Frank Feighan (Sligo-Leitrim, Fine Gael)
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I move: "That the Bill be now read a Second Time."

I am pleased to address the House on Second Stage of the Health Insurance (Amendment) Bill 2022. This is an annual technical Bill comprising eight sections, all focused on the specific area of health insurance. This legislation is required each year to revise the amounts of credits and levies, ensuring not only that the risk equalisation scheme operates in a consistent and fair manner but also that it generates sufficient income in order that it is self-financing. The amendments outline in the Bill will ensure the ongoing sustainability of the private health insurance market, with the aims of avoiding overcompensation being made to insurers and having fair and open competition in the market, as required under the EU framework for state aid.

I will outline briefly the background and purpose of risk equalisation before outlining the specific provisions, which will apply next year. Over 46% of the population of Ireland holds private health insurance. That amounts to 2.4 million people and represents a total annual premium income of approximately €2.97 billion. Health insurance in Ireland is provided according to four principles: open enrolment, lifetime cover, minimum benefit and community rating. Unlike with other types of insurance, in our health insurance market customers are not charged based on their risk profile. That means that the premium charged for a particular health insurance product is the same for everyone. Insurers cannot take into account personal circumstances like health status risk or age, in which case older and sicker people would pay much more for health insurance than they currently do.

Risk equalisation is a mechanism designed to support the objective of a community-rated health insurance market. The risk equalisation scheme has operated in the health insurance market since 1 January 2013 and is provided for under the Health Insurance Acts. Under the scheme, insurers receive risk equalisation credits from the risk equalisation fund to compensate for some of the additional costs of insuring older and less healthy members. Risk equalisation credits are funded by stamp duty levies. The levies are payable by health insurers on all health insurance contracts written and are paid into the risk equalisation fund. None of the stamp duty on health insurance contracts goes to the Exchequer; it is all used to fund risk equalisation credits.

The risk equalisation fund is managed by the Health Insurance Authority, the independent regulator of the health insurance market. A health insurance Bill is necessary each year to update the amounts of risk equalisation credits paid to insurers and the stamp duty levies required to fund them. The rates of credits and levies are based on recommendations from the Health Insurance Authority following an evaluation and analysis of health insurance claims. The Minister for Health has approved the risk equalisation credits to apply in 2023 and the Minister for Finance has approved the corresponding stamp duty levies. As the risk equalisation scheme is deemed to be state aid, it must be approved by the European Commission. It was last approved in March 2022 to operate until March 2027.

In addition to the standard technical amendments, this year's Bill provides for the specification of the end date of the act of entrustment. The act of entrustment is the legislative mechanism under which the risk equalisation scheme operates. This is a requirement of the European Commission as part of its approval of the risk equalisation scheme earlier this year. The Bill makes further provision for the appointment and powers of authorised officers of the Health Insurance Authority, thus strengthening the enforcement powers of the authority in carrying out its role as regulator of the private health insurance market.

I will now outline the sections of the Bill.

Section 1 defines the principal Act as the Health Insurance Act 1994.

Section 2 amends the principal Act by inserting a new section 6B. The new section specifies the end date of the act of entrustment, the legislative mechanism under which the risk equalisation scheme operates, as required by the European Commission as part of its approval of Ireland's risk equalisation scheme. The end date for the period of entrustment should be viewed as a technical end date required under European law. The date matches the duration of the Commission's approval of the operation of the risk equalisation scheme. This section provides for an order-making power for the Minister to specify a new date after consultation with the European Commission and the Minister for Finance. This power will provide the Minister with the authority to extend the duration of the period of entrustment in exceptional circumstances in order to ensure the continuity of the risk equalisation scheme.

Section 3 amends section 11C of the principal Act to provide for 1 April 2023 as the effective date for revised credits payable from the risk equalisation fund.

Section 4 amends section 18E of the principal Act by making further provision for the appointment of authorised officers of the Health Insurance Authority. The amendments outline in more detail who may be appointed as an authorised officer and when the appointment may cease. It follows, insofar as possible, the Central Bank (Supervision and Enforcement) Act 2013, as amended.

