Kieran O'Donnell (Limerick City, Fine Gael)
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I move: "That the Bill be now read a Second Time."

I am pleased to have this opportunity to speak on the Second Stage of the Health Insurance (Amendment) Bill 2025, which I am taking on behalf of the Minister for Health, Deputy Jennifer Carroll MacNeill. This is an annual, technical Bill with eight sections, focused on the specific area of health insurance. It also seeks to make a change to the term of appointment of the chairperson of the Health Insurance Authority.

Today, 46% of the population, 2.54 million people, hold private health insurance. This represents an annual premium income of about €3.8 billion. Health insurance in Ireland is built on four key principles, and I will briefly outline each of them. The first is open enrolment. This means that anyone can buy a health insurance policy at any time, regardless of age, health status or medical history. Insurers cannot refuse cover because someone is older or has an illness. The second is lifetime cover. Once people have health insurance, they can keep it for life provided they pay their premiums. Insurers cannot cancel a policy because the person becomes sick or make claims. The third is minimum benefit. Every policy must include a basic level of cover set by law. This ensures that all customers receive a minimum standard of benefits. The final principle is community rating. Everyone pays the same price for the same plan, regardless of age or health. Insurers cannot charge more because someone is older or has a medical condition. These principles are the foundation of fairness in our health insurance system.

What is the risk equalisation scheme? The risk equalisation scheme is the key mechanism that keeps our health insurance market fair and sustainable. In a community-rated market, everyone pays the same price for the same policy, regardless of age or health. However, older and sicker people cost more to insure. Without the support of the risk equalisation scheme, insurers with more high-risk customers would face higher costs and premiums could rise. The risk equalisation scheme helps to resolve this. It works by redistributing funds between insurers. Insurers which cover older and sicker members receive credits to offset their higher costs. These credits are funded by stamp duty paid by the insurer for each health insurance policy it issues. The Revenue Commissioners collect the stamp duty and transfer it to the risk equalisation fund, which is managed by the Health Insurance Authority.

What are risk equalisation credits? There are three types of credits in the risk equalisation scheme. The first is age-related credits. These are payments to insurers to help cover the higher cost of insuring older customers. Older people generally use more healthcare services, so their claims cost more. Without these credits, insurers with more members who are older would face higher costs and would likely pass these on to their members in higher premiums. The second is hospital utilisation credits. These credits compensate insurers when their members use hospital services, either for overnight stays or day cases. They help spread the cost of hospital care across the market. The third is high-cost claims credits. These credits are for very expensive claims. If a claim goes above €50,000 in a year, part of that cost is covered by the risk equalisation fund. This protects insurers from the impact of extremely high claims and keeps premiums stable. The Bill makes changes to all three risk equalisation credits. The proportion of age-related credits will decrease slightly while health-related credits will increase by the same amount. Age is not always an indicator of bad health, so this change better aligns credits with actual health status.

In terms of stamp duty rates, health insurance policies fall into two categories: advanced and non-advanced. Non-advanced contracts mainly cover treatment in public hospitals. They provide a more basic level of cover and are generally less expensive. Advanced contracts, on the other hand, offer a higher level of cover, including access to private hospitals and additional benefits. These plans cost more because they provide greater choice and flexibility for customers.

There are four different rates of stamp duty depending on whether the policy is advanced or non-advanced and whether the customer is an adult or a child.

The rates for non-advanced policies and children are lower, reflecting lower levels of claims. Stamp duty is a ring-fenced contribution to the risk equalisation fund and supports the credits to enable fairness and sustainability in the private health insurance market.

Each year, credits and stamp duties are updated to reflect changes in claims and costs. Medical inflation and private hospital costs are driving claims higher. Medical inflation simply means the cost of healthcare is rising every year. Hospitals charge more for procedures. New treatments and technologies are more expensive and wages and operating costs continue to increase. Even if the number of claims stays the same, the cost of those claims goes up. This is one of the main reasons risk equalisation credits and stamp duties need to increase. The annual changes help to keep the system fair and sustainable. If the Government does not adjust the stamp duty rates every year, the scheme could run out of money. This could mean even higher increases to stamp duty later on or the Government having to step in to fund the scheme directly.

In terms of public support, there is strong public support for community rating in private health insurance. The Health Insurance Authority carried out a survey this year that showed that 64% of those surveyed agreed that health insurance prices should not depend on an individual’s health condition and 72% agreed older people should not pay more for their health insurance.

I will now briefly outline the sections of the Bill. Section 1 confirms that the principal Act is the Health Insurance Act 1994.

Section 2 sets the 1 April 2026 as the date when the new credits from the risk equalisation fund will take effect.

Section 3 updates the term of appointment for the chairperson of the Health Insurance Authority, bringing it in line with the code of practice for the governance of State bodies.

Section 4 increases the hospital utilisation credit. From April 2026, overnight stays will rise from €163 to €165 and day cases will rise from €81 to €100.

Section 5 revises the age-related credits. These credits depend on age, sex and level of cover. They will increase for all advanced products and most non-advanced products to reflect higher number and cost of claims.

Section 6 strengthens the high-cost claims pool credit, which helps insurers to cover very expensive claims. The share of costs covered will rise from 45% to 50% for claims over €50,000 in a 12-month period.

Section 7 sets new stamp duty rates to fund these credits. From 1 April 2026, adult advanced plan stamp duty is going up by €48 to €517, child advanced plan stamp duty is going up by €16 to €172, adult non-advanced plan stamp duty is going up by €9 to €103, and child non-advanced stamp duty is going up by €3 to €34. These increases are calculated to keep the scheme Exchequer neutral. An €8 million surplus in the fund will be used to reduce the level of stamp duty that would otherwise apply.

Section 8 deals with the Short Title, commencement and construction of the Bill.

This Bill ensures the continued fairness of our community-rated health insurance market. It strengthens the risk equalisation scheme and supports affordable premiums for older and sicker people, principles that are backed by the public. These amendments achieve our objectives in three ways. First, they support the sustainability of the private health insurance market by ensuring that credits and stamp duties reflect the real cost of claims. This keeps the risk equalisation fund balanced and avoids sudden shocks to premiums. Second, they prevent overcompensation to insurers. The changes to age-related and health-related credits are carefully calibrated so that insurers receive fair support from the fund. Third, they maintain fair and open competition in line with EU state aid rules. By aligning credits more closely with health status rather than age, we improve the efficiency of the scheme.

I commend the Bill to the House.

David Cullinane (Waterford, Sinn Fein)
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This is an annual Bill that renews the risk equalisation mechanism, which supports the community-based health insurance market. Obviously, I recognise the fact that many people rely on health insurance, so for that reason, we will be supporting the Bill. However, as in previous years, I will be critiquing what I see as a two-tier system and an insurance market system that I fundamentally do not agree with.

Many people take out private health insurance because they feel they must. There are some people who will take out private health insurance for other reasons, but the vast majority of people I represent have private health insurance because they cannot depend on the public system and they are waiting too long on waiting lists for things like a diagnostic scan, sometimes for elective procedures, planned procedures especially and maybe for some key issues like cancer or cardiac where they can be seen in private hospitals. Most complex work is actually done in our public hospitals. It is the planned elective procedures where there is an advantage if one is a private patient.

I accept that risk equalisation is important from the point of view of protecting certain cohorts of customers, which is why I am supporting the Bill, but we as a Parliament and as a people accepted when we signed up to Sláintecare that we wanted to move away from a two-tier system and embrace a single-tier health system, which exists in many countries in the world. They may not be perfect systems - no system is ever perfect - but I believe that universal healthcare systems are better than having a two-tier system.

We are finally getting to the point where I can see, even in recent weeks, private healthcare is being removed from public hospitals. That is a positive step. I have always believed that public hospitals must be for public patients, where people are treated on the basis of equality and where we do not have, in our public hospitals funded by taxpayers, any form of two-tier entry or two-tier access. We are somewhat moving in the right direction in that area.

There has been some progress made in recent years in relation to reducing the cost of healthcare. I would have proposed many of the measures that were brought in by the Government, and I supported them, but we are still a long way from where we need to be. For example, we do not have free primary care. Many people still pay for many primary care services, including GP access. I note that even the GP visit card, which was extended by the previous Minister, is not being taken up. Part of the reason is because it is very complex for people to understand who qualifies. Even I, with my so-called wisdom, had a look at it and was still not able to figure out whether some families were entitled to the GP-only card. That needs to be simplified and better explained because it is far too complex for people to understand.

The biggest reform we need to bring into the health service, if we are really interested in reform and dealing with waiting lists, is to build the elective public-only hospitals. That would be the biggest game-changer. It would be reform with a big R for a number of reasons. The primary advantage for anybody with private health insurance is that they can get a hip done, a hernia operation done, a cataract surgery done and all those day case procedures, which are the low-lying fruit for the private health insurance market if we are being honest. That is where private health insurers step in by covering lots of those procedures and making lots of money on them. The logic of the elective-only hospitals is that we would have four of those, two based in Dublin, one in Cork and one in Galway. They would do these procedures on scale and rapidly, so people would be seen within a couple of weeks as opposed to waiting years.

I am dealing with an elderly gentleman in my constituency of Waterford who needs two cataracts done. He has already been waiting eight months. I contacted hospital management and they said he could be waiting 15 more months. He cannot see out of either of his eyes, so his quality of life is affected. His options are to go to Belfast, get it done there and recoup the money or he can get it done elsewhere through the National Treatment Purchase Fund, NTPF, which the hospital has now kindly agreed to. Why are people waiting so long for procedures like that? A new cataract unit was put into the hospital in Waterford, yet we still have people waiting. I have people almost every day asking how long more they are going to have to wait for their hip or hernia operations to be done. These are simple procedures where people should not have to wait for years. I submitted a parliamentary question last week asking about the number of patients waiting for a diagnostic scan. The reply said 300,000 people were waiting for a scan - a CT scan, an ultrasound scan, very basic stuff. If somebody has private health insurance, they can go into a private clinic and get a scan or a scope done in a couple of weeks. If they are a public patient, they are waiting months and sometimes up to a year for a simple diagnostic scan. In fact, there are over 40,000 patients waiting over 18 months for a diagnostic scan. That is a shameful situation for us to be in. I told the Minister for Health in the Oireachtas health committee last week that, while I support the roll-out of the surgical hubs, we also need a roll-out of diagnostic hubs, which would be a sumilar system.

