Denis Naughten (Roscommon-Galway, Independent)
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I move amendment No. 1:

In page 4, to delete lines 8 to 11 and substitute the following: “but does not include a claim—

(i) under a policy that fails to provide cover for day case and inpatient care in model 2 hospitals, or

(ii) for the cost of drugs that are not listed on the Reimbursement List established and published by the Health Service Executive under section 17 of the Health (Pricing and Supply of Medical Goods) Act 2013;”.

We touched on this on Second Stage. This amendment is quite clumsy, but it is the only mechanism I have available to raise the discriminatory action being taken by Irish Life Health, which happens to be the only insurance company to take such an approach to public hospitals. The hospitals I am talking about are Mallow, James Connolly, Peamount, St. Columcille's in Loughlinstown, St. Joseph's in Raheny, St. Luke's in Rathgar, St. Michael's in Dún Laoghaire, Naas, Lourdes orthopaedic in Kilkenny, Our Lady's in Manorhamilton, mid-western orthopaedic in Limerick, St. John's in Limerick, Roscommon University Hospital and South Tipperary General Hospital, along with the following hospices: St. Patrick's, Marymount, Our Lady's in Blackrock and Our Lady's in Harold's Cross.

All of these are public hospitals and Irish Life Health has said, in quite a number of its policies, that it will not provide cover in them. I brought this issue up on a number of occasions, because many of these smaller local hospitals can take pressure off some of our bigger specialist hospitals. As the Minister of State knows, the policy is to try to move more elective work into these smaller hospitals, taking pressure off the bigger hospitals where more serious acute work is done.

I know the Minister of State will come back and use Sláintecare as her excuse to justify what Irish Life Health is doing. That is wrong, because, in fairness to the Minister's predecessor, the Minister, Deputy Harris, when he was the Minister in charge, he agreed with me that this discrimination was wrong. It is wrong that these public hospitals are being discriminated against. If Irish Life Health does not want to cover any public hospital, I do not have an issue with that. That is its decision, if it wants to do so.

I do not have an issue with the Minister for Health or the Aire Stáit and the officials coming in here and saying the Sláintecare policy is to take private work out of public hospitals, if that happens across the board. However, I will not accept a situation in which we have one insurer saying a select number of hospitals will be discriminated against in health insurance. I ask them to remember that the whole idea behind the legislation with which we are dealing is equity of access and yet one element of equity of access is not being provided.

People who are paying private health insurance are being told that if they want to get care in a public hospital, they have to run the gauntlet of going through accident and emergency departments, whereas the policy should and is supposed to be that we actively encourage people to go minor injury units, or their local GP to be referred and treated in their local hospital, where possible. However, if one lives in Blanchardstown, Roscommon, Kildare, north Cork, Limerick or south Tipperary, happens to have private health insurance and is unfortunate enough to have such insurance with Irish Life Health whose policies do not cover those hospitals, one's GP will not make the referral to one's local hospital. That is wrong and should not be allowed.

I was deeply disappointed with the parliamentary reply I received from the Minister, Deputy Donnelly, in September of this year, using Sláintecare as the justification for this. This action and policy taken by Irish Life Health has been taken prior to the adoption of the Sláintecare report. It is wrong that smaller hospitals are being discriminated against by one insurer. It is either whole duck or no dinner. It is either no coverage of any public hospital or every public hospital is treated the same. It is either one or the other.

The funny thing about this is that it seems some model 2 and model 3 hospitals are included, while other model 2 and model 3 hospitals are excluded. Where is the justification for this? The one thing it does is force people, who want to support their own local hospital, to go the regional hospitals. In some cases, they go to regional hospitals with some of the longest waiting times in emergency departments in the country, which is wrong. I ask that, instead of kicking this can down the road, a decisive decision is taken by the Department of Health on Irish Life Health to do either one or the other. All I ask is that everyone is treated equally.

The Minister is bringing in legislation here to treat everyone equally, regardless of age or health and yet one insurer is discriminating against people purely on their address and undermining some of our local hospitals. That should not be tolerated or accepted. I have said that until Irish Life Health does what every other insurer does, it should not benefit financially from this legislation.

Mary Butler (Waterford, Fianna Fail)
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I thank the Deputy for his contribution to yesterday's debate which highlighted the role model 2 hospitals can play in providing care to the community. However, I must reject the amendment and will outline the reasons for the rejection.