Section 5 amends section 18F of the principal Act by extending the current legislated enforcement powers to non-registered businesses purporting to be carrying on health insurance business in Ireland. This amendment bridges a limitation of the existing legislation, which permits investigation only of registered undertakings. Again, this section follows, insofar as possible, the Central Bank (Supervision and Enforcement) Act 2013, as amended.

Section 6 replaces table 2 in Schedule 4 to the principal Act. The table revises the applicable risk equalisation credits payable from the risk equalisation fund in respect of certain classes of insured persons. The amounts are applicable on or after 1 April 2023. The Bill provides for a decrease in the age-related risk equalisation credits payable across approximately half the age groups over 65. These decreases are to facilitate the redistribution of high-cost claims credits, which result in a more targeted distribution of credits based on health status rather than age.

Section 7 amends section 125A of the Stamp Duties Consolidation Act 1999 to specify the applicable stamp duty rates to apply to the market in 2023. As I outlined earlier, the risk equalisation scheme is Exchequer-neutral. It is not funded by the State, and the State does not derive any funds from it. The amount of stamp duty levy is calculated to offset the costs associated with the payment of risk equalisation credits. The Health Insurance Authority recommends the amount of stamp duty levy to the Minister, having regard to the risk equalisation fund sustaining surpluses or deficits from year to year.

The amount of stamp duty payable on a health insurance contract depends on whether a contract is advanced or non-advanced. Non-advanced contracts provide for mostly public hospital cover, while advanced contracts provide a higher level of cover and cover in private hospitals mainly.

For next year, the stamp duty payable on non-advanced health insurance contracts from 1 April 2023 will be €109 per adult, which is a decrease of €12 from 2022 rates and €36 per child, a decrease of €4. On advanced health insurance contracts, the stamp duty will be €438 per adult, this is an increase of €32 from 2022 rates and €146 per child, an increase of €11. A surplus of €55 million, or 7% of the fund, is expected next year as there was a lower level of claims on the fund than anticipated. The Health Insurance Authority recommended that this €55 million should be used to reduce the amount of stamp duty to be charged from 1 April 2023. The rates of stamp duty payable incorporate the €55 million surplus. This surplus has built up because of lower claims due to lower levels of hospitalisations as a result of Covid-19, and an increase in expected stamp duty receipts due to higher numbers of people entering the health insurance market than had been projected.

Section 8 provides for the Short Title, commencement, collective citation and construction of the Bill.

To summarise, this Bill allows us to maintain the community rated health insurance market. The provisions of the Bill increase the effectiveness of the risk equalisation scheme. Risk equalisation credits based on age are reallocated to those based on health status, in the form of high cost claim credits, without increasing the stamp duty payable, which is a fundamental support to the market. Importantly, the programme for Government commits to retaining access to private health care services for people in Ireland, ensuring choice for those accessing healthcare.

This Bill continues our policy of ensuring solidarity with and affordable premiums for less healthy people or older people. These policy aims are supported by the public according to a 2021 Health Insurance Authority national survey, where 79% of those surveyed agreed that premium prices should not be dictated by a person's current health. The same survey confirmed 72% agreed that older people should not be charged more for health insurance.

Finally, while the Government continues to maintain the community rated private health insurance market, I will conclude by highlighting the Government's commitment to improving public health services under the Sláintecare programme. As access to these services improves, the Department will monitor the impact on the health insurance market over time. I commend this Bill to the House.

David Cullinane (Waterford, Sinn Fein)
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Sinn Féin will support this Bill, as we always do. It is an annual Bill to review the risk equalisation mechanism that supports the community-based health insurance market. It revises the stamp duty levy on policies and the risk equalisation credits payable to insurers for 2023. It is a self-funded system. Risk equalisation as a principle ensures that costs are constant across the life span of the individual. It seeks to ensure where possible that age, gender and health status do not influence the cost of an insurance product.

