Dáil Éireann debate -
Tuesday, 21 Nov 2023

I move: "That the Bill be now read a Second Time."

I am pleased to have this opportunity to address the House, on behalf of the Minister, Deputy Stephen Donnelly, on the Second Stage of the Health Insurance (Amendment) Bill 2023. This is an annual technical Bill comprising seven sections, all of which are focused on the specific area of health insurance. I will start with an overview of the market and the risk equalisation scheme.

Currently, 46.8% of the population in Ireland hold private health insurance. This amounts to 2.48 million people and represents a total annual premium income of approximately €3.18 billion. Health insurance in Ireland is provided according to four principles: open enrolment, lifetime cover, minimum benefit and community rating. Unlike a risk-rated market, in a community-rated private health insurance market, everyone pays the same price for a particular health insurance policy. Insurers cannot take into account personal circumstances like health status or age, in which case older and sicker people would pay more for health insurance than they currently do.

The risk equalisation scheme is the mechanism designed to support the objective of a community-rated health insurance market. It has operated since 1 January 2013 and is provided for under the Health Insurance Acts. Under the risk equalisation scheme, funds are redistributed in the form of credits to compensate insurers for the additional cost of insuring older and sicker members. The credits are funded by stamp duty payable by health insurance providers for each health insurance policy issued. The stamp duty levies are collected by the Revenue Commissioners and transferred to the risk equalisation fund, which is administered by the Health Insurance Authority. The risk equalisation scheme is designed to be Exchequer-neutral, that is, the credits are funded entirely by the stamp duties raised annually.

The risk equalisation credits and stamp duty are updated on an annual basis to ensure they align with the estimates of the insured population and the type, number and cost of claims that will be made on the health insurance plans. Amendments to the health insurance legislation are required each year to update the level of risk equalisation credits and stamp duty levies necessary to fund the credits. This is the main purpose of the Bill.

The Health Insurance Authority provided the Minister with an annual report which analysed market data for a 12-month period from 1 July 2022 to 30 June 2023. This report recommended the risk equalisation credit rates and the stamp duty levies required to fund them to apply from 1 April 2024. The Minister approved the risk equalisation credits to apply in 2024 and the Minister for Finance has approved the corresponding stamp duty levies.

There are three risk equalisation credits and this Bill makes amendments to all three. This year, there will be an increased proportion of credits relating to health status rather than age. Increasing the proportion of credits associated with health status means that more credits are based on actual claims experience, rather than risk predictors like age. This helps to share risk more effectively across insurers.

The amendments outlined in the Bill take account of the ongoing sustainability of the private health insurance market, the aim of avoiding overcompensation being made to insurers and the aim of having fair and open competition in the market, as required under the EU framework for state aid.

I will now outline the specific sections of the Bill. Section 1 defines the principal Act as the Health Insurance Act 1994. Section 2 amends section 11C of the principal Act to provide for 1 April 2024 as the effective date for revised credits payable from the risk equalisation fund. Section 3 amends the amount specified for the purposes of the hospital utilisation credit for both the overnight and the day-case rate. The amounts are applicable on or after 1 April 2024. The Bill will increase the hospital utilisation credit from €125 to €163 for nights and from €75 to €81 for days. This is in line with the move towards increasing credits related to health status.

Section 4 replaces table 2 in Schedule 4 to the principal Act. This table revises the applicable age-related health credits payable from the risk equalisation fund. The amounts are applicable on or after 1 April 2024. The Bill provides for decreases in the age-related risk equalisation credits payable for the age groups over 65. The amount of the credit depends on the person's age, sex and whether he or she has advanced or non-advanced cover. The changes in the risk equalisation credits reflect a move towards having a greater proportion of credits related to health status rather than age.

Section 5 amends the percentage specified as the proportion of a health insurance claim that exceeds a certain threshold within a calendar year that insurers will be compensated for under the high-cost claims pool. The revised proportion will apply on and after 1 April 2024. The high-cost claims pool targets subsidies towards the claims' costs of sicker customers to spread the risk of insuring sicker customers among insurers. The high-cost claims pool operates by compensating a proportion of a health insurance claim that exceeds a certain threshold, currently €50,000, within a calendar year. The remainder of the claim will be covered by the insurer. The Bill will increase the percentage of the claim compensated for under the high-cost claims pool from 40% to 45%. The threshold will remain at €50,000. Increasing the percentage of the claim to be covered is in line with the move towards increasing the share of credits related to health status.

Section 6 amends section 125A of the Stamp Duties Consolidation Act 1999 to specify the applicable stamp duty rates to apply in the market for 2024. The amount of stamp duty levy is calculated to align with the expected risk equalisation credits. The risk equalisation scheme is Exchequer-neutral. It is not funded by the State and the State does not derive any funds from it.

When the Health Insurance Authority makes a recommendation on the amount of stamp duty levy, it must also avoid sustaining surpluses or deficits in the risk equalisation fund. The amount of stamp duty payable on a health insurance contract depends on whether a contract is advanced or non-advanced. Non-advanced contracts provide for mostly public hospital cover, while advanced contracts provide a higher level of cover and cover in private hospitals. For next year, all rates of the stamp duty will be reduced. The stamp duty payable on non-advanced health insurance contracts from 1 April 2024 will be €105 per adult, a decrease of €4 from 2023 rates, and €35 per child, a decrease of €1. On advanced health insurance contracts, the stamp duty will be €420 per adult, a decrease of €18 from 2023 rates, and €140 per child, a decrease of €6.

A surplus of €25 million is expected in the risk equalisation fund as there was a lower level of claims on the fund than anticipated and the growth in the insured population was higher than expected. The Health Insurance Authority recommended that the €25 million surplus should be used to reduce the level of stamp duty that would otherwise be payable.

Section 7 provides for the Short Title, commencement, collective citation and construction of the Bill.

To summarise, this Bill allows us to maintain the community-rated health insurance market. The provisions of the Bill increase the effectiveness of the risk equalisation scheme. Risk equalisation credits based on age are reallocated to those based on health status, without increasing the stamp duty payable. Increasing the proportion of credits associated with health status helps to share risk more effectively across insurers.

Importantly, the programme for Government commits to retaining access to private healthcare services for people in Ireland, ensuring choice for those accessing healthcare. This Bill continues our policy of ensuring solidarity with and affordable premiums for sicker and older people.

These policy aims are also supported by the public. According to a survey carried out in 2021 by the Health Insurance Authority, 79% of those surveyed agreed that premium prices should not be dictated by a person’s current health. The same survey confirmed 72% agreed that older people should not be charged more for health insurance.

Finally, while the Government continues to maintain the community-rated private health insurance market, I would also like to conclude by highlighting this Government’s commitment to improving public health services under the Sláintecare programme. Some recent Government achievements include the addition of 22,000 healthcare workers and an increase of 1,000 in hospital bed capacity in the last three years. Waiting times were reduced in 2022 for the first time since 2015. There has been an unprecedented shift in patient care from the hospital to the community sector.

Progress for patients has been made in the roll-out of national clinical strategies including in cancer care, maternity care, trauma care, palliative care, critical care, dementia care, mental health services, older persons services, health and well-being programmes, social inclusion, screening services and in our National Ambulance Service. The new public-only consultant contract is in place and more than 1,000 new and existing consultants have signed up to date. Public patient inpatient hospital charges have been abolished. Investment in women’s health care has increased and State-funded IVF has been introduced. These are just a few areas where we have seen better access, increased capacity, and improved outcomes. As access to these services improves, the Department will monitor the impact on the health insurance market over time.

On behalf of the Minister, Deputy Donnelly, I commend this Bill to the House.

I am sharing time. I thank the Minister of State for her opening statement. This is an annual Bill to review the risk equalisation mechanism which supports the community-based health insurance market. It revises the stamp duty levy on policies and the risk equalisation credits payable to insurers for 2024.

As a principle, risk equalisation ensures that costs are constant across the lifespan of the individual. Where possible, it seeks to ensure that age, gender and health status do not influence the cost of an insurance product. Legislation is required each year to revise the system of credits and levies to ensure that the risk equalisation scheme operates in a consistent and fair manner, while also generating sufficient income to ensure that it is self-financing. Recognising the reliance of so many people on health insurance, I will be supporting the Bill as our party has done in previous years.

