Wednesday, 21 July 1971
Seanad Eireann Debate
Save as otherwise provided in section 4 of this Act, health contributions shall be payable by persons who, by virtue of section 46 of the Act of 1970, have limited eligibility for services under Part IV of that Act, not being either persons referred to in section 46 (1) (d) of that Act or persons belonging to a class prescribed for the purpose of this section.
This impinges on what we have already discussed. It is correct to say that by placing No. 6 on the Order Paper today before this item we save time in that we would be discussing on section 2— we may have to have discussion on section 3—as to what “limited eligibility” means.
The Minister has made an effort to define “limited eligibility” in the regulations. However, it is not as cut and dried as most things of this nature should be. I can see a difficulty in having very definite grades such as a very definite lower limit and a very definite upper limit. I can see certain advantages in that, but there are other elements that enter into it. I will not delay the House any further on this point because I have put down an amendment to section 3 and when that comes up for discussion I can speak on the question of eligibility. So far as I am concerned I am prepared to let section 2 stand.
Mr. Boland: As Senator Belton has said, the earlier discussion relates to this discussion. The Minister will recall my asking him about the possibility of extending the limited liability clause in future to all classes of employed persons. If the Minister decided that this was practicable and that it was a good thing, would he be entitled to so extend it under this section? In other words, could he extend the limited liability class to such an extent as to embrace virtually all employed persons, or would it require a further Bill? As it stands, it would require the introduction  of a new piece of legislation, whereas with some slight modifications of this Bill he could have provided for what will be inevitable in the next few years.
Mr. Childers: I understand that there is no need to bring in a new Bill. This Bill could be used, and if by chance there was an extension from £1,600 to a higher figure, then we should bring a regulation before the Oireachtas. The Bill could remain in its present form; it would be a matter of simply amending the upper limit, by way of regulation.
That is approximately a definition of full eligibility and we had some discussion on it. However, the main reason why I put down the amendment was that the Minister in the Dáil, I think on the Second Reading, said in reply to Deputy Tully that regulations defining eligibility would be brought in during this session. In his explanatory memorandum to the regulations the Minister explains the reason for not defining full eligibility.
My amendment will not be pressed to any great extent, although it is  desirable that we have a far clearer definition of full eligibility. At least we should have some consistency throughout the country. Much of this has been adverted to already. The Minister himself called for a more consistent method of valuation throughout the country. A discrepancy in valuations from county to county exists to some extent at the moment. The decision as to who is eligible was with the county manager until the 1970 Act came in. Now it is at the discretion of the CEOs of the eight health boards established under that Act.
There is still room here for inconsistency. As I mentioned when I was speaking about the regulations, I think that if the Minister could get together the CEOs of the various regional boards and have discussions with them periodically about their methods of deciding what full eligibility is, it might go to some degree to meeting the amendment I have down here. I put it down because it is my understanding that it is quite impossible to define full eligibility. Indeed, it is quite impossible to define limited eligibility unless one has a definition of full eligibility. The lower limits of limited eligibility can never be understood until the upper limits of full eligibility are understood. It has been said that there is a certain area of greyness between the upper limits of full eligibility and the lower limits of limited eligibility. Perhaps the Minister sees some difficulty in it and may not want a complete definition of full eligibility. There should be some understanding throughout the country at large, and some consistency throughout the various regions, as to what full eligibility means.
I should like the Minister to accept my amendment, and the intent behind the amendment, I should also like him to accept the remarks that I have made and to ensure that there will be consultation between the CEOs and the Department. He should receive from the Valuation Office certain information that may be necessary when there are discrepancies from county to county as at present, and from health board to health board. Even within a health board there may be discrepancy from county to county. If the Minister  would take into consideration the points I have raised here, I would be willing to withdraw the amendment. It will depend on what the Minister says.
Mr. Honan: On Second Stage we discussed at length the question of eligibility. Senator O'Brien mentioned the difficulty of having too rigid regulations. A big number of factors must be taken into account. As he rightly said, there could be two families each with an income of £16 per week but one family could be twice as well off as the other. There may be a lot of sickness in one family and there may be difficulties such as bad household management. However, I do not consider it practicable to lay down rigid rules, because they would create more hardship than they alleviate.
