Tuesday, 10 December 2019
Health Insurance (Amendment) Bill 2019: Report and Final Stages
I move amendment No. 1:
In page 3, after line 28, to insert the following: “(b) Schedule 3 to the Principal Act, shall not apply to policies that fail to provide cover for day case and inpatient care in model 2 hospitals.”.
The amendment arose out of discussions on Committee Stage. This is an issue regarding model 2 hospitals, including those in Roscommon, Nenagh, Ennis and Bantry. Following the reconfiguration of acute services in the country, these hospitals are supposed to be the workhorse of the health system. They are supposed to deal with routine surgeries, day surgeries, day cases and inpatients that had traditionally gone to model 3 and model 4 hospitals. They do not deal with urgent or emergency cases but the conditions treated can become chronic conditions if left over time. The work includes colonoscopy and urology appointments, computed tomography scans, X-rays, magnetic resonance imaging scans and so forth.
All these hospitals have urgent care centres and patients stay over in hospital as a result. These patients do not end up in our accident and emergency departments, many of which, sadly, are chaotic at the moment. Two hospitals in particular hit the headlines on a regular basis, namely, University Hospital Galway and University Hospital Limerick. Funnily enough, those two hospitals are serviced by the hospitals in Roscommon, Nenagh and Ennis.
The difficulty arises because we have one cowboy insurer in the country. It has decided under one of its policies that it will not cover patients with health insurance who are going into model 2 hospitals. This issue needs to be nipped in the bud now.
We took decisions in the House to ensure everyone has equality of treatment in terms of access to health insurance. I was one of the Members who brought through the legislation at the time. The intention was to provide everyone with equal access to private health insurance if they could afford to pay for it.Whether a policyholder was 18 or 80 years of age, he or she would pay the same as others for the same policy. Now, we have one insurer which has decided to undermine the health structure in this country, even though the health structure is about encouraging as much work as possible in the local hospitals.
I see the Minister for Business, Enterprise and Innovation, Deputy Humphreys, in the House. The hospital in Monaghan is another one affected. This insurer has decided that people cannot go to the hospitals in Monaghan, Roscommon, Ennis, Nenagh or Bantry. Yet in these hospitals, patients do not have to wait for months to get a colonoscopy or access to X-rays or CAT scans; they can have the service within a few hours. If this particular organisation gets away with this, I have no doubt others will follow.
I want the Minister to amend the minimum benefit regulations here and ensure that all the insurance companies provide cover in every one of the model 2 hospitals in this country. That is in the interests of putting work through those smaller hospitals. It is in the interests of taking pressure off the waiting lists in the larger model 3 hospitals, such as Portiuncula, Sligo and Castlebar, and the model 4 hospitals, such as Galway University Hospital, where people have been waiting for years to get access to care.
Thankfully, smaller hospitals, such as Roscommon, are dealing with the backlog of waiting lists. We are trying to move more work from the bigger hospitals to the smaller hospitals. This is an issue I raised with the Minister recently regarding the charges for accessing the urgent care centres, which I firmly believe should be less than for people attending an accident and emergency department. If our policy is to encourage people to attend the smaller hospitals with less complex needs, then we should clearly define that in both the policy and the charges, and similarly in respect of health insurance. We are saying that we will encourage people to go into Galway University Hospital, Portiuncula Hospital and Castlebar and Sligo hospitals, where patients are lying on trolleys at present. While we are saying that we will incentivise those hospitals to take a private patient instead of taking someone off a trolley, yet we are not prepared to ensure that such private patients can access what probably would be better care in the model 2 hospitals, such as Roscommon and Nenagh, where there is less pressure in emergency departments and admissions. We are saying "No" and that this insurer can have a blank cheque in this regard. This cannot be allowed to happen.
I came across a constituent who, unfortunately, had a policy with this company. The constituent went for an inpatient procedure in the local hospital, Roscommon hospital, only to find out that the insurer will not cover that person. I found out that my own policy was the same and that I was not covered. Unfortunately, I was with the same insurer, as are many other people, because it has a strong standing in other areas in Ireland and has now got involved in the health insurance area. It should not be allowed.
I ask the Minister to give me a commitment today that an amendment will be brought forward to the minimum benefit regulations, rather than dividing the House on this particular issue.
Deputy Naughten makes a good point.
Prevention is the best cure. The elective procedures of the type Deputy Naughten mentioned and the prolificacy of urgent care centres for such admissions, which are springing up nationwide, is an important part of the health service.
