Tuesday, 23 June 2015
Universal Health Insurance
I welcome the Minister for Health, Deputy Varadkar, to the House and thank him for attending to respond to the matter I have raised. It is a question rather than a motion or statement because my inquiry is simply to seek from the Minister an update on his current plans for either the roll-out of the universal health insurance scheme, as initially conceived, or an alternative to it. We must all be mature enough to accept that it was a big ask and a big expectation not just within the term of the Government but in its second term or some alternative formation of it to roll out such a proposed scheme.
When the Minister took over the health portfolio last year he appeared to bring some new thinking to the table in terms of what the previous Minister, Deputy Reilly, had proposed. The latter proposed a scheme of universal health insurance with good intentions but perhaps the costing was not fully examined. My starting point is that at this stage we must start with a blank page in order to draw up a strategy for future health care delivery. We have examined many models, schemes and proposals which all sounded very plausible initially. We have looked at Dutch, Swedish, Australian and Canadian models, as well as a mixture of models, but we do not appear to have fixed on a particular plan to implement. I am reminded of the Chinese Premier, whose name, of course, I cannot pronounce. In the 1990s when he was trying to reform China, he made the famous statement that, as far as he was concerned, it did not matter whether the cat was black or white as long as it caught the mouse. That is something on which to reflect. Whether it be a private, public or combined scheme, what we need is a scheme which will deliver a top quality health care service to every citizen.
The concept of a universal health scheme sounded very attractive until suddenly it dawned on people that there would be a very hefty insurance fee to be paid by most taxpayers. It could never be a free scheme as somebody would have to pay for it. The Minister might update me on his current thinking on this point. I hope it is fluid, changing and open-minded because we are far from coming up with the perfect solution and a lot more work has to be put into it. As the Minister said when discussing the medical card issue, we have an almost universal education system which is not perfect, but it is reasonably good by international standards and every citizen has access to the prospect of receiving a good education. If we were to aspire to something similar in the health spectrum, it would need a lot of fresh thinking.
The Government is committed to a major reform programme for the health service, the aim of which is to deliver a single tier health service where access is based on need, not ability to pay. This is the most fundamental reform of the health service since the foundation of the State and it is imperative that we get it right. The White Paper on universal health insurance was published on 2 April 2014 and provides detailed information on the model of universal health care for Ireland. Under the White Paper model, everyone will be insured for a standard package of health services and have his or her choice of health insurer from a mix of private health insurers and a publicly owned health insurer.
A major costing exercise, involving my Department, the ESRI and others, is ongoing. The purpose of the exercise is to examine the cost implications of a change to a multi-payer, universal health insurance model as proposed in the White Paper. Draft results from the initial costing exercise were presented to me at the end of May and are now informing deliberations on the next steps, including the necessity for further research and cost modelling. Ultimately, this is a major project, with a number of phases. The next phases in the costing exercise are likely to include deeper analysis of the key issue of unmet need and a more detailed comparative analysis of the relative costs and benefits of alternative funding models using bottom-up costing techniques. The draft results from the initial phase, as well as the plans for the next phase of research, will now inform discussions with the Taoiseach and the Cabinet sub-committee on health on the best long-term approach to achieving universal health care and on the development of a roadmap for health care reform.
The Senator also asked about timeframes for the introduction of universal health care. When I became Minister for Health, I reviewed progress to date and concluded that it would not be possible to introduce a full UHI system by 2019, as envisaged in the White Paper. However, I remain steadfastly committed to implementing important reforms as set out in the programme for Government and I am pushing ahead with key building blocks for universal health care as quickly as possible, including the phased extension of GP care without fees; implementation of key financial reforms, including activity-based funding; the establishment of hospital groups on a statutory footing; and measures to make health insurance more affordable. Just this month we have seen significant progress with the extension of free GP care to children under six years of age. Starting on 1 July, over 400,000 children under six years will benefit from a new enhanced service under the new under-six GP contract. This will involve health checks focused on well being and the prevention of disease. The contract also covers an agreed cycle of care for children diagnosed with asthma.
In parallel, during August GP care without fees will be extended to all people aged 70 years and over. This service will benefit about 36,000 people and be provided under the existing GMS contract. Talks with GPs on the new contract to replace the existing core contract will begin shortly. The provision of universal GP access through greater public investment in primary care services is a critical reform in resolving inequities and rebalancing our services towards earlier prevention. The introduction of universal GP access for the youngest and oldest members of our community, those who need to see their GP most often, is an important step in the phased implementation of these reforms.
I thank the Minister for his reply. I note he has not yet outlined any timetable. However, I know a lot of work remains to be undertaken.
A concept of health insurance is obviously at the core of the Minister's thinking. The Minister outlined in his reply that he has taken steps to make health insurance more affordable. That is debatable. One such step was the introduction of the new levy, as a result of which younger people have been almost forced to take out health insurance. How does this tie in with the concept of the universal health insurance philosophy? Are we now trying to bring about universal health insurance by forcing everybody, by way of financial penalty or levy, to take out private health insurance with the current set of providers? How does this tie in with the Minister's longer term philosophy of a more generic national scheme? I presume it is the Minister's expectation that, with the new levy system, the percentage being covered by current private health insurance providers will increase substantially over the next number of years. Is the Minister using this as a partial solution to provide overall universal health insurance?
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.