill.

The increase in the acute public hospital in-patient charge from €75 to €80 and the charging of all private in-patients in public hospitals were announced as part of budget 2013. These measures will raise about €125 million in a full year. With regard to the private in-patient charge, the Government believes that the new charge makes sense. Up to now, we have had the situation where insurers have been enjoying a significant subsidy at the expense of the public hospital system, where private patients in public beds have only paid a standard €75 charge per night. In contrast, private patients in semi-private beds have paid up to €1,000 per night. In both cases, the patient sees his or her consultant privately and pays the consultant's private fees. In future, rather than paying €75 per night, the private patient will be charged €860, which is still well below the economic cost of those services.

The cost of providing hospital services to private in-patients is at least €200 million more than the amount that public hospitals are currently allowed to charge. Therefore, one can clearly see the imperative of addressing this situation. The subsidy is equivalent to the cost of running another significant-sized public hospital, or the cost of treating about 30,000 public patients every year. We cannot allow this situation to continue.

It is correct to state that everyone is entitled to use a public hospital. However, some people choose to be treated privately, in which case they have chosen to pay the consultant and the hospital. The Government believes that these users of private services should pay for the costs of providing them. The charge for private care in a public hospital should cover the costs of providing the service, including non-consultant hospital doctors, nursing staff, medicines, blood, medical and surgical supplies, radiology, diagnostics, operating theatres, laboratories, administration and support staff.

It does not make sense that two identical private patients getting the same medical treatment in a public hospital pay different amounts for using hospital facilities. Under the current system, one private patient pays €1,008 per day to the hospital and the other private patient pays €75 per day. The only difference is the room in which the patient is accommodated, all the medical care and treatment is identical. It is more rational that all private patients are charged in a similar manner for the public hospital resources they use. Given that all private patients are paying, it is possible to reduce the average daily amount charged by about 9%. These reductions are reflected in the rates that are set out in the Bill.

This approach is entirely in keeping with the move to universal health insurance, or UHI, where public and private providers will compete on a level playing field, free of unfair subsidies. Indeed, we will need to remove this subsidy one way or another as we move to UHI.

Other measures provided for include updating particular charging provisions under the Health Act 1970 and enabling outsourcing under the Nursing Homes Support Scheme Act 2009. Section 53 of the Health Act 1970, as amended in 2005 and in 2009, now covers three different charges. These are include first, charges for long-term residential care services under the nursing homes support scheme; second, public acute hospital daily in-patient charges; and third, long-stay charges.

The language and concepts used in the provisions for long-stay charges have become outdated over time and the replacement provisions aim to better reflect the evolution of a range of different models of residential care service provision which now addresses needs in the disability, mental health and care of older people sectors. The Bill repeals section 53 of the 1970 Act as amended and, instead, makes provision in distinct and separate sections for first, charges for long-term residential care services under the nursing homes support scheme; second, public acute hospital daily in-patient charges; and third, for an updated framework to replace long-stay charges with residential support services, maintenance and accommodation contributions.

In repealing section 53 the 1970 Act as amended the Bill provides a modernised and simplified legal framework replacing the charges currently required from those in receipt of long-stay in-patient services, other than acute hospital care or long-term residential care services under the nursing homes support scheme. The updated arrangements will require the payment of maintenance and accommodation contributions by those provided with long-stay residential care by, or on behalf of, the HSE in hospitals, convalescent homes, nursing homes or other forms of residential accommodation.

They will not apply to care services which are subject to their own distinct charging regimes, namely, acute hospital care and long-term residential care services under the nursing homes support scheme. The new arrangements are not intended to generate any additional revenue.

It is a well-established principle that those who are provided with long-stay residential care should make an affordable contribution. Maintenance and accommodation costs in providing quality services are high and it is fair and equitable that all those in receipt of publicly funded residential care make appropriate contributions towards these costs, if they can afford to do so. Funding derived from such contributions will continue to be directly applied by the HSE towards the provision of health services.

The requirement to pay an appropriate and affordable contribution towards the maintenance and accommodation costs to the State of providing such services will, therefore, continue. Contributions will be in line with current long-stay charges. The contribution will continue to be based on the individual's income level. The maximum level of long-stay charge is currently just below 80% of the non-contributory State pension and the maximum level of residential support services maintenance and accommodation contribution will continue at this level. The current long-stay charges exemptions will also continue to apply to residential support services maintenance and accommodation contributions. The HSE will retain the discretion to reduce the level of contribution required, depending on individuals' financial circumstances, the extent to which they already provide for their own maintenance and their assessed needs.

On the nursing home support scheme, the programme for Government commits to the carrying out of a Government-wide review to identify and eliminate non-priority programmes and to outsource, where appropriate, non-critical functions. With this in mind, a provision enabling outsourcing is being inserted into the Nursing Homes Support Scheme Act 2009. However, no specific outsourcing proposals are under consideration at this time.

The Bill also contains a provision which extends section 53A of the Health Act 1970 to public nursing homes. It is worth highlighting that the Government is committed to enhancing the quality of life of older people and is acutely aware of the evolving health and care needs of Ireland's older population. When the nursing homes support scheme commenced, a commitment was given that it would be reviewed after three years. A public consultation to inform the review was carried out last year and a summary report of the submissions received was published on the Department's website in December. Work will continue on the review in the coming months with a view to completion by late this year or early in 2014.

I now propose to briefly outline the main provisions of the Bill. Section 4 provides that the HSE may outsource its functions under the Nursing Homes Support Scheme Act 2009. Section 6 abolishes the entitlement for State support to be backdated to 27 October 2009 for people who were in nursing home care prior to commencement of the scheme. This provision was originally inserted in anticipation of a large volume of applications in the initial months of the scheme. It ensured that if any backlogs occurred at that time, applicants would not be disadvantaged. This provision applies only to people who were in private nursing homes when the scheme commenced. This cohort of people have had almost four years to apply for the scheme, which is more than reasonable.

Section 7 increases to 7.5% the asset contribution for new entrants to the nursing homes support scheme following enactment of the Bill. This will be capped at 22.5% in the case of the principal private residence. In the case of a couple, the cap on the principal residence will be 11.25% where one member of the couple enters long-term nursing home care.

Section 8 amends section 51 of the Health Act 1970 by adding definitions of "acute inpatient services" and "long-term residential care services" to the existing definition of "inpatient services".

Section 10 repeals section 53 of the Health Act 1970. The provisions being repealed are either relocated to or replaced by parallel provisions in new sections of the Act. The relocated or replacement provisions are inserted by sections 12 and 19 of this Bill.

Section 11 amends section 53A of the Health Act 1970. Currently, section 53A enables the HSE to charge the average cost of long-term nursing home care in public nursing homes to a person in an acute hospital who is no longer receiving medically acute care and treatment and has been certified as requiring long-term residential care services. This amendment will extend the provision to public nursing homes. Where a person enters a public nursing home for services other than long-term residential care, namely, respite or rehabilitation, and has subsequently been deemed by a registered medical practitioner to require long-term residential care services, the HSE may charge that person the average cost of care in public nursing homes. Crucially, this and the existing provision under section 53A are enabling provisions and will only apply where an individual refuses to co-operate with the application process for the nursing homes support scheme.

Section 12 inserts new sections 53B and 53C into the Health Act 1970. Section 53B is a technical amendment arising from the repeal of section 53. Section 53C provides for the public acute hospital inpatient charge and raises it from its current level of €75 to €80. Currently, this charge applies for a maximum of ten days in a rolling year. As there are no plans to change this maximum, the charge will be capped at €800 over this period. Section 53C also sets out the categories of persons who will be exempt from the charge, including medical card holders.

Section 13 amends section 55 of the Health Act 1970 and sets out the basis for the charging of all private inpatients in public hospitals. In future, where a person waives their eligibility to services as a public patient, the HSE, or someone providing a service on its behalf, may impose the relevant charge. The charge is set out in the Fourth Schedule.

Section 14 inserts section 74A in the Health Act 1970 and updates the provisions for the collection of outstanding charges or contributions where the service has been provided on behalf of the HSE in line with more recent legislation.

Section 15 inserts as a Fourth Schedule to the Health Act 1970 a list of charges in respect of inpatient services provided to private patients in public hospitals. The charges are dependent on whether a patient is accommodated in a single or multiple occupancy room or on a day case basis and to which Schedule, as outlined in sections 16 to 18, inclusive, of the Bill, the hospital concerned is assigned. Sections 16 to 18, inclusive, insert, respectively, as Fifth, Sixth and Seventh Schedules to the Health Act 1970 the lists of hospitals to which the charges set out in the Fourth Schedule apply.

Section 19 provides for the insertion of new sections in the Health Act 1970 regarding residential support services maintenance and accommodation contributions. These contributions replace the current maintenance charges required from those receiving long-stay care, excluding acute hospital care and long-term residential care services under the nursing homes support scheme.

Section 67A defines "residential support services" as services other than outpatient, acute inpatient or long-term residential care services provided by, or on behalf of, the HSE to those residing in hospitals, convalescent homes, nursing homes or residential accommodation for persons with physical, sensory, mental health or intellectual disabilities where their accommodation is provided by or on behalf of the HSE. Section 67B permits the HSE to make residential support services available to persons with full or limited eligibility.

Section 67C provides that the HSE shall collect a contribution towards maintenance and accommodation costs from a person who is in receipt of residential support services if he or she has previously received specified services on at least 30 days within the 12 month period ending on the day in question. It allows the Minister for Health, with the consent of the Minister for Public Expenditure and Reform, to make regulations specifying the amounts of the contributions required from persons or classes of persons, which may not exceed 80% of the maximum rate of the non-contributory State pension as currently applies to long-stay charges. It also exempts particular categories of people from paying the contribution, consistent with current exemptions relating to long-stay charges. Exemptions will apply to children under 18, women receiving services in respect of motherhood, those detained involuntarily under the Mental Health Acts or the Criminal Law (Insanity) Act, persons who contracted hepatitis C from the use of human immunoglobulin anti-D or from blood products or blood transfusions within the State, those being treated for prescribed infectious diseases and those receiving State support or ancillary State support under the Nursing Homes Support Scheme Act 2009 or paying charges under section 53A of the Health Act 1970.

