Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697804590382.pdf (Ireland)
Bill Digest | Health Insurance (Amendment) Bill 2018 1 Bill Digest Health Insurance (Amendment) Bill 2018 No.

122 of 2018 Anne Timoney, Senior Parliamentary Researcher, Social Science Abstract 19 November 2018 The Health Insurance (Amendment) Bill 2018 seeks to adjust the Risk equalisation credits payable under the Risk Equalisation Scheme that operates in the private health insurance market.

It seeks to increase the number of members on the board of the regulator, the Health Insurance Authority.
The Bill aims to ensure appointees to the Voluntary Health Insurance (VHI) Board have sufficient expertise and experience.

It also proposes to allow the VHI to sell international healthcare policies directly in addition to acting as an agent for same and to provide that it does not need Ministerial approval to do so.
Oireachtas Library & Research Service | Bill Digest 2 Contents Summary ........................................................................................................................................ 6 Table of provisions .......................................................................................................................... 8 Introduction ..................................................................................................................................... 9 Explaining risk equalisation ........................................................................................................... 11 The health insurance market ......................................................................................................... 14 Trend in take-up of health insurance ....................................................................................... 14 Historical context to level of health insurance take-up ............................................................. 17 Providers and market share ..................................................................................................... 18 Position of Voluntary Health Insurance (VHI) ........................................................................... 18 Premiums (consumer prices) and tax relief .............................................................................. 18 Claims – trends and drivers ..................................................................................................... 19 Broader policy context .................................................................................................................. 20 Equity in healthcare in Ireland ................................................................................................. 20 Report of the Special Oireachtas Committee on the Future of Healthcare – the Sláintecare report ....................................................................................................................................... 21 Principal Provisions of the Bill ....................................................................................................... 25 Section 1 - Definition ............................................................................................................... 25 Section 2 - Amendment of section 11C of the Principal Act.
.................................................... 25 Section 3 – Changes to the Board of the Health Insurance Authority ....................................... 25 Section 4 - Changes to Risk equalisation credits ..................................................................... 26 Sections 5 – Voluntary Health Insurance board appointments ................................................. 27 Section 6 – Voluntary Health Insurance and the sale of international healthcare plans ............ 28 Section 7 – Amendment of section 125A of the Stamp Duties Consolidation Act 1999 ............ 30 Section 8 - Short title, commencement, collective citation and construction ............................. 30 Stakeholder commentary .............................................................................................................. 31 Appendix One: Regulation of private health insurance 1957- 2017 .......................................... 32 Appendix Two: Market share by age ....................................................................................... 33 Appendix Three: Background to the Health Insurance Authority ............................................. 34 Bill Digest | Health Insurance (Amendment) Bill 2018 3 Bill published: 12 November 2018 [as printed on the Bill] Second stage debate: 20 November 2018 This Digest may be cited as: Oireachtas Library & Research Service, 2018, Bill Digest: Health Insurance (Amendment) Bill 2018.
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© Houses of the Oireachtas 2018 Oireachtas Library & Research Service | Bill Digest 4 Glossary Non-advanced health insurance policy Advanced health insurance policy Community Rating Lifetime Community Rating (LCR) Risk Equalisation Scheme / System (RES) Risk Equalisation Fund Non-advanced policies: Broadly speaking, these policies provide a lower level of cover than advanced policies.

In general they provide cover mainly for public hospitals.
More specifically: Non-advanced cover is defined as a relevant contract which provides health insurance cover for: 1.

Not more than 66 per cent of the full cost for hospital charges in a private hospital, or 2.

Not more than the prescribed minimum payments within the meaning of the Health Insurance Act 1994 (Minimum Benefit) Regulations 1996 (S.I.

No.

83 of 1996), whichever of the two is the greater.


Advanced policies are all other policies – generally those that provide cover for care in private hospitals.

Community rating means that the level of risk that a particular consumer poses to an insurer does not directly affect the premium they pay.

Everyone pays the same for the same cover – regardless of age, gender or health status.
The system is built on inter-generational solidarity – with the premiums paid by younger people subsidising those paid by older people.

Older consumers who have long held health insurance will themselves have subsidised the generation(s) before them.

Ireland’s system of community rating is now adjusted by ‘Lifetime Community Rating’ (see below) which applies different rules for ‘late’ entry and discounts for young adults.
LCR is a system of ‘late-entry’ loadings meaning that people who take out health insurance for the first time after a certain age (age 34 in Ireland) have to pay a higher premium than others.

This is intended to act as a disincentive to people who might choose to delay taking out health insurance until later in life.

The aim of the risk equalisation system is to fairly distribute the costs that arise for insurers as a result of the differing health status of all their customers.
Risk equalisation aims to make health insurance more affordable for older people.

It also aims to support competition within the market.

Administered by the Health Insurance Authority, the Fund is the pool of money that pays out the Risk equalisation credits / Hospital utilisation credit (HUC).

Monies come into the Fund from the Revenue Commissioners through Stamp Duties levied on all open market health insurance policies provided by insurers.
The Revenue Commissioners, in turn, pay the monies to the Health Insurance Authority (to the Risk Bill Digest | Health Insurance (Amendment) Bill 2018 5 Risk equalisation credit Hospital utilisation credit (HUC) Equalisation Fund).

The Health Insurance Authority pays out monies to health insurers by way of two credits – Risk equalisation credits and Hospital utilisation credit (detailed below).

This is one of the compensatory credits to health insurers that form part of the Risk Equalisation Scheme.
Risk equalisation credits are made based on each insurers customer profile regarding age and gender and type of cover.

It is paid (at various rates) per policy on all people insured aged 65 and over.

The Bill seeks to adjust these rates.

The HUC is the other compensatory credit under the RES.

In effect, a hospital visit is used as an indicator of health status.

This credit is set at €100 at present for each overnight stay in a hospital bed and €50 for each day case admission.
The Bill does not seek to adjust these rates.

Health Insurance Authority (HIA) The Authority is a statutory regulator of the private health insurance market.

It was established in 2001 under the Health Insurance Acts.
Restricted Membership Undertakings Open membership undertakings Open enrolment There are a number of long-established health insurance providers that deal only with particular groups of employees; membership is confined to employees and retired employees and their dependants (hence the term – Restricted Membership Undertakings - RMU).

Examples include the Gardaí, prison officers and ESB employees.
The rules governing health insurance apply equally to all providers with some limited exceptions for the restricted membership schemes.

The RMUs are not subject to the Risk Equalisation Scheme.

Insurers other than Restricted Membership Undertakings – i.e.

those whose policies are available on the open market.

At present, health insurance companies must accept anyone who wishes to join, subject to any applicable waiting periods before cover takes effect, regardless of age, sex or health status.
Restricted membership undertakings must accept everyone who is qualified to join.

Oireachtas Library & Research Service | Bill Digest 6 Summary The Health Insurance (Amendment) Bill 2018 (the Bill) is the latest in a series of annual bills seeking to amend the risk equalisations system that applies to private health insurance.

The Principal Act is the Health Insurance Act 1994.
The Bill also seeks to amend legislation about the Health Insurance Authority (regulator) and Voluntary Health Insurance Board (VHI).

Risk equalisation is the system that seeks to spread insurance risks across insurers based on their relative exposure to customers at higher risk of making claims.
It underpins the principle of ‘community rating’ – whereby all customers, regardless of their age or health status are charged the same price for a health insurance policy (this ‘community rating’ principle is limited by a late- entry loading, known as ‘lifetime community rating’ which means that people taking out health insurance for the first time later in life pay a higher premium).
The risk equalisation system (also set out in an infographic on page 10 of this Digest) uses stamp duty to raise revenue – levied on every health insurance policy in the state.