In 2021, 47% of the population was covered by private health insurance. That is not always because they want to, but because they feel that they have to. Many of the people I meet are not inclined to private market solutions to healthcare but such are the challenges in the public system that they feel they have no other choice. This is relatively constant across age cohorts but significantly lower among adults under 30 years and among people aged over 85 years. Even in the depths of the recession, 44% of the population retained their private health insurance and with more than 1.3 million people on some form of health waiting list, it is no wonder that half of the population hold onto their private health insurance. There are 897,000 people on hospital waiting lists. That is up 18,000 since September last year. More than 200,000 people have been waiting over a year and while I recognise that figure is down from last year, it is still nowhere near what needs to be done. There are also more than 200,000 people waiting for a diagnostic scan. More than 97,000 children are on hospital waiting lists and more than 100,000 children on community waiting lists and 18,000 on children's disability network team waiting lists. Behind every one of those numbers are real people with families who, in many cases, are waiting for access to care which should be provided much more quickly and better.

Because we are discussing health, I must point out that the Minister's waiting list strategy is failing. The targets that were set have not been met. They have been missed and they were too low in the first place. It was never going to succeed without a multi-annual plan. We are now reaching the mid point of this Government. There is a lot of talk about whether there will be a switch in different Departments. The switch in Taoiseach is certain; to me it is inconceivable that we would keep in place a Minister for Health who has served up waiting lists of 1.3 million people; where we have the challenges in the children's disability network teams and those in accessing home care for people because of the recruitment and retention issues and the myriad problems in the health service that simply have not been addressed. There is no multi-annual capital funding. That is necessary to deliver quicker delivery of hospital expansions. There is no strategic workforce plan. It is accepted by the Minster and the Government that the targets that we set ourselves in recruitment and training of healthcare professionals are too low. There is still no plan to deliver universal GP care or to expand primary and community care, other than the Minister throwing out big figures on budget day. There is no real plan behind any of it. There is no plan to address the shortage of home care supports, as I said earlier, or transitional step-down beds which is partly causing the problems in our hospitals. There is no roadmap to remove out-of-pocket charges and make all health and social care free at the point of use. That is certainly true at least of the charges that are non-hospital related.

What we need is a much different plan for the healthcare system. Here today, we are dealing with the private health insurance market. If I get the chance of being Minister for Health, maybe that will happen and maybe it will not, I would want to do more to dismantle and disentangle private health insurance and the private health sector from the public system. That would be basic public service, whereby we would not have this deeply unfair but also very messy set-up we have in this State in which public and private healthcare are joined at the hip. Even in public hospitals we have huge amounts of private sector activity. There are consultants on contracts who do a mix of public here and private there. Recently, I had a case involving a chap I know who needs serious surgery. He went into the outpatient appointment and saw the consultant who told him he needed a certain procedure and that he could be waiting between 14 and 18 months. He had a follow-up appointment some weeks later and having thought about it, he said he would go to a private clinic in Waterford. He asked if he should get his GP to refer him to the private clinic only to be told by the consultant that he would make the referral because he would be the consultant carrying on the procedure in the private hospital. That is what is happening. That is the unfairness in the system. It makes no sense whatever for the patient. It might make sense for those who are profiting from our healthcare system but from a fairness and equity point of view, that is one of thousands of examples of people who are not getting the care that they need. Even those who have private health insurance do not always get full value for what they put in. They still have to pay. There are all sorts of surcharges when they go to hospital and they still have to pay for GP visits and lots of other out-of-pocket expenses for their healthcare.

In some cases, those who pay for private health insurance to cover them if they become seriously sick, which is why people get private health insurance, pay not only a second time but also a third or fourth. During a cost-of-living crisis, that is not what we should be allowing. Once and for all, we must ask ourselves the fundamental question as to when we will get the break and seriously move towards decoupling private healthcare from the public system. I am in favour of public-only hospitals delivering public-only care. We need the new public-only contract in place. There should be a full-time contract for whatever number of hours a consultant must work in the public system. What consultants do outside that is a matter for them. I do not have a difficulty with that as I am pragmatic in that sense. The contract has to be for the public system, and the consultant has to do public work. That is the only way we are going to have truly public hospitals. We also have to substitute the private income that hospitals are getting with State funding to wean them off giving preferential treatment to private patients or those who might have private health insurance. Once and for all, we must grapple with the big dilemma in the healthcare system, acknowledging it is unfair, inequitable and not working.