Section 67D permits the HSE to waive the contribution, in whole or in part, in specific circumstances and requires the HSE to prepare and publish guidelines approved by the Minister, with the consent of the Minister for Public Expenditure and Reform. These guidelines will set out the circumstances in which the HSE may waive or partially waive a contribution.

Section 67D provides that the HSE may take into account, in deciding on whether to reduce a contribution, the extent to which an individual may provide for his or her maintenance or partake in activities which are, for example, beneficial towards the individual's rehabilitation or address agreed care plan objectives. This will be of particular importance to those residing in settings in the community where there is a strong emphasis placed on ensuring that each individual is supported to the greatest extent possible in managing his or her affairs and living in the community.

The main purpose of the Health (Amendment) Bill 2013 is to provide for necessary budget measures to ensure the sustainability of the HSE's provision of important services. The funding generated will be for the benefit of those in acute hospitals and nursing homes. In addition, this Bill modernises charging and contributions regimes in our hospitals, nursing homes and other residential settings. I commend the Bill to the House and look forward to hearing the views of Deputies.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Fianna Fáil Party opposes this Bill for a number of reasons. It is clear from a cursory perusal of the programme for Government that it makes no reference to the measures being taken in the legislation. The proposals before run contrary to many of the claims and policies outlined in the programme for Government. While the Minister frequently states he has received a mandate to implement his policies, none of the policies proposed in the Bill was ever presented to the electorate. The Minister does not have a mandate to increase charges to fund the health services.

When one drills down into the proposals, they will clearly have serious knock-on effects for the insurance industry. Deputies deal daily with families in crisis who must decide whether to keep their health insurance policy or downgrade their cover. This legislation will drive even greater numbers of people out of the private health insurance system. This runs contrary to the Minister's policy of trying to introduce universal health insurance. He wants to introduce a single tier of health care in which access is based on need rather than ability to pay. The problem is that the number of people who will be unable to meet the costs of their private health cover is set to increase, with the result that more people will move into the public hospital system. The Minister's proposal is effectively another tax on hard-pressed families. He may wish to dress it up as something else but he cannot camouflage it.

The number of people who have dropped out of private health insurance demonstrates that the industry is in crisis. The Minister spoke of having a dynamic health insurance market to underpin his proposed system of universal health insurance. The opposite is the case and the market continues to contract. We have debated previously the reasons it is shrinking. What is certain is that if Government policies exacerbate the difficulties being experienced by families through increases in premiums, the corollary will be increasing numbers of people presenting at public hospitals. All the provisions in the Bill contradict statements the Minister made prior to 2011 and commitments the Government gave in the programme for Government.

On the increase in asset limits under the fair deal scheme, my party understands the pressure on the State as it seeks to provide services for older people. The changing demographic profile and the fact that people are living longer and healthier lives are placing a strain on services, including the provision of long-stay places. The Government has reduced home help hours and home care packages, failed to increase the number of public health nurses working in communities and is rolling out primary care services at a slow pace. This contradicts everything the Minister says.

Approximately 22,000 places are being funded under the fair deal scheme, which makes long-term residential support affordable to families. Given the need to fund the scheme, one can argue about the need to increase the asset contribution from 5% to 7.5%. However, when a measure is taken for the right reason and will have an appropriate outcome, my party will not oppose it for the sake of opposition. On the broader issue of how we fund services for older people and do everything possible to provides services and supports to help them maintain their independence, the Minister is stripping away home help services, home care packages, public health nurses and primary care and community services. At the same time, he speaks of pursuing a policy of trying to keep as many people as possible living at home independently and with dignity for as long as possible. This policy has been articulated in the fair deal review and everything that flows from it. The policies set out in the legislation contradict the objectives the Minister has set out in his broader policy statements. This is a cause of serious concern.

To return to the charge that will be levied on private patients in public hospital beds, the proportion of private beds in public hospitals was limited to 20% in an agreement thrashed out many years ago because the State was unable to make direct payments to consultants. Citizens fund the health service through general taxation but Government policy is inflating the cost of private health cover. The Government is telling those who hold private health insurance that they will be charged a second time if they go to hospital. This policy is anything but equitable.

The Minister's stated objective is to encourage as many people as possible to take out private health insurance in order that we have a vibrant health insurance market and an economic model to underpin universal health insurance. He should discourage shrinkage of the private health insurance market. Last September, when introducing other legislation, the Minister made a commitment to exempt lower levels of insurance cover from the higher health insurance levy. This has not been done. The measures being introduced incrementally feed into a price spiral. The figures are stark and show a shrinking market in which insurers are imposing the additional costs on customers, many of whom are deciding to abandon or reduce their cover and enter the public health system. This is not sustainable in the short or medium term because if, as the Minister wishes, we adopt the universal health insurance model, more people must take out health insurance cover.

It is clear from the demographic profile of those who hold private health insurance that younger people are not joining the system and are not being encouraged or incentivised to do so. The policies being implemented by the Minister undermine the basic principle of intergenerational solidarity and the need to create a sustainable health insurance market which will fund services and alleviate the burden on public hospitals.

The Minister said that public hospitals provide a direct subsidy of €200 million to the private health insurance market. The Minister argued that is a subsidy to private health insurance companies.

The difficulty is that it is not. It is and will be a charge on citizens with private health insurance who are doing their best to try to reduce the burden on the State in providing health cover for themselves and their families. In his press release after this was announced in the budget, the Minister outlined his reasons for it. That press release in December acknowledged that it would lead to an increase in premiums. Throughout this year he has said it would not have a major impact on premiums. Of course it will have a major impact. Every independent assessment of the health insurance market shows it will have a major impact on families. It will also have a major impact on the private health care providers.

The Minister has spoken about establishing hospital trusts and hospital groups which will tender against each other for work from the private health insurance companies in the provision of care. Equally, private hospitals have a capacity that is very beneficial to the broader health system. With this legislation the Minister will undermine their ability to continue to function thereby shrinking the capacity of the provision of health care. There is no point in camouflaging it in any other way. This is simply about taking money from people who have already paid private health insurance to fund the public health system and is effectively a double taxation on people. To state that the private health insurers are being subsidised is deeply disingenuous. The premium holders will end up paying more. Mr. Colm McCarthy, Dr. Brian Turner and many other independent experts who have analysed the insurance market have major concerns about this issue.

The fundamental problem we have is that the Minister has in his mind a universal health insurance model. He has spoken with passion about the Dutch model, but that seems to have faded to a certain extent. We are still awaiting the White Paper on universal health insurance. We are now in the third year of this Government. If we are to go down the route of changing fundamentally how we fund our health system one would have expected that two and a half years into Government the Minister would have at least the principle and some detail as to how it is intended to fund the health system. I have asked the Minister this on numerous occasions and he claims it is very simple and that we will have private health insurance companies, people will take out private health care if they can afford it and the State will take it out on behalf of those who cannot afford it.

If it is that simple why has the country been waiting for two and a half years for the White Paper, especially given that the detail of the policy was in the Fine Gael's general election manifesto - the Dutch model, which was supposed to resolve many of our difficulties? The people gave the parties in Government a mandate and one would think they would have acted on it and that a White Paper on universal health insurance would have been published to allow us to give an input in scrutinising it and proposing ideas. However, we continue to wait. In the meantime the Minister is proceeding with hospital groupings, hospital trusts and all that is to flow from the universal health insurance model without us having any detail of how we will fund a sustainable health care system here.

Fundamentally this comes back to how the State will fund health care that is fair, equitable and accessible to all. I do not believe the Minister's proposals on universal health insurance will do that and the steps he has taken to date have done anything but that. They have driven more people out of private health insurance into public hospitals that are already under huge pressure given the numbers for which they must cater and the resources available to them. In one fell swoop the Minister has done the exact opposite of what is needed to sustain his model of health insurance.

At no point in the programme for Government does it state that the Government would publish a health amendment Bill that would require the full cost of private patients in public beds to be recouped, nor did it state that there would be increases in the various charges. Any rational person would accept that there is huge pressure on the State finances and that the health system needs to be funded in some way. However, the Minister's approach is further undermining the very principle he is trying to establish and I cannot understand why he is going headlong into it.

Even more amazingly the Minister has ignored the advice the HIA has offered to him on a continual basis. It claimed there was a need to ensure that those with lower health insurance cover would be exempt from the higher levy, but that never happened. When we discussed that legislation in the Dáil last year the Minister gave us categorical assurances that this would be the case. In February we discovered that it would not happen. That has now forced health insurance companies to downgrade the cover to get into the lower levy. Older people now find they cannot afford the health cover they had previously and are being offered packages with less cover which removes the very areas of health care they most need at that stage in their lives. That again runs contrary to everything the Minister has said about universal health care being equitable and available to everybody based on need. I cannot understand how the Minister can claim this Bill is part of Government policy based on the programme for Government. It undermines every health care provision in that programme which promised fairness and equity. That is why we will oppose the Bill.

The Minister is now pursuing a policy that will probably close some of the private health care providers. One would have assumed if the Minister's universal health insurance plan comes to fruition that they would offer competition and capacity. The Independent Hospitals Association of Ireland has stated this policy will probably result in some of these institutions going out of business thereby diminishing the capacity of overall health care provision.

We can debate the successes or otherwise of people waiting for appointments to see a consultant on an outpatient basis. The Minister claims that 330,000 is not a large number of people because more than 200,000 are seen every month. However, the Minister said that to me six months ago and we still have the same problem. It is not as if it is getting any better for many citizens. If it is not a major problem, one would have expected a reduction in the number of people waiting to see a consultant on an outpatient basis.