It is a similar system where diagnostic hubs on site or close to public hospitals carry out diagnostic tests which are important in terms of patients' healthcare journeys and provide results much more rapidly.

Another benefit of elective hospitals is that we separate scheduled from unscheduled care. That will be a huge game changer. Every time we have a surge in our emergency departments, which we know happens almost every day in some hospitals and almost every other day in almost every hospital, one of the first casualties is elective procedures. That is the only option open to a hospital manager because they need to use all of the capacity in a hospital to deal with the surge of patients on trolleys. Separating scheduled from unscheduled care makes perfect sense.

The surgical hubs which are being rolled out will help somewhat in that regard but the biggest game changer will be elective hospitals. I have raised with the Minister, head of the HSE and Secretary General of the Department of Health the fact that €9.5 billion in capital funding was given to health up to 2031. I met all of the officials, including those responsible for capital investment in the Department of Health, before the last election. They told me that what was needed was €13.5 billion. They have to finish the national children's hospital and the new national maternity hospital. There is digitisation and the roll out of measures which could cost up to €1 billion or more, and money has to be ring-fenced for that. There are climate action measures. There are regulatory requirements, which comes under the remit of the Minister of State. HIQA costs money. The former Minister, Stephen Donnelly, promised 3,000 beds, half of which have not been funded. That was another mirage by a Minister who made loads of announcements but never followed through on most of what he announced and left a mess, including the roll out of free HRT.

I referenced GP only cards and hospital beds, most of which have not been and will not be funded. There are other elements of the health service which require capital funding, including every acute hospital and mental health and disability services. The money does not go.

At a meeting of the health committee, we were told the best we can do for elective hospitals is get them to planning by 2031. For me, that is a massive failure and lack of ambition from the Government. It also tells me that this is a Government that is happy to see people continue to pay private health insurance. I have no doubt that if people had rapid access to elective procedures like those I mentioned, namely, day case procedures, that would negate the need for many low and middle-income families to take out private health insurance. It would be the fastest way to eliminate that for many families and reduce the sphere of influence of private insurance companies.

We talk about efficiencies in health care and the fact that we are spending record amounts of money on health, which we are because health inflation is high and we have to spend between €1 billion and €1.5 billion every year just to stand still. This is the reality of the health service at the moment. It is very difficult to get new money for new measures. While that is happening and families are paying for private health insurance because they cannot depend on the public system, this year €800 million will be spent on agencies.

My partner is a nurse who left her job in Castlebar to move to Waterford about three months ago and is on a waiting list to get a job in a public hospital. There is still no offer of a contract. She is one of many people due to the strict embargo and bureaucracy that has been put in place in respect of staff recruitment. Workers like her were told to work for an agency and get a few shifts here and there. A premium of 30% is being paid. It is not ideal for the worker, taxpayer or anybody but that is what we are dealing with. We are going to hit a spend of €800 million on agency staff, yet nurses and other healthcare professionals who want to work in the public system cannot be hired, which makes no sense.

Insourcing is going through the roof. It has now been stopped because of potential conflicts of interest but hundreds of millions of euro are being spent. The same is happening with outsourcing through the NTPF. We are not building elective hospitals and will not fund 3,000 beds. Elective hospitals, which are a big game changer, will not happen. Agency spend is up. Inefficiency is everywhere in the health service, yet patients are waiting for basic procedures. It does not make sense. It is wrong. They are the key issues that need to be sorted.

Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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We are fortunate in Ireland to have the most highly qualified and dedicated healthcare professionals in the world. Generally, aside from the notable exceptions, when people receive care they give a sterling endorsement of the care they receive. The problem is that access to healthcare across the State is plagued by waiting lists, vacancies in key roles and the State even breaking the law by its failure to provide assessments of need.

Despite cross-party reports, Sláintecare commitments or general election manifestoes, unfortunately insurance remains an important aspect of many people's healthcare planning. Even insurance does not work for people in many cases. This is why I welcome the amendment to the Bill from my party colleague and Sinn Féin spokesperson on health, Deputy Cullinane, mandating a review of the current rate of profit of healthcare providers and an analysis of the potential impact of the removal of private practice from public hospitals on a cost of health insurance.

People are being ripped off when it comes to healthcare in the State. They are ripped off by Fianna Fáil and Fine Gael, who in government have failed to adequately utilise our taxes to deliver a public healthcare system that works. They are ripped off again by private insurers, if they can afford that.

One area I want to touch on is dental care. Last year, no child in the 2024-2025 academic year in County Monaghan received their annual dental checkup. The HSE informed me that is due to maternity leave and retirements. That implies it is due to the HSE's poor workforce planning. If the situation is so dire, and no workforce planning could surmount the challenge of delivering school dental checkups in Monaghan this year, then it is the fault of the Government and previous Fine Gael and Fianna Fáil Governments for failing to train enough dental professionals. Families in Monaghan are being ripped off by the Government. They are paying their taxes and the Government is failing to provide their children with the most basic foundational level of dental care. In the years to come, if these children take up health insurance, most ordinary plans will not include dental care.

Dundalk services Monaghan for orthodontic care - it is a disgrace that children in Monaghan have to go to Dundalk. There was a vacancy for a consultant post and two specialist orthodontists post. With the current staff comprising two dental nurses, a part-time dental hygienist and a part-time clerical officer, it seems there was no consultant to serve the entire region, including Monaghan. This is utterly scandalous and is happening on the watch of the Minister.

We know early intervention delivers better and more cost-effective care. We know developing good habits in terms of oral hygiene at an early age likewise leads to better outcomes and is the most effective for ordinary people and the taxpayer. However, the situation the Minister is currently standing over in Monaghan does not deliver that. The county has been utterly abandoned by this Government in terms of dental and ortho dental care. The Government has ripped them off. People pay their taxes and the Government is not delivering a substandard service; it is delivering no service at all. It is leaving people to go private or get private insurance where, again, they are being ripped off.

Sinn Féin has outlined our plans to train enough dental professionals to deliver the services people pay for and are entitled to through their taxes. I ask the Minister to reflect on this because the status quo in Monaghan is entirely unacceptable. I appeal to the Minister to accept Deputy Cullinane's amendment to the Bill, so that we can address and end the rip-off insurance that many people across this country are burdened with, arising from the Government's poor stewardship of our health services.

Ruairí Ó Murchú (Louth, Sinn Fein)
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I join Deputy Bennett in calling on the Minister of State to look at Deputy Cullinane's straightforward amendment. We all are aware of the issue with rising insurance costs. It is no shock that this arises not only with public liability and motor insurance but also health insurance. A lot of people feel they have no choice but to take out insurance because of deficiencies in the health system. We need to see that amendment passed. We need a report and to see the ins and outs of what can only be called gouging and profiteering off the backs of people who see that they have absolutely no choice but to take out insurance. I call on the Government to come to a moment of clarity on this issue and to take the necessary action.

We will support the legislation because we accept the reality that people are forced to take out private health insurance. It tells us all we need to know about what is wrong with the two-tier system. As Deputy Cullinane said, we welcome the removal of private healthcare from public hospitals, the need for which we have pointed to for a long time. We need to see that done and we must ensure the public system gets the maximum capacity. Deputy Cullinane spoke about the huge issue of the 300,000 people in the public system waiting for scans and procedures, with more than 40,000 waiting over 18 months.

I have raised the need for a clinical specialist sonographer in Louth County Hospital. I have had some answers and promises from the HSE regarding the filling of that position and the delivery of the service into the future but I am not absolutely sure there is definitive surety around it. Having spoken to some people within the hospital setting, the situation is that the only person who had been working full time on ultrasounds is no longer there. We can all imagine how that impacts on capacity. Luckily enough, and with thanks to the Ceann Comhairle's office, I have been approved to raise this as a Topical Issue tomorrow, when I will follow up on it. I hope finally to get a definitive answer rather than an answer that looks definitive but anybody who knows anything will say is far from it.

Unfortunately, this is all the one particular issue. We are talking about delivering a decent public health system, no longer having a two-tier system and bringing public capacity up to the absolute maximum. It will come as a shock to nobody here that I deal with a considerable number of people in my constituency office who are facing issues that should be dealt with, in a proper system, in elective hospitals. This could be anything from cataracts to knee and hip replacements. If not for the cross-border health directive, we would be in a really critical situation. The system is just not good enough. We need a system that provides not bang for buck for private hospitals, no matter where they are situated, but bang for buck for the Irish taxpayer and, beyond that, for the citizens who require healthcare.

I cannot let the opportunity pass to refer to Michael Shine and the dreadful crimes he committed against a huge number of people over a long period. It is a cause for hope that there has been engagement, as we urged for many years, with Dignity4Patients, which is currently briefing its members. It is absolutely frightening that we are looking at numbers upwards of 390 to 400. It should not be a big shock when we consider that Michael Shine operated in a position of power for more than 30 years. Many questions will have to be answered. The scoping exercise must identify the best way to find out the detail and knowledge that are out there and to ensure this leads to a full statutory inquiry that can provide answers for the people who have been through an absolute nightmare at the hands of a paedophile. The issues were brought to the attention of the powers that be for far too long without being dealt with.

Duncan Smith (Dublin Fingal East, Labour)
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We will support the Bill, as we do with related legislation every year, but that endorsement is not an endorsement of the two-tier system that exists in our health service. Why do 46% of the population, or 2.5 million people, feel they must have private health insurance? It is because our public health system is buckling at the seams. As of 31 October 2025, there were 626,000 people on outpatient waiting lists. So far this year, 103,545 people spent time on trolleys awaiting beds. Many of us in this House have had family members waiting on trolleys this year. There are 6,858 vacant posts in the public health service at this time. A total of 400,000 people entitled to medical cards and GP visit cards are not availing of them.

The public system is struggling in many respects. Health insurance providers step into that breach, with health insurance being a tax on people's fear that if they get sick, they will not get the help they deserve and that should be their right through the public system. Sláintecare is moving at a glacial pace, with a reduction in funding for its implementation from last year to this year. The question is whether the Government is as committed to Sláintecare as was the whole Oireachtas two Dáil terms ago when the cross-party group on the future of healthcare made its recommendations.