I will table an amendment on Committee Stage to limit the reasonable profit for providers to 4.4%. This was the rate of reasonable profit from 2016 to 2020 until this Government increased it to 6% for 2024. This is at a time when many families are facing significant cost pressures, when premiums are rising because of runaway health inflation and when 47% of the population rely on private health insurance. Because of this and previous Governments' failures to fix the problems in the public health service it is incumbent on private providers and insurers to do their bit to ensure affordability for ordinary workers and families.

At 47% of the population, this high level of private insurance is a damning indictment of the Government. The fact that so many people require private health insurance or feel they have to have it is testimony to the fact that far too many people simply cannot rely on the public system. They feel the only safeguard they can have to ensure they get safe care when they need it is to take out private health insurance.

In her opening statement, the Minister of State talked about the achievements of the Government in healthcare. Much has been done over the past five years. However, I want to unpick some of what the Minister of State said. She talked about the additional healthcare workers who have come into the system, and that is the case. However, right now we have a recruitment embargo which is having a significant impact on healthcare. In the past few weeks I have met many hospital managers in Mayo, Kilkenny and other hospitals. They tell me that this will have an impact on their ability to safely fund the health services for the remainder of this year and into next year. There are many posts and vacancies which they cannot fill. There are many unfunded posts that they would have wanted to be funded and continued, which they now have to make hard choices about. Also, they cannot recruit nurses coming from countries which they might have left to come back into the public system. They can only recruit nurses who are fourth-year graduates. Yes, there are some exemptions, but these are few and far between in community services. The Minister of State is talking about "right care, right place, right time". The Minister of State also said in her opening statement that there has been an unprecedented shift in patient care from the hospital to the community sector. Chief officers in community services say the enhanced community care model is good and we have many good teams working in the community from integrated care programme teams for older people to chronic disease management teams and community intervention teams, all of which are important. The vast majority of these teams are understaffed. They do not have the staff to deliver the necessary services. Because of the recruitment embargo they cannot recruit staff. This means home care services, chronic disease management and all of those critical areas where we need to have proper investment and resources to keep people out of hospital, will not now receive additional funding for next year. Worse than that, we now have a recruitment embargo.

The Minister of State also talked about an additional 1,000 hospital beds. In budget 2020, 1,047 additional beds were funded for 2021. It is now 2023, approaching 2024, and these beds have still not been delivered. In his wisdom, three times this year the Minister announced 1,500 rapid-build beds. Half of them were going to be built next year and what has happened? They have fallen off the face of the cliff and because there was no new money in the budget I have not heard a whisper about those beds since. Yet, in every hospital I visit staff tell me they do not have the bed capacity. Without this capacity, hospitals cannot get patients into beds quickly enough, which is why emergency departments are clogged up and people are waiting so long. It is not the only reason, but it is a big part of it.

The Minister of State went on to talk about national clinical strategies. Yes, in the past number of years some of those have received additional investment, but many of them have not. The reality is that because of the disgraceful way in which the health service was funded last year and going into next year, very few or none of those strategies are getting any additional funding. This was clarified for us at a meeting for the Oireachtas Joint Committee on Health some weeks ago when it was made very clear that most, if not all, of the national strategies and national clinical programmes have no new programme funding for next year. Perhaps some got small amounts, but nothing of substance. This means all those programmes will stand still. All of those the Minister of State mentioned in her opening statement, cancer care, maternity care, trauma care, palliative care, critical care, dementia care, mental health services and older person services, will get no additional funding.

Regarding older person services, the Government promised a statutory home care scheme, which we are still waiting for. I do not know when it will be put in place but we are at the tail end of the Government's term in office and there is still no sign of it. Last week, I supported a motion from the Labour Party on home care services, an area where we are struggling to get staff. An expert group made recommendations on a living wage and on travel expenses. The Government did something on the living wage, but nothing on the travel expenses and nothing to try to achieve pay parity for those working in non-HSE settings. Now, as a consequence, we cannot deliver the home help that people need.

The Minister of State mentioned mental health services. Child and adolescent mental health services, CAMHS, are an absolute mess. That is not because the staff are not doing a good job. Everyone I have met who works in CAMHS does their very best. Consultants, psychologists, psychiatrists and support staff all do their absolute best, but very often with one hand tied behind their backs. Many reports, such as those from Mental Health Reform and the Ombudsman, have criticised the lack of investments in our mental health services. We are simply not resourcing mental health to the extent that is needed.

If the Minister of State is going to outline a long list of achievements it is incumbent on me as the main Opposition health spokesperson to paint a different picture. Yes, there have been some improvements and of course there has been some additional funding and things have happened over the last number of years, which I welcome. One of those is the public only consultants contract. However, there is a lot this Government did not do. The only way we will get to a point where people do not feel the need to take out private health insurance is to deliver on the commitment of Sláintecare.

One of the core commitments in Sláintecare - for me, this was reform with a big "R" - is to establish elective-only hospitals, although I know there is some debate about what they should be. Elective-only hospitals are, essentially, about separating scheduled care from unscheduled care but the vast majority of private hospitals provide elective care. If there were four big elective centres that could cover a volume of elective procedures, that would reduce the need for more and more people to take out health insurance, given that is really where people benefit from private health insurance. Many people pay for private health insurance and do not get a benefit; it is more of a comfort blanket.

There will always be people who will take out private health insurance, as they are absolutely entitled to do, and if they want to access private healthcare and pay for it, that is a matter for them. Nevertheless, if we want to get to the point, as I do, of there being support every year for this Bill, we have to get to a point where the taxpayer is not funding it, where we separate private care from public hospitals and where there are truly public hospitals, but also where there is elective care such that people are not constantly having their planned procedures cancelled, which happens every time there is a surge in a hospital, with all the chaos that creates for waiting lists and patients.

While I support what the Bill will do, and I have signalled the amendments I will move, there is a lot more this Government and, I would contend, any future government can do to reduce the dependency far too many people have on private health insurance, and to deliver a much better public service in which more people can have confidence and which can deliver both the scheduled and unscheduled care they deserve.

As Deputy Cullinane said, we will support this legislation. It is required in the context of the risk equalisation system. We all know people who, at times, cannot afford health insurance but who believe it is the only way in which they can keep themselves and their families safe. Even when they cannot afford it, they do everything they can to cut back with a view to paying for private health insurance. In 2022, that was 47% of people, a huge percentage, which tells us we have a two-tiered system that is not working for people. As much as we support the legislation, we really need to make those moves towards something closer to a national health service. Obviously, we would like that to be designed and operated on a 32-county basis but we definitely need something better than what we are dealing with.

As Deputy Cullinane noted, we are dealing with the health service and while there may be certain things the Government would like to point to in respect of added services it has been operating in the past while, anybody who works in the health service, whether in management or at the coalface, will tell you that what such people are seeing at the moment, not least with the escalation of the recruitment embargo, is risk, risk, risk. We are talking about 7,000 essential posts being scrapped. We all know the issues that exist in the health service, such as the huge waiting lists and issues with EDs, so we have an absolute fear regarding how this disaster funding model the Government is or is not operating impacts on patients.

We will only know in the near future whether we are talking about the loss of beds or whatever else from a system that is constantly under pressure. We have been talking about how we do not have those essential posts in those essential services. It is only a week or two since I was in the Chamber debating the issues in home care with the Minister of State, Deputy Naughton, and the Minister for Health. Louth County Hospital is fine as a step-down facility but we do not have the capacity. Likewise, Our Lady of Lourdes Hospital, Drogheda, is under significant pressure to try to get people out of there. People are, at times, under a great deal of pressure to get their family members out, in some cases to go into nursing homes because we do not have the home care facilities and because we do not have that step-down facility to the degree we would like to see it.