This is paid into a risk equalisation fund (managed by the Health Insurance Authority (HIA)).

Risks are equalised by the payment of two credits paid to insurers.

The ‘Risk equalisation credit’ is paid prospectively (ahead of time) based on the age, gender and level of insurance cover of an insurers customers.
The second is a ‘hospital utilisation credit’ paid retrospectively (after claims have been settled) based on hospital stays and day case attendance.

Due to the historical position of the Voluntary Health Insurance (VHI) organisation in the health insurance market, and the older age profile of its customers, the VHI is the net beneficiary of the Risk Equalisation Scheme.
This year, the Bill proposes (Section 4), from 1st April 2019, to reduce some Risk equalisation credits, increase others and leave one unchanged.

The Bill does not propose any changes to the stamp duties levied on health insurance policies (these are paid by insurers but in the past there have been concerns about the impact of increases on consumer prices).

Section 7 seeks to set stamp duty from April 2019 at current levels.
Hospital utilisation credits (another compensatory measure within the Risk Equalisation Scheme, paid based on usage of hospital stays and day cases) would be unchanged by the Bill.

Apart from changes to Risk equalisation credits, the Bill (Section 3) seeks to increase the number of members on the Board of the statutory regulator, the Health Insurance Authority, from five to seven.

Related to this, it seeks to increase the number of members required to form a quorum for Board meetings from three to four.
The Minister for Health, Simon Harris, TD, has stated that this is intended to strengthen governance of the regulator, ensuring greater oversight of the health insurance market.

Section 5 and 6 relate to the Voluntary Health Insurance Board (VHI).

Section 5 seeks to amend the Voluntary Health Insurance Amendment Act 1996 to ensure that VHI board appointees have “sufficient experience and expertise” related to the Board’s functions to be able to make a substantial contribution to its performance.
Bill Digest | Health Insurance (Amendment) Bill 2018 7 Section 6 seeks to allow the VHI to sell international healthcare policies directly (at present it is allowed to act as an agent for such policies).

It is reported that this change is intended to allow the VHI to be more competitive in the market.

The potential market and consumer implications of these proposed changes around international healthcare plans are not known.
The Department of Health did not publish a Regulatory Impact Analysis (RIA) relating to the Bill.

The Government’s legislative programme for Autumn 2018 stated one of the aims of the Bill to be: “…the introduction of DRG (Diagnosis-related Groups) coding to private hospitals.”1 However, no provision for DRG coding is made in the Bill as published.

Stakeholder commentary: At the time of writing, no stakeholder commentary on the bill had been identified.
Commencement: If enacted, different sections of the Act would come into force on different dates:  Section 3 would come into operation on such day or days as the Minister for Health may appoint;  Section 7 would come into operation on 1 January 2019;  Sections 2 and 4 shall come into operation on 1 April 2019; and  Other sections would commence on enactment.

1 Department of the Taoiseach (2018) Legislation Programme Autumn 2018.
Oireachtas Library & Research Service | Bill Digest 8 Table of provisions Section Title Effect 1.

2.

3.

4.

5.

6.

7.

8.

Definition Section 1 specifies that the Principal Act is Health Insurance Act 1994.

Amendment of section 11C of the Principal Act Changes date for applicable rates from 1 April 2018 to 1 April 2019.
Amendment to Schedule 1 to the Principal Act Increases from five to seven the number of members of the Health Insurance Authority, and increases a quorum for meetings from three to four.

Amendment to Schedule 4 to the Principal Act Amends Risk equalisation credits payable to insurers under the Risk Equalisation Scheme.
Amendment of section 4 of the Voluntary Health Insurance (Amendment) Act 1996 Provides that VHI board members appointed must, in the opinion of the Minister, have sufficient experience and expertise to make a substantial contribution to the performance of the VHI’s functions.

Deletes subsections relevant to board member selection.
Amendment of section 1 of the Voluntary Health Insurance (Amendment) Act 1996 Allows the VHI to sell directly international healthcare plans, without the use of an intermediary as currently required.

Amendment of section 125A of Stamp Duties Consolidation Act 1999 Short title, commencement, collective citations and construction Leaves stamp duty rates levied on health insurance policies unchanged.

Standard provision.

If enacted: Section 3 may be commenced by ministerial order.
Section 4 shall commence on 1 January 2019 and sections 2 and 4 on 1 April 2019.

Bill Digest | Health Insurance (Amendment) Bill 2018 9 Introduction See the Glossary at the beginning of this Digest for definitions of the terms used throughout.

This Bill Digest presents the background and details of the Health Insurance (Amendment) Bill 20182 (hereafter “the Bill”).

The Bill was not subject to Pre-Legislative Scrutiny by an Oireachtas Committee.
This Digest is presented in the following sections:  Explaining risk equalisation;  Overview/recent trends in the health insurance market;  Broader policy context;  Principal provisions of the Bill;  Stakeholder commentary.

The Bill seeks to make changes to existing legislation governing private health insurance, specifically in relation to the Risk Equalisation Scheme (RES).
The Risk Equalisation Scheme was established on a permanent footing in Ireland in 2013 when the Health Insurance (Amendment) Act 2012 was commenced.3 The current Bill seeks to amend the Principal Act - the Health Insurance Act 1994 and amend other legislation in relation to the VHI and Health Insurance Authority.
The Bill seeks to:  Amend the Health Insurance Act 1994;  Specify the amount of premium to be paid from the Risk Equalisation Fund from 1 April 2019, in respect of certain classes of insured persons;  Amend the Voluntary Health Insurance (Amendment) Act 1996 to vary the basis on which person are appointed to be member of the Voluntary Health Insurance Board (to ensure they have sufficient expertise and experience);  Amend the Voluntary Health Insurance (Amendment) Act 1998 to enable the Voluntary Health Insurance Board to act as an insurer in addition to an agent for health insurance in international healthcare plans;  Amend the Stamp Duties Consolidation Act 1999 and to provide for related matters.
Increase the number of board members on the Health Insurance Authority (sector  regulator) and related measures.

The Explanatory Memorandum to this Bill can be found here4.

2 https://data.oireachtas.ie/ie/oireachtas/bill/2018/122/eng/initiated/b11218s.pdf 3 This Act amended the Health Insurance Act 1994.

For further information on the establishment of the Risk Equalisation Scheme see the Library & Research Service Digest for the Health Insurance (Amendment) Bill 2012.
4 https://data.oireachtas.ie/ie/oireachtas/bill/2018/122/gle/memo/b11219s-memo.pdf Oireachtas Library & Research Service | Bill Digest 10 Further related L&RS resources (available to those with access to the Oireachtas intranet) On this Bill : L&RS Bills Tracker page On Previous Bills: Bills Digest: Health Insurance (Amendment) Bill 2017 Bills Digest: Health Insurance (Amendment) Bill 2012 (The 2012 Act established the permanent Risk Equalisation Scheme).
This Digest examined key implications and stakeholder comment; including issues around competition and market entry in relation to risk equalisation (see pages 33 – 39).

Bill Digest | Health Insurance (Amendment) Bill 2018 11 Explaining risk equalisation Risk equalisation is a system of compensating insurers who carry heavy risk burdens (in proportion to their market share), by transferring payments from other insurers who carry lighter ones.
Heavy risk burdens include claims costs associated with policy holders who are older or less healthy than the rest of the population.