How this is to be finally adjudicated perplexes me. The people operating the health authority in County Clare knew practically everybody they were dealing with and they had personal knowledge of their conditions. Now that health authority has moved away. I do not know how somebody in the health authority in Limerick will be able to adjudicate on the case of a person living in Clare. I have had the experience very recently of going into the health office in Clare and being told that they had no function in this matter any more. I think myself the suggestion I made on the Second Stage of the——
Mr. Honan: I just wanted to make the point that there will have to be some deciding person. If there were trained almoners they could act as intermediaries in the final decision between the authority and the person involved. Somebody must operate between the authority and the person. I should like once again to emphasise that an almoner is urgently required to act between the chief executive officer and the person who is making a claim.
Professor Jessop: This might be an appropriate time to ask Senator Honan not to use the word “almoner” in this  connection. An almoner is somebody who gives alms. This is an ancient title given to women working in hospitals to make it easier for patients to get over their illnesses. It should not be applied to people who go around collecting information about the standard of living and so on which might be a possible disadvantage to those applying for benefits. The word is obsolete now and those concerned have asked to be known as medical social workers, and in that connection it is even less appropriate to use that kind of person for this purpose. I quite agree that somebody with a skill of that kind is required to get this information for the local authority or the chief executive officer, as the case may be. I do not think it comes within the category of the medical social worker.
Dr. Belton: The reason I have this amendment down is that, if the Minister is going to define eligibility, it should be done before the measures envisaged in this Bill are enacted. I am not disputing what Senator Honan has said; neither am I disputing the Minister's explanation in his explanatory memorandum. I quote now from col. 232, Vol. 250 of the Dáil Official Report, where Deputy Tully said:
It has been my experience that if the breadwinner, and it is the breadwinner who has to pay this extra impost, goes to hospital on very rare occasions the local health authority pay the 50p or make arrangements so that at least the person concerned does not have to pay for it. I thought the Minister would start off by deciding who is entitled to a medical card but he says he is going to bring in regulations some time to make that decision.
Dr. Belton: No. I explained, while the Minister was absent, that the reason I put down the amendment at all was his reply to Deputy Tully that he was bringing in regulations to cover eligibility in this session. I understand the Minister's difficulty, and to some extent I agree with what Senator Honan has said about the difficulty involved in the definition of eligibility. But I felt that eligibility should be defined before the measures envisaged in the Bill were enacted. That is the reason for my putting down this amendment. But, as it is now on record, I am prepared to withdraw the amendment and let us go on to discuss the section.
Mr. Childers: I thank the Senator for withdrawing the amendment. As the operation of the health contributions scheme is not dependent on the publication of medical card limits, people who have cards may claim exemptions. I could not accept the amendment, but I have given an assurance to the House that the chief executive officers are looking into this question of providing a consistent system of full eligibility limits. They will try to do this and have group limits as consistent as possible. These will become known to the public so that everyone will be aware of the position. This will not be easy but we have prepared a great deal of statistical information. We have an officer from the Department who has been to a great many counties and has gone fully into this question. The practices very a great deal. Some counties assess full eligibility on farmers on a general valuation basis but the majority of health authorities have assessed full eligibility for farmers on an income from the farm basis. All those matters have to be gone into by the chief executive officers so that we  have a consistent arrangement. That is all I need say at this stage. I went into this in some detail on the occasion of the previous regulations coming before the House.
This whole Bill was opposed by us on Second Reading and, as the Second Reading was agreed to, we now have to make do here with the best we can get out of this. It is not our intention to obstruct the Minister. If we take that imposition on the limited eligibility class, or the middle income classes as some people refer to them, in conjunction with section 12 (2) (a), it means that the Minister can increase, by regulations, the rate of contribution in either of these categories. If my reading of section 12 is correct it means that the Minister may make regulations in relation to any matter referred to in this Act as prescribed or to be prescribed. I may be wrong, but I think this is the section which empowers the Minister to increase the rate of contribution.
Dr. Belton: A certain fear entered my  mind during the Minister's reply on Second Reading. He was replying to a statement by Senators, including myself, that the new rate of contribution would be an incentive for people to go into hospital. The Minister said in reply, and I quote from Vol. 70, col. 1265, of the Seanad Official Report:
The first observation made by Senator Belton and others was that this new contribution would encourage middle-income group people to go to hospital. If they go to hospital excessively their contributions will go up again.
It is implied therein that at any time the Minister or the Department thinks that contribution needs to be raised this method can be used. This is the thin end of the wedge. Of course, the Minister is collecting £5 million a year by these contributions and he is relieving the contributors to the extent of £700,000 by abolishing the daily charge of 50p in the hospitals.
