Catherine Connolly (Galway West, Independent)
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Amendments Nos. 1 to 6, inclusive, and 8 to 11, inclusive, are related and may be discussed together.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 1:

In page 3, between lines 10 and 11, to insert the following:

“PART 1

PRELIMINARY AND GENERAL

Short title, collective citations, construction and commencement

1. (1) This Act may be cited as the Health Insurance (Amendment) and Health (Provision of Menopause Products) Act 2024.

(2) The Health Acts 1947 to 2022 and Part 2 (other than section 5) may be cited together as the Health Acts 1947 to 2024.

(3) The Health Insurance Acts 1994 to 2023 and Part 3 (other than section 9) may be cited together as the Health Insurance Acts 1994 to 2024 and shall be construed together as one.

(4) Sections 2 to 5 shall come into operation on such day or days as the Minister for Health may by order or orders appoint either generally or with reference to any particular purpose or provision and different days may be so appointed for different purposes or different provisions.

(5) Sections 7 and 8 shall come into operation on 1 April 2025.

(6) Section 9 shall come into operation on 1 January 2025.”.

With the agreement of colleagues, I will try to answer some of the important questions raised. It is slightly off the subject of amendment No. 1 but with the agreement of the House I will return to the amendments.

Deputy Cullinane asked when it will come into effect. The plan is that HRT will be provided for free from January.

The Deputy asked if it will apply to everybody. The answer is "Yes". I took a decision in rolling this out. There was €20 million, which is a lot of money. There were two ways we could have gone about it. We could have done it the way we did free contraception, which was to fund all care, including GP consultations, but it would have to be limited on some grounds, be it age or something else. Alternatively, we could make it available to everybody and provide the medicines, patches and devices for free but, for now, those without a GP card would pay their own GP costs. We recognise pharmacists will have to apply some charge because there is no margin for them from selling the product. The decision I took was the latter, to make it available to everybody. I would like to see the scheme expanded in the same way we have done with end-to-end cover for free contraception but I felt the better way to do this was for everybody.

To Deputy Cullinane's question as to whether there is an age limit, there is none at all.

The Healy-Raes are gone so I will address their points when they come back.

Deputy Shortall asked about the perinatal mother and baby unit. I thank her for the question. It is essential and the plan is that it will go into St. Vincent's and be fully integrated with the new national maternity centre. Feasibility work is going on. There was a meeting with the regional executive officer last week. The plan is the feasibility study will be back in this quarter. It is very much live.

Róisín Shortall (Dublin North West, Social Democrats)
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What is the timeline involved? Is it years away?

Stephen Donnelly (Wicklow, Fianna Fail)
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It is a bit away but it is certainly part of the planning. The latest information I have is St.Vincent's, that is, the national maternity hospital, is still the preferred location for that.

On Deputy Boyd Barrett's point, sometimes a spirited response is required.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I am all for that.

Stephen Donnelly (Wicklow, Fianna Fail)
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I know you are. I was smiling because, like the Deputy, I speak to healthcare workers every day. He heard me repeatedly accept everything is not perfect. I am the first to admit that. We deal with it every day. We are about halfway through the journey that needs to be taken. It goes to something Deputy Healy-Rae was saying, which is that I am acutely aware the vast majority of the discussion - like 99% of it - in the Oireachtas and media is, for perfectly understandable reasons, about what is not working.

I know Deputy Boyd Barrett talks to healthcare workers. I listen to healthcare workers a lot and they tell me they hear all our debates, read the newspapers, listen to the radio and watch "Prime Time", and that they become demoralised by the relentless negativity. It is part of my job to put forward the positives. When I push back, it is not on my own behalf. I am not trying to defend myself; rather, I am trying to provide a strong counterbalance because we rarely hear about what our healthcare workers are doing. How many times do we hear about waiting lists versus how many times have we heard they have halved the waiting time? There is no other country in Europe I am aware of where healthcare workers have achieved that. That is part of the spirited response. I know our healthcare workers hear it all. I am not for a moment suggesting Deputies should not do it; I did exactly the same when I was sitting there and I get it. However, they hear it and it affects them. I used to work with the NHS before I ran for the Dáil and it was the same thing. It is a facet of healthcare that we focus on what is not working and that dominates the discussion. It can be exhausting for our healthcare workers. I am not suggesting there are not challenges but there is way more good and they are achieving way more progress than they ever hear acknowledged publicly.