The Minister has claimed he is making inroads into the numbers of people awaiting procedures on an inpatient basis. The problem is that any cursory investigation shows people cannot get on the inpatient list because they cannot even see a consultant on an outpatient basis. By stealth the Minister is not allowing people to be assessed, processed and deemed to need a procedure and placed on an inpatient basis. Last year and again earlier this year the Minister told me in replies to parliamentary questions that 200,000 a month are seen by consultants and therefore that we would get on top of the issue but it has not happened as we stand here early in July 2013.

That is an area where the Minister promised a good deal but it is certainly not being delivered in accordance with his commitments.

We will consider the Bill and what the Minister is proposing on a forensic basis and we can do more of that on Committee and Report Stages. I find it remarkable that the Minister can say that he may not outsource the running of the fair deal scheme but it is a provision in the Bill. That is fine and it is something the Minister has said may or may not occur, but he is making provision for it. He has also said that he may not implement all of this if the insurers play ball, if they can find further savings within their administration and if they can negotiate prices downwards. However, the problem is that they cannot negotiate prices downwards in the public hospitals because the Department of Health and the Minister have set them in stone. We are asking the private health insurers to negotiate on a per procedure basis, to strike deals with the private health care providers and to seek deals with consultants for the provision of care. However, by the same token they are not allowed to enter into negotiations with the public hospital system. Insurers are having difficulty with this and have to operate with one hand tied behind their backs in terms of negotiating. At the same time, the Minister will charge every private patient who digs deep into his pocket to pay for private health insurance. The Minister will burden them with further costs to retain health cover. I cannot believe that the Minister is contemplating that, never mind bringing it to the floor of the Dáil and asking us to support it.

There is an increase in the daily charge for public inpatient services in acute hospitals from €75 to €80. I realise the Minister can put a cap on it from between seven and 15 days and that the maximum that can be charged in one year is €1,200. However, all these costs add up. At one time the now Minister was apoplectic with rage because there was a 50 cent charge placed on prescriptions. The Minister used to fall over himself arguing about 50 cent. He continually highlighted that this was something that would diminish people's ability to access basic medicines. However, he increased the charge. Here the Minister is increasing charges again not by 50 cent but by €5 and up to a maximum of €1,200 in a full year. All these things impact on people's ability to access health care.

The Minister has referred to health care based on need, not ability to pay. Certainly, in this legislation there is a requirement to have additional funds to afford health care in this country, even in the context of the public hospital system. The Minister is increasing the charges and there is no two ways around it. The principle the Minister is trying to enshrine is being undermined by these charges. At one time 50 cent to the Minister was an amount of money that could put people's lives at risk. That is what the Minister said. He said it would diminish their ability to access health care, but it was only 50 cent. The Minister has increased that up to a maximum of €20 per month although it was something he had proposed to abolish.

I find it difficult to accept because what the Minister says and what he does can be at complete variance. This is the case in the context of what is outlined in the programme for Government, the universal health insurance model, the White Paper to be published, the establishment of hospital trusts and hospital groups, the competition that would be created as a result and the dynamic health insurance market to underpin everything. However, now we are back having to deal with figures of people who are simply unable to sustain it.

I know the Minister's stock-in-trade answer. He will stand up and say that it is hard to take lectures from me, across the floor, because the reason people cannot afford private health insurance is because of the policies we pursued for 14 years, and I will listen to that.

James Reilly (Dublin North, Fine Gael)
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The truth is not fragile; it will not break.

Billy Kelleher (Cork North Central, Fianna Fail)
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I will listen to that as well. However, if that is the Minister's stock-in-trade answer, then it is cold comfort to the thousands of families who are either contemplating dropping health insurance or having to reduce cover. If that is the only solution the Minister can find and the only answer he will give, then I genuinely hold out little hope.

We are now in 2013, half way through the lifetime of this Government, if it runs its full course. However, we have not seen the full implementation in terms of the review of the fair deal scheme and what exactly that will entail thereafter. This is another area of concern. I have no wish to sound alarmist but the Minister knows the demographics coming down the tracks as well as I do. All the statistics are available. Many of the difficulties that will arise are for reasons we welcome, in the context of people living longer healthier lives, improvements in medical technologies and medicines and the greater well-being of people generally. However, to go back to what the Minister is trying to achieve in terms of keeping people in their communities and in their homes, the policies in place are completely at variance with the objective.

We are discussing the Health (Amendment) Bill and therefore I wish to raise the broader policy of the Minister and the Government with regard to primary care. We have been waiting two and a half years for the first part of the Minister's programme for free general practitioner care for everyone. Last year, the Minister highlighted that there would be some legal issues and difficulties. We asked the Minister what these were but we did not get much of an answer. However, the difficulty is that the 60,000 people on the long-term illness scheme who were promised, in advance of the election, that they would be the first people to receive free GP care are still waiting two and a half years later. We are no wiser about what is happening with the roll-out of the programme. Given what has happened in terms of policy implementation and the impact it is having on people, I have considerable difficulty in understanding why the Minister is pursuing these policies.

We have discussed the need for community-based primary care services, the roll-out of centres, the development of physical structures, the establishment of primary care teams working closely with GPs and other health care professionals and the vision for change policy in terms of mental health and having all these services in the community. However, it is simply not working and there is no point in the Minister standing up in the House and pretending that it is. I will accept the criticism that progress was slow during the time of the last Government, but I had thought I would have been walking past health care centres dotted throughout the country by now, some two and a half years later. There has been a decidedly slow take-up.

I have no wish to go back over the old ground of the logarithmic logistical progressions and how the Minister assessed the primary care centres. The point is that even some of those placed on the list are not moving ahead either. Reference has been made to European investment funds to fund some of these primary care centres and public private partnership packages and so on. However, it is very slow and in the meantime people are waiting for the services.

Another alarming area is the Minister's comments on GPs. The Minister is himself a GP and has represented them in a previous incarnation. There has been no negotiations with the professionals who are expected to work in primary care teams and to lead them. That was to be the central tenet of how we had intended to provide health care in the country in the years ahead. I find it rather startling that while we talk the talk of establishing the teams and having the centres clinically led by GPs in the communities, there has been no genuine discussion with the organisations that represent them with regard to how this will actually work.

There has been no discussion on how primary care and free general practitioner, GP, care will work. There has been no discussion on how the contracts with the individual doctors will work. Moreover, although none of this has taken place, I am asked to come into the Chamber. As there are only 19 Fianna Fáil Members, our support or otherwise does not make much difference and we can only oppose on the grounds on which we choose. However, Fianna Fáil will oppose the Bill because the policies advocated and the policies pursued are completely different. Every decision Deputy Reilly has made since becoming Minister for Health does not coincide with what was put before the people in 2011. While one might argue things changed because of the formation of the coalition, I can find nothing in this legislation that correlates with the contents of the programme for Government.

In conclusion, this Bill is a tax on access to health care. It is an increase in taxes, as a charge is a charge no matter how one looks at it. People who present in public hospitals will be obliged to pay more either through the charges themselves or through the Minister's stealth tax with regard to increasing premiums for families nationwide who are as entitled as anyone else to access a public hospital and seek treatment in the public hospital system. Such people make sacrifices and lighten the burden on the State. They agree to pay their own private health insurance, thereby lightening the burden on the State and giving it a break. However, what the Minister has decided is they will pay their taxes and all their charges, after which the Government will levy them again when they actually access health care, even though they are not getting what they should, namely, treatment outside the designated beds that are present in the public hospital system. This simply is wrong and will put huge pressure on the health insurance market. More importantly, families throughout this country will pay for this flawed legislation.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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In his concluding remarks, the Minister spoke of how the funding generated will be for the benefit of those in acute hospitals and nursing homes. He also referred to the Bill modernising the charging and contributions regimes and claimed it was for the benefit of those concerned. While I would warrant that few would buy that sales pitch, even if the Minister could convince some of his claim that it will be for the benefit of - I emphasise what the Minister said - those in acute hospitals and nursing homes, what of those who will be forced by some of the measures included in this Bill to put off seeking access to acute hospital settings and nursing homes because they simply cannot afford it given their other competing responsibilities? I do not believe this modernising approach, as the Minister claims it to be, would be of any comfort to them at all.

This Bill is gift-wrapped as health reform but it is no such thing. The bottom line is it is another shoddy item of legislation designed to facilitate cutbacks in the public health services. The Bill also contains a mixture of provisions that make some significant and totally unsignalled changes, which have received little public scrutiny and virtually no public debate. In this Bill, the Minister for Health, Deputy Reilly, seeks to impose higher charges for shrinking public health services and the Bill again exposes how the Fine Gael-Labour Party Government’s health policy is full of contradictions. The Bill increases the daily charge for public inpatient services in acute hospitals from €75 to €80 and increases the asset contribution under the so-called fair deal nursing home scheme from 5% to 7.5%. These increases, arising from budget 2013, received little attention when the Bill was published. I have no doubt but that was much to the satisfaction of the Minister. The Bill provides that the insurers of private patients should pay the full cost for the use of scarce public beds and on this, the Minister and I agree. This is right and proper and is something for which my party, Sinn Féin, and I have called consistently. However, this must be perceived as an interim measure towards a fully public system with equal access to hospital care for all, based on medical need alone.

Fianna Fáil, the main architects of the two-tier public-private health system, used to claim the public-private mix gave us the best of both worlds. I heard this claim several times in this Chamber and a former health Minister made much of it. Of course, what Fianna Fáil created and sustained for the many years its members were at the lead of government in this State was a grossly inequitable and inherently inefficient system, which the superficial prosperity of the so-called Celtic tiger years could not disguise. After five years of recession, we now have the worst, not the best of both worlds. Incomes have decreased or have been wiped out, the private health insurance market has consequently shrunk and the result is many more people are totally dependent on the public health system. Moreover, that system has been undermined, weakened and downgraded by five years of health spending cutbacks, as it struggles to provide care for a growing and aging population with more complex health care needs.