What is the purpose of the Risk Equalisation Scheme?

Ireland has traditionally adhered to a community rating system in relation to the health insurance market.
This system assumes a principle of intergenerational solidarity between all insured persons, whereby all consumers, irrespective of age profile, gender or likely future health status, pay the same price for equivalent levels of cover.

Risk equalisation is a common mechanism in countries with community rated health insurance markets.

The purpose of which is to make it easier for insurers who insure policy holders with higher risk profiles, i.e.
people more likely to have higher medical costs, to compete with other insurers.5 The stated goal of the scheme is to ensure that private health insurance is affordable to as many people as possible in a sustainable, competitive market.

How does the Risk Equalisation Scheme work?

The information in Text Box 1 below describes in detail the operation of the Risk Equalisation Scheme (RES).

The key points of operation of the scheme are represented in an infographic provided later in this section.
Box 1: How the Risk Equalisation Scheme operates The Health Insurance (Amendment) Act 2012 provided for the Risk Equalisation Scheme (RES) from 1 January 2013.

The scheme applies to open-membership health insurance providers only and not to restricted membership providers (see Glossary).

The scheme takes account of sex, health status and type of cover as well as age.
The scheme involves a transfer of credits to health insurance providers in respect of older and less healthy customers and a stamp duty levied on health insurance providers in order to pay for these credits.

The Health Insurance (Amendment) Act 2012 sought to establish a permanent fund from which Risk equalisation credits are payable.

The health insurance companies pay stamp duty on individual policies to the Revenue Commissioners, who then transfer the proceeds of the stamp duty to the fund.
The fund is administered by the Health Insurance Authority (HIA).

There are four rates of stamp duty.

The rate that applies to each policy depends on whether the policy provides for advanced cover or non-advanced cover6 and whether the insured life is that of a child or an adult.
The HIA can make regulations for the categorisation of health insurance products 5 Community rating is an approach in which an insurer spreads the cost of insuring risks evenly across the entire group of people being insured, rather than those with a higher risk profile paying larger premiums than those with low risk profiles.

6 See Glossary at page 1 for definitions.

Oireachtas Library & Research Service | Bill Digest 12 into advanced and non-advanced cover.
Risk equalisation (RE) credits are currently paid out to the health insurance companies in respect of the premiums of people aged 65 and over.

The amount of the credit depends on the person’s age, sex and the type of insurance cover (current and proposed rates are set out in the Principal Provisions section below).

Health status is also taken into account when calculating credits and a Hospital utilisation credit (HUC) is awarded based on each visit to hospital by an insured person.
In effect, a hospital visit is used as an indicator of a policy holder’s health status.

The greater the number of hospital visits and the longer the stay in hospital, the sicker an insured person is deemed to be (for the purpose of HUC) and as a result, the greater the number of credits their insurer receives.

At present, this credit is set at €100 for each overnight stay and €50 for each day case visit for insured people of all ages.

The health insurance provider claims the credits from the HIA.
They receive a greater amount in respect of policy holders who are older and less healthy.

The levels of credits and the stamp duty payable are reassessed annually.

The HIA makes recommendations to the Department of Health on annual RE credit rates and on the corresponding stamp duty required to fund them under RES.

The Minister for Health takes this into consideration when proposing rates for RE credits and recommends the corresponding stamp duty levy to the Minister for Finance.
Source: Adapted from Citizens Information Board (2013) Relate, March 2013.

Available at http://www.citizensinformationboard.ie/publications/relate/relate_2013_03.pdf The Text Box above illustrates how the Risk Equalisation Scheme operates within a community rated health insurance market.
In 2015, two new schemes intended to support the health insurance market by attracting more younger adults, were introduced which altered the community rating system somewhat.7 These are:  The Lifetime Community Rating Scheme: This is a system of mandatory ‘late-entry loading’ which means that people who take out health insurance for the first time at age 35 or over pay a higher premium than others (2% per year of age up to a maximum of 70% for those aged 69 or over).
 Discounted Schemes for Younger Adults: Health insurers may offer reduced premiums for young people between the ages of 18 and 25 years, on a sliding scale.

Also, health insurance premiums for children may not exceed 50% of the cost of an adult premium.

7 Lifetime Community Rating was first provided for in 2014 by means of regulations under the Health Insurance (Amendment) Act 2014.

Those regulations provided that Lifetime Community Rating would be mandatory for insurers and take effect on 1 May 2015.
Bill Digest | Health Insurance (Amendment) Bill 2018 13 Figure 1: Infographic of Risk Equalisation System Oireachtas Library & Research Service | Bill Digest 14 The health insurance market Appendix 1 provides a 60-year timeline (1957-2017) of the regulation of the health insurance market.
Size of the market The private health insurance market is the largest non-life insurance market in Ireland - with total premiums (gross of tax relief) of €2.66 billion in 2017 - marginally higher than the €2.53bn in 20168 (which itself was marginally higher than the previous year9).

In terms of overall health expenditure in the State, insurance and other voluntary schemes make up 15% of funding (with public expenditure making up 72% and 13% the rest accounted for by out-of-pocket payments e.g.
private payments to GPs etc.

).10 Health insurance accounts for a greater proportion of health expenditure in Ireland than in most other European countries.

In 2016, authors of report by the World Health Organisation’s European Observatory on Health Systems and Policies found that: “Health spending channeled through VHI (voluntary health insurance) is low in most countries.
In 2014, VHI accounted for over 5% of total health spending in only 11 out of the 53 countries in the WHO European Region.”11 In that report Ireland ranks third highest (behind Georgia and Slovenia) for voluntary health insurance as a percentage of total spending on health.
12 Trend in take-up of health insurance Ms Sheelagh Malin, Chairperson of the Health Insurance Authority (HIA), summed up the take-up of health insurance in 2017 and related factors as follows: “During 2017, continued improvements in the wider economy resulted in a further increase in the numbers insured to 2.17m (45% of the population) at 31 December, an increase of 22,000 compared with the prior year.
In the last 3 years, growth in employment, reduction in net emigration, the introduction of young adult rates and lifetime community rating have all helped to reverse the previous trend of declining numbers experienced since the market peaked at 2.30m in December 2008.”13 8 Health Insurance Authority (2018) Annual Report 2017, p.15 9 Health Insurance Authority (2017) Annual Report 2016, p. 18 10 Figures for 2016, published in June 2018 by Central Statistics Office, System of Health Accounts.https://www.cso.ie/en/releasesandpublications/er/sha/systemofhealthaccounts2016/ see also Library & Research Service Note on Irish health expenditure: the comparative context (revised October 2017).
11 Saagan, A and Thompson, S (2016) Voluntary health insurance in Europe – Role and regulation.

Copenhagen: WHO Regional Office for Europe and European Observatory on Health System and Policies.

12 Saagan, A and Thompson, S (2016) as before; Figure 2.1.

13 Health Insurance Authority (2018) as before.

Bill Digest | Health Insurance (Amendment) Bill 2018 15 The increase in take-up of health insurance in 2017 was in line with increases in 2015, and 2016.
However, as shown in Table 1 below, the longer term picture has been more variable – and in tune with broader economic fortunes.
Table 1: Number of Insured people and proportion of the population (2003-2017)* Year ended / most recent Total insured persons (000s) Private health insurance coverage as % of population December 2003 December 2004 December 2005 December 2006 December 2007 December 2008 December 2009 December 2010 December 2011 December 2012 December 2013 December 2014 December 2015 December 2016 December 2017 1,999 2,054 2,115 2,174 2,245 2,297 2,260 2,228 2,163 2,099 2,049 2,025 2,122 2,152 2,174 49.8% 50.2% 50.4% 50.3% 50.5% 50.9% (PEAK) 49.7% 48.8% 47.2% 45.6% 44.3%** 43.4% (LOWEST)** 45.0%** 45.2%** 45.1% Sources: HIA (2018) Annual Report & Accounts 2017 Notes: *All figures relate to the total private health insurance market, i.e.
open enrolment and restricted undertakings.