We also need to discuss health insurance in the context of the cost-of-living crisis. We talked in this Chamber today about the big energy providers in regard to profit making and price gouging. The same arguments can be made about health insurance providers. Irish Life Health recorded post-tax profits of €24.1 million in 2023, with dividends of €11 million paid last year. VHI reported a net surplus of €36 million for 2024. Laya recorded pre-tax profits of €19.02 million in 2024, which was a doubling of its profits from 2023. People are struggling with mortgages and rent, high energy costs and food prices. They have little left of their wages. With 46% of people availing of private health insurance, the average policy increased from €1,683 in July of last year to €1,839 in July this year. The average price rise between 2023 and 2024 was more than 12%, which is a lot higher than the rate of inflation. Health insurance is not a luxury item or elective product; it is for basic healthcare. This is the Ireland of today and the health system that currently exists.

We need to see a real drive towards the implementation of Sláintecare. It must happen not only in our acute hospital settings but also, as Deputy Cullinane outlined, in the delivery of elective hospitals, the pace of which has been glacial. We also need to look at the community level. Mental healthcare in the community is underresourced and does not have enough staff. People are falling through the gaps. I have huge concerns about the number of people with acute mental health illnesses, unquantified to this point, who are not in receipt of a service at the moment because they have been discharged for missing appointments. That is a huge concern and one the HSE must take seriously. Children are timing out awaiting assessments of need in the public waiting system, which dictate what services, if any, they will get and assist with securing an adequate school placement. Those families are having to resort to claiming from their private insurance to access private assessments or, if the insurer does not cover that, paying out of pocket on top of their insurance. Even then, there are waiting lists in the private system. That is how broken the system is in terms of assessments of need for neurodiverse children. It is utterly broken.

This Bill is a technical one. It is a risk equalisation Bill and a complicated one in many ways but it supports an insurance system that is being presided over by companies making huge profits off the top of bills and premiums that are going up and up while the service is diminishing.

We need Sláintecare. We need it to be delivered as soon as possible. There is a creeping sense within the health system, the public and the political class that this Government is not truly committed to the delivery of Sláintecare. It feels as far away now as it did when it was first decided and agreed upon not seven years ago.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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While this Bill comes every year and so on, it relates to the implementation of the scheme already there and the costs involved and reflects the current cost of insurance. However, I want to raise the issue of the cost of private healthcare and ask the Minister of State to reflect on the increases that have taken place over the years in that cost.

We need to ensure that the private health insurers are diligent in how they pay out and investigate the payments being sought. We need to ensure they are paying hospitals on time for what was done, not for any extras that may have been inadvertently put into the invoice. I believe that is an issue that needs to be addressed because any type of increase in the cost of the care of a person in a hospital that does not fully reflect the type or extent of care they receive will simply increase further the cost of premiums to cover the profitability, if you like, of the private health insurers offering that cover.

It is significant money that people are paying. There is also a significant number of people who believe they have to pay that money. That should cause us to reflect on the system we have. Many speakers before me have highlighted the failures of the system itself. We are not criticising - or I am not - the staff who administer that system or, indeed, those at the coal face of the delivery of health services because they are pushed from pillar to post to deliver that service in a working environment that is not necessarily supportive of the task they are being asked to complete.

One of the issues this and previous Governments have had to deal with is the lack of value for money in our healthcare system and the amount of money going into healthcare that is being wasted. That is something we need to get a handle on because that figure is increasing every year. We just have to look at the 100 years of the PAC, which is being celebrated today, to see the amount of inquiries relative to healthcare is increasing by the year. The amount of moneys the courts are settling cases for is increasing every year. We are looking at millions of euro being paid out because of negligence of one kind or another in the hospital system. There is no business that could tolerate the payments being asked by the courts except for government because it can reach into the taxpayer's pocket and provide the payment the courts decide on. We should be looking beyond that and wondering why these things happen. What are the failings in our own systems - in the systems of public administration - that have caused the person to go to court?

I have a lady in Kilkenny whose father was cared for in hospital and who later died. The HSE has recognised the lapses of care in that hospital, yet it still continues to fight with the family in respect of a promise of apology. The HSE acknowledged its wrongs and said it would apologise but that has not been a fulsome apology. I find that shocking. If you have a customer in business and something goes wrong, own up to it. Take ownership of it and deal with it without having to spend a fortune going to the courts. In that game, it is only the legal profession and others who will win. The State Claims Agency and the HSE need to look at best practice. They are wrong in what they are doing. The individuals who go to court are not wrong because, obviously, they have a case and they went to court. The HSE or the Department of children is now standing over the payment of a hotel room, going back over the past 12 weeks or more, for a child who is kept there because it cannot get a proper, bespoke place for that child. The HSE and the Department are in the business of health and children long enough to know where they can get that care without squandering a fortune on a private hotel bedroom and without putting pressure on the parents to do a roster over the 24 hours to visit and look after that child. What in the name of God have we come to in Ireland that this would happen, given the billions of euro currently being pushed into the health services?

I look at the delivery of health for older people and what I see in our public hospitals is people who are going in for one health issue or another, experiencing lack of care, falling in the hospital ward and ending up being in even more difficulty coming out of the hospital than they were going in. The families are then promised home care hours and support, only in the attempt to have the patient removed from hospital and taken home. Once home, the hours are often not delivered at all and the family is pushed to a point where some have to give up work, the person is often left alone but should not be left alone, and the health of the individual then takes a nosedive. That is not acceptable in a country that is spending the type of money that we are on healthcare. It is not acceptable that the hours would be allocated and then, when they are not sufficient, they would not be topped up by the HSE.

I see it every day of the week. The Minister of State should look at the parliamentary questions being asked and ask himself why they are being asked. Why are so many questions about delivery of services turning up on the Question Paper every single day? The answer is the administration is wrong, it is not efficient, it is not delivering in the way that it should and it is not getting value for money. Families often then turn to private healthcare. What I am encountering now is a wait for hip operations, knee operations and so on even within private healthcare. Something is wrong with the output for the money being spent.

There is a new hospital in Thomastown in County Kilkenny, which is state of the art and a wonderful location. However, I have yet to determine when that hospital will be fully staffed and open so that the patients on waiting lists and in the hospital can be put into a better facility.

I ask that someone at least explore that question, find out and let us know. There is a wonderful hospital in Castlecomer, County Kilkenny. People use it for respite and it is used for the care of older people. That is a hospital model that should be developed. The community hospitals, those that are in the community supporting the care of older people, are not being funded in the way they should be. They are providing a brilliant service. It is an incredible service. For some reason or other, there is a high number of those hospitals in Carlow-Kilkenny. Every single year, they are being pushed by HIQA, or for some other reason, to spend money that they do not have. When they appeal to the Government, they receive a snail's pace response. When we have something that works, we should fund and develop it and, if possible, roll it out to the rest of the country.

In the past, in healthcare, religious orders sometimes looked after the hospitals and they set up new hospitals and community hospitals. They are still going and they are a proven model. Why are we in trouble with our healthcare given the billions available now that were not available previously? I support the hospitals in Castlecomer, Thomastown, Kilmoganny and all the others getting money to continue their development because they are doing a community service. They are not just hospitals. I ask that the care of our elderly in our public hospitals be looked at. There are times when they are admitted to hospitals where it is not the right place for them. Some are ending up on beds in accident and emergency departments and not being properly cared for.

I have respect for people in their senior years who are looking for the types of operations that would give them more years in life. I can never understand why the same ethos is not in place in hospitals to ensure that a hip or knee is replaced or cataracts are done. What have we come to?

I listened to other speakers. I ask the Minister of State to listen carefully to what is being said. Everyone has a contribution to make in terms of their own locality. They are not talking out of the top of their hat. They are giving facts about projects that are working. They should be supported.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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I am glad to speak on the Health Insurance (Amendment) Bill 2025. As we know, many people in the country, almost 50% of the population, have health insurance. This is high when we consider that almost 77% of the cost of healthcare is provided by the State. You would wonder why the imbalance is there. Many people feel they have no option other than to have health insurance, particularly as they get on in life. There is always the fear of ending up on a waiting list, particularly for a diagnosis. I know many people who are waiting to get scans, scopes or other services. They go to their GP, who writes a letter to the hospital and says they will get an appointment at some stage. They wait months and months. It turns into years. Then they get very ill and end up having to go to accident and emergency.

In my constituency, Sligo University Hospital was recently described as one of the most overcrowded hospitals in the country. In fact, I was recently informed that the ambulance service at one stage got a notification not to bring patients to the hospital, such was the overcrowding in the accident and emergency department. It is the same all over the country. In one cases I had recently, a woman waited outside Sligo hospital in an ambulance for six hours because there was no space to bring her into the hospital. That ambulance came from south Leitrim. During the time the ambulance was waiting, there was no ambulance cover in the region. That is happening everywhere all over the place. It is small wonder, therefore, that people feel the service is so poor in the public system that they need to get insurance to be able to have a service provided. Yet, when they have that insurance, the level of service they get is often not up to the standard they would expect in those circumstances.

We have a two-tier health service and unfortunately it does not work for anyone. What we find is that people pay taxes all their lives in order to have a health service and then when they get ill, they have to take out their chequebook to pay for it. That should not be the case. There is a huge amount of work to be done to be able to provide the kind of service that people require. We recognise that the private system is withdrawing from the public system. That should happen as soon as possible. It has been my experience that the private system only wants to provide the easy parts. It wants to do the parts that are easily done, the clean-cut bits, such as the cataract that needs to be taken off, the hip or knee replacement and the stuff that is clean and easy. The harder part, the more complex cases, are put back into the public system again and the pressure is always on the public system to provide for it.

We have a health system which is run by professional and competent people. My daughter is a nurse who works in the health service. I know the level of commitment the staff have. She experiences it among the people she works with. We find, however, that the system is somehow or other under strain and stress, mainly because there are not enough people to provide the service. Many health workers will talk about the experience of working abroad being good. In general, when they go to other countries, they find that where there is meant to be three or four nurses and a number of care assistants in a ward, there is half that number in the Irish ward looking after patients. That creates huge strain because if a couple of people happen to need urgent care or are sick at the same time in those circumstances, they do not have the ability to look after them. They feel under pressure, stressed and unappreciated in the system, and the system fails. That is the experience of so many.

Having health insurance does not solve the problem for a lot of people. In fact, all it does is make them pay more and still get an inadequate service. There needs to be a full review of how our system works. I know Sláintecare was supposed to do that, but it has not delivered. There needs to be a re-examination of what we are going to do to get a proper health system in place that provides adequate services for all of our citizens.

