Dáil Speech on Universal Health Insurance
The White Paper is utterly unconvincing. It is a White Paper in name only and perhaps by virtue of the fact that it is printed on white paper. That is all that makes it a White Paper. A White Paper is supposed to be preceded by a Green Paper which sets out the broad thrust of an approach to a particular issue. A White Paper is intended to fill in the detail of the approach at a later stage and following discussion. This White Paper contains no detail of any kind. It is in effect a Green Paper. It sets out the very early stages of a notion which has not been thought out at all. It is clear from many of the contributions from the Government benches that not only have people not read the document, but they cannot answer questions on any of the detail involved in the proposal.
This is an attempt to paper over the cracks of an entirely leaderless health service. Nobody knows where it is headed. One must recall that on the day the White Paper was launched, an Assistant Secretary General in the Minister’s Department admitted that it posed as many questions as it answered. That says it all.
One must ask what expertise was used to draw up the document. Immediately after the general election, a commitment was made to establish an implementation group. There was a long delay and it was a year after the election before it was established. The group brought together a number of international and national experts to examine this issue. One of the difficulties is that prior to the implementation group setting about doing its work and examining the detail of what is required for a new model in this country, it was specifically precluded from considering any other type of model, such as a social insurance model or an NHS-type model. It was constricted from the very start and could only examine multi-payer private insurance models. This was a very clear direction given to it by the Minister for Health. This was not an objective exercise to look at what system is best for Ireland. It was an attempt to shoehorn a particular ideological position of the Minister into a draft policy. We did not have a fully objective examination of the system or objective recommendations on what the country needed. Another question I must ask about the implementation group is what input it had to this document. It is very difficult to see that any of its thinking was brought to bear in any serious way. I must also ask, given there is no health economist in the Department of Health, whether any health economist had a role in drawing up this document.
It is interesting to note that before the document was published, the word from the Cabinet, and the Departments of Finance and Public Expenditure and Reform in particular, was this was not a sustainable model. This was quite clear. There was a rush to get out to the media to make this point. This could never work because it is far too expensive, would mean a huge loss of entitlement for medical card holders and a huge increase in the cost of private health insurance across the board, with an average figure of €1,600 used. These were very serious concerns which the two economic Departments had on this proposal. In a matter of a couple of weeks, these serious concerns were buried and suddenly disappeared. We then had the narrative that approval was given to the Minister, Deputy Reilly, to go ahead with this so-called plan on condition it would not cost the State any more than it does at present. There is no way to give this undertaking. Who knows what the circumstances will be in 2019? Who knows who will be in government? Stating it
will not be allowed unless it costs the same as it does now just buys time.
If it costs more, what happens? If the State will not pick up the tab, individuals will have to do so and health cover will cost the ordinary individual an awful lot more. If it turns out to be completely unsustainable, which it most likely will, what if this is discovered in two or three years time when the Minister has already dismantled what we have as a public health service? Where do we go then? The system will be in disarray. There is no coherent plan whatsoever from the Government on the handling of this issue. Many questions remain unanswered.
When will we actually have a White Paper on universal health insurance? When will all of the detail be filled out? When will we hear about what the Minister and the Government have planned for our future health service? Does anyone on the Government benches, even after reading this document, actually know what the future shape of the health service will be? What do we know of the future shape of the health service that we did not know before the publication of this document? This does not fill in any of the blanks.
Of course we would all love a more equitable health system, but just because the Minister states universal health insurance will deliver a more equitable health system does not mean it actually will. This depends on a great many factors, most of which have not been addressed. A number of key questions arise.
How basic will the basic package of health insurance be? The experience with the Dutch model suggests the basic package will become increasingly basic, so people who now have a certain level of health cover pay more and have fewer entitlements. There is no doubt this will happen.
What is the future of the services and entitlements enjoyed by people with a medical card? How exactly will the Government prevent insurance companies from denying these entitlements, particularly with regard to free medication? What insurance company will pay for a public health nurse to visit an elderly person to dress a leg ulcer? What insurance company will pay for family support workers to go to vulnerable families to assist them in surviving and keeping children within the family and prevent them from being taken into care? What insurance company will pay for other types of family support and home care supports? This is the big danger. We have a certain level of public health cover at present. It may not be ideal, but the big concern is this basic level of health cover will be diminished even further under this very scatty and ill thought out plan.