The provisions being introduced in this Bill on high-cost claims are the result of significant work carried out by the Health Insurance Authority in the past few years. The authority provided its recommendations to the Minister for Health in June of this year and as a result, we have the definition in the Bill, which excludes drugs not approved by the HSE and takes into account other credits claimed from the fund.

To include the Deputy's amendment would introduce additional requirements for high-cost claims credits which have not been planned or factored into the authority's recommendations for other credits or the stamp duty. I also note the coverage of model 2 hospitals was not raised in the public consultation on the new scheme, which was conducted in January of this year.

The proposed amendment raises a number of concerns. First, the legal consequences of a change in the Act would effectively compel insurers to change their existing cover of hospitals and this would lead to an increase in premiums for consumers. This would also be an additional element for the new scheme which has not been notified to the European Commission and which could have knock-on effects on the negotiation process. The scheme was notified to the Commission in July and does not include the requirement that model 2 hospitals have to be covered for high-cost claims credits to be paid out. Amending the Act to include cover for all model 2 hospitals would introduce a favoured category of public hospital, which is not appropriate for the health insurance Acts. Model 2 hospitals are intended to have a role in providing a medical assessment unit and local injuries unit, as well as elective care. It is intended under Sláintecare that there will be no private activity in public hospitals, including model 2 hospitals. In answer to the concerns the Deputy raised yesterday, it is not intended that model 2 hospitals will be used as a testing ground for the policy. It will apply to the whole public hospital system, not just model 2.

Department of Health officials have surveyed the insurers and confirmed that the majority of plans across all insurers provide cover for model 2 hospitals. Those that do not are entry-level plans which still provide cover for some model 2 hospitals. These entry-level plans are intended for entrants to the market at an affordable rate. Forcing cover for all model 2 hospitals would have the unintended impact of driving up the price of entry-level plans. These are plans that are unlikely to lead to high-cost claims, which are to be covered by the definition the Deputy is trying to amend.

It is important that people who want to buy health insurance are clear on what they are buying. Health insurers generally issue suitability statements to make sure the customer is aware of where they are covered and is buying the right level of cover for that individual. Applying this amendment to the Act would be counterproductive and in direct contravention of Sláintecare's aim of ultimately removing private care from public hospitals. Public health policy recognises and is committed to securing and developing the role of smaller hospitals but this amendment would not further this aim.

Denis Naughten (Roscommon-Galway, Independent)
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I made it clear at the start of my contribution that this was a clumsy amendment. As the Minister of State knows, if I tried to word an amendment on this, it would cause a cost on the Exchequer and be ruled out of order. Second, it is disingenuous to talk about the public consultation because officials here have known for years about this issue. This is not the first time I have raised it. I have been consistently raising it every December for a number of years. This has not come as a surprise to anyone.

I know Government has made the decision not to accept the amendment, but the situation is discriminatory and wrong. I gave the Minister of State the example last night of the oral commitments being given in relation to our smaller hospitals. Talk is cheap. If the Government is serious about supporting model 2 hospitals, why do we have this situation? It is not just me saying this. The Minister of State's colleague, an Aire Stáit, Deputy Feighan, is saying it is wrong that we do not have basic sterilisation facilities at Roscommon University Hospital to allow us to expand the number of patients we treat in that hospital through day procedures. On the other side of that coin, when we ask Government to protect the model 2 hospitals and some model 3 hospitals from being discriminated against by an insurer on a number of policies, the Government is not prepared to intervene.

I will not dwell on this because other legislation is coming in but it sends out a clear message to people around this country concerning the approach of the health system to the smaller hospitals. The health system is prepared to turn its back on them when it comes to health policies that are discriminating against people based on geography. We have had all the pontificating from Ministers through the years since this risk equalisation legislation was first proposed about ensuring there would not be discrimination based on age or illness, but we are happy to have discrimination based on geography.

We say we support smaller hospitals but when it comes to putting the lámh into the póca, the health system is not prepared to do it. We are waiting three years for additional information regarding an ongoing review to be completed and a decision made on capital investment to put into an empty room. The room is already built yet we cannot get equipment to provide sterilisation facilities to enable us to treat more people in public hospitals, rather than going through the National Treatment Purchase Fund, where, bizarrely, some of the same doctors carry out the procedures in private hospitals.