The amount the Exchequer is receiving is approximately £4.7 million, not £4.3 million. That is a lot of money for a contribution compared to the benefits these people are receiving. The danger is that this system will be used in the future as an easy way of collecting money for the Exchequer. I have great faith in the present Minister's intention that this money will be devoted to health. However, under a further amendment later on, the Minister must get the consent of the Minister for Finance; and if this is not forthcoming even the present Minister may be prevented from devoting to health matters what has been collected here.
Mr. Childers: I thought I made this. clear to the House on Second Stage. We are now repeating the debate we had on Second Stage. I made it absolutely clear to the House in a very honest way, if they refer to my speech, that I did not know of any consistent method of paying for health services in any country of Europe. I said that it was a piecemeal system that had grown up in the course of years and that all the perfect systems had been shattered completely, such as systems involving patient charges plus contributory insurance.  They had been shattered by the enormous increase in the cost of hospital services. I cited in particular Denmark, the Netherlands and Sweden in that connection. I pointed out that in the case of the British the insurance contributions were supposed to provide the cost of the health services and only 12½ per cent of the cost of these services is paid for out of insurance. All the rest is collected in the form of general taxes upon the community.
I made it clear that, in deciding how to pay for the cost of the health services in respect of the middle income group, it will have to be based on political hunch, human psychology and the requirements of the service. I did not know how to define the limit to which one could charge health contributions or evolve a psychological or financial formula for it. I explained to the House on that occasion that the middle income services totalled £35 million and that nobody would presume that I could collect 105p instead of 15p by way of contribution, because it would be quite impossible to know how to relieve the middle income group of the taxes and rates that they were paying to cover their share of the middle income group's services. I made it clear that we would move carefully in regard to this.
It is also provided for in the Bill that, if the amount was increased measurably over the 15p per week or £7 a year, we would have to do it on a pay-related basis. I shall have the benefit of the advice of the Minister for Social Welfare who is looking into the whole of the Social Welfare code with a view to having a pay-related scheme. It is a very complex matter. That is the best advice that I can give to the House. If we increase the contributions, the Bill will have to be amended and it can be discussed all over again.
I have noticed that Senators on both sides have no material at their command to tell me that there is anything particularly wrong with £7 a year applied to the middle income group. I am convinced that it is an amount so low that the middle income group can afford to pay for it. When we reach the higher limits there may be controversy  and more care may have to be exercised in deciding on a higher limit. I have been absolutely frank with the House on this matter. When my predecessors were asked to completely re-shape the whole methods by which health services were paid for, they were in the most frightful difficulties. You cannot create a revolutionary new system for paying for health services without running into problems of all kinds and particularly the problem of the psychological impact of taxes, rates and insurance contributions on ordinary human beings. The psychological impact can be quite illogical in many cases. People may feel they will refuse to pay a particular tax and throw the Government out because of it.
This Government has had a long record of administration. Whatever mistakes we have made—I am certain we have made mistakes from time to time in our levying of taxes—we have managed to shape the taxation system on an accumulative basis. We have arrived at the present level of taxes. Now there is argument as to whether they are sufficiently progressive or whether they are regressive. The argument seems to me to be limited to the time of Budget debates and it relates generally to particular proposals in the Finance Bill or particular new impacts of taxes. I do not think I can say anything more about it.
To delete all words from and including “disposed” in line 48 to the end of the section and substitute “devoted to financing in part the health services for the country at large provided that any intended grant or intended supplementary grant to a Health Board shall not thereby be reduced.”
To delete all words from and including “disposed” in line 48 to the end of the section and substitute “devoted to financing in part the health services for the country at large and that any intended grant or intended supplementary grant to a Health Board shall not thereby be reduced”.
The main purpose of this amendment is to ensure that the consent of the Minister for Finance would not be necessary. The Minister for Health may reply that this consent is usual. However, when we were discussing why this method of raising money had not been introduced in the Budget, where it would normally come under the control of the Minister for Finance, the Minister for Health said that this was a health matter and that the resultant moneys would be devoted to health. The hands of the present Minister and those of his successors will be tied if we keep the words in this section “with the consent of the Minister for Finance”. The Minister for Finance will not give his consent. By not giving his consent, it is tantamount to appropriating money that is being collected for health purposes and allocating it to other purposes. The intent of this amendment is to prevent the Minister for Finance from so doing. I am not suggesting it might happen. It is not good legislation, and never was good legislation, to say something in a Bill could happen. The interpretation of the section as it stands without the amendment is that the Minister for Finance could refuse to allow the Minister for Health to allocate the money which is being collected under this Bill for health purposes. It has been said that £5 million will be collected, or that there will be a net sum to the Exchequer of £4.6 million. All of that should go  towards health purposes. The ultimate decision should be left with the Minister for Health and the Minister for Finance should not interfere in any way with the distribution of that money. The Minister for Health should devote that money to the country at large, so that there would be some relief for the rate-payers in respect of health charges. I also hope that this would not prevent the Exchequer from giving supplementary grants to health boards for the relief of rates. I know this may be only a pious hope.