As I have said previously in the context of community care, the orthodontic care system in Louth County Hospital is, again, not able to deliver. A huge number of people are on the 5A list, that is, the more critical of the lists, and while kids in category 4, which is not quite the same set of circumstances, are being dealt with in Beacon Hospital at the moment, that is being paid for by the HSE. As welcome as that is for those parents, parents of children in more abject need are wondering what the problem is. That needs to be dealt with. As part of the issue is there is only one orthodontic consultant in Dundalk, I do not foresee these issues being rectified as we are in the middle of this recruitment freeze. Separately, I have sent a note to the Minister regarding an IT issue. Old IT systems are being used and that needs to be rectified. I have heard that the new laptop systems are lying in Dublin, so that is one issue where, I hope, action will be taken although, as far as I am aware, it has not yet been.

I have raised with the Taoiseach an issue with the ambulance service. On Friday, 10 November, a 93-year-old woman in Dundalk had to wait from 5.20 p.m. to 9.05 p.m. in abject pain. The ambulance arrived at 9.05 p.m. and there was a great deal of over-and-back with the family. She was brought to Our Lady of Lourdes Hospital and diagnosed with a fractured pelvis and a kidney infection. You can imagine the pain she was in. She lives in Dundalk, very close to where the ambulance station is. Those who work in the ambulance service talk about issues with rosters, facilities and systems. That needs to be addressed.

I too welcome the opportunity to discuss the Bill. We will support it, given the large number of people who are reliant on private healthcare providers to receive care in a timely manner. Risk equalisation, which the Bill will provide for annually, ensures costs will be constant across the lifespan of the individual. It seeks to ensure that, where possible, age, gender and health status will not influence the cost of an insurance product. Let there be no doubt, however, that this support is not immune to our misgivings, given the two-tier health system that results for some people, whereby they can find themselves carrying the cost burden of private health insurance because they cannot trust the health service to deliver care in as timely a manner as they should be able to receive it.

The level at which people are reliant on it is reflective of the problem people use it to address. Currently, almost half of the population is covered by private health insurance. It has tapered off from its peak in 2008, when it was at 51%. As a consequence of the economic crisis, the level fell to 44%, but the number availing of it has again increased and stood at 47% last year. The question must be asked as to why so many people are finding themselves with little option but to fork out this substantial cost for private health insurance. The answer is obvious: hospital waiting lists are unacceptably long, patients wait months and years to receive the treatment they require, and those who are at the beginning of the process can, in many cases, find themselves spending lengthy stretches of time in emergency departments.

The emergency department at University Hospital Limerick, UHL, is a case in point, while only yesterday, Tipperary University Hospital had to appeal to people to stay away where possible unless there was a genuine need to visit an emergency department. More and more people are having to opt for private healthcare to get not just an assessment of need for their child but also the services of which they are subsequently identified as being in need. This is just one example of where the failings of the public system result in parents having either to rely on health insurance or, more likely, to use whatever savings they have, or to get a loan from the credit union to access in a timely manner the care or treatment they need.

At the other end of the scale, and this makes no sense to me whatsoever, beds are removed from communities only to be replaced by a reliance on the private sector. Again, I have a local example of this with the closure of St. Brigid's Hospital in Carrick-on-Suir, where beds were closed, with some of them contracted out to the private sector. This matter has been repeatedly examined and discussed, yet it still makes no sense that private providers that are farther from the community in which the beds were originally located are seen as a better option.

Also, the fact nearly half of people have private health insurance would lead an outsider to conclude this level of reliance on the private sector means the public system has a significant level of demand lifted from its shoulders and must therefore be in a better position to provide for its patients. This is obviously not the case.

Given we have such a high level of people availing of private health insurance, we must ask why the public system is still buckling. The answer is decades of mismanagement from the Department. Ultimately, the fact so many people find themselves in need of private health insurance to the extent they do is an indictment of this Government's failure in the overall area of healthcare provision and access. Moreover, the fact that, despite this level of private healthcare take-up, the public system is still buckling is a further indictment. I could also add to this the Government's reliance on outsourcing to the for-profit healthcare sector as a third example of how the health system under this Government is unable to meet the demands it should. All this results in unequal access to healthcare and while the system as it is must have the private sector to fall back on in times of need, we really must aim for better. We need to increase capacity. We need to stop removing beds from the community settings that would otherwise help take the pressure off our emergency departments. This would help reduce the deterioration of conditions that otherwise could see an increase in waiting lists and therefore waiting times. The ambition to reduce our reliance on the private sector is one that must be given more weight.

To conclude, Sinn Féin will table amendments to the level of reasonable profit this Bill makes provision for. This Bill seeks to increase the benchmark amount of reasonable profit, which is the level used in the assessment of whether an insurer has been overcompensated by the risk equalisation scheme. The proposal here is to increase this to 6%. We will be calling for this to be limited to 4.4%, which is the lowest level and was set from 2016 to 2020.

The Labour Party will be supporting this legislation. Every year we have this same debate, in which we amend the Health Insurance Act to modify the regulations governing the private health insurance sector. This is in the context of the goal of our health policy being the drive towards the delivery of Sláintecare, a universal, single-tier healthcare system that has the support, at least in theory, of all sides of this House. It would provide access for all and service free at the point of use. It causes me great concern that movement on Sláintecare seems to be slowing year on year, rather than increasing.

An area seldom discussed in the context of Sláintecare - it is silent on it - is health insurance. Until Sláintecare is delivered and we see it in operation, we cannot know what the long-term future of our private health insurance system will look like. As long as we have such a system and it remains as large as it is, with 2.44 million people or 47.6% of the total population having private insurance, we will be existing with a private healthcare system and the two-tiered system. That two-tiered system is not serving the wider interests of the country and certainly not those of the people who live here. Most people who understand and are engaged with the health service are 100% behind the delivery of Sláintecare. They see it as our opportunity to form a link with our health service, similar to that emotional link citizens of the UK have with the NHS. The Irish have an appetite to feel closer to their health service and we saw that during Covid, but if the health service continues to be mismanaged, underfunded and unfair due to the two-tier system, that link will never be delivered.

The people are losing faith this Government has the ability and indeed the power to deliver it. They do not see the required staffing numbers coming through or the level of student intake in our third-level institutions being sufficient to meet the need. They see a Government underfunding our HSE. We have seen a supplementary budget of €1 billion announced today just to meet the need for this year, but people see a recruitment freeze that is going to further cripple our front-line services. People see waiting lists, which many of them are on given the number waiting is nearly 900,000, only getting longer. People see a workforce that is burnt out and struggling to retain existing staff. The healthcare staff who are coming through cannot afford to live here. They cannot afford the housing and even some of the job and training opportunities in the healthcare service do not match what is on offer in other healthcare services, such as those of our near neighbours or further afield in the Middle East, North America or Australia-New Zealand. We are not retaining enough people who are educated through FETAC or to degree level and the staff currently in the system are being forced out of it due to the uncertainty of our healthcare system, which is only exacerbating all these issues.

Private health insurance cannot become a synonym for good healthcare, though some on the right would have one believe that is the case. With waiting lists as bad as they are, there is a perception among people that they need private health insurance out of fear more than anything else. As we know, many people who pay sometimes thousands of euro per year so they and their families can have private health insurance are not getting any benefit from it. It is there, as Deputy Cullinane said, as a comfort blanket in case the worst happens. This is not the sign of a good healthcare system. Unfortunately, in some instances where people are let down by the public system and have private health insurance, they still cannot get the care they need because the private system is also absolutely crippled. We are seeing this in a number of areas. We see this with assessment of needs waiting lists and especially in the area of mental healthcare. There is a huge issue in communities all over the country. People facing mental health issues and parents of children with mental health issues are being told to go private due to extensive waiting lists with the HSE. Whey they go through a private health insurer, if they have one, they realise either the condition is not covered or if it is, the service still is not there. It is an absolute mess. Mental health is an issue I do not feel this Government has taken seriously at all and we have seen that in the derisory mental health allocation in budget 2024. What it means in real terms is people are being let down and they are losing hope. Access to mental health services cannot be a choice between the year a person is lucky enough to get on a waiting list or whether their health insurance provider will cover those costs.

