Leo Varadkar (Dublin West, Fine Gael) | Oireachtas source

The initial measures in the health insurance area were designed more to make the current system sustainable rather than to create a new one. During the financial crisis huge numbers of younger people in particular pulled out of health insurance, thereby making the existing system unsustainable. For a community rated health insurance system to work we need young healthy people paying in so that we do not have to levy older, sicker people with higher premiums, which we do not do. For this reason a number of measures were introduced, including, as mentioned by the Senator, lifetime community rating, which imposes a levy on people over 35 years who have not taken out health insurance to date, although it remains the case that private health insurance is voluntary. Whether one considers people over 35 years to be young or not is a matter of debate.

At the other end, we introduced discounts for young people. For example, the student rate has been replaced with a young rate for people aged up to 25 years, whether students or not. This has resulted in cheaper health insurance for younger people. The Pfizer index figures published today indicate that 46% of people in this country have health insurance. This is the first time in a long time that that percentage has increased. It would be much easier to get everybody into health insurance if that percentage increased to approximately 60% or 70% before the big leap to 100% was made. This would require a combination of factors, including subsidies to make it more affordable and penalties for those who do not take out health insurance before it becomes compulsory.

I would like to touch on two other points. Senator Bradford mentioned the different models. One thing I am absolutely sure of is that there is no one model that can be imposed on Ireland. Whatever we do in Ireland has to be bespoke for Ireland. It is not possible to adopt the Israeli, Dutch or Australian models and shove them into Ireland because we are starting from a particular place. We are starting from a place where people have contracts that cannot be changed. There are 100,000 people working in the health service who have contracts that cannot be changed. They cannot be made private sector employees. That would not work. I do not think it would be viable. We also have a very strange hospital system in that we have State-owned statutory hospitals, owned and controlled by the HSE, voluntary hospitals, such as the Mater and St. Vincent's, which are largely funded by the HSE but have their own autonomy, ownership structures and history and the private hospitals, which have no particular involvement with the State. Bringing all of those together into one system would be tricky. It is not something that other countries ever had to do.

On the question of funding, I think we have gotten really hung up in Ireland on the question of how money is collected, be that through tax, insurance or out of pocket or a combination of all three. To get the health service right requires one to answer three questions about funding. The first is how should it be collected; the second is how should it be spent, while the third is would it be enough. If it would not be enough, any system would be bad. There would no be point in putting in place a new system that would be unfunded and which would just result in waiting lists for everyone. If we do not spend money correctly, it does not matter how much we have because if it is not spent correctly, it will not deliver what we want. How it should be collected is the least important of the three questions. The aim of the work I want to have done is to find out what would be the cost of meeting the unmet demand, through whatever system was in place. The initial ESRI statistics suggest something like €650 million a year will be needed to meet unmet demand. I think the real figure must be much higher than this. There is then the issue of how the money should be spend. I am very committed to activity-based funding, whereby the money follows the patient, where hospitals are paid for the work they do such as the number of gerontology appointments and the number of gall bladders taken out, rather than receiving a block budget. I often hear Senator John Crown talking in favour of a multi-payer universal health insurance system on the basis that it would this bring about, but actually that is not true. Any system can provide for activity-based funding; it does not have to be a multi-payer or a single payer UHI or a tax funded system; it comes down to the way one spends the money. It is a case of needing to get these two things right and they are actually much more important than how the money is collected, whether it be through social insurance, health insurance, tax or out-of-pocket expenses. That is the position if that reply makes any sense.