The so-called solution being put forward by Fine Gael is to convert the system to one based on competing private health insurers and there is no other word for it than privatisation, plain and simple. As to how exactly this will work, one still does not know as the details of the plan have yet to be seen. However, international comparisons tell one that despite the claims of the Minister and other voices, it simply does not work. The truth is the health policy of the Fine Gael-Labour Party Government is full of contradictions. It claims to be aiming for free GP care for all yet it has further restricted access to the medical card, including within the past six months. The promised initial extension of free GP care to long-term illness patients has not been delivered and, it claims, cannot be delivered but that another way will be found. As to what that other way might be, again Members do not know as they have been given no details and no prospect of an alternative that would deliver this promise any time soon has been presented. The Government claims to seek universal health care but yet the private health insurance model it favours would see everyone who already pays tax to fund public health services also being compelled to pay health insurance with a significant profit margin for the private insurers, that is, the private for-profit interests.

This Government, like its predecessors in Fianna Fáil, vehemently opposes proposals from Sinn Féin, other Opposition voices and many others, including the trade union movement. Our arguments are for higher taxes for the highest earners and for a wealth tax rather than the measures the Minister incorporates in this Bill. Yet, at the same time, the Minister proposes to introduce a system of compulsory private health insurance, the cost of which will be artificially inflated to ensure profits for the private insurers. That is why they exist.

We would have greatly improved public health services today if, in the decade from 1998 to 2008, we had introduced a truly fair taxation system, with the wealthy paying their fair share and the revenue being invested in vital infrastructure contingent on public health needs. Instead, what we have is a two-tier system and such waste as, for example, the consultants profiting from both public and private systems being reinforced.

From this Government we are getting not real reform but a tinkering with the fundamentally flawed system, the prospect of yet undefined change and, above all, more cutbacks and more charges for reduced services.

I do not intend to revisit the current perilous state of our public health services - the overcrowding, the trolley count, the waiting lists, and the services simply not available to those who need them. We have aired those on many occasions and will continue to do so in other opportunities that present here and at committee. However, I want to cite just one example. The Irish Nurses and Midwives Organisation has reported an average of 79 patients per day placed in overcrowded and inappropriate environments on inpatient wards, above the stated bed complement of those wards. That is in addition to the scores of people daily on trolleys and chairs in emergency departments. It is an outrageous situation for people to have to endure.

Looking at the detail of the Minister's proposals in the Bill, the €5 increase in the daily charge for public inpatient services is, for those who will be obliged to pay, a significant rise. It is a significant further demand and will, as I said at the outset, further dissuade people, including parents of children in need of inpatient care, from presenting for important and essential services with all the potential consequences involved for all concerned. Make no mistake about it. The argument the Minister made about the 50 cent, as already highlighted by Deputy Kelleher, most certainly applies in a €5 increase.

The least signalled part of this Bill is Part 2, which makes significant changes to the Nursing Homes Support Scheme Act 2009, the so-called fair deal scheme. Again, we are seeing increased charges. The Bill increases the asset contribution under the nursing homes support scheme and abolishes the requirement to backdate State support to the date of the scheme's commencement for those who were in nursing home care prior to that date. Section 7amends Schedule 1 of the Nursing Homes Support Scheme Act 2009 to increase the asset contribution from 5% to 7.5% for people who enter nursing home care after the enactment of this Bill.

Significantly also, the Bill, in section 4, provides for something not already highlighted, namely, the privatisation of the administration of the nursing homes support scheme. That is in line with the privatisation agenda of the Minister's party to which the Labour Party clearly has now completely surrendered. We know that the downgrading of the public service is in full flow, and nowhere has been more affected by the recruitment embargo than the health services, but where has the proposal to privatise the administration of the so-called fair deal scheme come from, and what is its motivation? What research or consultation has been carried out regarding the working of the nursing homes support scheme? This is a key State scheme requiring great care, sensitivity and scrupulous fairness in its implementation. It is a right of citizens who qualify under the scheme, and that right must be vindicated. Anyone who has gone through the process of application to the nursing homes support scheme will say it is one of the most complex, confusing and long drawn out processes. It is a bureaucratic and legal nightmare. It needs to be simplified, streamlined and better fitted to the needs of citizens who require this service.

I want to remind the Minister what he said when addressing the Nursing Homes Support Scheme Bill in the Dáil in 2008: He stated:

However, we do not wish to discover, as we so often have previously, that a perfectly good concept in principle turns into a mire and nightmare for people in practice. I do not wish to introduce an adversarial tone to the debate but we must be mindful of what happened with the HSE. We cannot allow that type of mess to be inflicted on people.

I believe this is another example of cutting out the public service element, bringing in private contractors with staff on lower pay, to reduce the public service pay bill, with no regard to the effect of the changes on the citizens who use the service. I strongly oppose this section of the Bill and urge instead a reform of the administration of the scheme to make it more accessible, comprehensible and viable for service users. Any among our number could be among that number in our own turn and time.

I wish to reaffirm, as I did when the Nursing Homes Support Scheme Bill was debated in 2008, my strong objection in that I believe it effectively removed the universal eligibility for a place in a public nursing home as provided for under the Health Act 1970. This Bill reinforces that position. The statutory eligibility to a bed in a public nursing home as provided in the 1970 Act was never vindicated in terms of the provision of the resources to make those beds available. That led to a huge reliance on the private nursing home sector and a complex and inequitable system of State subsidy for nursing home care. Undoubtedly, that had to change but I believe the previous Government, in doing so, went in the wrong direction. The Minister also was somewhat of that view at the time.

If a person suffers a heart attack, and I have had the experience, he or she is entitled to a bed free of charge in a public hospital. However, under the Nursing Homes Support Scheme Act 2009, if a person becomes so dependent, say, from the effects of a stroke that he or she needs constant care in a nursing home, his or her entitlement to a public bed free of charge is effectively gone and he or she must pay. A fundamental shift took place with that Act and the implications for the entire health service were and continue to be profound. This Bill continues that trend.

I was not the only Deputy to raise these concerns at the time. I cite none other than the current Minister of State, Deputy Jan O'Sullivan, who, as its health spokesperson at the time, stated on behalf of the Labour Party:

Age Action Ireland put the argument well when it stated that the legislation sounds the death knell of the public bed for those who need a residential nursing home bed, and that it also means the introduction, for the first time in the Irish health service, of a charge beyond the grave for essential health care services. The organisation went on to state that if this legislation is passed, it will mean that those who have conditions such as dementia and stroke will be treated differently from those who have heart attacks and cancer. We must be concerned when legislation such as this is introduced because we are, in effect, treating different elderly people differently, depending on the condition from which they suffer. The Labour Party is committed to a universal system of health care whereby everybody is treated the same irrespective of income and age.

We also need to place this matter in the context of the way in which we care for older people. The National Economic and Social Forum's Care for Older People report, which was published in 2006, stated that the then current official funding of services was not "consistent with the policy objective of encouraging community-based responses" and that "Considerable resources have been invested in nursing home care responses, some of which was unnecessary, not wanted and inappropriate". The NESF report identified the weakness of community care, the poor integration between systems and sectors, under-resourcing, the lack of responsiveness to the needs of older people, poor co-ordination and the fact that care is not embedded in local communities. That report is even more relevant today.

This Bill is another piece of patchwork legislation designed to do another patch-up job on our tattered health service. The Bill also facilitates cutbacks, privatisation and further and higher charges in respect of shrinking services. Where is the fundamental reform so long promised by this Fine Gael and Labour coalition? It is certainly not contained in this Bill and there is no sign of it on the horizon. The only thing we can see on the horizon is the onward march of the privateers under the Fine Gael banner, with Labour's tattered banner trailing behind. The Bill does not merit our support. We have consistently indicated our support in respect of the need to address a particular core matter. Regrettably, that matter is not being properly dealt with in this legislation and all the other issues which have been appended to it are being adversely impacted upon in the context of the broader public interest. We will be opposing the passage of the Bill.

Bernard Durkan (Kildare North, Fine Gael)
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I call Deputy Catherine Murphy of the Technical Group who, I understand, proposes to share time with her colleague, Deputy Finian McGrath. The Deputies have 30 minutes between them.

Catherine Murphy (Kildare North, Independent)
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The main media focus surrounding this legislation has been on the charges that will, if it is enacted, apply to private patients occupying public beds in public hospitals. This is a matter of concern to those who are facing the prospect of abandoning private health cover and moving to the overburdened public system. I will return to this matter later but there are other troubling aspects of the Bill which I wish to explore in the context of the charges relating to the nursing homes support scheme, formerly known as the fair deal scheme.

A number of fundamental questions arise with regard to the operation of the nursing homes support scheme and the way in which the nation treats those who require long-term care. The troika recently highlighted two areas, one of which is that which relates to health care, where further savings are to be sought. This obliges me to ask whether it was the latter which prompted the introduction of the Bill before the House at this time. We have been informed that the legislation will assist in increasing the funding available to the public health system. In fact, it will probably add nothing extra to that system. What the Bill more probably represents is an attempt on the Minister's part to remain within a certain budget. We are witnessing a decline in the overall level of service. I completely agree with Deputy Ó Caoláin who referred to the measure before us as a patchwork attempt at legislation which contains no vision, thought or general philosophy regarding the type of health system we should have and the kind of solidarity that should go with it. We had an expectation that such a system was going to be the objective of the current Government.

On numerous occasions I have been asked to indicate what it is we are paying for when we make pay-related social insurance, PRSI, contributions, which include an incorporated health levy, and the universal social charge. I find it impossible to provide answers to people's questions in this regard. Many individuals opt, if they can afford to do so, to join private health insurance schemes, primarily because they are concerned that their needs will not be met by the public system and not because they want to pay for private health care. I am in this position and I have private health cover. However, I prefer to rely on the public system. I can openly state that I would be prepared to pay more tax in order that we might end up with a good public system.