Who will pay the wages of the 100,000 public sector health care staff in the system? This has not been addressed. Who will be their employer if the HSE is abolished next year? Who will set the terms and conditions of employment of these workers, particularly when some part of the work may be funded by the Exchequer and other parts may be funded by an insurance company? One cannot just decide arbitrarily that 100,000 public sector workers will work for another entity yet unknown. None of this detail has been worked out.
How will preventative medicine be incentivised in a system where people can switch insurers?
If health insurance is to become compulsory, what will the effective marginal rate of tax be for people who choose not to have health insurance at present?
How is it at all beneficial for our health system to have our public hospitals compete against each other? Surely this will result in a race to the bottom.
All the issues regarding the efficiencies we should be trying to achieve can be worked towards in the existing system, but it is a nonsense and a market view of the world to speak in terms of public hospitals competing with each other.
Who will pay for the myriad of regulatory bodies envisaged in the White Paper? Has anyone actually done a count of the new agencies which will be created? We are told the HSE will be abolished next year, but it will be replaced by umpteen agencies and many different bodies with their own boards of directors, well-paid chief executives and all the rest that goes with it. In recent times we have seen what happened with Irish Water. Who is to say there will not be a repeat of this with all these agencies?
The White Paper states the future model of universal health insurance involves a sea-change in the role of the State. Do people realise this? There will be a sea-change in the role of the State. The White Paper states that, in essence, this change will see the Stage shift from direct financing and delivery of health services, which is what it does at present, to regulation and oversight of a competitive system of purchasers and providers. Our health system, for all its faults at present, will transform into a competitive system of purchasers and providers and the State’s role will be reduced to a regulatory one. Is this what we want for our health service?
A total of €12.5 billion of taxpayers’ money is spent on the health service. What is the sense of rerouting that vast amount of public money through insurance companies that will have to cream off their profits?
The Taoiseach has said that everyone will win, but the opposite is actually much more likely to happen.
The medical card system will be scrapped, in effect, which means that the poorest people will risk losing the current entitlements that are available to them from the State.
People who currently have private health insurance risk losing the kind of access for which they pay their insurance premiums. A great deal of nonsense has been spoken about tackling waiting lists. We know that progress has been made in reducing the amount of time that has to be spent on waiting lists by those who have been waiting for the longest periods of time. However, the amount of time being spent on the waiting lists by those in the mid-range is increasing. The waiting lists are still long; it is just the outliers that are being addressed.
The people in the middle, who choose not to have health insurance because they cannot afford it, will not be able to afford it under this system either but will have no choice in the matter.
The health insurance companies and other price setters in the health system will be the only winners. Under these proposals, we will have a State-sponsored profit system for insurance companies.
If there is anything concrete in these proposals, it is that they will turn a largely not-for-profit health system into a largely for-profit health system. I have to ask whether this is what we want. Do people realise that this is the direction we are going in?
At the heart of these reforms is the belief that competition can solve the problems in our health service. There is very little evidence to support this contention. With competition comes profit margins, which act as an added cost to our health services. It is as simple as that.
People are becoming increasingly sceptical that universal health insurance is actually the most desirable model for our health service.
I would like to remind the House of what the Minister has said about the legislation that will be necessary for these changes. According to this document, “the legislation represents a critical interim step on the path to UHI as it will legally create a purchaser/provider split, thereby preparing healthcare providers to operate as independent entities in the future market-based health system”. Do people in this House and the public realise that we are heading towards a “future market-based health system”? Is that what we want? Is a market-based system what health care should be about? I do not want to see that and I think the vast majority of Irish people do not want to see it.
It is about time people on the Government benches woke up and realised that this is the direction of travel. This is where the Cabinet wants to take us. According to the document, “Under the new system, the Department of Health will have a central governance and policy development role in relation to the health service”, and that is all. In the future, the principal purchasers of health care will be insurance companies. That will apply at primary and community level as well as at hospital level. I believe this is a disaster for our health service. It is not the way to deliver a single tier universal health care system. There are much better models that suit the Irish situation. We should start looking at them. If we go down this route, it will result in a completely dismantled and disjointed health service that will certainly not meet the needs of the people.