Pádraig Rice (Cork South-Central, Social Democrats)
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As in previous years, the Social Democrats will be supporting the Health Insurance (Amendment) Bill. Risk equalisation is necessary to ensure that older and sicker people do not face huge premiums because of their perceived risk. This modest measure also helps mitigate cherry-picking low-risk groups, such as younger and generally healthier people. In the context of our two-tier health service, where approximately 46% of the population have health insurance, the risk equalisation scheme is essential. Eight years on from the publication of Sláintecare, it is concerning that the private health insurance market continues to grow. That should give the Minister of State pause for thought, because it is hardly a ringing endorsement of his predecessor’s track records on reform.

A total of 2.5 million people in Ireland have health insurance. That is almost half the country. Last year, total premium income stood at €3.6 billion, up from €3.2 billion in 2023. According to the Health Insurance Authority, the average individual plan increased by 12% in 2024. As of June, the average premium stood at €1,830, an increase of €147 in 12 months. This is a huge expense for households, and it is way beyond the reach of many workers.

Even though almost half the country has health insurance, only 12% of overall health expenditure is paid for by private health insurance. In fact, despite some reform, there has not been much change in the last decade. In 2014, private health insurance accounted for 13% of health spending. However, we should, hopefully, see a more considerable drop in the figure in the years to come, as the process of disentangling public and private healthcare progresses. Ultimately, we cannot continue to stand over a system where the taxpayer is subsidising private healthcare. It is totally unjust and unfair that taxes pay for 77% of health expenditure, yet people with private health insurance have quicker access to healthcare compared to their fellow taxpayers without insurance.

Equally, those who have private health insurance should not feel the need to have it. They should not feel pressured into it, out of fear for themselves or their families failing ill. They should not feel obliged to dig even deeper every year to pay health insurance premiums, but the reality is that they do. This is not a European norm.

Ireland is an outlier.

Sláintecare recognised this dysfunction in our health system. In fact, it was the motivating force behind the setting up of the Committee on the Future of Healthcare. Sláintecare had and has cross-party support and remains official Government policy but momentum has undoubtedly stalled. Implementation has always been patchy but now more than ever, it seems as though the reform programme is being slow walked. I do not think that has been done consciously but I believe that a lack of political will has converged with a lack of institutional knowledge. On the latter point, I, like so many others, was not in the House in 2017 when Sláintecare was agreed. The membership of both Houses of the Oireachtas has changed considerably in the years since and just five of the 14 TDs who sat on the Committee on the Future of Healthcare are still in the Dáil. Of those five, not one is in the Department of Health, nor indeed is their party’s health spokesperson. I do not say this to suggest there is not an understanding of Sláintecare in this House, but we are, as Professor Steve Thomas has warned, in "danger of mission creep". To be clear, Professor Thomas is not just some commentator. He led the Trinity College team that supported the Committee on the Future of Healthcare in developing Sláintecare. He, like the Social Democrats, remains entirely committed to Sláintecare but I am not sure if the same can be said of all parties, particularly those in the Government. Everyone is still signed up to Sláintecare in principle but are they still committed to its vision or are they just paying lip service to the reform programme?

As Professor Thomas pointed out at a recent health policy conference, Sláintecare can mean almost whatever we want it to mean; therefore, it risks losing coherence. To emphasise his point, Professor Thomas pointed to the bizarre fact that eligibility and entitlement is still being debated. This is something I am particularly concerned about. Why, eight years into Sláintecare, is a review of the eligibility framework being carried out? Sláintecare was clear that an entitlement to universal healthcare should be provided to all, underpinned by legislation. In 2025, however, there are still virtually no universal entitlements to healthcare, only "eligibility" for some services. This point, while overlooked, is crucial - the distinction between "entitlements" and "eligibility". "Entitlement" means that a person has a right to something, while "eligibility" is defined as having the necessary qualities or satisfying the necessary conditions to qualify for a scheme. That is a very important distinction.

I accept that a review of the long-term illness scheme was needed and should have already taken place but this so-called strategic review of the wider eligibility framework concerns me. First, if it is anything like the long-delayed strategic review of general practice, it strikes me as a delay tactic, a way of doing nothing on eligibility under the guise of awaiting its findings. Second, there is no need for a review. What exactly is there to review? Yes, in the absence of clear entitlements, a complex system of eligibility has developed. There is no denying that but reviewing it is not the answer; undoing it is.

In a reply to a parliamentary question I submitted earlier this month, the Minister said that in order to achieve the goal of universal healthcare in line with the commitments made in Sláintecare, we must first review existing eligibility arrangements. This far into a ten-year plan to achieve universal healthcare, the Government wants to look at the existing arrangements now. This does not fill me with confidence. The focus is entirely misplaced.

The 2017 plan recommended legislating for a legal entitlement to healthcare. The proposed Bill would provide for a universal entitlement to a broad package of health and social care services. This universal entitlement for everyone living in Ireland was to be phased in over a five-year period and completed in 2023. I accept that Covid interrupted that timeline but that is not the real reason it has not progressed. Unfortunately, this Government has no interest in conferring any right to services on people. As usual, it is treating Sláintecare recommendations like a menu rather than a manual. That is not to say that every single word in the 2017 report must be accepted and that we cannot adapt to changing circumstances, but one cannot pick and choose from recommendations that are fundamental to delivering an integrated, universal, single-tier public health service delivered on medical need and not ability to pay.

Regrettably, I do not think there is an appreciation of the fact that the key recommendations in Sláintecare are interrelated and interdependent. Take for example one of the central elements of the reform programme, namely, integration. The recommendations related to delivering integrated care are particularly important. Why is this the case? It is because even if this Government were to make good on commitments related to entitlement to care, this would not ensure access. The integration section of Sláintecare is about improving access through a recalibration of our health system away from hospitals and towards the community, but integration also includes fundamental reform of HSE governance structures. It should be acknowledged that we are seeing some critical changes to the governance structures, most notably the phased implementation of health regions. However, I have concerns about the accountability mechanisms in place. It is deeply regrettable that the Minister has no intention of putting national and local accountability structures on a statutory footing.

I am also concerned about other key Sláintecare reforms, such as salaried GPs and a statutory right to home care. The latter is a long-standing commitment dating back to the Tánaiste’s time in the Department of Health. Since then, every target for the introduction of the statutory scheme has been missed. All the while, home care waiting lists have grown. This year alone, they have increased by 12% since January.

Looking at this year’s health budget, one would struggle to be optimistic. It is short on reform and even shorter on detail. Rarely has there been a more underwhelming budget for health. The Minister has shown limited ambition and limited commitment to change. It looks like Sláintecare has been put on ice for 2026. Why the standstill? In recent years, there have been some belated but encouraging signs of progress, such as the take-up of the consultant contact, the reduction in some out-of-pocket expenses and better access to community diagnostics, to name a few. However, since this new Government entered office, Sláintecare has been sidelined. I accept that a new action plan was published last May but that was two years overdue, and in those two years, the Department was unable to even come up with costings or provide a figure of implementation. The new plan lacks any substance. It is little more than a box-ticking exercise. Ultimately, the Social Democrats will always support genuine efforts to implement Sláintecare but I am afraid that those instances have been few and far between. That needs to change. Otherwise, people will continue to feel obliged to fork out almost €2,000 a year for private health insurance and that is not acceptable.

Ann Graves (Dublin Fingal East, Sinn Fein)
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In this State, we have a two-tier health system and it is clearly highlighted in the Bill. The lack of a universal healthcare system free at the point of delivery has created a private market for healthcare. Removing private healthcare from public hospitals is an important and necessary development. It will reduce the dependency on private healthcare but it demands that the Department step up to the challenge and increase the public capacity. It is unacceptable that access to healthcare depends on the ability to pay. Many households see health insurance as a necessity because they can no longer rely on a broken system propped up by broken promises. Waiting lists are too long. There are 300,000 people waiting on scans and more that 40,000 have been waiting over 18 months.

My office in Swords is inundated with constituents looking for assistance for the most basic medical needs. A woman contacted me looking for help. She is distraught. Her son is on a waiting list for occupational therapy. The waiting list for her son is 55 months. This is a disgrace. The blame for this waiting list lies with the Government. A man from Malahide in his late 80s has been in hospital for over a year. He needs to be at home with appropriate care. A hospital is totally inappropriate for his needs. Unfortunately, the respite centre wants to send him home with an inadequate care package. He was offered additional hours and subsequently told that this was a mistake. This man has worked his entire life, helped build this country and paid his taxes and the least he can expect is to be given care in his time of need. In a case involving another family, the son has a disability and is waiting for an operation. The wait for the operation has been so long and his health has deteriorated so badly that he has since had to give up employment. These are just a few examples of the struggles families have to deal with to access healthcare in one of wealthiest economies in the world.

Consecutive governments have implemented polices that have made the situation worse for people. Health policy has been driven by a system that views healthcare as a commodity that can be bought and sold in the free market. Government should be aiming to develop a public health care system that removes the need for any citizen to spend their hard-earned income on private insurance.

The facts are a damning indictment, in that 2.53 million people, which is almost half the population, are covered by private health insurance. They are paying out a massive €2.5 billion every year in premiums and now they are facing increased costs. The healthcare model being pursued by the Government is designed to facilitated a two-tier healthcare system, which allows those who can afford to pay to speedily access high-quality treatment and care, while those who cannot afford to pay continue to languish in queues waiting for scans, appointments, therapies and operations.

The good news is this does not have to be this way. Sinn Féin has a plan to tackle the waiting lists and deliver a national health service for Ireland. We would bring an urgency to fixing healthcare and deliver better services for everyone across the island. We would use the current fiscal surplus of €9 billion to catch up on lost decades of underinvestment. The public deserve better than what is currently on offer. We need a comprehensive multi-annual plan that addresses capacity, workforce planning and adequate funding to deliver a world-class healthcare system free at the point of delivery. We need a single-tier system and we need Sláintecare.

Michael Collins (Cork South-West, Independent Ireland Party)
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This Health Insurance (Amendment) Bill may sound technical but its impact is very real. From April onwards, the stamp duty levy on advanced health insurance plans will rise by €48, bringing it to €517 per adult. For families, this will mean an extra €128 a year on top of already soaring premiums, which now average nearly €1,900. These increases will hit households hard at a time when every euro counts. While the levy funds fairness in the system, we cannot ignore the pressure this places on ordinary people. Government must ensure transparency and affordability so fairness does not come at the cost of financial strain. I recently raised in the House the deeply unfair case of a constituent paying €1,470 a year for health insurance who was guaranteed 100% cancer care and was denied access to a life-saving cancer treatment drug when he needed it. Patients should never suffer because of cost-cutting by insurers. After intense media and public pressure, the insurance company agreed to cover the cost but it should never take a public outcry for a patient to get essential treatment. The bottom line is if people pay health insurance and the company tells them they are 100% covered – comprehensively covered is what we call it with car insurance – then when they get something like a serious cancer, they should not be told by the company that they are not covered and it forgot to tell them that. Health insurance companies are looking for extra money but they are not delivering the way they should be.