I will give an example from the Deputy's hospital, St.Michael's Hospital. There has been a modest increase in staff. It is 5%. It could be more but the number of staff has gone up. Of course maternity leave should be covered.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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It is not.

Stephen Donnelly (Wicklow, Fianna Fail)
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I accept that and I am not suggesting everything is perfect. The Deputy talked of an application for a new CT scanner. That will be looked at. The capital budget is bigger than it has ever been. The Deputy did not say and may not have been told that last year and this year two new X-ray machines were funded, there is a national pelvic floor health centre in St.Michael's and additional specialist roles have been funded through last year and this. There is ongoing investment in St. Michael's. St. Michael's bigger brother up the road is St. Vincent's. St. Vincent's, St. Michael's and Loughlinstown hospitals work closely together. There has been a 35% increase in the number of staff in the lifetime of this Government. There are nearly 1,000 extra healthcare workers in St. Vincent's University Hospital and that is relevant to the debate about the Deputy's constituents who are served by the hospital.

Róisín Shortall (Dublin North West, Social Democrats)
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On a point of order, everybody is pressed for time and the Minister is going way off the script.

Stephen Donnelly (Wicklow, Fianna Fail)
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I will finish on this.

Róisín Shortall (Dublin North West, Social Democrats)
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It is one thing to respond to points raised but the Minister is going way off the subject.

Catherine Connolly (Galway West, Independent)
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I was giving the Minister some leeway but there is no more leeway. The Minister has time to address the amendments. There is no time limit but we are not addressing the amendments and we are setting a precedent for other Members.

Stephen Donnelly (Wicklow, Fianna Fail)
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We do not want to do that.

Catherine Connolly (Galway West, Independent)
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It has already been done. I gave some leniency but it would be helpful-----

David Cullinane (Waterford, Sinn Fein)
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The point is well made.

Stephen Donnelly (Wicklow, Fianna Fail)
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Thank you. In section 1, amendment No. 1 is a consequential amendment to the preliminary and general part of the Bill, required as a result of amendments inserting the hormone replacement therapy provisions.

Amendment No. 2 inserts a new Part 2 into the Bill, to provide for free hormone replacement therapy products related to menopause for certain women. It also provides a drafting clarification relating to how the Health Act 1970 is referenced within the Bill.

Amendment No. 3 provides that the new section being introduced - section 67F of the Health Act 1970, which gives effect to the provision of free hormone replacement therapy products related to menopause - is included for reference within section 47A of the Health Act 1970.

Amendment No. 4 inserts the new section 67F into the Health Act 1970. It contains the main provisions for the free menopause products. Within this proposed new section, there are six subsections. Subsection (1) provides that the HSE will make menopause products on the HSE reimbursement list available without charge to women ordinarily resident in the State who have been prescribed such products by a relevant healthcare provider, that is, a registered medical practitioner, a registered nurse or a registered midwife. Subsection (2) provides that a woman shall receive the menopause product from a pharmacy which has entered into or agreed to enter into an arrangement with the HSE for the dispensing of menopause products to women. Subsection (3) provides that, separate from the provisions outlined within this legislation, women with full eligibility, that is, medical card holders, will continue to receive free menopause products under section 59(1) of the Health Act 1970. Section 59(1) currently provides for the provision of free drugs, medicines, medical and surgical appliances to medical card holders. Subsection (4) provides that the Minister may, following consultation with the HSE, by regulation prescribe the form and manner in which the HSE may reimburse pharmacy providers for the supply of the menopause products, the form and manner in which the pharmacy providers may claim for the reimbursement and the forms that would be used to make the claims and reimbursements. Subsection (5) provides that every regulation made under this section must be laid before the Oireachtas. Subsection (6) provides for the definitions of certain terms in the amendments.