There is an awful lot to do and a long road to go before we realise the big promises of Sláintecare. I understand from the INMO that the number of patients on trolleys today was possibly the highest in the history of the State, or certainly close to it. This winter, we are going to have several pandemics or epidemics at the same time. We will have Covid on the one hand and the flu on the other. We have had a very mild winter to date but it will become much more difficult in the months ahead, yet I do not see any plan from the Minister for Health to invest in the public system other than to provide more outsourcing and money for private healthcare and medicine, which drives many to obtain private health insurance. I do not see the necessary investment being made in the public system to ensure we can deal with the challenges. We do not have the step-down beds to allow people to be transferred from hospitals. We do not have the beds we need in the first place. There are patients going to the wrong place at the wrong time for the wrong care rather than what Sláintecare promised, which was the right care in the right place at the right time. There are people going to emergency departments because they cannot gain access to out-of-hours pharmacy or GP services. They have no choice. Once and for all, we must deal with all these issues.

The Bill is welcome insofar as it goes because it provides equalisation. Of course I support that but there are many things that need to be done in healthcare and far too many challenges for me to say any more than that. I contend, without wishing to create fear, that we could be heading into one of the most difficult winters ever faced by the Irish healthcare system. We are asking healthcare professionals, who are already burnt out, to step up to the plate again, to provide a line of defence and mask over all the failures of politicians and the Government. That will result in a bad outcome for patients and healthcare professionals. Much more should have been done.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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Of course we support the legislation before us, recognising there has to be a system in place to ensure equalisation for people with health insurance. Very many have health insurance because they feel they have no choice, their incomes being above the threshold under which they would be eligible for a medical card. It is not that a medical card is wonderful in many cases because patients still end up waiting for very long periods, particularly if they are seriously ill. The card gives them, or attempts to give them, the comfort of having something to fall back on or having their medical expenses covered if they have a serious illness or accident, and the comfort of being seen faster. The latter is the main thing people want. They wish to be seen faster and dealt with more efficiently and effectively in the private system, although this is often not the case. However, the insurance gives people a certain amount of comfort.

The reality is that we have a public health system in chaos. The Minister of State, Deputy Feighan, and I know about the circumstances in Sligo University Hospital, which is in our constituency. Many of the consultants in the hospital, including senior ones, have been writing to the Minister for Health about the major problems in the hospital, the people on waiting lists who cannot get beds and the chronic overcrowding in the accident and emergency unit. All the time, we are told it is down to having more facilities, beds and staff. However, we have been promised these for years. I am aware that the Minister of State and my other constituency colleagues are all on the same page when it comes to delivering for our constituents but we must ask what has been delivered for the hospital since 2011, from which year the Minister of State's party has been in government. Very little has been delivered. The waiting lists are getting longer and longer. This points to why people opt for private insurance. A man said to me recently that although you pay taxes all your life, you have to write a cheque again when you get a health problem. That should not be the kind of society we have. We must do, and need to be, better than that.

Another point I want to make on private health insurance concerns mental health. Many who have had a mental health difficulty find it very difficult to get private health insurance. That needs to be investigated very closely. It is the same for mortgage protection insurance. When people take out a mortgage or want to buy a home, if they can afford one in this country, they naturally have to get mortgage protection insurance. If they are truthful and state they have had a mental-health-related incident, such as depression, at some stage, it is very difficult to get the insurance. This is freezing those people out of the possibility of progressing in their lives. These issues are genuine ones that people deal with daily.

Let me return to the matter at hand. I spoke to someone recently who said they had a scare with cancer but did not have health insurance. The person was really worried because they were told they would have to wait several months for an appointment with a specialist. In the context of the major crisis and the trauma for the family, the person rang VHI and got health insurance immediately so they would have it if things got worse. We need to recognise that we have to be better than that. We have to have a system that delivers for people when they need it, such that when they think they may have a problem with their health, they will not feel so scared that they take out their lives' savings and spend vast amounts on health insurance.

When anyone purchases anything in this country, he or she pays VAT on it. It is not just those who are in employment who are paying very high taxes; everyone is paying tax all the time and it all goes into the same pool. It should be available to help everybody, particularly those in need of health services at any time in their lives.