Moving forward, we need to see an end to the recruitment freeze and adequate funding for our health services year on year so we are not facing the circus that is supplementary health budgets totalling €1 billion being brought in at the end of the year. We need to see real actions on the true delivery of Sláintecare in order that it works for every citizen of the country. We also need to see the Government acknowledging the damage it has caused in this area. Budget 2024 will forever be known as the disastrous health budget, the budget that delivered nothing but a recruitment freeze, underfunding and uncertainty in the most important sector in our public service, which is our health sector.

I have no difficulty with the Bill before us and the annual requirement that we pass this legislation. As an insurance system, community-rated voluntary private insurance is fine and it is essential there is a risk equalisation scheme as part of that. We cannot really argue about that if we are talking about a health insurance system. However, the difficulty arises with the health system we have, which is a two-tier, dysfunctional, mix-and-match one. It does not serve people terribly well. Many people wish they had the money to afford private health insurance and many others struggle to meet the cost of that. In the main it is higher paid categories of people who tend to be in very senior jobs and decision-makers at administrative and political level who have private health insurance. There is very much an attitude of “I’m all right” and that it is too bad if others cannot afford private health insurance.

The dysfunction within our health service was the motivating force behind the Committee on the Future of Healthcare being set up and it developing the Sláintecare reform programme. The programme was agreed by all parties in the House and is official Government policy, though sometimes one wonders whether that is really just a matter of lip service being paid. While nothing happened for the first few years and there was the pandemic and all of that, in the last couple of years there was progress on that reform programme and I have no hesitation in acknowledging that.

We were starting to see real change in the health service, a commitment and a belief among many healthcare workers that we were serious this time, in spite of all the false dawns in the past. Over the past two budgets, we saw reductions in the cost of accessing care. Cost is a significant barrier to accessing care and feeds people's belief that they have to have private health insurance. There were important initiatives. The removal of the €80 a night charge, the reduction in the drugs payment scheme threshold and the expansion of access to free GP care were all very important initiatives and they gave the impression that we were on the road to serious reform.

That is why the Government's decision in last month's budget was so disappointing and surprising. As some commentators have said, it was an own goal by the Government. When we were reaching a stage at which people were seeing these improvements in respect of access, the new consultants' contract and the expansion of GP care, all of which seemed to indicate that we were going in a certain direction and were experiencing much-needed reform, the door suddenly came down and no additional money was provided for healthcare. The programme that was under way has now come to a shuddering standstill and people are asking what that is about. They are asking why, after having made a certain amount of progress and with the Taoiseach, the Tánaiste and others claiming credit for the past couple of years, which is fine because we did make progress, we are now stopping. We were going in the right direction but have now suddenly come to a standstill. It just makes no sense at all and it results in health becoming a political football once more.

The Government has asked for that. Health is going to become a political football and there are going to be rows about it because Government has smashed the consensus there was about the need to move forward on a cross-party basis and get Ireland to the point practically every other European country is at, a point where there is a single-tier universal healthcare system. A major mistake has been made. I do not know if Fine Gael was pushing for this but there was always doubt about its commitment to universal healthcare that is free at the point of use.

I will also raise a few other issues. One relates to one of the most surprising facts about the dysfunction within the healthcare system. More than 47% of people in this country now have private health insurance. Looking at the global figures for the funding of our health service, it would be expected that if nearly 50% of people pay very expensive premiums for private health insurance, it would make a major contribution to the cost of healthcare but it does not. Private health insurance contributes 14% or 15% of the cost of running the health service. That is extraordinary. I do not know if the Minister of State is aware of that figure but it is extraordinary that it is so low. It can, therefore, be seen that the public system and the public purse provide a major subsidy to private healthcare. It is a bit like private schools. Those who can afford to get in then get all the benefits from the State, which is not a very fair way of funding the health service.

The value that people get for private health insurance is very poor. Most people buy private health insurance to skip the queue. It enables people to do so and that is, in itself, wrong. It should not happen like that. However, most people accessing the healthcare system do not need to go to hospital. They need care at community level. In the main, private health insurance does not pay for GP care or to see a consultant. We are talking about fees in excess of €200 to see a consultant. It can be as much as €300 or €350. People are paying for private health insurance and forking out something in the region of €300 to see a consultant. That is an indication of the shockingly dysfunctional nature of our health service. People are paying for healthcare through the taxation system but they are paying on the double because they are also paying what amounts to a health tax through their expensive private health insurance. That should not be the case.

In the vast majority of cases where people really need hospital care, when they are in an emergency situation and have to attend an emergency department, they do not go to a private hospital because, if it provides any emergency department service, it only does so between 9 a.m. and 5 p.m. The rest of the time, people have to use the public service. In many ways, that service is very good, especially in the case of a serious emergency or something like a heart attack, but it is a public service and private health insurance does not cover it. In most cases, people also have to fork out to avail of diagnostic services, which can cost a few hundred euro. They are again paying on the double. It is entirely dysfunctional.

We need to move away from that. The stronger the public health service is, the weaker the case for people to buy private health insurance. We should not force people into a situation where they feel they have no choice but to pay for such insurance. There are many people who are on very low incomes but who, through fear, feel they have to scrimp and save to buy private health insurance, which is a terrible reflection on the health service.

The last point I will make relates to the Minister of State's own remit. Of course, there should not be this great emphasis on hospital care, waiting lists and so on. There should be much greater emphasis on prevention and health promotion, which is the subject of one of the five chapters in the Sláintecare report. I do not know if she has read that report. We have not heard anything of any great substance from her with regard to health promotion and prevention since she took up her current role. That is really where she should put her energies to raise people's general standard of health through improving lifestyles. There is an awful lot of work that can be done in that area.

I will probably only take ten minutes but you never know. I will try to keep to ten. This legislation comes before us every year. While we continue to operate a two-tier system of healthcare in this country, which we believe is fundamentally wrong, this legislation goes towards trying to keep premiums down for health insurers that cover a larger cohort of older people, particularly the VHI, to prevent them putting up premiums for older people. Within the parameters of a fundamentally unfair system in which great numbers of people are forced to take out private health insurance, we support this minimal measure to equalise premiums. Much of the debate I have heard rightly reflects what we say every year, which is that this measure highlights the need to get away from the two-tier system, which people are, by and large, forced into. A very high level, just under 50%, of people feel the need to take out private health insurance and to pay very hefty monthly insurance premiums, which are a significant burden on them.

In one recent case I was involved in an elderly family was being made homeless. They were in their late fifties and early sixties, which is not really elderly these days. They had health issues in the family and they were being evicted, through no fault of their own, from their family home. A significant part of their outgoings was private health insurance. They were terrified about the prospect of not paying their health insurance because the husband had a serious heart condition and his partner also had health issues. For them that is money they have to pay because they are terrified of having to rely on the public health system, given it is such a mess. That was money they desperately needed to try to find alternative accommodation to avoid being homeless. They had been living under the terror of being homeless when they were seriously unwell but they felt obliged to pay private health insurance because of the terrifying prospect of them needing the health system to deal with their illnesses. That eviction went ahead; they were evicted from their family home where they had lived all their lives with their two children. Much of the conversation I had with them during the eviction was about their fear that they would die because of the stress of it. These were working people. The following is something the Minister of State might look at: in assessing their income they found they could not get on the social housing list. They had no options because their income was over the threshold. A significant portion of their outgoings was money for private health insurance against the possibility of being ill. It was not money they had in their pockets but it was money that was counted by the local authority to say they were not entitled to social housing. As a consequence they were entitled to nothing.

A lot of working people are caught in that bind, paying large amounts for something they should not have to pay for and for which they are paying twice. That is the reality of private health insurance; people are paying twice. What are they paying it for? Critically, they are paying it to make an awful lot of profits for private health insurance companies that want to exploit people's fear of having to be put on a waiting list where they could wait months or years for treatment. It is worth noting, if we take Laya Healthcare as an example, that its pre-tax profits for this year are up from €28.85 million to €36.55 million. Private healthcare is making lots of profits, essentially out of the fear and terror that working people have of having to rely on a public health system that is in very significant trouble. That private system is pulling public resources and money in order to make money. As well as taking huge amounts from working people to pay the premiums, it is also pulling resources and money from the public system.