Population figures are based on Central Statistics Office population estimates.

** Population data is from the Central Statistics Office annual population of estimates, which were revised for the years 2012 to 2016 in September 2017.
Oireachtas Library & Research Service | Bill Digest 16 Issues relating to trends in take-up  Decreases during the recession (with a low of 43.4% of the population having health insurance at end December 2014) were particularly linked to cuts to income and the decline in employment among people of working age.14 They were also linked to cost increases for consumers.15  This decline prompted concerns about the stability of the current model of private health insurance and the impact on the public health system of meeting fully the care needs of those patients who may previously have used private healthcare.16  Increases in 2015 and subsequently may be attributed, at least in part, to the introduction of a system of discounts for young adults and Lifetime Community Rating (a mandatory loading on premiums making it more expensive for consumers to take out insurers the older they get – starting at age 35).
As noted by the HIA Chairperson above, further factors likely to be contributing to the increase is the recent trend of employment growth, and reduction in net migration.
Dermot Goode17 of totalhealthcover.ie has argued that “People fear waiting lists and they're joining [health insurance] because they can't trust the public system.”18  While in 2017 the number of people insured recovered to 2006 levels, the proportion of the population with cover is lower (45.1% vs 50.3%) because of overall population growth in the interim.
Advanced and non-advanced products and related take-up rates There were 339 insurance products on the market in July 2018 (that is 26 more plans than a year previously, excluding restricted undertakings).

The proportion of insured people with non- advanced plans is 10% (compared with 9% in 2017 and 10% in 2016).

14 Health Insurance Authority (2015) Annual Report 2014, p. 21 15 Turner, B (2013) ‘Premium inflation in the Irish private health insurance market: drivers and consequences’.
Irish Journal of Medical Science, 182:545-550.. 16 Weston, C. (2014) ‘21,000 drop health insurance in first quarter of year’, Irish Independent http://www.independent.ie/business/personal-finance/latest-news/21000-drop-health-insurance-in-first- quarter-of-year-30327125.html 17 Dermot Goode is a commentator on the private health insurance market.
18 https://www.rte.ie/news/business/2018/1114/1010813-over-60s-overpaying-for-health-insurance/ Bill Digest | Health Insurance (Amendment) Bill 2018 17 Figure 2: Number of private health insurance in-patient plans: Product numbers and advanced / non-advanced take-up, 2018 Number of Plans, 1 July 2018 % of insured people by level of cover (12 months to 1 July 2018) 339 total (313 in 2017) Advanced cover - 90% Non- advanced cover - 10% Source: data from Department of Health briefing paper to Oireachtas Library & Research Service, 14 November 2018.
Non-advanced policies, held by 10% of insured people, have been criticised by some for failing to deliver a satisfactory level of cover (as they only provide cover for care in public hospitals).19 Though they have also been seen as a way for people to gain entry into the market with a view to upgrading cover in the future (i.e.
taking out health insurance that is cheaper and offers a low level of cover but would allow people to avoid late entry loadings at a later date).20 Historical context to level of health insurance take-up Originally, when the Voluntary Health Insurance (VHI) body was established in 1957, health insurance was envisaged as something that would be of interest to/held by a minority – about 10% of the population,21 drawn from the top 15% of earners22 who, by virtue of their high incomes were ineligible for free or heavily subsidised hospital services.
Over time, however, despite expanded eligibility for public care, the number/proportion of people paying for private health insurance grew (peaking at just over half the population in 2008).

19 Weston, C (2015) ‘Adults unaware that health insurance levies are on the way in May’, Irish Independent, 18 March 2015.

20 Dermot Goode, Cornmarket Insurance, cited in: Weston, C (2015) as before.
21 Lynch, B (2018) ‘Significant developments in Irish health insurance and healthcare since 1950’, Health Insurance Authority, The Irish healthcare system – An historical and comparative Review.

Dublin: Health Insurance Authority.

22 Turner B (2013) as before.


Oireachtas Library & Research Service | Bill Digest 18 Providers and market share At the start of 2017, there were four open market health insurers available to consumers (there are currently three following the merger of Irish Life Health and GloHealth).

VHI has the largest market share at 50%, followed by Laya healthcare at 26% (see full market share figures in Table 2 below).
Table 2: Health insurance market share by provider, at the end of 201723 VHI Healthcare Laya Healthcare Irish Life Health RMUs* December 2017 50% 26% 20% 4% *Restricted Membership Undertakings (do not provide insurance on the open market and are not subject to risk equalisation24) Position of Voluntary Health Insurance (VHI) Until 1997, the State-owned company, VHI, was the only private health insurer in the State.
As a legacy of this market position, it has a greater proportion of older customers than other insurers.

For instance, while VHI insurers 49% of insured people at 0-49 years, it insurers 79% of insured people aged 80 and over (figures for open market insurers, i.e.

RMU data excluded) (see Appendix Two for details of market share by age).
For this reason the Risk Equalisation Scheme affects it differently than it does other insurers, in that it receives a greater proportion of the risk equalisation credits paid (these are paid based on age and gender) and hospital utilisation credits (HUCs).

The VHI has been referred to as the “net beneficiary” of RE credits.25 The VHI retained its 50% market share from 2016 into 2017, however, its share has been in steady decline since the introduction of competition to the market.
For example it held 82% of the market in 2001.

As well as its shrinking market share, it now insures a smaller share of insured older people.

The Health Insurance Authority points out that: “…at the end of 2017 Vhi Healthcare insured 64% of those aged 70-79 with insurance, compared with 72% at the end of 2014 and 80% at the end of 2011.”26 Premiums (consumer prices) and tax relief The average amount paid for health insurance per person rose by 3.7% between 2016 and 2017.
The average gross premium paid by consumers was €1,220 in 2017 compared with an average of €1,177 in the 12 months to end of June 2016.27 These prices are before tax relief to consumers - the State subsidises private health insurance directly by providing consumers with tax relief on 23 HIA (2018) as before.

24 These mainly provide insurance to workplace schemes e.g.

gardaí, prison officers and the ESB.

25 By the Health Insurance Authority and European Commission.
See HIA Annual Report 2016, for example.

26 HIA (2018), as before.

p.16.

27 HIA (2018) as before, p.16.

Bill Digest | Health Insurance (Amendment) Bill 2018 19 premiums at the standard rate of tax (20%).
The degree of subsidy has been reduced in recent years by a reduction to the standard rate of tax from the marginal rate and a cap placed on the premium price that will be allowed for tax relief (€1,000 for an adult, €500 for a child, in place since October 2013).28 Claims – trends and drivers In 2017, the average of the claims paid per insured person decreased by 1% - following increases of 1% in 2016 and 6.5% in 2015.
29 The Health Insurance Authority attributes much of the increase in 2015 to the change in rules for charging private patients in public hospitals.
In the period 2008 to 2012 there was an annual average increase of 12.6%.30 In relation to the trends and pressures in relation to the costs of claims, the HIA argues that: “Restraining the growth in insurance claims is critical to the sustainability of the voluntary health insurance market, especially when considered in the context of acknowledged long- term drivers of healthcare costs, viz; lower tolerance of people towards ill-health, new medical and surgical interventions and population ageing.”31 28 See Citzens Information webpage on: Taxation and Medical Expenses.
29 HIA (2018) as before.