Health care must be paid for and it is a question of deciding how we should do that. This is a profoundly political issue. PAYE, PRSI and the universal social charge almost take the form of a solidarity tax but the problem is that there is no return for most of those who pay these. We are informed that 45% of private patients in public beds are treated in this way. How did these people end up in public beds? It seems that many of them are put in such beds because they were taken to accident and emergency departments in ambulances. Those to whom I refer are patients who ended up in public beds and who happen to have private cover. The explanatory memorandum to the Bill states that section 13(1) "provides that where a person waives his or her eligibility to services as a public patient, the HSE may make inpatient services available to him or her and impose the relevant charge set out in the Fourth Schedule." Such patients can be pursued by debt collectors or whomever in order to ensure that payments are made.

One must question the capacity of public hospitals, in which wards have been closed, to absorb the additional intake of those who will be obliged to opt out of the private system. I am no fan of the two-tier system but even if the political desire exists, it will take time to move to a single-tier model. It is my opinion that the public system is unable to absorb the extra intake to which I refer. I must query the savings which it is stated will be made. Too often the Government has put in place initiatives whereby it saves on one side only to pay out on the other. That makes no sense.

I supported the second referendum on the Lisbon treaty. I did so because the treaty makes provision for the application of the Charter of Fundamental Rights of the European Union. That was the only reason I could find to support the referendum. Article 35 of the charter states:

Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all the Union's policies and activities.

We have all received letters from the Independent Hospitals Association of Ireland which comprises 21 hospitals which account for approximately one third of the acute hospitals, employing 8,500 people and treating 400,000 patients. I realise the hospitals have two concerns, one of which is about their own viability. However, the public system does not have the ability to absorb the patients for whom they will be unable to cater if they close down. They have told us they support a plan to introduce a health system which promotes equitable access to high quality care, as promised under universal health insurance, but that they firmly believe the impact of the planned legislation is entirely contrary to that objective and, therefore, the components of the Bill relating to the designation of all beds in public hospitals as chargeable should not be proceeded with. They further state that the proposed legislation would see patients having to waive their entitlement to public treatment in a public hospital because they have purchased private health insurance, with a claim being made on their health insurance policy for a service for which they have already paid through their taxes. That is the point I made about PRSI and the universal social charge.

I spoke about the savings on one side and the cost on the other. Recently, I attended a presentation by the Irish Hospice Foundation, which was very interesting. It is looking for a broad end-of-life care strategy, which I thought made great sense. It is interesting to note that some of the providers in the private nursing home sector are looking for a framework for long-term residential care. That should be part of a broader strategy. I would like us to take a more strategic approach to this whole area.

The Irish Hospice Foundation told us that 30% of the whole of life health care cost occurs in the last year of life. It gave us some very useful information on the savings that could be made by the provision of home care from the hospice foundation. That needs to be looked at. If one is looking for the optimum, in terms of health care, one can find savings by doing the right thing as well as by looking at things as a crude means of raising funds for what is there already. That is what is happening here. A joined up approach is not being taken.

I received a reply to a parliamentary question the other day in which I was told that the latest information available to the Department indicated that there were 873 people on the national placement list for the nursing home support scheme at the end of April and that the average time spent awaiting funding was 49 days but that not all people were in acute hospitals. However, a significant number - approximately 43% - were in acute hospitals. The fact we do not have a strategy for moving people to more appropriate type care ends up causing terrible trauma and costing more money.

When dealing with people at our advice centres, we get a fuller understanding of how policy impacts on people. I dealt with a man whose father was over 90 years of age, had a whole host of ailments and was staying in a nursing home. However, the man was then classified as needing acute care and the nursing home was forced to ask him to leave, even though he had premium level insurance, due to a shortage of beds. The option for the family was to call an ambulance, with the possibility that the man, who was very ill, would end up in accident and emergency on a trolley. Instead, the family sourced another nursing home bed but had to wait weeks to be paid at considerable cost to themselves. They are the kind of choices people must make. Unfortunately, that gentleman has since passed away but the case was appalling. If one looks at the chaotic situation where someone who ends up in hospital after a stroke wants to return home, there is a lack of any kind of joined up system. Approval of the carer's allowance or a grant to adapt a home, where the need appears to be long term, can take months, if one gets either at all. The lack of a coherent approach is forcing people to make choices they would not otherwise make. Some of those choices are being made by people who would like to be cared for at home by their relatives but, unfortunately, they are in a position where the only option available to them is to look for a residential place in a nursing home, which their health profile permits them to do, even though it is not ideal. In fact, it is a more expensive approach than having people cared for at home.

There is a problem in terms of the lack of a joined up thinking, of a strategic approach and of any vision for the kind of health care system we should have. Instead, a piecemeal or patchwork approach is being taken and it is making matters worse rather than better.

There is a terrible language of dishonesty with this Government and this fits into that. Recently, we were told the money collected in motor tax this year - €150 million - would be used to pay the national debt. That was even stated in the legislation. The carbon tax is not used counteract the effects of smoky fuels and so on but it goes to the central Exchequer to pay off the national debt. There is nothing local about the local property tax, which is collected nationally. There is a dishonesty here.

We should call this what it is. Having assumed property prices would remain as in the boom years, we have found they have not, so there is an increase from 5% to 7.5% to cover that cost. Why does the Government not just say that? Couching it in something else is fundamentally dishonest. It is the kind of thing to which people react very negatively and it leads them to believe there is a second language around politics, which is not the kind of language they speak.

A broad strategy is required so I cannot support this legislation. Health care must be paid for but the way the Government is going about it is fundamentally wrong and it adds to the dishonesty of politics.

Finian McGrath (Dublin North Central, Independent)
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I welcome the opportunity to speak on the Health (Amendment) Bill 2013. It is important in any debate on health that we speak up for the most vulnerable, senior citizens, the sick and the disabled.

Any health system that does not have equality and fairness at the heart of the service will not help to defend or respect our people and citizens. It is an important aspect of the debate. We must not hammer or exploit our elderly and senior citizens, who have made a major contribution to this country.

Last week I received a letter from a constituent on the matter and I will highlight exactly what was written. It states:

The Bill to increase the levy on the assets of nursing home residents by an appalling 50%, from 5% to 7.5%, is coming before the Dáil this week and maybe you would seek an explanation please as to why the financial penalty on the people concerned far exceeds that on any other category of citizens under the terms of the budget. The defence that the money must be saved will likely be trotted out but why are old and sick people kicked the hardest?

The Health (Amendment) Bill 2013 seeks to introduce or increase a number of charges across the health sector. It increases the financial contribution of people availing of the nursing home support scheme, and it also seeks to allow the HSE outsource the management of the scheme. It introduces charges for private patients in public beds in hospitals and it increases the charges for public inpatient stays. It also seeks to introduce a charge for those receiving residential support services, which will replace the current long-stay charge.

We must focus on the details of the legislation and the costs to our senior citizens, as a 50% increase is wrong and unjust. I would challenge anyone to say otherwise. Will the Minister confirm the impact of the Health (Amendment) Bill on the lives and economic resources of people with intellectual disabilities? What will the specific impact be for people with intellectual disabilities in State residential care? What effect will be felt by people with intellectual disabilities and their families when they avail of life-saving respite care? What, if any, consultation was undertaken by the Department in an attempt to explain the impact of this proposed legislation? Was there communication with those in the disability community, particularly those with an intellectual disability and who have seen an impact in residential arrangements and personal economic resources? I hope the Minister can answer those questions, and it is important that we put those hard questions to him.

We cannot have people with an intellectual disability and their families being persecuted. We saw a recent row about resource hours, and although they won that battle, a war is ongoing. The mobility allowance is on the agenda and many people are fearful of what will happen in that respect. I raise these issues as part of a constant battle. I thank the Ceann Comhairle as I received a letter this morning indicating that my Down's syndrome (equality of access) Bill will come before the House when the time is appropriate. That legislation is concerned with equality for young children with Down's syndrome and it is also about respect and the rights of citizens in this country.

The Independent Hospitals Association of Ireland is a representative body of the country's 21 independent hospitals. Its member hospitals play an essential role in the delivery of acute and mental health services, accounting for almost a third of acute hospitals in Ireland, employing 8,400 people, or close to 15% of staff in the sector. It provides almost 20% of the beds in the system and treats in the region of 400,000 patients every year, or one in every five patients. The Independent Hospitals Association of Ireland is very supportive of the plan to introduce a health system that promotes equitable access to high quality care, and that is a position I share. However, it firmly believes that the impact of this planned legislation will be entirely contrary to that objective, and it argues the components of the Bill related to the designation of all beds in public hospitals as chargeable should not proceed.

The proposed legislation would see patients having to waive their entitlements to public treatment in a hospital because they have purchased private health insurance, with a claim being made on a health insurance policy for service that has already been paid for through taxes. The likely 30% hike in health insurance premia and the subsequent exodus of more than 300,000 consumers from the health insurance market predicted by the Insurance Ireland Health Insurance Council will lead to an environment where independent hospitals will face closure. As a result, there will be a serious reduction in health services available to the people. The consequences for patients will be reduced capacity in the independent health care sector, reduced choice and growing reliance on already overly burdened public hospitals.

The association is advised that the proposed legislation is contrary to EU and competition law because it will have the effect of restricting competition and a consequential adverse effect on consumers by limiting choice and reducing quality of care. The Minister should answer that argument in this debate as ultimately the proposal will impair access, quality and affordability of health care for all consumers. It will also lead to the failure of some independent hospitals and increase the burden on the public system. There is also the potential to distort competition in the market for provision of new privately funded health care.

These concerns must be answered by the Minister and his Government. We are all in favour of equality and reform but we must ask the hard questions, to which I will return later. On Friday, 14 June, Ireland's four main insurers indicated that as a direct result of this proposed legislation, they will have to increase premiums by up to 30%, meaning up to 300,000 consumers will leave the private health insurance market. The Minister does not accept the 30% figure and on television recently he argued the actual figure would be in the region of 5% or 6%. Nevertheless, the economist Mr. Colm McCarthy recently indicated in a report on the future of private health insurance that the price of health insurance will rise by 25% as a direct result of this proposal. Once again the Minister has got his figures wrong and many people are concerned about that. We must closely examine this issue.