The point on model 2 hospitals is well made, particularly in regard to the minimum benefit regulations. The Deputy has talked about community rating, which is the pillar underpinning the health insurance system we have had for decades. It is important that it is protected. The point has been made that whether one is eight or 88, one pays a common price regardless of health status, age or other factors that may be priced into a risk market where that would be brought to bear in a competitive pricing model. We do not have a competitive pricing model for reasons of public policy. For that reason, we cannot discriminate against those insurers that apply the principle properly, equally and fairly across the country and across all benefits.
The minimum benefit regulations were introduced at a time of the minimum benefits legislation. Health insurance policies initially were extremely comprehensive and covered almost every ailment under the sun. With the advent of competition in part and of risk pricing and of the greater risk profile, it was becoming far more expensive and health insurers were put to the pin of their collars to fund those. Even with community rating, they could not afford to keep paying for all benefits all the time and they began to scale back the plans. It was in response to that scale-back, in which benefits such as outpatient cover were removed from health insurance plans, that the minimum benefit regulations were introduced to provide that there is a certain bar below which an insurer cannot drop in terms of provision of cover. If one is an insurer providing a health insurance plan, one must have a certain minimum level of cover. There are certain anomalies in that cover but at the same time, the principle is good. The principle of community rating is good. Deputy Naughten's point is well made. That applies to the universality of cover geographically as much as it applies to the benefits themselves and to the procedures covered.
I thank Deputy Naughten for bringing forward this amendment. I will not be able to support it at this Stage but I will explain what action I intend to take following on from his request.
First, it is Government policy and the policy of the Oireachtas to drive more patient traffic through the smaller hospitals. It makes sense to fully utilise our hospitals. I visited Roscommon hospital with Deputy Naughten, where we worked together to make that hospital busier in recent years and that is and must be the direction of travel.
While it is fair to say that there are significant capacity pressures in the Irish public health service, it is not entirely fair when others suggest that there is no capacity because there is underutilised capacity in some of our smaller hospitals. My colleague and friend, the Minister, Deputy Humphreys, brought me to Monaghan Hospital, where there is a capacity to do more. We are using the National Treatment Purchase Fund, NTPF, as a vehicle to drive more procedures through the smaller hospitals, such as, for example, the cataract theatre in Nenagh. The NTPF should no longer be merely a vehicle for outsourcing to private hospitals but we should be using it as an access tool to make our smaller hospitals busier. That is Government policy.
Second, Deputy Naughten made a fair and timely point on urgent care centres and minor injury clinics. The Deputy suggests the fee for them should be lower than the fee for attending an emergency department. I agree with the Deputy. I was intending to make this announcement tomorrow but I will make it this evening. I will be signing a statutory instrument within the next week to reduce the fee to attend a minor injuries unit from €100 to €75, making it a little more costly than going to the GP if one does not have a medical card but lower than going to the emergency department, ED. I hope that will particularly help during the winter pressure period. I very much accept the Deputy's counsel in that regard. That is probably the quickest resolution the Deputy has ever got to an issue.
Deputy Naughten also raised the matter he has just spoken about at length on Committee Stage, when my colleague, the Minister of State, Deputy Daly, took the debate on my behalf. My officials were in a degree of provisional contact with Deputy Naughten in this regard. My officials have also consulted with colleagues in the Health Insurance Authority and with the Department's internal legal advisers.
I very much understand and accept the Deputy's motivation. It does not seem to make sense to the Deputy, to me or to this House that where the fee for providing the procedure would be the same in one hospital versus another, why a specific public hospital would be excluded, particularly a level 2 hospital. Indeed, on Committee Stage Deputy Naughten stated:
insurance companies should not refuse cover in small hospitals such as those in Ennis, Roscommon, Mallow or Bantry. People should automatically get cover in these hospitals.
For the record of the House, I need to clarify today that many insurance companies provide cover in these type of hospitals. The Deputy acknowledged that as well. Insurers operating in the Irish market are required to provide services according to the Health Insurance Act 1994 (Minimum Benefit) Regulations 1996. All of the plans available on the Irish market have been approved by the Health Insurance Authority, which is, as the House will be aware, the statutory regulator of the private health insurance market.
Pursuant to Article 9 in Part VI of the 1996 regulations, insurers may exclude specified services and specified providers in their policy. Therefore, it is the law of the land, through those regulations, that an insurance company can exclude a certain service or a certain provider. The Deputy is asking me tonight if I would review those regulations in respect of the specified provider and should that be looked at in the context of level 2 hospitals.