30 HIA (2018) as before.. 31 HIA (2018) as before.

Oireachtas Library & Research Service | Bill Digest 20 Broader policy context This section looks at the broader policy context to the Health Insurance (Amendment) Bill 2018.
It is organised into the following parts:  Equity in healthcare in Ireland  Report of the Special Oireachtas Committee on the Future of Healthcare – the Sláintecare report and its implementation Equity in healthcare in Ireland A commonly occurring theme in debates on healthcare is equity.
As noted above, the Risk Equalisation Scheme seeks to address issues of equity of access to private health insurance in Ireland, so that in general premiums can be (with the exception of young adult discounts and the loadings under Lifetime Community Rating) charged at the same price to all customers.

It is considered to be more equitable to do this than to charge older or sicker people more, i.e.

for premiums to be risk-related like car insurance.
More broadly, the issue of equity of access to healthcare is also relevant to the Bill.

Ireland has a mix of public and private healthcare, in terms of both financing and delivery.

Due to different access provided to different groups it has become known as a two-tier health system, with less than half the population having private health insurance.

There is much literature around the pros and cons of private market provision, and issues relating to the gap between those with and without health insurance.
Despite there being universal eligibility for public hospital care in Ireland, as shown above a large minority of the population pay for private health insurance.

The international literature indicates that people have different motivations for taking up voluntary (private) health insurance depending on the type of cover it bestows.
In Ireland, cover is generally seen as ‘supplementary’32 – meaning that it: “…offers access to health care that is covered publicly, but gives policy holders greater choice of provider and level of amenity (usually including access to private providers) and may enable them to bypass waiting lists for publicly financed services.”33 The drivers for take-up of such insurance are considered to be “perceptions about the quality and timeliness of publicly financed health services.” 34 Attitudinal studies in Ireland are in line with this, suggesting that people want health insurance to avoid delays in accessing care, and have some issues with the quality of care in public services.35 The OECD has stated that: 32 See Turner, B (2013) as before.
33 Saagan A and Thompson, S (2016) as before.p.29.

34 Saagan A and Thompson, S (2016) as before.p.29.

35 See: Nolan, B.

(2001) Health Insurance in Ireland: Issues and Challenges; ESRI Working Paper No.

10; and HIA commissioned Millward Brown Landsdowne Consumer Survey (2011) http://lenus.ie/hse/bitstream/10147/312355/1/xHIAConsumerSurvey2012Report.pdf ; also NESF (2004) Equity of Access to Hospital Care - Forum Report No.
25; http://files.nesc.ie/nesf_archive/nesf_reports/NESF_25.pdf Bill Digest | Health Insurance (Amendment) Bill 2018 21 “Private health insurance affords insurees greater choice over providers and the timing of care, thereby improving health system responsiveness.”36 However, there are long-running concerns about fairness in the system: Professor Brian Nolan, in an Economic and Social Research Institute paper, has argued that: “The…two-tier system is now widely regarded as problematic from an equity perspective.”37 In relation to social justice, Ms Suzanne Quin, Senior Lecturer in Social Policy and Social Work, UCD has stated: “It can be argued that…a policy which enables those who can afford it to access alternative paths to what they see as being a more comprehensive, superior quality and faster service is hard to justify on grounds of social justice.”38 While, in 2009, Dr Samantha Smyth, ESRI, while acknowledging that there is no universally agreed definition of equity, noted that: “In health care, empirical investigation of equity has focused on adherence to two principles: that healthcare should be financed according to ability to pay, and delivered according to need.”39 Report of the Special Oireachtas Committee on the Future of Healthcare – the Sláintecare report These principles (noted above by Dr Smyth) were influential in the terms of reference of the Special Oireachtas Committee on the Future of Healthcare (2016-2017).
It was formed on a cross- party basis, following an acknowledgement that the health service was under severe pressure and, that amongst other issues, waiting lists were excessive.
The Committee’s report, known as the Slaintecare Report came to the overall conclusion that the healthcare system must be: “Re-oriented to ensure equitable access to a universal, single tier system, and …[in which] the vast majority of care takes place in the primary and social care settings.” (p.14) And the Committee envisages that in a reformed system: “everyone has equitable access to services based on need and not ability to pay.”40 36 OECD (2004) Private health insurance in Ireland: a case study; http://www.oecd.org/ireland/29157620.pdf 37 Nolan, B.
(2001) Health Insurance in Ireland: Issues and Challenges; ESRI Working Paper No.

10 38 Quin, S (2005) ‘Health policy’ in Quin, S. et al, Contemporary Irish Social Policy, University College Dublin Press, Dublin.

39 Smyth, S (2009) Equity in Health Care – A view from the Irish Health Care System, Adelaide Hospital Society, and University of Dublin, Trinity College.
http://www.esri.ie/UserFiles/publications/20090406113247/BKMNEXT136.pdf 40 Committee on the Future of Healthcare (2017) Press release: Future of Healthcare Committee publishes Sláintecare – a plan to radically transform Irish healthcare.

Oireachtas Library & Research Service | Bill Digest 22 Specifically in relation to private care (generally paid for, at least in part, by health insurance), the Committee recommended ceasing all private care in public hospitals.
Box 3 (below) presents the Committee’s position in more detail, including its recommendation.

Box 3: Oireachtas Committee on the Future of Healthcare Removing private care from public hospitals – one of Six Critical Changes The Committee has recommended: “The disentanglement of public and private care and the phased elimination of private care from public hospitals.
This will require a range of measures including, addressing the replacement of private income currently received by public hospitals, and careful workforce planning and strategies to recruit and retain staff.
As noted above, the Committee recommends an independent impact analysis of the separation of private practice from the public system with a view to identifying any adverse and unintended consequences that may arise for the public system in the separation” (p.21) Also in relation to private health insurance, the Committee recommended: “…a model where private insurance will no longer confer faster access to healthcare in the public sector, but is limited to covering private care in private hospitals.” (p.28) In terms of funding healthcare, the Committee recommended the establishment of a single ‘National Health Fund’ – funded by general tax revenues and some earmarked taxes, levies or charges.
At the time of publication, there was a mixed reaction to the Sláintecare report.

For instance, the Irish Cancer Society welcomed it, saying it "represents a unique opportunity to revolutionise Ireland’s health system for the better".

However, while the Irish Medical Association said it was in favour of access being based on need rather than ability to pay, it highlighted a number of issues it considered problematic.
Specifically on the proposal to remove private care from public hospitals, it stated: “There is no evidence backed assessment of how this measure would increase capacity in our public hospitals nor any analysis of the impact of the loss of indirect co-payments on budgets in public hospitals, payments on which hospitals rely upon to deliver services to all patients.
This proposal fails to recognise the right of all citizens to avail of publicly funded services, regardless of whether or not they hold private health insurance and what affect such a measure will have if there is any significant trend among the population to cancel private health cover.”41 As well as the specific recommendation to separate public and private hospital care, the improvement in the public health system envisaged, if realised, may affect people’s motivation to take out private health insurance.
41 Irish Medical Organisation, cited in http://www.breakingnews.ie/ireland/mixed-reaction-to-new-10-year- plan-for-free-gp-and-hospital-care-791751.html Bill Digest | Health Insurance (Amendment) Bill 2018 23 Implementation of Sláintecare The Minister for Health, Simon Harris, TD, has stated: “I am strongly supportive of the vision for the future of the Health Service set out in the Sláintecare report.”42 The Sláintecare Implementation Plan, published by the Government in August 2018, sets out the case for change, including the following: “Access to healthcare is unequal; the tiers we have created are both unfair and a fundamental barrier to progress.
Ireland is the only western European health system that does not provide universal access to primary care.