While we support what is being done in the legislation – it has to be done because it is part of the system – the fact that we need the system is a poor reflection on our society. We should have a proper public health service, delivered to everyone on the basis of need and not the wealth they happen to have.

Donnchadh Ó Laoghaire (Cork South Central, Sinn Fein)
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The previous speakers have outlined clearly that Sinn Féin supports the legislation, although we will be tabling amendments because we recognise the reality that many families rely on health insurance because they feel they have no choice. That is not a reality that we savour or are heartened by. In truth, we have a very poor model, a model that is expensive and ineffective because of the duplication that exists in the public and private systems. This is the case with several public services, unfortunately. We should have a system in which you pay your taxes based on your income and consequently expect decent public services, but the system we have means you pay your taxes and then, on top of that, pay €60 for the general practitioner, pay an inpatient fee, potentially pay for health insurance, pay a voluntary contribution to the school, pay third level fees and pay any amount of additional charges. My attitude is that people should be entitled to public services on the back of the taxes they pay and should not be asked to pay twice. The latter seems to be the model of the State. Nowhere is it more obvious than with health insurance. I support many of the calls my colleague Deputy Cullinane has made.

It seems the Government is not pursuing the implementation of Sláintecare and its vision of a public healthcare system with anything like the vigour and enthusiasm that are needed. I urge the Government to move forward with the public-only consultant contract. It is a crucial step that must be taken. It will not be cheap by any means but it is an important investment in the future shape of our healthcare sector. It is absurd that having consultants working only in public hospitals with public patients would be a new development, but that is the case. It should not be beyond anyone's expectations for such a system to be in place but, unfortunately, the way our healthcare system has operated means it would be a radical departure. That is where we need to get to.

I raise a specific issue relating to an anomaly that arises out of the Covid period. I will forward the details to the Minister of State. Many health insurance plans cover private procedures in public hospitals. There is good and bad in that system and it is not ideal in many ways. However, those are the policies that exist and are purchased by people. During the course of the Covid crisis, the State, in effect, took over many of the private hospitals. In fact, I would say it was, to a large extent, a formal takeover. Those hospitals performed public procedures. I had an X-ray in one of the private Cork hospitals as a public patient during that time. A person who contacted me had a procedure for glaucoma in a private hospital during the same period. He anticipated, as did his GP, that he would be refunded for it because the hospital to which the GP referred him for the purpose of undergoing the procedure was operating as a public hospital. Unfortunately, his insurer has taken a different view and despite the fact the facility was operating as a public hospital at the time, is not covering the procedure as what it was, namely, a private procedure in a public hospital. This is grossly unfair and I am sure this person is not the only one who has been caught by this. I will forward the details to the Minister of State and I ask that it be addressed.

I have serious concerns about the healthcare system in the coming months. The number of people on waiting lists, at 897,000, is enormous. It is the guts of 1 million people. The number includes 97,000 children waiting for procedures, some of them very serious. A total of 200,000 people are waiting more than a year. I want to bring a particular focus on the 106 people who are on trolleys in Cork. It is important to note that we are far from being into the worst of the bad weather or the worst of the flu season. I have been calling for a number of months for a specific plan for Cork, which seems to be among the worst-affected areas in terms of pressure on beds. Some of that is because of the lack of follow-on facilities. We have fewer step-down beds now than we did before the Covid period, which is a huge problem. We need a tailored response for Mercy University Hospital and Cork University Hospital because the situation seems only to be getting worse. Cork has had some of the highest numbers of patients on trolleys in recent weeks and months. I urge the Minister of State to take that on board and to work with the INMO and the two Cork hospitals to put in place a dedicated plan to ensure we do not have more than 100 people on trolleys every day for the next couple of months. I do not mean to be alarmist but that danger is there and it is very concerning.

Catherine Connolly (Galway West, Independent)
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Táim ag bogadh ar aghaidh go dtí an Páirtí an Lucht Oibre. I advise Deputy Duncan Smith that I will be interrupting him to adjourn the debate.

Duncan Smith (Dublin Fingal, Labour)
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When will that be?