Let us take the national children's hospital as an example of that. It is expected to cost more than €2 billion and included in that are consulting rooms for private healthcare. The public are paying €2 billion for this state-of-the-art hospital and public money is being used to subsidise two-tier private healthcare to make money for the private consultants and health insurance companies. It is also being used to force working people, who feel compelled to take out private health insurance, to pay twice. They pay with their taxes already and then they must pay again with hefty private health insurance premiums.

The worse the crisis gets in the public system, the more people feel the pressure to go into the private system. It is understandable why people feel compelled to do so. As a matter of principle I do not take out, never have taken out and never will take out private health insurance because it is fundamentally wrong to do so. It is particularly wrong for public representatives who are charged with maintaining the public health system to in any way benefit from a two-tier system. If we are going to represent the majority of people in this country, we should be the ones who have a personal incentive to ensure the public health system functions for everybody.

I will make a few comments on how bad things are in that regard and provide evidence on why people might be pushed towards the private healthcare system. The INMO is feeling compelled, though it is not something it wants to do, to consider industrial action because of the recruitment freeze the Government has imposed. That is against a background where the INMO reckons we are 2,800 jobs short of having the nurses and midwives needed to make the health system function. The Irish Hospitals Consultants Association, IHCA, is saying that the Government is significantly behind in achieving the 10% reduction in waiting lists that it promised by the end of 2023. We are already facing a 65,000 shortfall by the end of September. There are 893,000 people on some form of National Treatment Purchase Fund waiting list, which is up almost 23,000 or 3% this year alone, and by an additional 309,000 or 53% since Sláintecare. The IHCA president, Robert Landers, said:

The 2023 Waiting List Action Plan is now unlikely to achieve the reduction targets set for the end of the year. The Government needs to urgently increase public hospital capacity to address the increasing number of patients on waiting lists.

That leads to all of the fear that leads people to think they have no choice but to take out private health insurance. Then, as I have mentioned previously, there are advertisements week in week out for the Beacon Hospital and the Blackrock Clinic. The subtext of those advertisements if that if people go there, they do not have to queue, but if they go to the public hospital, God help them because they will be sitting on a trolley or be put on a waiting list for weeks and months.

A lot of people need occupational therapists. For example, if they need to get housing with certain types of adaptations, they need occupational therapist reports. Even to get their wheelchair fixed if they are disabled, as someone informed me recently, they need an occupational therapist but there are hardly any available in the public service. In Dún Laoghaire, the service was recently cut to two days per week. It used to be that there was an occupational therapist available every day for an hour. People could ring somebody in the local health centre to say they needed to service their wheelchair or they needed a new wheelchair, for example. Now that has been reduced to only two days per week because of a lack of occupational therapists. These are the basic things that result from the lack of staffing and the failure of the Government to address the staffing crisis in our health service. This is terrifying people and they end up, in one shape or form or another, having to go private, which is not acceptable. Healthcare should be for everybody.

I support the fact that a Bill has been introduced again this year so that we can end up creating a situation where people who are older or sick are protected through the equalisation of premiums. That is important. I want to speak to the matter at hand, namely why we have to have private health insurance in this country. Some people want to have private health insurance but if we had a universal health service, we would not need it. We are a fair shot away from that yet. If we are to strive to get to universal healthcare, we need to do a number of things. We are doing those things but we are doing them at a slow pace.

In my home town of Tuam, a mental health day hospital has opened at the former Bon Secours Hospital at The Grove, which was closed for 20 years. It took 20 years to open it. A new children's disability network team, Team 7, is in a fine building in the same complex but unfortunately it is only at half staff level, if even that. I have parents ringing and emailing me all the time and they are now clubbing together because they are all sharing the same bad experiences. They cannot get services for their children.

Why is this happening? People are afraid that they will not get any service unless they have health insurance. In Galway we have University Hospital Galway, or the regional hospital, as we call it. We know there are plans to do a fantastic amount of work there and while it is moving in the right direction, it is at a very slow pace. This is the problem when a regional hospital is serving more than 1 million people. It is a centre of excellence for cancer. It is very hard to attract staff to that hospital because prefabs and old-style Nightingale wards from the 1950s and 1960s are still in operation. All of that is going on in a centre of excellence. The Government needs to push on with investment in the infrastructure. Where such investment happens, it is fantastic. A new bed block is being bulit in Portiuncula University Hospital, which will be a major addition but that has been going on for nearly ten years. To give another small example, a fine primary care centre was built in Tuam and opened seven or eight years ago but it was forgotten to put in an X-ray facility. In 2017, the then Minister, Deputy Harris, provided funding to put in the facility. In the past couple of weeks the bit of construction that is needed has started and the facility will probably be open next year, seven years after the funding was provided. That project just involved the conversion of a space within an existing modern building but because of the type of public-private partnership contract involved, it involved layers and layers of legal letters and contracts before the contractor could get in to do that work. That X-ray facility will take some of the pressure off the accident and emergency department in Galway because people from north Galway and south Mayo will be able to have their X-rays done in Tuam. The X-rays will be read in Portiuncula and that will free up some capacity in the regional hospital. The equipment was bought a number of years ago and I just hope it is not out of date when the staff go to use it.

That is the archaic way the delivery of infrastructure has been dealt with. If we have good infrastructure and good, modern hospitals, the HSE will be able to attract staff. The staff it needs to attract are those who have gone to foreign lands, having got their education here, be they nurses, doctors or therapists. They fly the nest and off they go but if we want to attract them back, we need to have inviting facilities for them, not prefabs and old buildings. We need to have them coming back into modern facilities where they can enjoy their work and thrive at it.

Finally, my own experience of the health service over the years tells me that we are delivering a great service in the public sector. Anybody I know, bar a few, who has gone into the health service here has been taken care of very well. Our workers, particularly our nurses and doctors, are all first class. Based on my experience with my family, I can say that without fear or favour. Once someone is in the system, he or she is taken care of, but the problem is getting in. We should try to improve our infrastructure so that we can attract staff and that way we can leave private health insurance behind us in the time to come. We need to set out that vision and a plan by which we will achieve it over a number of years.

I am delighted to welcome this legislation, which comes before us annually. Ar an gcéad dul síos, ba mhaith liom a rá libh that I have private health insurance. I had it ever before I came into this House, unlike Deputy Boyd Barrett. I have had ongoing difficulties with my eye and want to salute Professor David Keegan and his team in the Mater Hospital and Dr. Dervan in Bon Secours Hospital who looked after me very well. I took ill over a year ago and was brought into St. Vincent's Hospital in Dublin, a public hospital, and I could not say enough about the doctors and staff there. The treatment I got, including the follow-up treatment, from a public hospital was exceptional.

As Deputy Canney said earlier, thousands of people get good results from hospitals run by the HSE and the Department of Health but there are logjams and blockages. There is too much bureaucracy, For example, for years we could not get home help and home care packages approved. The new stunt is that the HSE approves them within a couple of weeks because it knows there is nobody to provide them. It is an awful situation. We are trying to keep people out of hospital. People are happiest in their homes and that is where they should be kept if at all possible, with a small bit of support - le cabhair bheag ó na daoine sa pharóiste. The people that are around who know them want to come and I salute the people to give home help and home care. I salute carers as well.

There was approximately 3.4% growth in the market during 2022, with 79,553 more insured individuals compared to the previous year. People are being forced to get private insurance because they cannot get timely access to healthcare. They cannot get an appointment with a GP. If my family wanted a vet to see one of our pet dogs tonight, we would have one in half an hour but we cannot get a doctor. People can ring the out-of-hours service and if they get through, they will have to answer 110 questions and then they will be told to wait and wait. That service has deteriorated rapidly. I know that GPs are overworked and they have their own issues as well.