Amendment No. 5 contains a number of consequential amendments to the Health (Pricing and Supply of Medical Goods) Act 2013. These are necessary to provide the legislative framework for the HSE’s conditional supply and reimbursement of listed menopause products, meaning hormone replacement therapy drugs, medicines and surgical and medical appliances used to alleviate the symptoms of menopause and which are on the reimbursement list administered by the HSE.

Amendment No. 6 is a consequential amendment required as a result of amendments inserting the hormone replacement therapy provisions. It provides a drafting clarification in respect of how the Health Insurance Act 1994 is referenced in the Bill.

Amendment No. 8 is a consequential amendment required as a result of the amendment inserting the hormone replacement therapy provisions. It substitutes the principal Act by the Act of 1994.

Amendment No. 9 is a consequential amendment required as a result of amendments inserting the HRT provisions.

Amendment No. 10 is a consequential amendment required as a result of amendments inserting the HRT provisions.

Amendment No. 11 is a consequential amendment required for the same reason.

David Cullinane (Waterford, Sinn Fein)
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I welcome the Minister's response in providing clarity on how free HRT will be rolled out. If I am reading what the Minister has said right, there are any number of ways in which this could have been done, including providing free GP consultations, but what the Minister has gone for is free medicines and free products, stating this is the best way to do it. I would like clarity on this point. When the Minister responded, he said there would also have to be a margin for the pharmacist. What does this mean? If the State is paying the cost of a medicine why is there, in this instance, a margin has to be provided to the pharmacist? What will this be? We do not want it to be X amount in pharmacy A and Y amount in pharmacy B with no sense of what the margin is. How do we control this? How do we know what the costs will be? Has the Minister had discussions with the Irish Pharmacy Union? Some clarity on this would be helpful.

Danny Healy-Rae (Kerry, Independent)
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I welcome the provisions for the ladies who reach the menopause age and they are very welcome. I hope it will be of benefit to all of them. I have other questions on the nurses protesting outside the hospital in Tralee today. I understand it is because of the embargo that started last November which is still carrying on. A girl who came home last March after a career break-----

Catherine Connolly (Galway West, Independent)
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Deputy, these are very specific amendments and I am going to have to hold you to them.

David Cullinane (Waterford, Sinn Fein)
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They are all on the topic of HRT.

Catherine Connolly (Galway West, Independent)
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There is limited time. There is a guillotine.

Danny Healy-Rae (Kerry, Independent)
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I will finish now.

Catherine Connolly (Galway West, Independent)
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I know but I have an obligation to tell you that we are discussing amendments and we must stick to them.

Danny Healy-Rae (Kerry, Independent)
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All of this is relevant to providing a service. If we do not have the nurses or GPs on board we cannot operate the service. The main question is why the Minister closed the ophthalmology unit in Tralee general hospital. There are 800 people on the waiting list there. If someone gets hit in the eye or something steel or whatever goes into someone's eye, and there are accidents happening every day of the week, where are they to go now? The Government cut off the insurance and cancelled the insurance for that unit in Tralee. Why was this done? It is the truth. I am not making it up. I am duty bound to highlight it. I thank the Leas-Cheann Comhairle for her for forbearance.

Catherine Connolly (Galway West, Independent)
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Does Deputy Boyd Barrett have a question?

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I want to hear the Minister's response about the charging and the margin.

Stephen Donnelly (Wicklow, Fianna Fail)
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I cannot get into ophthalmology in this debate but I am more than happy to speak to Deputy Healy-Rae about it offline. I will respond to his relevant question on the healthcare providers who are required to support patients.