Catherine Connolly (Galway West, Independent)
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It will be in just under 12 minutes. However, the Deputy will be in possession when the debate resumes tomorrow.

Duncan Smith (Dublin Fingal, Labour)
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I probably will not take the 12 minutes but I want to make sure the debate will continue if the following speaker is not here.

Catherine Connolly (Galway West, Independent)
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The debate will continue. There are eleven and a half minutes left in the slot.

Duncan Smith (Dublin Fingal, Labour)
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I thank the Leas-Cheann Comhairle. We have the same debate annually in which we amend the Health Insurance Act to modify the regulations governing the private health insurance sector. The whole goal of health policy at this time is the delivery of Sláintecare, that is, the delivery of a universal, single-tier healthcare system, with access for all and service free at the point of use. Sláintecare is silent on health insurance because the gamble is that once it is delivered, people will be so impressed, looked after and cared for in the universal one-tier system that the need for private health insurance will diminish. That is a big gamble to make. Until Sláintecare is delivered and we see the proof of the pudding, we do not know what the long-term future is for our private health insurance system. As long as we have such a system and it remains as large as it is, with 2.2 million Irish people having private insurance, we will have private healthcare in this country. As long as there is private healthcare, we will have a two-tier system. It is an unvirtuous circle. Until Sláintecare is truly able to deliver in our communities across a whole range of primary and community services, we will be back here every year dealing with this legislation and with what we have now, which is a health service that is across two tiers and is not functioning as well as it should.

As a previous speaker stated, people who have private health insurance sometimes do not get the care they expect to get. In some instances, where people are let down by the public system and have private health insurance, they still cannot get the care they need. I refer specifically to speech and language therapy. There is a huge issue in communities all over the country whereby parents of young children who are facing speech and language challenges are told to go private. The first thing they do is call their private health insurer only to be told they are not covered for that service. They pay their taxes and are let down by the public system. They pay for private insurance and are let down by that system. They are in the private system off their own bat only to find the waiting lists are out the door. Even if they get an appointment and access to a service, they are paying on the triple for it. This is not good enough and it is another example of how our health system is fundamentally failing people at the point at which they need it. We are not getting the delivery of care right in the community.

Most people in the country who understand and are engaged with the health service are 100% behind Sláintecare. They want to see it delivered but they are losing faith that the Government will do so. They do not see the required staffing numbers coming through or the levels of student intake that are needed in our third level institutions. The public sector unions that represent nursing and midwifery staff, healthcare assistants, doctors, physiotherapists and occupational therapists say we are not educating and delivering enough staff into the workplace. The healthcare staff who are coming through cannot afford to live in this country, cannot afford housing and are going abroad. We are not retaining enough of the people we are educating to Further Education and Training Awards Council, FETAC, and degree level. The staff who are currently in the system are being forced out of it. If they are in the capital city, they have to move down the country or go abroad. We are fundamentally failing in the delivery of the core part of our health system, which is about providing a workforce that can deliver Sláintecare and everything else we need. The Sláintecare progress reports we receive every quarter from the Minister include lots of green, amber and red indicators. The green lights seem to refer to administrative issues. They are not indicative of the delivery of services in primary care centres, healthcare centres, emergency departments or speech and language therapy clinics across the country.

A version of this technical Bill comes around every year. I have a question on policy for the Minister of State, which I hope he will respond to at the end of the debate. Will community rating still be needed if Sláintecare is delivered? We do not know the answer to that. How much money is collected for risk equalisation under lifetime community rating due to loading penalties paid by people aged between 35 and 50 who do not take out health insurance before the age of 34? We recognise that this Bill must go through, but the fundamentals remain the same. We have more people on trolleys this month than we ever had before. December will likely be worse and January worse again. The perpetual crisis in healthcare, the lack of progress on Sláintecare and the fundamental continuation of our two-tier health system, underpinned by a massive private insurance system, are unsustainable because they are not delivering for the people of Ireland.

Catherine Connolly (Galway West, Independent)
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I ask the Deputy to stay on his feet because the Labour Party will lose its time.

Duncan Smith (Dublin Fingal, Labour)
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What?