As we all know, the cost of the health services is rising so rapidly that the imposition on the rates will be so catastrophic as to cause an outcry. I want to retain all this money, plus whatever would be intended as a health grant or supplementary grant for health purposes. That is the purpose of this amendment.
Mr. Childers: First of all, in reply to Senator Belton, the Minister for Finance cannot appropriate the income arising as a result of the passing of this Bill and the contribution system from persons in the middle income group. You cannot appropriate for other purposes, and section 2 of the Bill makes it perfectly clear when it states:
There shall be paid, in accordance with this Act and regulations thereunder, contributions (in this Act referred to as health contributions) towards the cost of the provision of services under Part IV of the Act of 1970.
Secondly, Senator Belton spoke of a pious hope that I could guarantee that the whole of this health contribution revenue would be devoted to the relief of rates. We hope that the rates will be relieved to a greater extent in the future as a result of the collection of these contributions, but I could not give the House an absolute guarantee of that. I merely state it as an objective that the collection of these contributions will tend to relieve the rates. Therefore,  I am afraid I cannot accept the amendment.
Dr. Belton: I know that it is the Minister's intention. I know what is in section 2. But at the same time, section 8 says: “Regulations made by him”— that is the Minister for Health—“with the consent of the Minister for Finance”. What then is the purpose of having the consent of the Minister for Finance in section 8?
Dr. Belton: This is what I am getting at in this amendment. I know that under section 2 the intention of the Minister is that it should go to health. I am aware of that. But the words “with the consent of the Minister for Finance” are superfluous unless he can refuse. There is no point in having them unless they empower the Minister for Finance to refuse; they imply he has the power to refuse.
Mr. Childers: The Minister for Finance must have some say in the way this money is spent, because money is raised from taxes, from rates and from the Hospitals Trust Fund. It is only reasonable to suppose that in the utilisation of this contribution revenue the Minister for Finance would wish to give his consent to the method by which it was used. That is entirely reasonable and it has come into a great deal of the legislation in this country for years. When there is anything connected with finance, the Minister for Finance gives his consent. The Senator knows this very well. In the legislation passed ever  since the State was founded this has been the case.
Dr. Belton: I am sorry to press this, and I do not want to delay the House. The words “with the consent of the Minister for Finance” imply—and I repeat this—that the Minister for Finance will have some control over the disposal of the moneys collected under this Bill. Otherwise, there is no necessity for that phrase.
Mr. Childers: I cannot go into it any further. The Senator knows perfectly well that the Minister for Finance has this power in respect of a great deal of legislation of all kinds. You will find it in relation to social welfare legislation too.
Mr. Childers: Yes. I am obliged to do that when this Bill is passed and is signed by the President. I cannot do anything else. Section 2 makes it perfectly clear that these contributions must go towards the provision of services under part IV of the Act of 1970.
Mrs. Robinson: I introduced this amendment because, as I said on Second Reading this is largely an enabling Bill. What it does or what will happen under it depends on the Minister making regulations, and there is a very wide power to make regulations. I have sympathy with the Minister in this. The Bill is just a skeleton which will be filled out by regulations of the Minister from time to time.
Nevertheless, I am very concerned that Parliament should have control, to the greatest extent possible, of the way in which these regulations and this power are implemented. Therefore, I welcome the fact that in section 12 there are two sorts of regulations and there is a different provision for each. In relation to the first type of regulation —these are regulations under section 3, subsection (2) and I want to add “and subsection (5)”. The Minister has first of all to obtain the consent of the Minister for Finance for the regulations and lay them before the House and they must be passed by resolution of the House, as the regulations which we considered earlier today had to be passed in draft by resolution of the House.
This is very valuable. It gives the Seanad an opportunity to discuss these regulations. It is important in areas like this that the regulations should be laid in draft. This can be contrasted with the other type of regulation which is laid before the House but which is only subject to a provision that if it is annulled within 21 days it will no longer be operative. All of us have been long enough in the House to realise that these regulations are very rarely referred to and very rarely debated. This is not a very good method of holding a watching brief on regulations; it is not a very good method of control and does not compare with the laying of the order in draft before the House.