Let us take the example of the national children's hospital. The Rural Independent Group tabled a motion to have that hospital relocated. We had the support of representatives of the Jack and Jill Children's Foundation, nurses, Dr. Finn Breathnach and Mr. Jimmy Sheehan, who built the Beacon Hospital and a hospital in the Minister of State's own county, as well as the Mayo Clinic and other facilities. He would have built a children's hospital on an 80-acre site off the M50 for between €1 billion and €1.1 billion and he would have built it in 13 months. It would have had a huge garden, not like the rooftop garden that will be in the shambles out in Dublin 8, and three helipads. There is no helipad in the one being built, apart from one that is three storeys high for a small helicopter on a fair day, with no wind. I pushed the motion to a vote here but all parties, including the Cathaoirleach, Sinn Féin and Fine Gael, voted against it, having heard the evidence we heard. It was a severe lesson in the pandering to the public that Deputies do. The audiovisual room was full. Approximately 70 Oireachtas Members turned up to listen to our guests but the next day, they came in and voted the opposite way. They voted for this misery that will never be any good. The bill is €2.1 billion now but hundreds of additional claims have gone in. Deputy Healy-Rae and myself visited the site and the back yards of houses are falling into it. We could not believe it. It was the wrong site. You cannot make a silk purse out of a sow's ear. There was not a hope because the space and site were wrong. Nurses cannot get parking there. At the time, someone who was promoting this project said that children could come by Luas. Let us imagine a sick child travelling by Luas to hospital.

Of course, we also have the closure of St. Brigid's District Hospital in Carrick-on-Suir, as mentioned by Deputy Martin Browne earlier. That was a shocking decision. The hospital was taken over and became a Covid step-down facility. The Minister told Councillor Kieran Bourke and Deputy Cahill that the hospital was going to be reopened but it was unceremoniously closed. There are three hospice care suites at the hospital that were second to none. A lot of fundraising was done by the community to put those suites in place. Families whose loved ones had died had collection boxes at their wakes, made donations and so on. A lot of equipment was purchased by people and now that funding is not being returned to the people. We are trying to set up a system to return it nearly a year and a half later - a shocking vista.

We lost our accident and emergency units in St. John's hospital in Nenagh and in Ennis. A group appeared before the Joint Committee on Public Petitions and the Ombudsman last week that is trying to get those units reopened. I support the reopening. Those units should never have been closed.

I want to hold to account Dr. Harrold and others who said we did not attend that meeting last week. First of all, I became aware of the meeting when I heard the news headlines on Tipp FM last Thursday morning. I had meetings of the Business Committee and other meetings and we had to launch a report for my committee. I attended the meeting in question for as long as I could and I listened to the contributions. I then had a hospital appointment, so I had to leave the meeting. It is very unfair when action committees want to call people out. We were not invited to attend and nobody let us know they were coming. I stand over my record.

We also have the situation of people being forced into private insurance. I have no real hang-up about consultants working in the private and public systems. They get massive experience in both areas and they share that experience. Indeed, the consultant I attend is doing it. There are many issues and blockages, however. The recruitment freeze that has been brought in is simply appalling. I will not say it is on the lowest tier, but it is on the most vital tier of workers, such as home help workers, who keep people out of hospital, and nurses. I visited a small community hospital on Sunday and met a nurse who has been appointed as a manager but the appointment has been put on hold. These people have to live. They have mortgages to pay and families. These things are being done at the stroke of a pen. We saw the Secretary General moving into the Department of Health from the then Department of Public Expenditure and Reform. He did not do a great job there either. The pay increase he demanded and got is obscene. As for the amount of money the CEOs get, "obscene" is the word. Meanwhile, there is the embargo on recruitment of junior doctors, of whom we are short 500 or more. As a result of industrial action last year, we were promised new people would be recruited. As for the nurses on the ground, na banaltraí iontach, they are wonderful angels of health. I refer to the work they do and the problems they have. They are the people who are not being recruited. The Government regularly refers to thousands of people having been recruited last year but it is mainly pen-pushers and managers who are being recruited. When is this madness, blackguarding, nepotism and downright scurrilous behaviour going to stop? When will the HSE treat the people who are sick instead of people pulling up the ladder after them and the best of nurses then going into management? It is all managers and no one to manage.

What is going on in the emergency department of University Hospital Limerick is shocking. It is a so-called centre of excellence but what is going on there is an abomination. I have been in that hospital, as have members of my family. All my kids were born in St. Joseph's hospital in Clonmel but the Government is more interested in banishing the saint's name from the name of the hospital than doing anything else. It was changed to South Tipperary General Hospital and now it is Tipperary University Hospital. What about the cost of all those stupid, silly and pedantic name changes? People want good care to be provided in hospitals and for the staff to be supported. They do not want name changes on badges.

The Department of Health and the HSE have lost the run of themselves. The senior management have moral responsibility for this but they will not accept it. There is zero accountability. It is shocking to have that kind of smugness in this day and age. The former CEO, Mr. Reid, is now chairman of a citizens' assembly. It is rewards and jobs for the boys, but for doing what? The money they are on is unbelievable. It is pure bedlam in the organisations they are responsible for. It is inept management of the highest degree. This is not the fault of na banaltraí ar an úrlar, on the floor. They do a great job, as do the domestic staff and everyone else, but they are overworked and blackguarded every which way. There are layers of managers. God, when the matrons ran the hospital, they ran them well, all by themselves. Now we have floor managers, emergency department managers, construction managers, bed managers, linen managers, hygiene managers and food managers. God almighty, there are managers for everything and no one managing. The lunatics are definitely running the asylum when it comes to the HSE.

Two former taoisigh told me they were going to disband the HSE. Bertie Ahern and Brian Cowen both told me while they were Taoiseach that they were going to disband it but it is becoming a bigger monstrosity every day of the week. The Minister of State across the Chamber can look this way, that way or whatever way she wants to look. I am telling her what she already knows. She is hearing it from people. The HSE is a monstrosity. It is unaccountable and out of control. When we had regional health boards, there was accountability, but the HSE just marched on its merry way. People's health and welfare is far from the minds of many senior people in there. It is about careers, getting up the ladder and readying themselves to go into private practice afterwards.

I am glad to have the chance to speak on this important matter. The Bill is regarded as pivotal legislation in the ongoing effort to fine-tune risk equalisation credits and stamp duties within the private health insurance market. It does absolutely nothing, however, to reduce the cost of private health insurance. In fact, it is more about helping insurance companies than it is about doing anything to help people with the challenges of the affordabilty of health insurance or the escalating cost of the public healthcare system.

As I have said before, insurance companies have been doing exactly what they like since Seán Quinn was forced out of the insurance market. He provided competition and made insurance available, even in the motor industry. He insured young fellas who were trying to get on the road and for whom insurance was unattainable before that. Likewise, he was helping in the private health insurance sector as well.

The Bill does nothing to reduce the cost of private health insurance. The cost of the average adult policy has increased by at least 5% since last year. Year on year, it is going up 5%. Many people have contacted me to say that even if you have health insurance, you will have to wait six months to be seen, which is ridiculous. We all know that cancer can go from stage 1 to stage 2, 3 or 4 very quickly if it is not challenged or treated. The sooner it is treated, the better. People who have tried to pay their way and who pay for the health insurance are not even being seen by a doctor. Something has to happen.

We have all heard of people who have been found unconscious, brought by ambulance to a hospital and put on a ward. When they come around, it is invariably the case that the first question they are asked is whether they have health insurance. Maybe the Minister of State sitting opposite does not know why that question is asked. It is to ensure the HSE gets the maximum payment for each patient. The patient has to sign a form. Instead of the HSE getting €70 or €80 for each day of a stay in hospital, it can bill health insurance companies something like €800 to €900 a night for that patient. Is it any wonder health insurance is going up? It is all a merry-go-round. The HSE charges much more to the health insurance companies than it would if it was asking the private person to pay the bill, but the level of care does not go up. That is one of the reasons the cost of health insurance is increasing. Another reason, of course, is that there is no competition in the market.

The private health insurance market, which opened to competition in 1994, features three major providers: VHI Healthcare, Laya Healthcare and Irish Life Health. Market data highlights 3% of growth in the market during 2022, with 79,553 more insured individuals than the previous year. The total premium income for 2022 reached €2.9 billion. As of June 2023, 47.6% of the population, or 2.46 million people, held health insurance, with the average adult policy priced at €1,509, reflecting a 5% increase this year. The tax relief in respect of health insurance resulted in €355.3 million of forgone taxes in 2019.