With regard to the margin for pharmacists, the current situation is that pharmacists will have two types of patients. These are patients with medical cards and private patients. At present a patient with a medical card already has full free access to HRT and the pharmacist is paid a set amount by the State for this. For the private patient, typically the pharmacist must make a margin for the provision and dispensing of the products. Typically what a pharmacist does is to add a margin to the cost of the product. Some might charge a dispensing fee. Various pharmacists do it in various ways.

David Cullinane (Waterford, Sinn Fein)
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Why does the State not just cover the entire cost?

Stephen Donnelly (Wicklow, Fianna Fail)
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For the reason I gave previously. We had a choice. This comes down to option 1 or option 2. We could have looked to cover GP fees-----

David Cullinane (Waterford, Sinn Fein)
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I am speaking about the full cost of the medicine.

Stephen Donnelly (Wicklow, Fianna Fail)
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I am answering exactly that. Option 1 would be what Deputy Cullinane is suggesting, which is the margin for the pharmacist, the product and the GP consultations, as we have done for free contraception.

David Cullinane (Waterford, Sinn Fein)
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Leave the GPs out of it; just the pharmacists.

Stephen Donnelly (Wicklow, Fianna Fail)
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Just the pharmacists. That option would cost more money. If we had gone further than providing the medicines for free, we would, in the first instance, have had to bring in something like age bands. I do not think that would have been appropriate. I spoke to the National Women's Council about it. The view I got back was that the way we are doing it is the right way to do it, which is to make it available for everybody. Whoever is sitting in this seat next year coming into the budget should be looking at exactly this expansion. It was important we covered all women and this was the way to do it.

Deputy Healy-Rae is gone so I will leave that response.

David Cullinane (Waterford, Sinn Fein)
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I have a quick further point. Is there any sense as to what that margin might be? That is the obvious question we are going to be asked. I get what the Minister is saying. I am not interested in the GP side of it. When a woman goes to get the product, the State will pay for the cost of the product and then the margin, profit, or whatever we want to call it is paid by the person. What can the person expect to pay? Is there any sense as to what this cost will be?

Stephen Donnelly (Wicklow, Fianna Fail)
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I thank Deputy Cullinane. This will be a matter for various pharmacists, just as it is today. A private patient going to a pharmacist today buying HRT products-----

David Cullinane (Waterford, Sinn Fein)
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So it is not free HRT

Stephen Donnelly (Wicklow, Fianna Fail)
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It is free HRT, of course it is, but we cannot expect pharmacists to prescribe without a fee or a margin. They do it today.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Who will pay the margin?

Stephen Donnelly (Wicklow, Fianna Fail)
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We have been very clear from day one that the funding is for the full cost of the medicines or devices to be covered. This is what the State is going to fund.

David Cullinane (Waterford, Sinn Fein)
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If there is a charge, it is not free.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I have a question. Is it free or is it not free? Will the Minister explain because it is not coming across very clearly? The State is covering the costs of the products and the HRT.

Stephen Donnelly (Wicklow, Fianna Fail)
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The cost of the medicine.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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But there is a margin. Who will pay the margin and how much will it be? How much is it likely to be? Why is the State not paying the margin?

David Cullinane (Waterford, Sinn Fein)
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I have the same question.

Stephen Donnelly (Wicklow, Fianna Fail)
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I thank the Deputies. It is the same question and the same answer. What we are doing is funding the costs of the medicines and the devices. What is not included is the GP visit, which is just as relevant. I know the Deputy is not asking about the GP visit but it is just as relevant because it is for a prescription. Half the country now has access to free GP care. For the other half there is a charge to see a GP. Similarly, there will be a dispensing charge or a prescription charge from the pharmacist.