In addition, access to public acute hospitals is inequitable.

The majority of our population pays out-of-pocket fees to access primary healthcare and 45% of the population purchase inpatient health insurance plans, which can provide faster access to private health services in both public and private hospitals.
This inequality of access is embedded in our current system and creates barriers and perverse incentives that stand in the way of doing the right things for patients that need care.

Moreover, wider health inequalities persist among some groups of the population.” Box 4 below outlines key developments in the implementation of the Sláintecare report.
Box 4: Steps towards implementation of Sláintecare  The publication of a Sláintecare Implementation Strategy and Next Steps document (August 2018).43  The establishment of a Sláintecare Programme Office in the Department of Health.
 The establishment of a Sláintecare Implementation Advisory Council (October 2018) comprising healthcare professionals, managers and patients / service users and healthcare and change management experts.44 Professor Tom Keane will Chair this Council.45  The establishment of an Independent Group to examine Private Practice in Public Hospitals – chaired by Dr Donal de Buitléir46 This Group is due to report later in 2018.47  A public consultation on the geographical alignment of Hospital Groups and Community Health Organisations.
 The commencement of negotiations for a new GP contract.

 Publication of the National Development Plan, providing for a major programme of investment totalling €10.9 billion in the health service.
This was informed by, and makes provision for, significant additional capacity as recommended in the Health Service 42 Department of Health (2017) Press release: Minister Harris updates Government on Sláintecare, 13 October 2017. http://health.gov.ie/blog/press-release/minister-harris-updates-government-on-slaintecare- and-announces/ 43 Government of Ireland (2018) Sláintecare implementation strategy and next steps 44 See Department of Health press release: https://health.gov.ie/blog/press-release/minister-simon-harris- announces-membership-of-slaintecare-implementation-advisory-council/ 45 Prof Keane previously led the reorganisation of Ireland’s public cancer services.
46 Dr Donal de Buitléir currently leads the independent thinktank publicpolicy.ie, and was formerly a member of the board of the HSE and was Secretary to the Commission on Taxation.

47 Department of Health (2018a) Sláintecare Implementation Strategy, p.6.

Oireachtas Library & Research Service | Bill Digest 24 Capacity Review.

This includes 2,600 acute hospital beds, 3 new elective facilities and 4,500 community care beds.
 Publication of legislation providing for the establishment of an independent Board for the HSE (the Health Service Executive (Governance) Bill 201848).

Source: L&RS using sources as referenced and Government press release, 12 July 2018.
Potential impact of Sláintecare implementation on private health insurance Recommendations in the Sláintecare report most relevant to health insurance are those that propose changes changes to the private / public mix of healthcare provision and funding – such as expanding eligibility to primary care to achieve universal coverage and the removal of private practice from public hospitals.
Considering the potential impact of Sláintrecare, Dr. Brian Turner, University College Cork, has speculated that if improvements in the public health system are achieved, it may impact on the private health insurance market: “…if the public hospital system receives the investment that is proposed [in the Sláintecare report], this would likely lead to a reduction in the number of people with private health insurance as it would remove one of the main drivers of demand for such insurance.”49 48 This Bill is currently before Dáil Éireann, Second stage.
https://www.oireachtas.ie/en/bills/bill/2018/90/; See Library & Research Service’s related Bill Digest.

49 Turner, B (2018) ‘Irish healthcare: A comparative analysis’, chapter in Health Insurance Authority, The Irish healthcare system – An historical and comparative Review.

Dublin: Health Insurance Authority.

Bill Digest | Health Insurance (Amendment) Bill 2018 25 Principal Provisions of the Bill This section looks in detail at the provisions of the Bill.
Section 1 - Definition Section 1 specifies that the Principal Act is Health Insurance Act 1994.

Section 2 - Amendment of section 11C of the Principal Act.

Section 2 seeks to amend Section 11(c)(1)(b) of the Principal Act to make 1st April 2019 the effective date for revised Risk equalisation credits to be payable from the Risk Equalisation Fund, in respect of certain classes of insured persons.
Section 3 – Changes to the Board of the Health Insurance Authority The Health Insurance Authority is a statutory regulator for health insurance in Ireland.

At present, legislation provides for it to have five board members.

Section 3(a) of the Bill seeks amend the Schedule to the Principal Act to increase this to seven board members.

Section 3(b) seeks to amend paragraph 18 of the Schedule to the Principal Act to increase the quorum for board meetings from three to four members.
Section 3(c) seeks to establish an explicit link between paragraphs 22 and 18 of the Schedule.

This means that the Authority may act notwithstanding one or more vacancies among its members so long as the quorum of four members is reached.
In relation to this section, the Department of Health’s press release on the Bill stated: “This year’s Bill…provides for strengthened governance of the independent health insurance regulator.” 50 In the Department of Health’s press release, Minister for Health, Simon Harris, TD stated: “I’m…pleased to announced that the Board of the Health Insurance Authority will expand, ensuring greater oversight and regulation of the health insurance market, in this ever- changing and complex environment.”51 On 13th November 2018, the Irish Times reported that: “Mr Harris told Ministers [at Cabinet] that since the establishment of the authority in 2001 with a provision for five board members, the health insurance market had become more 50 Department of Health (2018b) Press release: Minister for Health published Health Insurance (Amendment) Bill confirming no increase in stamp duty for health insurance.
(13 November 2018).

51 Department of Health (2018b) Press release: Minister for Health published Health Insurance (Amendment) Bill confirming no increase in stamp duty for health insurance.

(13 November 2018).

Oireachtas Library & Research Service | Bill Digest 26 complex with insurers increasingly adapting innovative marketing and product propositions to expand their client base and improve their risk profile.
He said it was desirable that the board of the authority had a broad range of skills and experience but that limiting the number to five members at present resulted in a situation where some skills could be absent or where it was reliant on the expertise of just one director in particular areas.” 52 Appendix Three gives an overview of the Health Insurance Authority.
Section 4 - Changes to Risk equalisation credits Each year, since the introduction of the Risk Equalisation Scheme, the Risk equalisation credits (paid to insurers to compensate them for their share of older customers) are adjusted based on an assessment of the market undertaken by the Health Insurance Authority and its subsequent recommendations to the Minister for Health.

This years proposed changes are set out in Section 4 of the Bill.
It seeks to amend Schedule 4 of the Principal Act by substituting a new table for Table 2.

The current Risk equalisation credit rates and the rates the Bill proposes to apply from 1st April 2019 are shown in Table 3 below.
Table 3: Risk equalisation credits – current rates and those proposed in the Health Insurance (Amendment) Bill 2018 Advanced policies Non- Advanced policies Age Bands Men Now From 01/04/2019 Women Now From 01/04/2019 Men Now From 01/04/2019 Women Now From 01/04/2019 64 & under €0 €0 €0 €0 €0 €0 €0 65-69 €1,000 €1,050 €650 €700 €400 €400 €300 70-74 €1,750 €1,775 €1,250 €1,225 €725 €650 €550 75-79 €2,550 €2,775 €1,925 €1,900 €1,075 €925 €850 80-84 €3,450 €3,300 €2,700 €2,475 €1,450 €1,050 €1,150 €0 €275 €475 €725 €925 €4,975 €4,600 €3,350 €3,100 €2,175 €1,350 €1,450 €1,075 85 and over Code: Red = Credit decrease Yellow = Credit increase Grey = No change Source: L&RS using data from Health Insurance Amendment Act 2017 (current rates) and Table 2 of the Bill (proposed rates).
52 Wall, M (2018) ‘VHI to be allowed sell international healthcare plans directly’, Irish Times, 13 November 2018.