In 2022, the Commission on Taxation and Welfare suggested phasing out this tax relief as part of the ongoing implementation of Sláintecare's healthcare reform recommendations. God almighty, when is enough enough? This is something that I and many TDs in the Minister of State's own party do not support. It has to be halted. Our group is adamant that the tax relief must remain because if not, many people will not be able to afford private health insurance.

The Health Insurance Authority not only serves as the regulatory body overseeing the private health insurance market but it also gives essential advice to the Minister for Health on health insurance matters, including duty and the risk equalisation scheme. In a concerning trend, Irish Life has announced its third price increase in the past 12 months, with the latest surge of 4.8% to be implemented in January 2024.

It is very clear that the health insurance system we have is not effective. There is not enough competition. The story is that health insurance is not even helping people who have it because they do not get any reward for having it. They have to wait six to 12 months, the same as people on the public waiting list. That is not right. I do not begrudge the people on the public waiting list. They must be looked after as well. However, the people who are paying are not getting any reward for it.

I have another matter to raise with the Minister of State, of which he is likely to be aware. HSE management and administration-grade staff in the Fórsa trade union commenced industrial action on Friday, 6 October. Unfortunately, one of the areas affected is the processing and answering of parliamentary questions and representations. This is hurting me and every other public representative, especially in the area of home help. I had a simple request, on or about 7 or 8 October, related to a case where the woman of the house is seriously ill. The family has pulled out all the stops to try to assist her. She always got up between 8 a.m. and 8.30 a.m. She is after getting notification that the home help will not come to help the family member who is staying at home to get her out of bed until 11 o'clock and the home help will not come back again until 5 o'clock in the evening. What the family is saying is that spending this amount of time in bed is not good for her. The day is too long from the time she goes to bed in early evening until the time she gets up in late morning. It made a very simple request. Have I got an answer about the case since? No, and that is not fair. I am asking the Government to deal with whatever gripe, grudge or concern the staff have. They are saying they are not being recognised or being paid for the grade they are working for.

There is another thing, and this is a fact. I will call it out one of these days if it is not sorted out. I have been reliably told something by the home helps, who will not leave, and I have to compliment them as they do their work so diligently. However, they have been told by their manager that they will not be paid for the overtime they have worked. They helped the people who went off sick by taking their places because they did not want to see the patients short-changed or not seen after. They went to help their comrades who were off sick or had to go somewhere. Then they were told by the manager that they were not going to be paid for the overtime. There has been a lot of talk in this Chamber about trying to keep people in their homes for as long as possible and they save the State a fortune when they do not go into hospitals.

I am asking the Government to sort this out. It says it has funds and it gave the HSE more funds the other day. Someone has to be responsible and call them out for what they are not doing. They are not helping the patients and in the healthcare system in many parts of my county, people are being short-changed. I have a lot more to say. When the motion is discussed later on I will highlight a couple of other very serious issues because the care of our elderly people is of paramount importance.

I welcome the opportunity to speak on the Health Insurance (Amendment) Bill, which is legislation that is introduced annually. I thank the Department and the Minister for the work. That will be the end of my praise as I will now I go into the background as to why this is necessary. It is a short Bill of ten pages and seven sections. We go through this process every single year. What we have created here is a necessary mechanism to equalise the risk faced by different insurance companies.

The briefing paper has been very helpful. For anyone listening to this subsequently, it is important that it has been spelled out that the risk equalisation is a process that aims to equitably neutralise the differences in insurance costs that arise due to differences in the age profile and health status of the health insurers' customers. In the limited competition that we have, with a small number of insurers, VHI - which is non-profit - would be left unable to cherry-pick whereas the other insurance companies could cherry-pick who they decide to insure or not to insure, depending on age or vulnerability. In that sense, this is very welcome legislation because it equalises that risk.

However, when we look at why this legislation is necessary, the word "surreal" comes to mind. I will go with facts first and then go into the surreal reason this mechanism and legislation are needed every year and also the hypocrisy of Government after Government with regard to the commitment to a public health system, while all the time promoting the private system, albeit on a non-profit basis with VHI. Due to pressure arising from EU free trade laws, the health insurance market had to be opened up. That was hailed as great progress, and it was if one takes a limited view of it because it opened up the sector to more insurance companies. The Minister of State may remember when BUPA came in. It was one of the first, and one of the first to leave when it did not get its own way on risk equalisation. It fought many court cases to stop that.

In the time I have, I will give some background and address why we are praising a scheme like this. We see what the naked market does when we look at what BUPA did in bringing the Government to court after court with regard to the equalisation scheme. If BUPA had won, it would have meant the insurance companies could have cherry-picked who they wanted.

Prior to the market being opened up 30 years ago, VHI had a monopoly. In June of this year, we learned that 2.46 million people, almost 50% of the population, or 47.6% to be precise, have health insurance, the annual cost is over €1,500 per year and so on. In 2022, the total premium income was €2.93 billion. As Deputy Shortall mentioned, the actual money collected in premiums is tiny relative to the spend by this Government and other governments on providing a public health system. Yet, that income, and the entitlement that goes with a premium, allows extraordinary leverage to consultants and patients and also a sense of entitlement, all of which I hope to come back to.

I am someone who has seen the system from both sides, having had the privilege, through family, of having VHI membership in the past. I am no longer a member. Interestingly, the size of the private insurance market grew by 3% in 2022 compared with 2021. There are 79,553 more people with health insurance, which, although it is a relatively small number, is an extraordinary increase at a time when the Government and its predecessor have committed to a universal public health system. There was cross-party agreement under Sláintecare that we would go down the road of public medicine, with equal access for everybody, and that insurance, and certainly the tax relief on it, would be phased out. People who continued to choose to have an insurance policy would do so in the understanding that they would be treated in a private hospital, full stop, with no more access to the public system. I am sure the Minister of State and a lot of his colleagues in Fianna Fáil agree with that. The problem is that Government policies have complicated matters no end and we now have a surreal situation whereby a State-owned company, VHI, is actively promoting private medicine. "Surreal" does not capture what successive governments have done.

Looking back to 2004, which is almost 20 years ago, the ESRI's report, Health Insurance in Ireland: Issues and Challenges, stated in its conclusions:

Almost half the Irish population [at that time] now pay for private health insurance, one of the highest levels of coverage in the OECD. This is despite the fact that everyone has entitlement to public hospital care from the state, and hospital care is what private health insurance mostly covers. The insured can avail of "private" health care, although much of the private health care is actually delivered in public hospitals.

A scheme was set up to encourage people to take out a premium in order to be entitled to treatment in public hospitals by paying privately for the right to access.

The report goes on, "The resulting two-tier system is now widely regarded as problematic from an equity perspective, but there are also serious efficiency issues to be faced because of the incentive structures embedded in this particularly close intertwining of public and private." It points to the incentives in place to attract more private patients to public hospitals in order to gain income. The report further concludes, "The recent introduction of competition in the health insurance market, in a tightly regulated setting, has led to the introduction of a wider range of insurance products." The Government, ostensibly, was doing something good in opening up the competition. However, as the ESRI clearly sets out, this did not address the fundamental problems of inequity. The report states, "The Irish experience shows that a structure designed to take advantage of possible benefits for the public system of close interaction with private care can create perverse incentives, be inequitable in terms of access and utilisation, and undermine the public system. The political economy of reform is however highly problematic."

That report was written 19 years ago. I can go back further. In 2001, the national health strategy stated openly that the public-private mix of beds in public hospitals was intentional, in order to ensure the two sectors could share resources, clinical knowledge, skills and technology. However, the overlap also gave rise to complex incentive patterns and concerns about equality. In 1989, the Commission on Health Funding recommended the introduction of a common waiting list. We had got to the point in this country, which had been declared a Republic in 1949, that we needed a commission to tell us that a common waiting list was required, that we should not be distinguishing between private and public patients and that service should be prioritised according to medical need. It goes on and on.