Referring back to section 3, subsection  (2) provides that the health contributions shall, in the case of persons other than those mentioned in section 46 (1) (c) of the Act of 1970, be at a rate related to the person's income and fixed by regulations made from time to time by the Minister for the purposes of the section, and also under section (b), and these are the regulations to be laid in draft. Subsection (5) of section 3 states:
The Minister may, by regulations made with the consent of the Minister for Finance, define income for the purposes of this section, either by reference to any other enactment or in such other manner as he thinks fit.
I think this is crucial to section 3, subsection (2). If the Minister can define income “either by reference to any other enactment or in such other manner as he thinks fit,” then he can use this definition of income by regulation, which does not have to be laid in draft before the House and which might not come to the notice of the House, to get around the provisions of section 3, subsection (2). He could use the redefining of “income” to avoid the necessity of any regulations under section 3, subsection (2) and yet substantially change the range of people who would be provided for in section 3, subsection (2). In drawing up the provision for the regulations in section 12 it is logical there to include subsection (5). This is something to which the Minister should have no objection because it is the type of control that is intended in the Bill.
I am not saying that the Minister would abuse his powers and evade the subsection by redefining “income” at his discretion—and I think he will admit he has a very wide discretion there, “either by reference to any other enactment or in such other manner as he thinks fit”. I do not think the discretion to define income could be wider. I do not think the Minister would abuse this, but we are now drawing up legislation for the future and we must be concerned with the way in which it is drafted; and it is logical and desirable that subsection (5) be included in the types of regulations which must be laid in draft and which would come to our  notice and require a positive resolution of the House.
Mr. Childers: I am afraid I cannot accept either of these amendments. As Senator Robinson has said, the regulations under section 3, subsection (2), which fix the actual proportion of income to be represented in the graduated contributions that may come later, must be put to the House in draft form and approved before they have effect. It would be only right that the Dáil and the Seanad should be able to debate formally the actual proportion of income, whether it is 1 per cent, 2 per cent, 3 per cent or 4 per cent of people's income.
When it comes to section 3, subsection (5) in which the Minister has power to define the income on which a person's graduated contribution will be determined, this is purely for administrative purposes so that the Revenue Commissioners can operate the graduated scheme. In practice the definition of income would be as for income tax and there would be no departure from that. When the regulations are laid before the Houses of the Oireachtas and annulled within 21 days it would be very easy for anybody in the Dáil or the Seanad to notice that the Minister for Health of the day, with the connivance of the Minister for Finance, had entirely altered the principle of assessing income. I do not think it is necessary to have a special resolution in regard to this; it is a purely administrative matter. As I have said, the definition of income would be as for income tax.
Mrs. Robinson: If that is the case, why not state here that the definition of income would be as for income tax purposes? My quarrel with this is that, as it is phrased, it gives a very wide discretion. I do not think it would be a very difficult matter for the amendment to be accepted, so that any definition of income would come before the House in draft. If the unlikely happened—and I accept the Minister's contention that it would be unlikely—that the definition of income would not be the same as for income tax purposes, I still think it is  open to the Minister under the terms of this Bill to depart from the usual practice and to define income as he thinks fit. If he does so, it is only coming before the House in the form of a regulation subject to annulment. I ask the Minister to accept that most of these regulations do not even come to the notice of the House, as happened recently in relation to the salaries of judges, and this is not a sufficient control. The Minister is arguing the point in such a way that I find it hard to understand why he would refuse to accept this amendment.
Mr. Childers: I am sorry. I have made the position clear. I cannot put the words “income tax” into the Bill without saying “to define income as being for income tax purposes.” It is too loose a thing to do and is not practicable. Any Government would be in shocking trouble if they took advantage of a Bill such as this to distort the definition of income and what it is generally accepted to be. I do not think any Government would dare do it. If there was a departure in relation to the method of defining income, the Minister of the day would have to publish this specially so that the Dáil and the Seanad could ask for a debate within 21 days. I do not think there is any need for a special debate on the subject by way of resolution.
Mrs. Robinson: I am very reluctant to be put in a position where I take a Minister's assurances that very wide wording in a Bill would not be construed as I can see it could quite clearly be construed. The argument the Minister has raised is therefore an argument for clarifying the meaning and allowing the regulations to be as for the rest of section 3, subsection (2) and providing that regulations under the section would also be included in draft. I would think that they would very often go together and that the Minister in drawing up regulations under section 3, subsection (2), would also draw up regulations under subsection (5). It seems to me to be lacking in logic as well as lacking in  the proper control of this House that they would not be laid in draft before the House. In view of the fact that the Minister is confident that there would not be any variation from income as defined for income tax purposes I withdraw the amendment.
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