Bill Digest | Health Insurance (Amendment) Bill 2018 27 Table 3 shows 20 categories of rates to apply from 1st April 2019, based on age, gender and level of cover.

The Bill proposes:  A decrease in the Risk equalisation credits payable in respect of most (15) categories.
 An increase in rates in four categories: males holding advanced cover in the age brackets 65-69, 70-74, and 75-79 years and females aged 65-69 years of age with advanced cover.

 No change in one category - males aged 65-69 with non-advanced cover.

Hospital utilisation credits (another compensatory measure within the Risk Equalisation Scheme, paid based on usage of hospital stays and day cases) are unchanged by the Bill.
Sections 5 – Voluntary Health Insurance board appointments The VHI is the largest provider in the current health insurance market – half of the people who have health insurance in Ireland have VHI health insurance – giving it a market share that is almost double its nearest rival (Laya Healthcare at 26% market share).

As noted above, the Voluntary Health Insurance Board (VHI) is a statutory body established in 1957.
Under the Voluntary Health Insurance (Amendment) Act 2008, the Voluntary Health Insurance Board has established a group structure with the creation of subsidiary companies responsible for different aspects of its business activities, including VHI Healthcare DAC and VHI Insurance DAC.53,54 The Bill seeks to make changes to the appointments to the Board of the VHI.
The Voluntary Health Insurance (Amendment) Act 1996 provides that the VHI Board: “shall consist of a chairman and such number (not being more than 11) of other members as the Minister may from time to time determine.” The Bill seeks to ensure that board members have the required attributes to undertake their duties.55 Section 5 of the Bill seeks to amend Amendment of section 4 of the Voluntary Health Insurance (Amendment) Act 1996 by deleting the word ‘determine’ and replacing it with the following: 53 VHI webpage on corporate structure: https://www.vhi.ie/about/corporate-structure 54 A DAC is a ‘Designated Activity Company’, i.e.
a “corporate form for a private company limited by shares.

Its activities are limited by its objects clause, and its constitution comprises a memorandum and articles of association.” Source: Mason, Hayes & Curran law firm website.

55 The Department of Public Expenditure and Reform’s Code of Practice for the Governance of State Bodies (2016) sets out the roles and responsibilities of members of state boards.
Oireachtas Library & Research Service | Bill Digest 28 “determine each of whom, in the opinion of the Minister, has sufficient experience and expertise relating to matters connected with the functions of the Board to make a substantial contribution to the performance of those functions.” In addition, Section 5 of the Bill seeks to amend section 4 of the Voluntary Health Insurance (Amendment) Act 1996 which deals with the composition of the board.
This removes the restriction on the number of health service providers who can serve on the board at any time.

And it removes the definition of ‘health service provider’ from Section 4 of the Voluntary Health Insurance (Amendment) Act 1996.
When the Voluntary Health Insurance Bill 1995 (which was enacted as the Voluntary Health Insurance Act 1996) was being debated in the Houses of the Oireachtas, the then Minister for Health, Michael Noonan, TD, set out his reasons for limiting the number of health service providers on the VHI Board as follows: “Section 4 also provides that the number of board members who are health service providers is to be limited to two persons.
Subject to the provisions of the law, it is the prerogative of the Minister to select board members.

While the VHI is about the business of healthcare, it is first and foremost an insurance undertaking.

The skills and expertise it needs to thrive are those relevant to the insurance sector generally — actuarial, financial and marketing — as well as expertise in the healthcare industry.
Against this background, I am satisfied that the law should place an acceptable upper limit on the number of board members who come from a provider background.

I want to make it clear that those from a provider background, employer or medical, who have served on the board have done so always with the best interests of VHI members and subscribers central to their contributions and actions.
It is not in question that a person's health service expertise and specific knowledge of the area enables him or her to make a valid and positive contribution to the work of the board.

The issue is rather one of the appropriate balance to be struck in providing the VHI with the composition of skills and expertise at board level which will best serve the organisation's needs.
I consider that not more than two persons who are health service providers out of not more than 12 members overall represents an appropriate balance.”56 Section 6 – Voluntary Health Insurance and the sale of international healthcare plans At present the VHI can only sell international healthcare plans, covering treatment abroad, as an agent.
The Bill seeks to amend the Voluntary Health Insurance (Amendment) Act 1998 to allow the VHI to sell such plans directly as well as maintaining its ability to act as an agent.

56 Dáil Éireann, Second stage debate of the Voluntary Health Insurance Bill 1995, 5 December 1995.
Bill Digest | Health Insurance (Amendment) Bill 2018 29 In addition, Section 6 (b) of the Bill seeks to amend Section 1 of the 1998 Act to replace the current definition of an ‘international healthcare plan’ to delete the provision that the plans may be sold for periods specified by the Board.
Section 6(b) proposes a new definition: “’international healthcare plan’ means a plan, scheme or other insurance arrangement made available by the Board which provides for the making of payments by an insurer to, or on behalf of, persons resident outside the State in respect of medical, surgical or related services.” In 1998, when introducing the Bill seeking to give the VHI powers to sell international plans, then Minister for Health and Children, Brian Cowen, TD stated: “Up until now VHI members who have spent time living abroad as part of their job have relied either upon the public health system in the foreign country or have arranged private health care insurance overseas — something that may prove awkward or inconvenient to arrange.”57 And: “The purpose of the Bill is to enable the Voluntary Health Insurance Board to act as agent in the making available of health insurance to persons who will be resident outside the State for temporary periods.
It is necessary to amend the Voluntary Health Insurance Acts, 1957 and 1996, in order to empower the board to act as agent to make available an international health care plan.
The VHI board made strong representations that it must be able to offer an international health care plan to corporate and individual clients as soon as possible, if it is not to be vulnerable to competitive challenge.” 58 It has been reported that Minister for Health, Simon Harris, TD stated the following in relation to the provisions in the section: “This amendment will…remove the requirement for VHI to seek ministerial approval before selling these plans.
This development is consistent with the VHI’s current status as an authorised insurer competing in a highly competitive and regulated marketplace and it will remove the impediment in VHI’s ability to compete with its competitors and ensure VHI may avail of significant business opportunities.”59 In the time available to prepare this Digest, it was not possible to source information on the size of the international health plan market or the potential implications of same.
No Regulatory Impact Analysis (RIA) was published relating to the Bill.

57 Dáil debate, Voluntary Health Insurance (Amendment) Bill, 1998: Second Stage (Resumed), 15 October 1998.

.https://www.oireachtas.ie/en/debates/debate/dail/1998-10-15/5/ 58 Dáil debate, Voluntary Health Insurance (Amendment) Bill, 1998: Second Stage (Resumed), 15 October 1998.
.https://www.oireachtas.ie/en/debates/debate/dail/1998-10-15/5/ 59 Wall, M (2018) ‘VHI to be allowed sell international healthcare plans directly’, Irish Times, 13 November 2018.