Catherine Connolly (Galway West, Independent)
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If the Deputy resumes his seat, his colleague will lose his slot tomorrow. It is the Deputy's choice but there are five and a half minutes left. It is not my role to do this, but in case there was a misunderstanding at the beginning, I must to point out that the debate will be adjourned in five and a half minutes. If the Deputy sits down, I will move on to the next slot and the rest of the Labour time will be lost.

Duncan Smith (Dublin Fingal, Labour)
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What is the next slot?

Catherine Connolly (Galway West, Independent)
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I will not go into that. I have gone beyond my role already.

Duncan Smith (Dublin Fingal, Labour)
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I will resume my seat. I had not planned to talk for long on this. I will just end up going around the houses.

Patricia Ryan (Kildare South, Sinn Fein)
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I welcome the opportunity to speak on this Bill. It is an issue that is dealt with in a similar Bill around this time every year to provide for risk equalisation. Risk equalisation is a mechanism designed to give effect to the objective of a community-rated health insurance market where customers pay the same premium for the same health insurance plan, regardless of age, gender or health status. The Health Insurance Acts provided for a risk equalisation scheme in 2013. Under the scheme insurers receive risk equalisation credits to compensate for the additional cost of insuring less healthy or older members.

Some 45% of the population is covered by private health insurance. Those people pay over €2.5 billion per year in premiums. The Irish market is dominated by three main players. The statutory corporation, VHI, has a 51% market share, Laya has 28% and Irish Life Health has 21%. For many workers and families, health insurance is an unaffordable luxury. They make great sacrifices to pay for it, hoping they will not have to use it. Many people with health insurance scrimp and save to make up the consultant fees necessary to start the journey towards getting a procedure done under their health insurance. The only reason to pay is our health system. It is so bad that people fear the long waiting lists in public hospitals.

There are hundreds of thousands of people on long waiting lists. The Government has no credible plan to address this. We need to fix the imbalance in healthcare in order to remove private healthcare from our public hospitals and our public healthcare system. Sláintecare is on life support and needs a major focus from Government to keep it going. We need to move away from a two-tier health system. There are many people falling through the cracks and earning too much to qualify for a medical card and too little to afford health insurance. Ability to pay should have no bearing on how you are treated by the healthcare system. People are languishing on waiting lists and getting sicker, while those with health insurance are fast-tracked to the front of the queue. In some cases, they are treated by the same doctors and even in the same hospitals. For those who have to wait their mental health is suffering and in some cases their life expectancy will be lowered. That is simply not good enough.

Health insurance exploits a failed public health system, a public health system that Government policy has been trying to kill off for years because it favours a private health system. Treating our health service as a commodity is hurting those who need it the most, namely, the elderly and the working poor. My office is inundated with people who are in great pain and waiting for badly needed treatment. If delivered, this treatment would be life-changing. It is a disgrace that people have to go to their local Deputies to get letters sent to the Minister to wait weeks for a reply because the issue is brushed off to the HSE. The Minister of State needs to take responsibility for the mess and sort it out urgently.

Catherine Connolly (Galway West, Independent)
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I call Deputy Shortall. I will be interrupting her shortly after she begins speaking to adjourn the debate.

Róisín Shortall (Dublin North West, Social Democrats)
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This is the latest in the series of annual Bills required to adjust the levels of risk equalisation credits and stamp duties that underpin the risk equalisation scheme and the private health insurance market. The Bill also prolongs the scheme until 2027, following the European Commission's approval under state aid rules, and provides for changes to the appointments criteria and powers of authorised officers in the Health Insurance Authority.

As a starting point it is interesting to look at some of the statistics that are emerging in health insurance. In 2021, premiums paid for health insurance totalled almost €3 billion, which were paid by almost half of the public. This was essentially a health tax . It completely disregards the social contract whereby people pay their taxes according to their means and get access to proper public services in return. That contract does not apply in this country. The Government is levying €3 billion on the public in order for them to get timely access to healthcare; that is what this amounts to. We have this symbiotic relationship between the private health service and the public health service where the weaker the public health service the better it is for business in the private health service.

Sláintecare is all about creating a properly functioning public health service in order that people will have a right and a legal entitlement to access to timely healthcare. This would negate the need for private health insurance.