Mary Butler (Waterford, Fianna Fail)
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Forcing cover for all model 2 hospitals would have unintended consequences. It would drive up the price of entry-level plans. A high-cost claim under this Bill will arise when a customer's health insurance claim or claims exceeds €50,000 in a 12-month period. The fund will then pay 40% of the portion of the claim that exceeds that amount. So, for a claim of €60,000, the fund would pay out €4,000. The types of activities conducted in model 2 hospitals are less likely to result in these high-cost claims as, typically, there are of lower complexity and do not result in long-term stays. In circumstances where a patient was being treated for such a long time on a private basis that it results in a high-cost claim, that would be a patient that was covered by their health insurance for that hospital. It is important that people who want to buy or already have health insurance - we know that is 46% of people in the country - need to be clear on what they are buying and what they are covered for. Health insurers generally issue statements to make sure the customer is aware of what they have. Unfortunately, I am not in a position to accept the amendment.

Denis Naughten (Roscommon-Galway, Independent)
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For the Minister of State to say the reason she is not prepared to support the principle of what I am talking about is that including smaller hospitals on health insurance plans would lead to health insurance policies costing more is, with all due respect, a load of rubbish. As I said this year, last year and in preceding years, we are talking about an insurer, rather than the insurance industry. A single insurer has selected a number of hospitals that it will not cover. What would happen if that insurer decided to only cover policies in the city of Dublin? Would the Government intervene if only Dublin hospitals were covered? Yet it is okay to discriminate against some geographic regions. It is funny how every other insurer can compete in the market without excluding smaller public hospitals but the Minister of State is saying it would lead to an increase in the cost of one insurer's policies if it was to include such hospitals. The Government has made its position clear regarding its approach to smaller hospitals so I will press the amendment.

Mary Butler (Waterford, Fianna Fail)
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I will repeat what I have said already. First, to include the Deputy's amendment would introduce additional requirements for high-cost claims credits which have not been planned, a matter I have just addressed. Second, forcing cover for all model 2 hospitals would have the unintended impact of driving up the price of entry level plans. The Deputy has not addressed that. It would force up the price of entry level plans. Third, amending the legislation to include cover for all model 2 hospitals would introduce a particular favoured category of public hospital. That would not be appropriate in the context of the Health Insurance Acts. Those are the facts.

Denis Naughten (Roscommon-Galway, Independent)
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It may be that the Minister of State is not prepared to listen to me. I made those points to here. As I indicated, all the other insurers cover those hospitals. How can it increase the cost if a number of hospitals with one insurer are included when every other insurer is prepared to do it? We are talking about a level playing field here. That is all I am looking for. A principle of this legislation is that there should be a level playing field. We are saying that in terms of age and illness it must be a level playing field, but that one insurer that wants to discriminate geographically is allowed to do so. That is the point I am making. I am looking to have equitable treatment across the board. The issue is with Irish Life Health. This is not an issue with the other insurers. If the other insurers can do it cost-effectively, why can Irish Life Health not do it? The Minister of State says she cannot and will not intervene because it will push up the cost of policies.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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For the purposes of clarity, the Minister of State has repeatedly indicated that the effect of the Deputy's amendment would be to force up cover costs. Can she set out precisely how that could be the case? I have listened to the exchange and I am unclear as to how or why that claim is being made by the Minister of State.

Mary Butler (Waterford, Fianna Fail)
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I will respond first to Deputy Denis Naughten. The Department of Health officials have surveyed the insurers and confirmed that the majority of plans across all insurers provide cover for model 2 hospitals. The plans that do not are entry level plans, which still provide cover for some model 2 hospitals. The entry level plans are intended for first-time entrants into the market and are offered at an affordable rate.

In response to Deputy McDonald, as already stated, including the amendment would introduce additional requirements for high-cost claims credits which have not been planned and have not been factored into the authority's recommendations for other credits or for the stamp duty. The proposed amendment raises a number of concerns. The legal consequences of a change in the legislation would effectively compel insurers to change their existing cover for hospitals and this would lead to an increase in premiums for consumers. Also, there would be an additional element for the new scheme which has not been notified to the European Commission and which could have knock-on effects for the negotiation process. The scheme was notified to the Commission in July and does not include this requirement that model 2 hospitals have to be covered in order for high-cost claims credits to be paid out. In most instances, high-cost claims do not occur in model 2 hospitals because, as I said on Second Stage, they mostly relate to people with cancer who would be in hospital for a long time and whose claims would exceed €50,000.

Denis Naughten (Roscommon-Galway, Independent)
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Before we move on, I just want to state that it would help immensely if we had a consolidated Act. The principal Act has been amended nearly 15 times. It is impossible for any human being to try to read through it. If it could be consolidated, it would, at least, make it easier for people to draft an amendment.