Oireachtas Library & Research Service | Bill Digest 30 Section 7 – Amendment of section 125A of the Stamp Duties Consolidation Act 1999 Section 7 provides for specified rates of stamp duty on contracts entered into in the period 1 April 2018-31 March 2019 and those entered into on or after 1 April 2019.
The Bill proposes that the rates remain unchanged from current levels.

The amounts are set out in Table 4 below.
Table 4: Stamp Duty Levy Rates (April 2018 - March 2019) and Proposed Rates (from 1 April 2019) Age Bands Advanced Non- Advanced 01/04/2018- 31/03/2019 01/04/2019 onwards 01/04//2018- 31/03/2019 01/04/2019 onwards 17 and under 18 and over €148 €444 €148 €444 €59 €177 €59 €177 In relation to stamp duty rates for next year, the Minister stated: “While the numbers of persons with health insurance continues to grow, affordability remains a key consideration for people when taking out a policy.
With this in mind, I am pleased to announce that there will be no increase in the stamp duty on health insurance contracts next year.”60 Although stamp duty is levied on insurers (payable per policy), in the past there have been concerns about the impact of increases on consumer prices.61 Section 8 - Short title, commencement, collective citation and construction Section 8 of the Bill provides that, once enacted, the Bill may be cited as the Health Insurance (Amendment) Act 2018.
Upon enactment, the Health Insurance Acts 1994 to 2017 and this Act (other than sections 5 to 7 – because they amend other legislation) can be cited together as the Health Insurance Acts 1994 to 2018 and they will be read as one Act.

Likewise, the Voluntary Health Insurance Act 1957 to 2008 and sections 5 and 6 may be cited together as the Voluntary Health Insurance Acts 1957 to 2018 and they will be read as one Act.
If enacted, different sections of the Act would come into force on different dates: 60 Department of Health (2018b) press release, as before.
61 See media article: https://www.irishexaminer.com/breakingnews/ireland/three-health-insurance-firms-to- pass-stamp-duty-rise-on-to-customers-613135.html Bill Digest | Health Insurance (Amendment) Bill 2018 31  Section 3 would come into operation on such day or days as the Minister for Health may appoint;  Section 7 would come into operation on 1 January 2019;  Sections 2 and 4 shall come into operation on 1 April 2019; and  Other sections would commence on enactment.
Stakeholder commentary At the time of writing of this Bill Digest, no stakeholder commentary on the bill had been identified.
Oireachtas Library & Research Service | Bill Digest 32 Appendix One: Regulation of private health insurance 1957- 2017 Summary of main events in the regulation of private health insurance 1957 Establishment of Voluntary Health Insurance 1992 Third Life Directive requires an end to monopolies 1994 Health Insurance Act 1994 provides for liberalisation of the market 1996 Regulations to introduce Risk Equalisation Scheme (RES) 1997 BUPA enters the market 1999 “Harvey Report” submitted to the Department of Health; Department of Health publishes White Paper on Private Health Insurance; 1996 Risk Equalisation Scheme regulations revoked 2001 Health Insurance Authority is established Three-year exemption from RES for new market entrants to promote competition 2003 New Risk Equalisation Scheme introduced RES does not contravene state aid rules according to European Commission 2004 VIVAS Health enters the market 2005 HIA recommends payments to be commenced under RES Minister decides not to act on recommendation and to defer payments 2006 The High Court upholds the RES 2007 BUPA is taken over by Quinn Healthcare.
Three year exemption from RES for new market entrants removed 2008 BUPA unsuccessfully challenges European Commission’s 2003 decision RES deemed ultra vires (beyond the powers of the Minister) by the Supreme Court as it was based on a misinterpretation of community rating in the 1994 Act.
Minister announces new initiative to stabilise the system to be implemented by the Health Insurance (Amendment) Bill 2008 2009 VIVAS is taken over by Hibernian Health 2009 Interim RES introduced based on tax credits (Health Insurance (Miscellaneous Provisions) Act 2009 2010 Administrators appointed to Quinn Insurance Limited HIA consultation on risk equalisation in private health insurance 2011 Amendments to RES and one year extension of Interim Scheme (Health Insurance (Miscellaneous Provisions) Act 201162 2012 Glo Health enters insurance market, bringing the number of insurers in the market to four.
2013 2015 Introduction of permanent Risk Equalisation Scheme – Health Insurance (Amendment) Act 2012 Introduction of ‘Lifetime Community Rating’ of late entry loadings for people aged 35 and over taking out health insurance for the first time, and discounts for young adults.
2016 RES 2016-2020 approved and introduced Aviva Health Insurance becomes Irish Life Health and Irish Life Group increases ownership of GloHealth to 100% (from 49%) 2017 Irish Life Health and Glo Health merged their operations, effective February 2017.
62 See also Health Insurance Act 1995 (Information Returns) (Amendment) Regulations 2011 Bill Digest | Health Insurance (Amendment) Bill 2018 33 Appendix Two: Market share by age The table below shows the variation in market share by insurer at the end of 2017.

The data in the table show that VHI has the largest market share in every age group – and more markedly so in older age groups.

Table A1, below, refers to open membership insurers only – excluding members of restricted membership undertakings.
(See Glossary at the start of this Digest for full explanation of terms.)

Table A1: Market Share by Age – Irish Health Insurers (Open Membership Undertakings Only) at the end of 2017 Age Group Irish Life Health % 0-49 50-59 60-69 70-79 80+ Total 22% 20% 19% 12% 8% 20% Laya Healthcare Vhi Healthcare % 29% 27% 29% 24% 13% 28% % 49% 53% 53% 64% 79% 52% Source: Health Insurance Authority, Annual Report 2017.
Oireachtas Library & Research Service | Bill Digest 34 Appendix Three: Background to the Health Insurance Authority The Authority is a statutory regulator of the private health insurance market.

The Authority was established in 2001 under the Health Insurance Acts.

The Authority is independent in the exercise of its functions.
The principal functions of the Authority as provided for in the Health Insurance Acts include the following:  To monitor the health insurance market and to advise the Minister (either at his or her request or on its own initiative) on matters relating to health insurance;  To monitor the operation of the Health Insurance Acts and, where appropriate, to issue enforcement notices to enforce compliance with the Acts;  To carry out certain functions in relation to health insurance stamp duty and Risk equalisation credits and in relation to the Risk Equalisation Scheme;  To take such action as it considers appropriate to increase the awareness of members of the public of their rights as consumers of health insurance and of health insurance services available to them; and  To maintain “The Register of Health Benefits Undertakings” and “The Register of Health Insurance Contracts”.
The Authority shall exercise such powers as are necessary for the performance of its functions.

The Minister for Health (“the Minister”) may assign further responsibilities to the Authority as provided for in the Acts.

The Authority is audited by the Comptroller and Auditor General and subject to the requirements thereof.

The Authority is also subject to the corporate governance procedures of the “Code of Practice for the Governance of State Bodies” issued by the Department of Finance.
The Authority is a public body to which the provisions of the Freedom of Information Acts and the Data Protection Acts apply.
Source: Health Insurance Authority webpage: https://www.hia.ie/about-us Bill Digest | Health Insurance (Amendment) Bill 2018 35 Notes Oireachtas Library & Research Service | Bill Digest 36 Contact: Houses of the Oireachtas Leinster House Kildare Street Dublin 2 D02 XR20 www.oireachtas.ie Tel: +353 (0)1 6183000 or 076 1001700 Twitter: @OireachtasNews Library & Research Service Tel: +353 (0)1 6184701 Email: library.and.research@oireachtas.ie