The information relating to the services covered by any policy is contained in the policy document provided to the consumer when purchasing such a policy. Insurers can, of course, have many reasons that they do not cover certain services or providers. One of them can be that not all hospitals can or should provide the full range of health services available in the State. I take it that is not the point Deputy Naughten is making.
Notwithstanding the exclusion clause allowed under the minimum benefit regulations, there are policies available on the market that explicitly provide coverage in many model 2 hospitals across the country. To be clear, it is the view of my Department and me that there is no need to legislate for insurers to cover model 2 hospitals because some insurers already provide this coverage. Consumers obviously have a choice when they go to purchase an insurance policy to purchase one that meets their healthcare needs. The current insurance regime allows insurers to provide policies at a range of prices and different rates as well.
However, in response to Deputy Naughten's request, I will ask my Department, in working with the Health Insurance Authority, to review those regulations, specifically, the exclusion clause relating to service providers, and I will report back to this House on that matter.
I appreciate the fact that Deputy Naughten stated that he did not wish to divide the House on this.
Were I to accept this amendment, my fear, based on legal advice, is that we could accidentally and entirely unintentionally interfere with the risk equalisation scheme. I acknowledge that is not Deputy Naughten's intention. The amendment would interfere with the scheme and policies that do not include this type of cover as envisaged by the amendment would have to be excluded from calculations and projections that the Health Insurance Authority, HIA, carries out, therefore invalidating the other recommendations the Bill makes. I ask the Deputy to consider not pressing his amendment on Report Stage. I will work with my Department and the Health Insurance Authority to undertake that review of the regulations, specifically insofar as it pertains to the idea of excluding specific public service providers and I will report back to the House.
The Minister has me put on the back foot in that he has accepted the suggestion I put to him recently on the fees for minor injury units and urgent care centres. I welcome that most positive development, which shows the direction we should be taking in terms of accessing healthcare. I was in this House when the whole issue of community rating was crumbling around us and we were obliged to bring forward legislation to protect that principle. I never thought we would be in a situation where community rating would not apply to people from Roscommon, Tipperary, west Cork, Monaghan or Clare because one insurer, Irish Life, has decided it does not want to cover the level 2 hospitals. It is wrong that this is allowed. There is absolutely no justification for it. Now that the Minister has made the decision on the injury units, which I welcome, we are saying that public policy is to encourage people to attend the injury units. However, we also are telling those who have private health insurance with this insurer that we do not want them to go to the urgent care centre. If they go to such centres and the doctors wants to keep them overnight, their policy will not cover that. It is wrong. It is bizarre that an insurer like Irish Life would sell policies to people living in County Roscommon while not covering their own local hospital. I was caught the same as everyone else. A stop needs to be put to this and it must be nipped in the bud straight away. The regulations need to be changed.
I support Deputy Naughten. I also am concerned that a particular insurance company would sell these policies. People are presenting at a hospital and they are not being covered. We have the same situation in South Tipperary General Hospital as that in Roscommon. It may be unintended but there are all kinds of issues around insurance. Surveys have shown that only 22% of people ever change their insurance provider and only 20% of people with health insurance said that they regularly shop around. There is a lucrative market out there. It should be a case of buyer beware but they are not getting fair play and they are not getting proper upfront information. It is a worse situation when they are on a policy, end up in hospital and find they have no cover. Something needs to be done to change that because it is not fair on people. They are unsuspecting. They think they have a policy and they trust the insurer but they cannot trust them.
I thank Deputy Naughten for the constructive way in which he has engaged on this matter. We do listen in this House when good suggestions come forward such as that on the minor injury units. We will have that statutory instrument formalised in the coming days. It is currently with the drafters. I hope to be in a position to sign it by next week. On the reviewing of the regulations, I have already made my position clear. We will take on board the suggestion the Deputy is making on the current level 2 hospitals that are excluded. We will review the regulations in conjunction with the HIA and will revert to the House.
In light of the Minister's response and in light of his response on the minor injuries units, I will accept his proposal. I do not know who will be sitting in the Minister's seat this time next year.
I do not know who will be sitting in my seat this time next year. If the people of Roscommon-Galway decide to send me back in here, I will be putting this amendment down again if the issue is not addressed. I will not be as generous on that occasion. While things in this House change and Ministers and Deputies change, if I am lucky enough to be here this time next year, I will be putting this forward unless the change is brought about. It is wrong and unfair. It is undermining the principle of community rating and stated health policy, which is about bringing more work into the local hospitals and ensuring that as many patients as possible use those injury units, rather than ending up in accident and emergency departments for hours and hours.