We have already seen an exodus of approximately 129,000 people from the private health insurance market in the past two years, with a further 500,000 having downgraded their plans because of austerity and other Government plans and economic policies. Further premium hikes in this quantum will undoubtedly result in many more thousands of consumers relying on the public system for their care.

The new risk equalisation levy has already burned a family of four who hold an "advanced" plan to the tune of €180, which is a 24% increase before any increase on the underlying premium. Government policy seems very strange as private health insurance is becoming increasingly unaffordable for thousands of citizens, particularly young people who are cancelling cover in great numbers while older citizens struggle to retain cover. Such issues should be addressed by the Minister.

Insured patients who are being billed for care in a public hospital may not receive the same elements of private treatment that they may if they present in an independent hospital. If the public hospital system sees significant increases in numbers seeking treatment, it may be unable to provide access to equivalent private or semi-private accommodation or a treating consultant. Over 2 million consumers in this State purchase a health insurance product with the expectation that when needed, it will entitle them to specific criteria of care, including access, accommodation and clinicians. In circumstances where they receive a standard of care that is the entitlement of all the citizens free of charge, the cost is none the less charged to health insurance companies. The insurance premia ends up defraying the cost of providing public health care. Will the Minister provide an answer on these hard issues?

When one looks at it from the perspective of the State and taxpayer, one can see that a significant consequence of this proposal will be a substantial increase in the volumes of patients presenting for care in the public hospital system, putting pressure on the existing capacity and adding to current waiting lists. That is something about which we all have concerns. The Insurance Ireland Health Insurance Council forecasts that the net effect of the legislation will cost the Exchequer in the region of €90 million. The Minister should wake up, smell the coffee and see what is going on. We hear much talk about reform and action so let us see the reality and let the Minister deal with the points I raised in the debate on this legislation today.

I am also aware that no regulatory impact assessment has been undertaken regarding the effect of the Bill on the Irish health care system. Where is the Minister going? Where is all the talk about regulation and planning? It has gone pie in the sky. No regulatory impact assessment has been undertaken regarding the effect of the Bill on the Irish health care system. Given the fundamental nature of the change proposed, it is vital that this key part of the legislative process is completed prior to the enactment of the Bill. The Minister should wake up and smell the coffee. He is not delivering and is waffling again. He is all hot air and is not dealing with the real issue.

Let us go back again to talk about our senior citizens and respect for them. A total of 5% of the population over 65 - over 22,000 people - live in nursing homes in the private and public sectors. The care is expensive and can range from €430 to €2,500 per week. The cost of care is prohibitive for most of these people and they are eligible to apply for State support for the nursing homes support scheme to assist them in meeting these costs. The nursing fees of those on the scheme are met by a combination of means-related contributions from them and the State. The 2013 budget for the scheme is in the region of €974 million. This Bill seeks to increase the amount that people must pay on their assets towards the cost of care.

The nursing homes support scheme, which is known informally as the fair deal scheme, is a system of financial support for residents in long-term nursing home care. It began on 27 October 2009 and replaced the nursing home subvention system and the practice of contract beds and long-stay charges in public nursing homes. Its aim was to ensure that nursing home care is accessible and affordable for everyone and that people are cared for in the most appropriate setting. Under this legislation, older people must pay more for their nursing home care. In the current economic climate, this is very difficult for a group of senior citizens and vulnerable people who have already paid taxes for many years and made their contribution to this country. I ask the Minister and Government to stand up for the people, the poor and senior citizens and look at the issues I raised in respect of disability. Let us build a proper health service, bring in reforms that are equitable and sensible and examine the costs. It is a national disgrace that these issues still exist. In spite of all the talk and waffle from the Minister, he has still not delivered and I urge the Minister and other Ministers to look seriously at the points I made in this debate.

John Browne (Wexford, Fianna Fail)
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I welcome the opportunity to speak on the Health (Amendment) Bill 2013 [Seanad]. Our party will find it very difficult to support this legislation unless major changes are made by the Minister on Committee Stage. The proposal to charge all private patients in public hospitals will increase health insurance premiums. This will add to Government costs as more people will give up private health insurance thereby putting more pressure on the public health system. Many speakers have outlined that situation.

The Government's policy is to introduce a system of universal health insurance commencing in 2016, although there is not much sign of that at the moment. The Bill seeks to give effect to budget 2013 measures, including charging all private patients in public hospitals, increasing the daily charge for public inpatient services in acute hospitals from €75 to €80, increasing the asset contribution under the nursing homes support scheme from 5% to 7% and abolishing the requirement to backdate State support to the date of the commencement of the scheme for those who were in nursing home care prior to that date.

It is quite obvious that the Minister is continuing to take more and more money out of the pockets of older people. We already saw major changes in the budget this year where the respite care grant, the home care package and home help hours were reduced. In some cases, as in my county of Wexford, the home help service is in abeyance because the HSE is not providing the monies for an increase in home help services. It is very difficult to get approval for new home help applications.

It is quite obvious that if we charge the full cost of private beds in public hospitals, we will further drive up the cost of health insurance. There is already a crisis in the private health insurance market with 1,100 policyholders exiting the market per week although the Minister does not seem to accept that or want to take this situation on board. He continues to drive on with further measures that will ensure that more and more people will leave the private health insurance market. A total of 2,078,000 people were insured with inpatient health service plans at the end of March 2013. This represents a reduction in the number of insured people of 21,000 in the first quarter and 61,000 over the year. The market peaked at almost 2.3 million at the end of 2008 but because of job losses, reductions in wages and other issues, people have continued to leave the private health insurance market on a regular basis.

In respect of charging private patients the full cost of beds in public hospitals, most people are entitled to universal health care by virtue of their citizenship and status as taxpayers. If we charge the full cost of private beds in public hospitals, we will further drive up the cost of health insurance and force more and more people out of the market. People are voting with their feet on this issue. All health insurers agree that it is a very serious challenge to the sustainability of the market. As Deputy Finian McGrath outlined earlier, the Insurance Ireland Health Insurance Council, which includes the State's four main insurers, has warned that the Government's proposed new public bed charge will lead to an increase of over 13% in health insurance premiums. In a submission to the Government, it said that a price increase of this magnitude would force over 300,000 members out of the health insurance market, leaving just over one third of the population insured by 2015. A significant further exit of people from the private health insurance industry would have a dramatic and appreciable impact on the public hospital system as the cost burden of these individuals is shifted from private insurance to the Exchequer. There are already huge waiting lists in our hospitals. People are waiting months and sometimes years to see consultants. The delays, which are continuously highlighted by the general public, are nothing short of a disgrace. Some people are waiting for over a year or 18 months, many of them with serious illness, are finding it very difficult to see a consultant to diagnose them and are finding it nearly impossible to get into hospital because of the lack of speed of consultants when dealing with people who are seriously ill.

The hospital system in Wexford has been redesignated by the Minister and we now find ourselves in no man's land. At the moment, we are tied to Waterford and Cork.

It is the Minister's intention that Wexford patients will go to Dublin eventually and he should explain when will this happen. Many people are concerned they may have to go to Waterford, Cork or Dublin. Last week people from Wexford who were patients in Waterford found it impossible to get into the Mater Hospital, St. James's Hospital or St. Vincent's Hospital.

Private hospitals have warned they are in danger of closing if the Government presses ahead with plans to charge private patients the full cost of using public hospitals. The Minister must listen to private health insurers and private hospitals, because they are expressing concern about what will happen. They are not making it up and it is not out of a comic show. It is the reality but the Minister does not seem to want to listen. He seems to have no interest in what the providers of the services state. I call on the Minister to explain why he continuously ignores the views of private health insurers and private hospitals and the warnings they send out.

The nursing homes support scheme, which was known as the fair deal scheme, has been running for a number of years. More than 20,000 people avail of the service in long-term residential care. The scheme pays towards the cost of care for those participating, with individuals contributing 80% of their income and 5% of their assets per year fixed at a maximum of three years or 15%. In the Bill the Minister wants to increase the maximum proportion of a person's assets payable from 5% to 7.5% with a cap at three years or 22.5% in the case of principal private residences. In 2013 the budget for the scheme was €974 million. I do not know whether it was the Minister or the HSE who made a particular decision with regard to the nursing homes support scheme in rural Ireland. People applying for the nursing homes support scheme receive letters stating they are on the national waiting list for funding but the Minister tells us there is adequate funding. I am led to believe there was a huge build-up of applicants in Dublin and Cork and that the Minister instructed the HSE to put on hold applications from rural Ireland until Cork and Dublin applicants were approved.

Charlie McConalogue (Donegal North East, Fianna Fail)
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Deputy Browne has been speaking for nine minutes and up to 20 minutes are available in the slot if he wishes to take it all.

John Browne (Wexford, Fianna Fail)
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I accept that. The Minister should clarify the situation. Why would Dublin and Cork get priority over the rest of the country? People from Wexford who apply for the scheme encounter long delays. Those who operate the scheme tell them to take it up with the Minister and the HSE, that they are on the national waiting list for funding but they do not know when the funding will be obtained. We have been told quite openly that because of the huge list of applicants in Dublin and Cork rural Ireland was being put on the backburner and priority was being given to Dublin and Cork. If this is the situation it is not good enough. If people qualify for the fair deal scheme they are entitled to be paid immediately and it is not good enough that they are put on the backburner.

I believe the fair deal scheme is good and has worked reasonably well. It will be needed more and more because we have clear indications from surveys that the number of older people in the population will increase significantly from 2011 levels of 532,002 to somewhere between 850,000 and 860,000 by 2026. At present it is very difficult to obtain home care and respite grants. It is practically impossible to get home help support in rural Ireland.

The Bill will take more and more money from the elderly and will continue to increase the amount of money they must pay. The Minister has no broad policy for the health service and seems to be making it up as he goes along. I call on him to respond to the point I have raised about the nursing homes support scheme funding and why it is not available in some parts of the country to the same extent as it is in cities and large urban areas. I ask him to clear up this situation once and for all.