There are a lot of issues related to health that we need to talk about. I have been fighting for Deerpark Nursing Home for a long time. We have a massive crisis where people cannot get home help, cannot get into a community hospital and cannot get into a nursing home. Sometimes I run into a brick wall because there might not be a bed available or the hospital is full, as it was last week. It was the local community hospital. The local newspaper and I were running with the story but the hospital is full. They cannot put people up in the attic. They have to have a room for them. Deerpark Nursing Home has rooms and I would appreciate the Minister of State, Deputy O’Donnell, getting personally involved in this. He was talking to me recently and I appreciated that. I would just like to get answers. I think there are 12 to 14 rooms available there and they fully meet all the standards. There is an issue because someone went bankrupt or whatever nonsense went on, but it is there for the taking. Beds are desperately needed in west Cork and we cannot understand what the problem is.

There is the same situation in County Galway. Councillor Noel Thomas has told me about the issue in his constituency. Councillor Michael Leainde is a councillor down there for us as well. Some two years ago the people of Galway were promised Áras Mhic Dara nursing home in Carraroe would be fully staffed and all beds open by winter 2024. That promise is not being kept as nine rooms remain empty. This is the problem we have. This is happening in Bantry and in Galway. The respite services are gone and the day care facility has been abandoned. Meanwhile, 12 people are on a waiting list for care they urgently need. Families are being forced to travel long distances for respite and Irish-speaking residents are left without support. This is unacceptable. We need immediate action from the Minister of State, the HSE and the senior Minister to honour commitments and ensure the facility serves the community as intended. Councillor Thomas, after making representations, was told it is hoped to reopen the beds once staffing has been recruited at the start of the new year. The winter of 2024 is gone and we are into the winter of 2025 with no answers. We need the Minister of State to get cracking on this. There are people crying out for this to be done.

We have to have a very serious sit-down discussion about community hospitals and nursing homes too. The problem is the elderly population has risen throughout the country. I am only talking about my own community hospital in Skull, which is probably one of the best in Ireland. There was investment in it by a previous Government, which was top class and I am not going to take anything away from that. There is Beara community hospital, St. Joseph's unit in Bantry General Hospital and the facilities in Dunmanway, Clonakilty, Kinsale, Bandon and Skibbereen. When has an extra bed been put into any of those hospitals? The one in Skull has 21 beds, and I am pretty sure it had 21 beds 20 years ago. We have a rising elderly population and we still do not have an extra bed, so where do people go? A home help service could keep them at home but that has gone too. I do not know why because home help people tell me they are willing to do the hours. Home help supervisors are saying they cannot get the people so there is a con job going on there and nobody seems to want to stand up and say somebody is mocking someone. It is the elderly person on the ground who is suffering. We need to invest in our community hospitals. A lot of investment was given. The former Minister, James Reilly, was the man who gave it to Skull hospital. I was there. That investment was superbly spent and brought the hospital up to a standard that is second to none. I wish the management and staff the very best because they are delivering, along with the staff of all the other community hospitals. However, the bottom line is no extra beds are available.

That community probably has the highest elderly population in Ireland and we have not looked after that population. It is the same up in Donegal. No matter where, community hospitals are not resourced. There are a few like Deerpark Nursing Home and the one in Galway I mentioned that have been built and which we desperately need, but the situation is left to drag on and on.

Another issue is the endoscopy unit was open in Bantry General Hospital. It is a fantastic service and we are absolutely delighted. I praise the Department of Health. It took me years of shouting and roaring here in the Dáil but it worked. We need an MRI unit in Bantry General Hospital and now we have to focus there. That is where the money needs to go next. The stroke unit is being worked on but the MRI unit is of huge importance. Is there a budget available? We have to look at Bantry General Hospital serving parts of Kerry, the Beara Peninsula, the Mizen Peninsula, the Sheep's Head Peninsula and all the way out to Kinsale. I was out canvassing in Kinsale and people asked me what I was doing for Bantry General Hospital. If it is serving a community from Kinsale to Kerry, it is doing something right and it needs to get as many services as possible.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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I will start with a headline from the Irish Examiner that ran "HSE warns it cannot fill vacancies even with agencies as staff shortage crisis deepens". We are talking about health insurance and the rising cost of it. Why do we have such a shortage in the HSE? Why are private hospitals being built and providing a service efficiently, with efficient staffing? We see the 96-bed unit open in Limerick, which I welcomed. Then we see we had a strategic policy to look at options. Option A was another 96-bed unit, option B was expanding the emergency department and option C was a hospital on another site that could have a step-down facility. We came up with a consensus at meetings of all parties in the mid-west. We are united on it and are meeting the Minister tomorrow to say we want options A, B and C. We had a private hospital built in Limerick in 16 months, from the time the sod was turned until it was finished.

It was built on budget and on time. Our children's hospital has gone €1.2 billion over budget. Why is it that every project a Department takes on goes over budget even though Departments do not need to make a profit? They go over budget by 50%, 60% or 70%. Regardless of the sector, every business in this country, including those who are self-employed, that is accountable for its own funding, its employees, its profits and its taxes can deliver projects on budget and on time.

A company has come to me and to other Deputies in the House to say it will build the hospital for the mid-west. This company does not mind if it is in Limerick, Clare or Tipperary; it will build the hospital. It will work a contract out with the State like you would do for a mortgage for a house. It says that it will build the hospital that is needed for the mid-west on budget and deliver it within two years. It is needed for the protection of the people in the mid-west, that is, our elderly, our vulnerable and everyone else. This company can deliver that project in two years. If the Department says it does not have the money for it, the company has said it can be worked out over 35 years and that the State can buy the building back for €1 at that time. It is the same as a mortgage. If the Government cannot deliver the projects, let someone else do it. The Government can fund it with it and enter into a contract. The company will then deliver it on budget and on time. The Government can facilitate that. The hospital will then look after the vulnerable people of Ireland.

This is why I have come up with a model. Where a Department intends to build hospitals, schools and all the rest of it, there should be a brochure that opens up. The Department can say it wants a classroom to suit 50 people or an operating theatre with specific facilities. It would be standard and the Department would just have to open the brochure. It can be done for houses. There was a housing system before where you could open a brochure and say you wanted this house or that house. It allows you to buy a certain number of doors or a certain number of windows. It can be built affordably and on budget and you can look at the stock you need to deliver. I am asking the HSE and the Minister to look at a model for one-bed, two-bed, three-bed, four-bed and up to 100-bed hospitals or whatever they want to do. That is the model. You would go to a contractor and say you want 50 or 100 rooms and what you want in it. There would be standardised electrics, plumbing, fit-outs and everything else across the board. That cuts out the preliminaries for which all the architects and engineers charge millions before we start at all. It also stops any changes mid-way through the projects. You get your hospital delivered but that same hospital can be dropped into Limerick, Cork or Kildare. These companies are providing the lands and a solution to deliver these projects. We would then see our health insurance premiums coming down because the Government would be providing hospitals and care for people along with a strategic plan for the health of everyone in this country going forward.

Why do I talk like this? I have been in business all my life. I have been self-employed all my life. What did I do for my headspace in my downtime last week? I laid a few blocks. Why? I am a blocklayer by trade. I know what I am talking about. I am also a businessman.

Kieran O'Donnell (Limerick City, Fine Gael)
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How many blocks did you lay?

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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I have employees. If I was in any other county, including Donegal, I would get paid an awful lot more for doing what I was doing than I am paid for doing what I do here. The reason I am here is to protect people. It is not about money. It is about protection and putting in place procedures using the experience I have as a taxpayer and an employer who has had employees all his life. We are here to protect people and to give the Government our experience and the tools to stop Departments wasting money. It helps Government to deliver. I do not care if the Government gets all the praise. I will praise it myself if it takes up a business model. That is what I am here to do. I do not need to score points with anyone. The day I cannot make a contribution to this Dáil is the day I do not want to be here. To be quite honest, I do not want to be here if I cannot make a contribution. I want the Government to listen to people who are in business, who pay taxes and who make a profit. If I do not make a profit, the employees and subcontractors who work with me have no other work to go to. I am providing a service but they are also providing a most vital service, building for the future. I ask both Minister of States and all other Deputies and Ministers in this House to listen to people who have track record of being in business and who can deliver projects. Let me give the Government a simplified model. Let me cut the waste of money involved in going out to different Departments with different funding schemes. Let me give the Government that brochure to help it. It is about a standard procedure. It is called common sense. If I could bucket it and give it to the Government, I would. I need it to listen to common sense. What I want here is accountability. I want to give the Government value for its money.

I want to ensure we can provide a service like that the private hospitals in his country are providing. I was in a private hospital recently myself because I needed to be dealt with. I had to go to a private hospital. I have a machine on me at the moment to measure my heart rate. Do the Ministers of State think that, if I had to go through the emergency department and all of the rest of it, I would be here today? I presume my heart rate is reading fairly high at the moment.

Kieran O'Donnell (Limerick City, Fine Gael)
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It is high at the moment.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I should not say your time is up then.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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You should not because I had seven minutes as well. I will have to teach the Chair how to read the clock.

Kieran O'Donnell (Limerick City, Fine Gael)
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I can only imagine what the Deputy's heart rate was like when he was laying the blocks.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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Exactly but that is what I do. I am sorry. Seven and seven is 14. I think that leaves me about two minutes.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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You have just reached eight minutes so that thing is not working.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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I will conclude on this. I am offering the Government assistance. I am offering to simplify and to allow the Government to spend money with accountability to deliver services so that it can help the vulnerable people in this country.