I spent ten years of my life as a member of a regional heath forum, which I have referred to many times in this House, as did other councillors. I watched the systematic undermining of the public health system and, simultaneously, the promotion of the private system. I was a member of a city council that took a majority decision to rezone land to allow a second private hospital to be built in Galway on the basis, the councillors agreed, that 20% of the beds would be reserved for public patients. We often talk about misinformation. This was a total fallacy, a total lie and total misinformation. It has never been the case that 20% of beds were kept for public patients.

What happened was that the National Treatment Purchase Fund was set up 21 years ago. Many of us are old enough at 21 to have a sense of reason and to realise our mistakes. The fund was established in 2002 to treat patients who had been longest on public hospital waiting lists. It should be remembered that the Government was actively promoting the private system while this was being done. Twenty-one years ago, when the fund was founded, it had an allocation of €5 million. In 2023, a total of €150 million was allocated to the fund. For what has it been used? Where the public system had failed to treat patients, funding was being provided for treatment in one of the two private hospitals in Galway city or the one in Kilkenny, for example, the North or abroad. What kind of a farcical, surreal system is that?

In the meantime, while that is happening, there are cases such as one to which I will refer without naming names. A person came into my office who was waiting for a hip operation. I never like anecdotes but this case goes to the kernel or heart of what we are talking about here. The person was on a waiting list in the public system. The wonderful consultant, who has both public and private patients, offered to do this person's procedure privately for €12,000. The person went off and got a loan for €12,000 to get the hip replacement done. This patient is in limbo now, needing a second operation. Using the private system will require payment and the person has been taken off the public list. A payment of €12,000 is being asked for by the same consultant who has stood over a long list building up in the public system. I do not hear voices raised in outrage about that.

As background to all of that, we have 588,813 people on outpatient waiting lists nationwide, of whom 81,356 are children. These figures have been stated here repeatedly. I will be parochial in referring specifically to the orthopaedic service in Galway, where there are 6,694 adults on the outpatient list, of whom 1,230 have been waiting 18 months or more. We should remember that we have a thriving private system in which patients who have €12,000 can get the job done. In the meantime, 1,230 adults are waiting 18 months or longer in Galway. There are 622 people on the UHG orthopaedics outpatient list, of whom 261 have been waiting 18 months or more. On the inpatient lists in Galway, 118 adults are waiting 18 months or more. According to Trolley Watch, on Tuesday, 22 November this year, 562 patients were on trolleys nationwide, of whom 428 were in emergency departments and 134 closeted away on wards. There were 39 patients on trolleys in Galway, 31 of them in the emergency department, which is not fit for purpose and is currently operating in temporary accommodation, and eight in wards elsewhere.

In this scenario, the Government announces a recruitment freeze that, it tells us, will apply only to management and not to consultants, nurses or midwives. Then a little more information comes out from the head of the HSE, whom I admire as an honest and straight person. I have heard him speak at the health forum in an absolutely blunt and straight manner. He tells us the recruitment freeze is not exactly what we have been told it is; it is more than that. In the meantime, we get letters from clinical psychologists and speech therapists telling us the recruitment ban will affect them.

Even more bizarrely, a speech therapist tells us that she is working through an agency, which is costing the health executive more money. I will not use up my time in reading out the letter but I am sure we all got these letters spelling out clearly what is happening around recruitment.

On top of that, when I was on the health forum I was told there was no money, that there had to be cutbacks and refurbishment of beds, and that people could not be employed. Since I came to the Dáil I am being told that money is not a problem and it is just that staff are not available. As I stand here I know there are five empty beds in the nursing home in Carraroe. Tá cúig leapacha folamh i gcroílár na Gaeltachta mar níl siad in ann foireann a fháil. They cannot get the staff. Now we have a staff recruitment freeze. Honestly. I have used the word "surreal" and I do not use it easily. I really have a difficulty in fathoming what is going on here in relation to a freeze on staff recruitment.

We have delayed discharges in the hospital in Galway. Some are for years because there are no nursing home beds. We have privatised the whole nursing home sector. I believe it is 17% that are public nursing home beds now. Can one imagine that it is 17%? Yet, on any given week when we open the newspaper we see another private company in trouble. The Minister of State, Deputy Butler, has acknowledged it - and it has been in the newspaper - about the nursing home company Aperee Living which owns a company in Galway as well. There are huge problems there in relation to governance, fire safety and so on. Who will pick up the pieces? It will be the public purse. It has happened repeatedly. It has happened in Oughterard, County Galway, where it was necessary to send in public nurses to operate the private nursing home. Most of the nursing homes now are huge companies.

I will now turn to primary care. As of the end of 2022, there were 160 primary care centres open nationwide. What is happening in relation to those? The vast majority are owned by companies. Indeed one of the company directors was the former head of the health executive who saw the gaps and the opportunities. The private companies are now providing the primary care centres and we lease them back. Does that make sense? Does it make sense that while we are ostensibly going down the route of Sláintecare and public medicine, at the same time we are promoting private insurance and private primary care, which is supposed to take the pressure off the hospitals? We have privatised it almost completely.

Does the Minister of State, Deputy Calleary, have any idea what analysis or risk assessment has been done on the move by this Government and the previous Government to provide health centres that are all owned by for-profit companies? What happens when they get into trouble? What happens when they fold? What do we do then?

There was an options appraisal in Galway back in 2019 on the future for Galway hospital services. We have the regional hospital, the Merlin Park hospital and two private hospitals. I foolishly relaxed when I saw the options appraisal going for a brand-new hospital in Merlin Park to be built for purpose. Nothing happened. When I asked lately, I found out there was a second options appraisal carried out a few years after that and suddenly they said they would keep building up the congested site and would put up a few little places in Merlin Park hospital, so the new elective hospital would be in Merlin Park and a new surgical hub. The original plan for a brand new hospital went - I was told by the clinical director - because the Government failed to act or give them the thumbs up for that options appraisal. We are now, therefore, down the road of a different options appraisal that is leading us to build on the congested site, build in a jigsaw manner without an overall picture for Merlin Park hospital, and constant delays.

Consider the accident and emergency capability. The then Minister for Health - the current Taoiseach - said that a new building was the only solution to the problems in University Hospital Galway. In 2015, Enda Kenny said that the ED was not fit for purpose. The 2016 programme for Government committed to looking at it and so on and so on. We got an interim ED - I believe it was for €15 or €16 million - which opened in October 2022.

It is hard not to despair. How can the Government not see that a public health system with equal access for everyone is the most fundamental requirement of a republic, as is housing that gives shelter, in order that people can then participate in society on an ongoing basis? The kernel is to have shelter and access to public health. Instead of that, we have privatised in every way we can, including allowing doctors to have a private building in Merlin Park for diagnoses.

I will finish on osteoporosis. There is a fantastic public service but not enough equipment. Everybody is directed to the private clinic for osteoporosis scans.

Gabhaim buíochas le gach Teachta as ucht a bheith páirteach sa díospóireacht ar an mBille seo. A high proportion of the population holds health insurance. The Government remains fully committed to the Sláintecare vision of a universal single-tier health and social care system. Work is consistently continuing within the Department of Health and the HSE to progress work on Sláintecare. The Minister, Deputy Donnelly, and the Minister of State, Deputy Naughton, are fully committed to the continued delivery of Sláintecare reform. Private health insurance policy aims to progressively align with Sláintecare reform objectives but it is important to maintain the effectiveness of the community-rated health insurance market and the risk equalisation scheme that underpins it while that work is ongoing.

This Bill is to ensure we can continue to provide the necessary support to ensure the costs of health insurance are shared across the insured population. Risk equalisation credits based on age have been reallocated to those based on health status without increasing the stamp duty payable. Increasing the proportion of credits associated with health status helps to share risk more effectively across insurers.

The programme for Government commits to retaining access to private care health services for people in Ireland, ensuring choice for those accessing healthcare. This Bill continues our policy of ensuring solidarity with, and affordable premiums for, sicker and older people. On behalf of the Minister, Deputy Donnelly, I commend this Bill to the House.