I am sure the Minister will accept amendments on Committee Stage. He has done many U-turns since coming to office, particularly with regard to GP care, universal social care and various promises he made when in opposition. It is not good enough that the Minister continues to attack the elderly. We had it in the budget and we have it again in the Bill. The Minister must re-examine where he is taking the health service because it is certainly not in the best interests of the patient.

Maureen O'Sullivan (Dublin Central, Independent)
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It is almost beyond belief we do not have a state-of-the-art health system when we consider the budget is €13.626 billion with a further €397 million in capital funding. I wish to make a general point about what is good and excellent in our health service. Excellent medical care and quality of services is provided in the areas of caring for people with cancer and advances for people with heart ailments, transplants, by-pass operations and stent procedures.

A friend of mine has had motor neuron disease for six years and with regard to long-term illnesses there is a great need for co-ordination of services. Her main carer spends much time making calls to a variety of services, whether for occupational therapy, palliative care, physiotherapy, home care, medical care or with regard to incontinence issues, instead of being able to make one call to a central person who could look after all of this.

We know we have a two tier system and most people would like to have a system which is fair and which treats people equally and in accordance with their needs and not their ability to pay. In the 1970s I bought into private health insurance and I am not too sure why. I have paid into it for more than 40 years and thankfully I have been very healthy and have only had to avail of it on three occasions for very minor procedures. The private health sector has received quite a lot of money from me and this is fine. In this system when one goes for an appointment it is speedy and prompt and when one arrives in the hospital one is dealt with efficiently and speedily. The procedure takes place and after care is provided. I do not understand why this cannot happen in the public health service also. Why can we not have prompt appointments and speedy delivery of services?

We know we have waiting lists and that we also have waiting lists in accident and emergency departments. I acknowledge the improvement in the new accident and emergency system in the Mater Hospital. In 2008, 2.3 million people had private health insurance. We have been told about the percentage decrease from 50.9% to 45.8%. One would need a degree to work one's way through all of the various private health plans and programmes available to establish what is cost-effective.

Regardless of the pros and cons of the proposed charges, or the philosophy behind private health insurance, I find the reaction of the private insurers predictable but not very helpful. They state this will lead to an increase of more than 30% in health insurance premiums and that the number of people taking out health insurance will decline. Aviva has stated the insurers simply cannot bear the cost and remain in business. VHI states it is the single biggest challenge facing the market. Laya Healthcare speaks of it as a significant threat to affordability and sustainability of private medical insurance. At least GloHealth asked for initiatives which would not drive up premium costs and which would entice young people to be explored. I call on the industry to examine wastage in private health care and for more efficient use of their resources. In 2012 the providers took in €2.3 billion but their only answer to this is to increase premiums.

Will outsourcing the operation and administration of the scheme by the HSE to another party mean it will be profit-driven rather than person-driven?

Primary care centres have been a major issue. I am still waiting for an update on the proposed primary care centre in the Summerhill area of Dublin 1.

The Library and Research Service included a section from Maev-Ann Wren from Trinity College's centre for health policy and management. She looked at the impact of demographic change. The number of people aged over 85 will more than double by 2021. The number of people aged between 74 and 84 years will increase by more than a half. It is vital that we get preventative measures right. There is much more that we could do on prevention. Illnesses that can be prevented include heart disease, diabetes and certain cancers. We are aware of the massive cost from alcohol abuse and alcohol misuse, yet the various recommendations and suggestions are not being taken up by the Government. I, like other Members, attended a presentation by the Alzheimer Society of Ireland. We are aware of the small amounts of funding that can improve people’s chances and keep them out of the system for as long as possible.

Investing in carers is an investment in community care and it helps families and communities and those people who want to stay at home for dignified living.

Charlie McConalogue (Donegal North East, Fianna Fail)
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Deputy O'Sullivan has been speaking for almost five minutes.

Maureen O'Sullivan (Dublin Central, Independent)
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I will just finish now.

Charlie McConalogue (Donegal North East, Fianna Fail)
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We are not stuck for time so she can continue speaking if she wishes.

Maureen O'Sullivan (Dublin Central, Independent)
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I have another one or two points to make. People should be facilitated to remain for as long as possible with their family and in their community. That makes much more sense, even on purely economic terms.

There are pressures on the maternity services in Dublin. The situation is not being taken seriously and because the services are so overstretched that presents a danger to the health of certain women. There are more urgent matters for us to address than the subject of the Bill. I echo a point made by other speakers that we do not want a further burden on the public health system.

Charlie McConalogue (Donegal North East, Fianna Fail)
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The next speaker is Deputy Michael Lowry. There are 15 minutes left in the slot if he wishes to avail of more time. I accept he had indicated that he wished to speak for five minutes. It is up to him.

Michael Lowry (Tipperary North, Independent)
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I have grave concerns on the proposals contained in the Bill before the House today. The Health (Amendment) Bill seeks to give effect to the measures advanced in budget 2013 to charge private inpatients in public beds and to increase from €75 to €80 the acute public hospital inpatient charge. If advanced in its current form, the Bill will have a devastating impact on the private health insurance market and will further destabilise and jeopardise its viability.

This legislation will mean that patients with private health insurance will be charged on the double, with a claim being made on their health insurance policy for a service that they have already paid for through their taxes. We are locked in a vicious circle of rising health insurance costs as a direct result of the flawed approach taken by the Government. The average health insurance premium for a family of two adults and two children has doubled in the past three years. Policyholders have seen three separate increases over the past year and the Government's risk equalisation levy has added a significant burden to all adult policyholders.

Individuals and families alike are under immense pressure at the moment and are struggling to survive financially. Week-on-week, hundreds and thousands of individuals can no longer finance, and subsequently drop, their health insurance policies. In the past two years almost 200,000 individuals have been forced out of private health insurance, with a further 500,000 downgrading their policy.

Our community-rated system requires a large portion of young, healthy policyholders to offset the high costs incurred by older members. Over the past two years there has been a rapid decline in the number of people aged between 20 and 29 taking up a policy. The system is not sustainable if young people continue to leave in their droves. Health insurance providers and economists have indicated across the board that this Bill will lead to a drastic increase in premiums. Mr. Colm McCarthy, in a report commissioned by Aviva, has found that the proposed public bed re-designation will add 13% directly to premiums on a full-year basis and that, coupled with the haemorrhaging of young adult members, will mean premium increases in the region of 20% to 25%. It is expected that this legislation will directly result in the exodus of a further 300,000 individuals from the private health insurance market. In many cases those who have faithfully paid their policies for years will now be unable to finance them any longer and will be left with no choice but to give them up, without realising any benefit from their years of payment.

The Government must be cognisant that this exodus will in turn place further pressure on an already chaotic public health care system and will bring it to its knees. We are all aware of the state of our health care system and the huge backlog for public patients in securing appointments. For each insurance increase, more families will rely on public hospitals and the already overburdened system will flounder further. It is short-sighted in the extreme to introduce such policies, as ultimately the burden will fall on the State and subsequently the taxpayer. It is my belief that the Minister, Deputy Reilly, must take a step back and consider the impact that his policies are having on middle Ireland.

The programme for Government promises to advance free health care for all but the reality is that since this Government has come to power there has been no positive difference, rather, the cost of health insurance has risen steadily. The Bill is entirely contrary to the Government's stated aims. If the deterioration in private health insurance continues, the public system will decline further and fundamental health reform will become substantially more difficult and increasingly unlikely.

This legislation serves to drive health insurance out of the reach of the squeezed middle and into the realm of the well-off only. It seems the Government is knowingly ploughing ahead with policies that drive the cost of health insurance upwards rather than taking any steps to buck the trend with regard to the drastically rising costs. The Minister should address the cost issues in the health service directly rather than seek to make up the shortfall by placing an additional burden on the shoulders of struggling private patients.

Charlie McConalogue (Donegal North East, Fianna Fail)
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Deputy Naughten has up to 20 minutes for his contribution. He should feel free to use as much time as he wishes.

Denis Naughten (Roscommon-South Leitrim, Independent)
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You are a bit like a salesman at the moment, Acting Chairman, trying to encourage people to prolong the debate. I welcome the opportunity to speak on this legislation. As the officials will know, I have spoken in debates on every piece of legislation that has come to the House on private health insurance. I have raised concerns and predicted that we would go down this road unless urgent action was taken.

In the past four years we have gone from a situation where a majority of people in this country had private health insurance to having a minority of the population with private health insurance. Between 2008 and 2012, a total of 200,000 people have left the private health insurance industry in this country. That is 1,100 people every week who are giving up their private health insurance because they cannot afford it. It is a very difficult decision for families to make because they know how long they could have to wait in the public system to access health care and for that reason they are loth to abandon their private health insurance. However, they are left with no other choice because of the cost of servicing their mortgage, the fact that their incomes have been reduced significantly and because the cost of insurance premia have gone through the roof. As a result, only one in eight of the population between the age of 18 and 29 has private health insurance in this country. At the other end of the age profile, one in five of those over 60 years of age have private health insurance.

As I stated in the House previously, these trends clearly indicate that only those who have to rely on health insurance or are wealthy enough to remain within the health insurance system are doing so and unless immediate action is taken to curb the haemorrhage of young people from the health insurance system, it will collapse.

Earlier this year an issue arose in terms of how the insurance levy was structured in the private health insurance market. We now have a situation where in some policies the majority of the premium is used to cover the cost of the levy that is being put into the risk equalisation fund.

It is not appropriate that the majority of the money paid by people who take out health insurance goes into the risk equalisation fund instead of being used to pay for the cost of their health insurance. The situation is unsustainable and many families that are struggling to meet current health premia costs are being forced out of the system. That it is discouraging young people from joining will compound an already grave problem.

For the community rating system to work effectively, a higher number of young people and generally healthier age groups need to join to offset the higher cost of claims among older members. The Health Insurance Authority, HIA's figures indicate that elderly people's claims cost approximately eight times those of the claims of young adults. According to Professor Colm McCarthy's report, for every scheme member aged over 60 years in 2008, there were 2.21 members aged between 18 and 39 years. That level has fallen to 1.54 members. This statistic is unsustainable and cannot be continued into the long term. Ireland's population is growing older and living longer. This trend will have a profound effect on the viability of private health insurance in this country. We need to start encouraging young people into private health insurance quickly.