Brian Stanley (Laois, Independent)
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I welcome the opportunity to contribute to this debate. The cost of private health insurance puts a huge burden on people. In particular, it puts a huge burden on pensioners, who feel they have no choice. People feel compelled to take up private health insurance because of the delays and inefficiencies in our public system. Some progress has been made in some areas. Some of the screening projects being run are very effective. However, we must do a lot better. It is another tax on people. That is the reality of it. I have dealt with pensioners who are on €280 a week who are paying €40 to €60 for private health insurance. We are seeing several hikes in the one year. There is not one increase but a number of them. Some of them are double-digit increases. We have a market model. While we are stuck with having to use private health insurance, the Government needs to address the charges put on public facilities by private companies such as VHI and Laya. There are flaws in this approach to private health insurance. It is based on profit rather than medical need. It is a two-tier system.

Every week, I see examples of people who urgently need medical care or surgery. I am sure it is the same for the Ministers of State. This surgery could be a hip replacement. The scandal of the two-tier system is that in spite of what the proclamation read out in 1916 said about treating everyone equally, these people are being told that, if they pay, they can be brought in next week but, if they cannot pay, they will have to sit there for two or three years. I have seen several examples of that. That is what we need to change.

There are those who profess that the private sector will sort everything. If somebody wants to operate a private hospital, that is all well and good. Good for them. It is okay if they want to do that but it needs to be separated out. I welcome the 80%-20% consulting model. That is a step in the right direction but we need to go the whole way on that. Mary Harney famously said that we could go with either the Boston model or the Berlin model. What she meant was that we would go with the American model. Previous speakers have said that we should go with the Thatcherite private model. That is the system in America. How has that worked out? You have to be a millionaire to get treatment. Are we seriously being told we should go down the route of the American model where you have to be a millionaire, or very close to it, before you can get your appendix taken out or something else done? That is not where we need to go. We need to look after people.

Let us look at the figures in this country. Some 2.53 million people have private health insurance.

A total of 1.57 million have medical card cover. This is based on figures from the start of the year, and they are probably still fairly accurate. However, we have 1.3 million who have neither - that is 1.3 million people without proper healthcare of any kind. Some of them may have a GP-only card, which I acknowledge is a help, but it is still a long way off. A small number of people have that card.

Let us look at this category of people for a moment. These are the same people who cannot get on a local authority housing waiting list. Many workers and their families cannot get on a local authority waiting list. They cannot get a mortgage - and if they do get a mortgage, they are crucified trying to pay it out of their wages. Most likely, they are paying for a car to travel to work. If they are in private rented accommodation, they are really at the mercy of a wild west system. Let us just think about these people for a minute. They are trapped in a very difficult place. On top of all of that, they do not have medical cover. I have met those people, as has the Minister of State. They ask me why they are being left out the whole time. They pay taxes. They get up every morning and drive their car to Dublin to work on a building site all day or they drive wherever elsewhere to work a ten-hour shift. They are doing the best they can and they do not even have basic health cover. That is what we need to change.

We are stuck with the current system. I accept that we have to do this every year and the risk equalisation fund is the only way it can be done. We are where we are. While we are here, we have to do this to spread out the burden. If we were to charge those who most need healthcare on the basis of their age and their health needs, they would not be able to do it. We would have people falling through the cracks. I recognise that the system has to be supported. That is recognising the real-world situation we are in now, but what I am saying is that we need to change the current model. The fact is that a lot of people do not have the option. Risk equalisation is based on having an annual adjustment. It is a logical approach, which spreads that burden.

I want to address value for money in the health system. We had the 100th anniversary of the Committee of Public Accounts today. As a former Cathaoirleach of the committee, I attended the celebration. There is no doubt that people in the health system are doing great work, but its finances are shrouded in fog. We put in a lot of money as a percentage of GDP. We are behind some other countries, but we have a high GDP, which is good. In terms of hard cash, we compare very well with other countries. We exceed the amount put in by most of them. I have no argument with that given where I come from on the left of the political spectrum. However, I question the value for money that we get and the gap between the money actually going over to Miesian Plaza - the headquarters of the Department of Health - and the actual services on the ground. It is a long and winding road. The one thing I would implore of the Ministers is that they would make sure that they can track where that is going. The Comptroller and Auditor General's office would have had difficulty at times trying to follow that route. In the five-year period I was there, I and the members of the Committee of Public Accounts had difficulty. We tried very hard at times and we made some progress, but it is a difficult route to follow. That route must be shortened. Money, budget and action need to be a straight line so that people can see exactly who is accountable along the way, that the route is the shortest possible one, and that there are not too many diversions. We must do that.

As I recall, the implementation programme for Sláintecare is a ten-year one. We do not have that much time left in it. I accept that Covid slowed it down. I also accept that that is the real world. I am not going to shout at the Government about that. That is something that we all had to deal with. We might have dealt with it differently if it came up now, but everybody did their best at the time and they did what they thought was right. We have to get Sláintecare up and running. We are an outlier in Europe. We do not have a national health system comparable to other north European countries. Per head of population we are counted as one of the richest countries. It is not a panacea for all. They have an NHS in the North, but that is not perfect. There are big long waiting lists. My niece works in it and I know all about it. It is a difficult system. If you put in the system and you do not put in the necessary checks, balances and procedures, you wind up with that result. We do need to move to a single-tier system to ensure the people I referred to at the outset do not feel compelled to pay €40 to €60 a week. We can work it out. The charges amount to €2,000 or €3,000 a year. If you are on a pension of €280 or €285 a week, and you have to pay €40 to €60 a week, that is the first thing that goes out of it. That is a huge pile of money, and a huge take out of the income of a pensioner. Even if they have an occupational pension of typically €80 to €120 a week, it is a huge pull on it every week. We must do better than that. We must try to move to Sláintecare.

I asked the Minister, Deputy Carroll MacNeill, before the budget if in the short term we could do something to help the 1.3 million citizens who do not have medical card cover. They are mainly workers and their families. It is unfair. The income threshold for the medical card has not changed for as long as I am here, and even before that. I am open to correction on this, but as I recall it is more than 20 years since the income threshold was increased. It is €186 for a single person. The lowest rate of social welfare for a single person is over €230. I know people automatically get a medical card if they are on social welfare, but they are not automatically entitled to it if they are working in a part-time job and that is their only income. That is an absolute scandal that we are ignoring that group of people. They are the people who cannot get a house. They cannot get a mortgage. They are paying taxes. They have to get to work. They have to make payments on cars and everything else, yet they and their children have no health cover.

I was challenged by a man while I was canvassing at this time last year for the general election. I know him and his wife, as she comes from the same area as me. He said to me that the people beside him have a medical card. He said he does not begrudge them it, but he does not have one. They had it by virtue of their status in this country. I do not like saying that. I do not want it to be taken off them either. The point I make is that the children in that family had been sick but they could not go to the doctor in the month of November. The Minister of State might recall how cold the weather was when she was canvassing last November. I remember the man saying that to me at the door one freezing cold night. It is not good enough that we do that. We must help those people. We must help the workers and their families in this country. We have had a lot of time to do it and we have made a lot of progress, but the one thing that has not moved, that is frozen in time, is the income thresholds for medical cards.

Paul Lawless (Mayo, Aontú)
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I welcome the opportunity to speak on this Bill. Health insurance reports show that the average premium rates rose by over 12% in 2024. Some plans even jumped by 25%, a quarter, for some individuals. The average adult premium in the country now is €1,800 - an incredible figure. The Health Insurance Authority is preparing to raise the levies again further by another 10% on insurance premiums. This is an enormous cost for individuals who are above the very low threshold for a medical card and find themselves grappling with this enormous fee every single year.

I would like to offer some positive suggestions. The Minister and the Government should take more proactive steps. The Government has a policy when it comes to smoking that it is going to tax cigarettes to the point where people will give up. I believe we are at that limit at the moment. What about the inverse? What about proactive policies, for example, tax credits for gym membership?

It would be good for one's health. It would be good for society, good for the Exchequer and good for the health system if the Government took a more proactive view of gym membership and supported gym membership across the country. Gyms are struggling with the cost of doing business, insurance costs and all of the other costs associated with it. I believe the Minister of State could introduce a tax relief for gym membership and also, potentially, tax deductions for gym equipment at home. These are proactive measures the Minister of State could take that would be a net benefit for society but also from the Exchequer perspective.

I want to raise as well the issues in relation to the National Treatment Purchase Fund, NTPF. The funding for the NTPF in 2017 was €17 million and this year it is expected to be €240 million. It is an incredible rise. While I believe the motives behind the NTPF are good and indeed many of my constituents have availed of it, there are significant issues in relation to the potential for a conflict of interest because of the issue of insourcing and, indeed, outsourcing. Insourcing is where the HSE and the hospital transfer patients from the public list onto the private list within the hospital, and sometimes with the same consultant. A question, therefore, arises. Are we incentivising a lack of productivity in relation to this? Also, who is managing this? Who is ensuring that we have good governance in relation to it? I was struck at the public accounts committee, PAC, recently when the hospital official was asked who is managing this and she said that the hospital operates on a basis of trust. It is extraordinary. There is €240 million of taxpayers' money gone into the NTPF and we operate on the basis of trust. I believe there is an enormous amount of work the Government must do to ensure that the taxpayer is getting value for money, particularly when it comes to insourcing and outsourcing. We have to ensure that we are incentivising productivity in the health system. There are huge questions in relation to this particular issue of transferring patients from the public list onto the private list and in some cases, the consultants themselves are over this particular issue. I ask the Minister of State to carry out an analysis of the productivity per hour of these arrangements on both the public side and the private side. It is important the Minister of State does that to ensure there is value for money here.

Thomas Gould (Cork North-Central, Sinn Fein)
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First, I want to make a comment personally in relation to everyone who works in the health service, the unbelievable staff, whether it is doctors and nurses, healthcare workers, or cleaners, canteen staff and maintenance staff. I myself was in a hospital yesterday for another appointment. I am regularly there because I have had a number of health issues over the years. It is inspiring to look at the people at the coalface providing the care. We can never underestimate and we should always mention the unbelievable work that they are doing.

When it comes to private healthcare, for far too many families in this State health insurance is no longer an option. It is a must because of the long waiting lists, the disastrous care that can happen if you have to wait years for treatment and the growing concerns that the public have that there is a lack of trust because of these waiting lists.

Many families want to be treated in the public health sector because that is the type of systems that should be delivered, but for many of them there is a lack of trust. It is not even a lack of trust; it is a fact that they will not be seen in time. The burden of having to pay private health insurance for many families is crippling because they know what will happen if they lose it. I know people who had to take a break from paying their health insurance because they could not afford it and to get back in a couple of years later, no illnesses in a five-year period can be put in. How is the Minister of State allowing that? Why is the Government not tackling the insurance company? If a person cannot pay and has to take a break for three, six or 12 months, they should be able. I have called to people who paid it for years and then they are starting all over again. That is not fair.

The Tánaiste, the Minister for Finance now as well, signed the contract for the children's hospital. I have a daughter aged 16. She will never see the children's hospital. It is not only my daughter, but all the other people out there who have children who have been waiting for this hospital for years. It is a scandal. Children who have suffered all their lives with illnesses will be aged out because this hospital that should have been delivered years ago, has not been.

This month, almost 800 people waited on trolleys in Cork's CUH and the Mercy hospital. Thirty thousand people are on waiting lists in both those hospitals. Three thousand people are waiting more than a year. Where is the elective hospital that was promised for Cork? If that elective hospital was there, those 3,000 people would be in and out of it within the year, and those 30,000 people could be treated. This Government is fooling no one when it comes to health. There is a cost-of-living crisis and at the same time, if you do not have private health insurance, your family will not get the treatment on time.

Last week, I was in this Chamber and a woman contacted me from a hospital in Cork because her elderly mother, who had issues with Covid and with her health overall, was in a room in an accident and emergency department and she needed to be in an isolation ward. The family was desperate. They were crying out for help. The nurses and doctors were doing everything they could but there was not the capacity there.

I will give the Minister of State a couple of facts. A study by the Geary Institute for Public Policy this year found Ireland's two-tier health system means those who cannot pay are pushed further down the list. This echoes the findings of the OECD in 2022 which ranked Ireland among the worst countries to access healthcare and for waiting times and found that we were the only western European state that does not offer universal coverage of primary care. We have no primary care centre in Glanmire. We have no primary care centre in Mayfield. We have no primary care centre in Blarney. All these need to be delivered.

We support this Bill today but this Government should be providing Sláintecare so that everyone has access to free health care. That is what the Proclamation said, that all people, all children of the nation, would be treated equally.

Mattie McGrath (Tipperary South, Independent)
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I am delighted to speak on this Bill.

Indeed, I was in the Cathaoirleach Gníomhach's chair when the Minister of State was speaking. I always listen to the Minister of State's speeches and learn from them and take them for she is succinct and to the point and not afraid to call a spade a spade.

There are many aspects to this Bill but the thrust of it, I suppose, is that we are enabling and putting funds out of stamp duty and other areas towards the insurance companies for them to mitigate the charges to the people paying for the insurance premiums. They might be doing that in some small way but they are milking - high and dry - the insurance customers. We have regulators here for everything and anything. We have the CRU and God knows what else. Why can someone not stop the insurance companies from the gouging? Then it continues in the private hospitals.

I have no hang-ups for private hospitals. I have been sick recently and I have been in a public hospital mainly, in South Tipperary General, and indeed, in St. Vincent's public. I was there again last week. I had occasion to go to Whitfield last week and Deputy Cullinane was in the Chair when I was speaking. The Deputy spoke earlier giving out about private. Whitfield was packed. What kind of problems would we have if we did not have the private hospitals? We have to have a bit of both. We have to have no ideological hang-ups, as Sinn Féin has, that you cannot have private anything.

They are reading from Stalin's little red book, the communist book. They are against everything and want nothing private. The Whitfield was so efficient that morning, last Monday morning week, and so busy. I know I paid a very princely sum of €320 for a consultation and €80 for an X-ray, on top of my insurance. One wonders why people have insurance, but I have no ideological hang-up one way or another.

In his speech the Leas-Cheann Comhairle mentioned that people in Kilkenny are so privileged to have a number of district hospitals. He referred to the one in Thomastown, which is a lovely district hospital. He is lucky. I have no doubt that he and the late Bobby Aylward and others fought to retain those. We also had them in Tipperary. We still have an excellent hospital in St. Theresa's in Clogheen. I could not say enough about it. Fuair my own máthair bás ansin 15 bliana ó shin. My own mother died there. My cousins were treated there with palliative care. HIQA was bedevilling the hospital but we got extra money by fighting. I must mention the late Councillor Con Donovan, a Fianna Fáil councillor who taught me a lot about politics. He fought so hard for that hospital. He was on the health committee with the late Jackie Healy-Rae and told many a funny story about the travails around the south eastern health board and the south western health board. It is an excellent hospital. Sr. Áine was there for years and we had Ann Hally as matron, and now we have Anne Walsh as matron and her team. I could not say enough about the role of matron. They do not call them matrons anymore. They have a fancy title now because the word "matron" is taboo. I would say to bring back the matrons and the hospitals would be clean. I say this always. With this lady, Anne Walsh, and her team, one could not ask for better than the care that elderly people, and the not-so-elderly, get there. There are also two palliative care rooms now, which have been supported greatly by the community, with lots of fundraising. By God, do they give it back in spades with the care and dignity their patients receive.

We also had St. Vincent's in Tipperary town, which closed a long time ago under a Fianna Fáil Government. We had Our Lady's in Cashel, which went as a hospital. Then there is St. Brigid's. I have to go back to St. Brigid's Hospital in Carrick-on-Suir. It was a wonderful hospital. I could be wrong on the number of beds - I think there were 18 of them. It had three palliative care rooms. It was funded and supported by the people. That funding has not been replaced yet either. During Covid, the former Minister for Health, Stephen Donnelly, decided to second the hospital for Covid care. When they no longer wanted it for Covid care, they said it was not fit for patients. I can never get an answer from the Minister of State, Deputy Butler, or from anyone else, as to how it was fit to treat patients during Covid but it was not fit for patients afterwards. It was down to spacing and separation, according to HIQA. The people of Carrick-on-Suir and east Waterford, and indeed south Kilkenny, used that hospital for palliative care. I know that there are extra palliative care beds in Waterford city, but that is no good for people from all over that area who have to go to Clogheen or to Cluain Árann in Tipperary town where there are two hospital beds as well. Is mór an trua é sin. It is an awful travesty that our hospital was closed. Consider the funding the families gave and the fundraising with all kinds of walks, hunts and bucket collections so that people who were dying could have some dignity, with palliative care and the wonderful nurses there. The head nurse there was Ms Lonergan, since retired. Her husband, Seán Lonergan, was a senior officer in housing. They were two great public officials. They collected money in buckets outside many a funeral. When I went to funerals I saw them raising money for St. Brigid's hospice care in Carrick-on-Suir. That funding has not been appropriated back. We had more meetings than anything else.

The Minister at the time promised there would be a state-of-the-art diabetic centre clinic in the big white elephant there beside it, which is a monstrosity. St. Brigid's Hospital in Carrick-on-Suir will be there for centuries to come. It is a solid building. They talk about flooding but that hospital was never flooded in its life. Then they built a cardboard box beside it. That is all it is. You could put your fist through it if you had to. Hey presto, they built it two or three storeys high but it has no lift. If you were building a house for someone in a wheelchair you would have to put in a ramp to make sure it got planning, but they built this with no lift, so we had to put a lift onto it. The Minister of State, Deputy Butler, promised us there would be a state-of-the-art diabetic centre, but that is no longer the case. The Minister for Health has stated in replies to parliamentary questions that it is no longer the case. There are no diabetic services now. There is nothing there. We have oceans of officials there and I do not know what else goes on inside in that cardboard box - that is what it is. A little better but not much better. The hospital is empty. Folamh. Dúnta. Tá an doras locked. It is sad. It saddens me. I have had my argument with the Minister of State over it and I do not want to continue on about it but it is a travesty and an injustice. That hospital should be there for the people of Carrick-on-Suir and the communities of south Kilkenny, east Waterford and parts of Tipperary. Is mór an trua an rud sin.

I will move on to the home helps. We have people in hospitals and there are blockages and they cannot go home because they cannot get home helps. We have noticed of late, in the past 18 months, that people have no bother getting approved for home help care but there is no one to do it. They throw them out of the hospital because it looks like they have help. I want to praise the home helps who are there from the highest heaven. They are angels of mercy in the work they do, flying around in their cars on bad roads and for little payment. They do great work and have such empathy for and engagement with their patients. That has all been cut out now, however. The HSE does not even want them to boil the kettle. This is all HSE policy now. They are not carers any more; they just go in and out. I do not know what they are supposed to do but they do it, in spite of ye. The home help hours are approved but then there is no one to do them and people have to go back into hospitals and clog up the accident and emergency departments.

I firmly believe that something must happen with accident and emergency departments. I was in an emergency department one evening lately at a special memorial service for people who have lost babies. I met this gentleman at the door. He was out of his head and abusing everyone and shouting at everyone. There should be a separate place for people who have taken drink or drugs - though not those who are suffering a psychotic attack - and need to attend an emergency department. At the moment they are inside in the emergency departments with a security guard trying to mind them and they upset everyone up and down the corridors. These people should not be brought into accident and emergency departments. They should be brought someplace else and detoxed or hosed down. I will be accused now of being a Methodist. They should not be in accident and emergency departments. They are causing untold grief to other patients. I sat one night in St. Vincent's public hospital accident and emergency department. My God, it was horrendous for the nurses, the other staff and the elderly patients who were there. They were afraid for their lives. In that case, it was a female patient doing it. Patients who are in psychosis are a different matter but those who are there for drug- or drink-related reasons should not be in there. There should be a special place built for them where they can sleep it off with some limited supervision and be dealt with in some other way. They are making life hell for the nurses, doctors, paramedics and security staff. I do not know how many security staff are needed now in St. Joseph's hospital in Clonmel. When my babies were born there20 nó 30 bliain ó shin there was no security and everyone was grand. Now some people want to go in there and misbehave and mistreat the receptionists, the security, the other staff and anyone else, even the poor priest administering the last rites. His name will come to me. Something has to be done to tackle that because it is going on in every hospital, especially at the weekends. It was a Friday night when I was there. It should not be happening. I will hand over to my colleague.

Danny Healy-Rae (Kerry, Independent)
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I am glad to get the opportunity to talk on health insurance and few other things because we have a lot of issues. Everyone who can possibly afford it should have health insurance. I welcome any moves by the Department of Health and the Government to put money into private health insurance to help bring down the premiums or the policies, if that is what will follow. I worry whether the insurance companies will take advantage and increase the premiums again because that seems to be what happens following interventions by the Government, in that those kinds of people take advantage.