I have raised this issue previously and tabled an amendment on Committee Stage before Christmas to introduce lifetime community rating, which would have given an incentive to young people to join up for private health insurance. We also need to consider increasing tax relief for those aged under 35 years, including their children, to purchase private health insurance and reducing or removing the Government levy on the same age group, at least for one or two years until they get used to paying insurance premia.

I have considerable concerns about this Bill because of its double taxation approach. The decision to charge the full economic cost of a private bed in a public hospital means that taxpayers who are directly contributing to the public health system through their PRSI and health levies are being disenfranchised from any entitlement to the tax-subsidised public hospital service. The Minister has given no indication that he is going to remove the health levy or reduce the cost of PRSI. People will pay on the double for the same hospital bed. Under the Minister's logic, the taxpayer who contributes to funding our health service and who has private health insurance will lose all rights to a public hospital bed. This is the equivalent of telling motorists who pay road tax, VRT and tolls that they can only use public transport if they are willing to pay the full commercial cost of hiring the bus. This is unsustainable.

Insurers have claimed that the cost of premia will increase by up to 30%. The Minister has claimed that this is scaremongering. When speaking at the national health care conference in March, however, he claimed that introducing bed redesignation all at once, as he is now proposing, would break the industry and that the measure would be introduced on a phased basis over four or five years. The Minister has since changed his mind and no longer sees any danger in introducing this measure in the coming weeks. The Minister is entitled to change his views, but the public has a right to know the basis for that change. In the Seanad, the Minister spoke of his Department having actuarial figures that refuted the suggested increases. If so, he should publish them so that we could all see what they are.

The decreasing number of people with private health insurance will have a direct impact on the public health system, which is already experiencing extreme pressures and lengthy waiting lists. Between the end of December 2012 and the end of April 2013, the number of patients waiting for longer than six months for hospital treatment jumped from 6,038 to 11,348, an increase of 88%. This trend will accelerate if increased numbers exit private health insurance.

With private patients now being charged the full economic cost of beds in the public hospital system, the use of private hospitals will also decrease. This will impact on the public hospital waiting list.

The introduction of universal health insurance, which many of us believe is the way to go, in 2016 will be severely threatened by the increased reliance on the public health care system over the private system by a growing segment of the population. When the Dutch introduced a similar system, close to 90% of their population had some form of private health insurance.

Under this legislation, the Minister sets bed and procedure charges, thereby removing insurers' right to negotiate with individual public hospitals. This will do nothing to drive efficiencies or force hospitals to become more effective in the delivery of health care services. Hospitals will get paid irrespective of the level of service provided. This legislation will institutionalise inefficiencies, not tackle them. The knock-on effect will be that the consumers of private health insurance may not always get best value for money or services if insurers are not in a position to negotiate the best deal for them. For example, the CEO of VHI, Mr. John O'Dwyer, recently admitted that there were circumstances in which hospitals were charging private patients the full cost, some €1,000 per night, of a private bed in a public hospital despite the fact that they were spending the nights in question on trolleys. There is also a question mark over this legislation regarding EU competition rules.

Under the Bill, the Minister has designated that public hospitals must charge a set daily rate of €828 for private patient procedures regardless of whether these take ten minutes or ten hours to complete. This daily fee can be nearly three times higher than the equivalent cost negotiated by health insurers for the same procedures in private hospitals. For example, a breast biopsy in a private hospital costs approximately €280, but it will now cost €828 in a public hospital.

The Minister has rightly berated health insurers for not reducing their costs or cutting fees for procedures that used to take two hours but now only take 20 minutes. However, he is enshrining in law this disconnect between the actual cost of the procedure and the set cost determined by the HSE and the Department of Health, which may not reflect the true cost of the procedure.

For these reasons, I have significant concerns about what the Minister is doing in this legislation. It undermines his objective of driving efficiencies in the system and allowing hospital groups the independence to negotiate with private health insurers. It also undermines the goal of introducing universal health insurance, something that the Fine Gael and Labour parties campaigned on in advance of the last general election. As such, I will oppose the legislation.

James Reilly (Dublin North, Fine Gael)
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I thank all of the Deputies for their contributions. I will raise a number of points, having listened to the debate.

One of the issues raised by Deputy Kelleher is the number of people who have left the insurance market, approximately 250,000 in the past five or six years. We all know what happened in that time. Some 250,000 people probably equate to 100,000 families. We know that more than 200,000 people lost their jobs as a consequence of the Fianna Fáil-led Government's mismanagement of the economy.

The Deputy also suggested that home help hours have been cut when they have not. They are at the same level as they were in 2012, and the same applies to home care packages.

Billy Kelleher (Cork North Central, Fianna Fail)
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They were cut.

James Reilly (Dublin North, Fine Gael)
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Several speakers, including Deputy Lowry, have used the industry's figures to say that premia will go up by 30%. I have made it clear that I have got actuarial figures that show quite a different scenario.

Deputy Lowry does not seem to understand risk equalisation because he said that it would increase the cost for all adults. It does not. It is a transfer between adults who are young and well, and older adults who are sicker and less well. That is what we call community rating, which is something that both sides of this House believe in.

Deputy Kelleher glibly mentioned the pressure on State funding and pointedly neglected to say how we find ourselves in this position. He contended that I said 380,000 people on the outpatient waiting list were not a problem, but I never said such a thing. I said it was daunting but that we see 200,000 people in our outpatients departments every month and that we could and would deal with it.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Minister promised he would.

James Reilly (Dublin North, Fine Gael)
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This is in stark contrast to the Government of which Deputy Kelleher was part, which was hiding it under the carpet. It was never exposed or counted before because they did not want to know. To paraphrase Bill Clinton, is it not the case that the Deputy is giving out because it is taking me so long to clean up the mess in which his Government left the health services? Nowhere in our history as a Republic have we been so failed in so many ways by a Fianna Fáil Government that presided over a financial fiasco and neglected the health service to the point where it nearly collapsed.

Despite the fact that we have had to reduce the health budget by nearly 20% and staffing levels by 10%, we have managed to improve the health service. We have had to do that because of the mess in which his party left this country. The Deputy should not try to paint it any other way. He has selective amnesia.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Minister certainly has it.

James Reilly (Dublin North, Fine Gael)
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Let us deal with the issues the Deputy raised. The number of patients waiting more than a year for an inpatient procedure is at its lowest level since records began. At the beginning of this year, the number of patients waiting more than a year for day case surgery is at its lowest level. Waiting lists in excess of a year for inpatient and day case procedures have been eliminated in 15 hospitals since the Government took office. The number of people who wait more than three months for procedures has been reduced by 18%. A total of 3,706 adults were waiting more than nine months for inpatient and day case surgery at the end of 2011, but by the end of 2012 the number had been reduced to just 86. In other words, the waiting list has been reduced by 98%. A total of 4,590 patients were waiting more than 13 weeks for a routine endoscopy procedure at the end of 2011, but within a year this waiting list was reduced to just 36 patients. Therefore, that waiting list has been reduced by 99%. A maximum waiting time target of 12 months has been set for a first time outpatient appointment and we hope to achieve that by the end of this year. Last year, the number of patients on trolleys was reduced by 24%, and so far this year there has been a further reduction of over 9%. All that has been done in the face of reduced staff and personnel resources.

Let us now return to the Bill before us. I can see that both Deputies have decided to take the insurance companies' figures at face value. I have alternative figures that indicate a very different picture. At a time of huge pressure on our health service funding, the budget measures provided for in the Bill are important both financially and from the perspective of reform. These measures will generate funding which is necessary to support the sustainable provision of a range of important health services in acute hospitals.

As I mentioned in my opening remarks, the Bill will increase the acute public inpatient charge from €75 to €80, and the charging of all private inpatients in public hospitals. The Government believes that the new private inpatient charge makes sense. Up to now we have had a situation where insurers have been enjoying a significant subsidy at the expense of the public hospital system where private patients in public beds have only paid a standard €75 per night. By contrast, private patients in semi-private beds have paid up to €1,000 per night. In both cases the patients see their consultants privately and pay the consultants' private fees. Indeed, they have already paid their insurer.

In future, rather than paying €75 per night, private patients will be charged €860 through their insurance, which is still well below the economic cost of those services. The cost of providing hospital services to private inpatients is at least €200 million more than the amount that public hospitals are currently allowed to charge. It is the Government's view that it simply does not make sense that two identical private patients getting the same medical treatment in a public hospital should pay different amounts for using hospital facilities.

Deputy Finian McGrath suggested that costs for those with intellectual disabilities will go up. The residential support services, maintenance and accommodation contributions do not involve increases in contributions levels. There will be no increase in this regard. In essence, the Bill continues existing arrangements for people in a range of residential settings, including those with intellectual disabilities who contribute towards the cost of their maintenance, but with a modernised and simplified legal framework. Deputy Browne commented on the fair deal scheme, but the placement list is run in strict chronological order on a national basis.

I commend the Bill to the House. It is an essential part of ensuring that we have the resources to run our health service. It is updating much legislation on the method of charging. In addition, it underpins in a major way and secures the future of the health services so that we can look after our citizens in an efficient, fair and effective fashion.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Minister could not even get his own Deputies to come in to speak. There is not one from the Government side.

James Reilly (Dublin North, Fine Gael)
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Am I not from the Government?

Billy Kelleher (Cork North Central, Fianna Fail)
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I mean there is no one to support the Minister.

James Reilly (Dublin North, Fine Gael)
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They will all be here for the vote.

Billy Kelleher (Cork North Central, Fianna Fail)
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They might not all be here.

Barry Cowen (Laois-Offaly, Fianna Fail)
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"Autocratic" is the new buzzword.

Charlie McConalogue (Donegal North East, Fianna Fail)
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The debate is now over, Deputies.