There is a lot of concern among people who have private health insurance when they need attention. I know a man who is suffering with his back, who will not be able to sleep and who will be up all night. He will not be seen until the end of February even though he has private health insurance. He has to go through Christmas in that kind of pain but it is the case with several others. A lot of the time it does not seem to matter that you have private health insurance and it does not seem to benefit the sick person in the way it should.

We are short of regular staff in many areas, including in our hospitals, home helps and in all health services. I know a few nurses who have retired. There is a new community hospital due to open in Killarney and they have said they would be available to work a number of hours during the week. Do you know what they got back? It was a letter threatening them that their pensions could be stopped if they did not answer this question about pension abatement. A number of nurses gave their lives to nursing in Kerry - very capable men and women. They are terrified now because they mentioned the fact that they would work a few hours. The end of the letter they got back suggested that their pensions might be cut off completely. I want that to be dealt with because it has happened to a number of people in and around Killarney and Tralee who would like to go back to work. I am asking for that to be dealt with.

I mention the new community hospital-nursing home in Killarney. The building is finished but there is no date for the transfer. I do not know if it can happen in the depths of winter but it needs to happen. Are the staff in place? Are they organised? When will it be fully open? A lot of people, including elected representatives, sick people and elderly people, are asking about this. So many other things depend on that. We were promised a minor injuries clinic, which is to be opened in St. Columbanus, in the nursing home and long-term bed part of the community hospital in Killarney. A primary care clinic is to be opened in St. Finan's. Is that going to happen? Some respite beds were to be opened. It is not happening at all in Kerry to the extent that it should. People are entitled to four weeks' respite. I raised it in September. People tried to get a few days but some of them did not get them. I know one lady who has not left her mother's side for the past five years and she wanted to go away for a week. She could not get anyone to mind her mother and she could not get respite in Kenmare, Killarney or anywhere. That is the other thing. We have a lot of beds in the likes of Kenmare and Dingle community hospitals that are not open. The beds are there but we do not have the staff, or that is what we are being told. We have been told that now for ten or 12 years. We need to sort that out. It is important.

The other thing that happens is that elderly people who are sick go into UHK. When they are better, because they are well looked after there, they are sent to Kenmare, Killarney community hospital, which I mentioned, Listowel or elsewhere to recuperate for a week or two. Invariably the families say their father, mother or aunt needs another week or two there but it is not available. They are under pressure. It is the same all over our network in Kerry. When people leave UHK, they are promised they will get a home care package. Even after the two or three weeks in the community hospital, there is no home care package. It does not arrive. The people go home, and even though they have been approved for so many hours of home help, it is not provided because the staff or the home helps are not there to come out at the times they are supposed to. If an elderly person is living with them, they are responsible for minding their companion, their partner or their husband but that is not right even though it does the person good to walk around, to get out of bed, to go to the toilet or to go to the kitchen for a cup of tea or something. We could save the nation a fortune if people could be looked after at home with proper home help, with two or three visits each day seven days a week and on bank holidays. If you are elderly and sick, you do not just get better at weekends or on bank holidays. You will not be well enough to go out and have a good time, or anything like that. People need the help but, invariably, it is hard to get it. More often than not they do not have the staff to go out on bank holidays or Sundays. We need to deal with that issue. I am not fighting with the Minister of State. I am only asking on behalf of the people who need this.

I believe we have the best palliative care unit in the country. It is a template for how people should be looked after in their final weeks and days. It is a massive unit and I compliment all the nurses and staff who work there. Their heart goes into the people going in there to finish up. It is tough. I have been there a number of times. Invariably, the patients will thank the staff for doing what they do. We are proud of that unit. When the Minister of State is in Kerry again, she must look at it because it is a template for the rest of the country.

The HSE wants to sell the lands and the buildings at St. Finan's. It does not seem to want to make any use of it. I have never felt that it should sell it because going back in time, Kerry County Council transferred those lands and buildings to the HSE when it took over the health service. There is valuable land there for housing but the HSE wants to sell the whole lot together. The Land Development Agency says it only wants the land. The Minister of State should not to let that happen and not let the Land Development Agency get it like that. We have a lot of young fellas and young girls who want to build their own homes. When you are above €36,000 or €37,000, you will not even get on the housing list. There are people above that, middle income earners, and those sites should be made at least affordable for people in that category, so they could build their own houses. It is impossible to get planning permission in or around Killarney. I ask that it be organised in some way. Get the local authority involved. These sites should be made available to people who want to build their own houses. There are a lot of people waiting on the social housing list. There are lot of houses being built there but the people who have been totally left behind are the working man and woman who want to build their own house. It is failing completely in Kerry. It is not happening there and I ask the Minister of State to deal with that too.

Martin Daly (Roscommon-Galway, Fianna Fail)
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I want to reflect on the Bill, which I fully support it. It is vital that we maintain community rating through a risk equalisation scheme and the stamp duty paid. I also want to ask and reflect on why 46% of people feel they must insure in this country. As a practising GP who has been involved in medical politics for many years, it is my view that one third of people cannot afford insurance and are covered fully by the public system. One third of people may always insure, no matter what public system we have in place, and I think that experience is borne out in other countries. One third of people feel that if they had a choice and the capacity was there in the public health service, they would not insure and they are certainly hard pressed to insure themselves.

They do so because they do not have confidence in the public health system to deliver healthcare for them when and where they need it. That is what we need to reflect on.

We also need to reflect on Sláintecare. I am a publicly funded doctor. I have worked mainly in public practice with the medical card system. I believe in a public health service but I believe we need to reflect on Sláintecare. The capacity is not there. It is difficult to see how we will create a capacity for the 46% of the population who feel they must insure themselves. Many sons and daughters fund private health insurance for their elderly parents because their parents cannot afford it and want access.

I am also concerned about private health insurance companies. There are in or around 336 plans and, to me, that represents a lack of transparency. I have had multiple patients come in to me to find out at critical times of illness that they do not have insurance cover for particular procedures in private hospitals and it was not that clear to them when their policies were being sold. I have sent them to the Health Insurance Authority and advised them to seek help there. However, that there are 336 plans means to me that people are being confused by what they are being offered and it does not serve the consumer well.

On the public side, productivity remains an issue, and one of the issues around productivity is that we can keep throwing money at an archaic structural organisation like the HSE but unless we achieve digitalisation and really improve productivity in our hospitals and our clinics, we will not get value for money. In fairness to the Minister, Deputy Carroll MacNeill, and as the Minister of State has said, there has been a significant increase in public funding, but without the commensurate increase in productivity.

I want to reflect briefly, because I am running out of time, and I do appreciate this time, that the major health insurance companies are now investing fortunes in advertising and in these big centres in urban areas offering all sorts of services. That is fine, but there is no risk equalisation for the rural person who is living in a county like Roscommon or east Galway, where there is no access to private beds. Are they subsidising access for people who are living in urban areas to these super-duper 365-day centres run by various health insurers?

Finally, people say private health insurers are so efficient. The public health service provides the bulk of healthcare in this country. Let us get that straight. If you have a stroke in this country in the morning, there is no private facility that will admit you to hospital, and the same applies for hospice care. People need to remember that. They need to remember that our public hospital service underpins everything that happens in this State and it is exceedingly good value for money for what we get.

Mary Butler (Waterford, Fianna Fail)
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I thank Deputy Daly. I hope he will stay because otherwise I will be speaking to an empty Chamber and I will-----

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I am always here to listen.

Mary Butler (Waterford, Fianna Fail)
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I know you are. I was just saying that.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Listen and learn.

Mary Butler (Waterford, Fianna Fail)
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We also have the Minister, Jim O'Callaghan, coming in, so there is someone in the Chamber to hear me.

It was great to finish on words of wisdom and lived experience from Deputy Daly. He is always there to give us all advice in relation to healthcare, and it is great to hear somebody speaking to the Bill.

I have been six years in the Department of Health. This is possibly my fifth or sixth time speaking on this Bill. I look forward to a stage when we will not have to speak on it, that we will get the legislation that means we will not have to come in every year and speak to it. However, it is important legislation, as we know. It is a technical Bill with eight sections focused on the specific area of health insurance.

A couple of points are worth mentioning. We know for a fact that a large proportion of people in Ireland have private health insurance, but it is important to put on the record of the House that 1.57 million people in Ireland have a medical card and over 700,000 people have a doctor-only card. I was struck by the point that some of the Deputies made, namely, that there was a cohort of people who could not afford private health insurance and who did not qualify for the medical card, but a lot of people qualify for doctor-only cards and have not applied for them. That is really important to say.

I also want to say, as somebody who has been in the Department of Health for six years now and having completed six budgets, that it is important to note what has been achieved to reduce the cost of healthcare for families over recent years, for example, free contraception up to the age of 35 and no more inpatient bed charges in our hospitals. You used to be charged up to ten days a year, and people found that quite hard. There is also the reduction in the drugs payment scheme for families, which is capped at €80 a month. All that has to be factored in as well. It is important to put such things on the record of the Dáil.

I thank all those who work in our health services all over the country, whether they are public, private or voluntary. They do a huge amount of work. I fervently believe that every person who goes to work in healthcare every day goes to do the best job they possibly can. However, I agree with our last speaker about the challenges we have in relation to productivity and, in some instances, culture. Those are areas where we have to see change.

As regards the Bill, I find every year that people do not always understand what we are trying to achieve. I refer to the risk equalisation scheme. To explain it in simple language, a community-rated market means that everyone pays the same price for the same policy regardless of age or health. That is really important. However, it costs more to insure older and sicker people, and without the support of the risk equalisation scheme, insurers with more high-risk customers would face higher costs and premiums could rise. This is why we have the risk equalisation scheme. It helps to resolve this.

I always see the glass as half full. I am very proud of the fact that we have one of the highest life expectancies in Europe. I am also very proud of the work that has been done over previous years on home care, day care and meals on wheels, that triangle of support that keeps people at home for as long as possible. The number of people who were under fair deal in a nursing home in 2019 is almost equal to the number of people in a nursing home in 2025 because people are living longer at home with the correct wraparound supports. I am not saying everything is perfect - far from it - but we have done a huge amount of work to support older people to remain in their communities. You only have to look at the number of home care hours that will be delivered this year. Yes, there are challenges in rural areas and at the weekend, but the fact that we have an ageing population who are living so much longer is something that should be cherished and that we should all acknowledge. That is because a lot of really good people are delivering really good services every day of the week.

I will leave it there. I believe we will have the Bill for Committee, Report and Final Stages tomorrow evening.