I would love to have announced a scheme that said, just like with free contraception, all of the costs end to end are covered but we would have had two very serious issues to deal with in the first year of the scheme. We would not have been able to cover all women, and I do not think that would have been right as it is important we cover all women. We would also have had to have agreements in place with the IMO, as we did with free contraception, and with the IPU. All of this takes a lot of time. To provide the service for all women in January, rather than potentially much later next year, this was the best way to go.

What the Deputies and I would like to see is full end-to-end cover and not just the pharmacy piece, which the Deputies are raising.

I would like to see the GP consultation covered too. Given the choice in the first year of the scheme, I am of the view, and certainly the feedback I have got, is that providing the service for all women was definitely the preferred option.

David Cullinane (Waterford, Sinn Fein)
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It is important for us to tease this out, and I think I am getting there in terms of what the Minister is proposing. I do not want to take away from the positivity of this measure, because it is extremely important. Women will ask us, however, what the likely prescription charge is going to be. For medical card holders, for example, it was free prescriptions, with everything covered, and the Government brought in a prescription charge for medical card holders. This has been brought down and is now at €1.50. I assume from what the Minister is saying that the charge for women prescribed HRT or the patches is going to be higher than €1.50 or even €2.50. If a woman asks me how much she will have to pay, I have no answer. I cannot answer the question, unless the Minister has some answer. When we were bringing this legislation in, I would have assumed we would have had engagements with the Irish Pharmacy Union and reached some agreement on what a cap or a reasonable price might be. I would prefer if the entire cost were covered, but as it turns out, I cannot say to women it is free because free means you do not pay anything. That is what free is in my world. Women will have to pay something but we do not know what that something will be.

Stephen Donnelly (Wicklow, Fianna Fail)
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I thank the Deputy. In a world where we were not concerned about getting this measure in place quickly and one of infinite resources, sure, but neither of those things are the case. We want to get this provision in quickly and, obviously, we have finite resources.

David Cullinane (Waterford, Sinn Fein)
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I acknowledge that.

Stephen Donnelly (Wicklow, Fianna Fail)
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I am very much loath to give a figure because there may be pharmacists who would perhaps have agreed to go below that figure and who would then say that because I have said X, that is where they will go to. Just as it is now for private patients, it is a matter for pharmacists themselves to decide. I fully understand the Deputy's questions because I asked exactly the same ones as we were teasing this out.

David Cullinane (Waterford, Sinn Fein)
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I accept that.

Stephen Donnelly (Wicklow, Fianna Fail)
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As I said, the two overarching priorities for me were to get this in place quickly, and this is why we are shoehorning this into this Bill-----

David Cullinane (Waterford, Sinn Fein)
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I accept that.

Stephen Donnelly (Wicklow, Fianna Fail)
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-----and I wanted it to be available to everybody.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 2:

In page 3, between lines 10 and 11, to insert the following:

“PART 2

PROVISION OF MENOPAUSE PRODUCTS FOR CERTAIN WOMEN

Definition (Part 2)

2. In this Part, “Act of 1970” means the Health Act 1970.”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 3:

In page 3, between lines 10 and 11, to insert the following: “Amendment of section 47A of Act of 1970

3. Section 47A of the Act of 1970 is amended by the substitution of “62A, 67E or 67F” for “62A or 67E”.”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No.4:

In page 3, between lines 10 and 11, to insert the following: “Menopause products for certain women

4. The Act of 1970 is amended by the insertion of the following section after section 67E:

“67F. (1) Subject to subsection (3), and sections 20 and 23 of the Act of 2013, the Health Service Executive shall make available for supply without charge menopause products for women who—

(a) are ordinarily resident in the State, and

(b) have been prescribed menopause products by—

(i) a registered medical practitioner, or

(ii) a registered nurse or registered midwife entitled pursuant to any enactment to prescribe the menopause products so supplied.

(2) A woman referred to in subsection (1) shall be entitled to receive menopause products from a pharmacy provider.

(3) This section shall not apply to women with full eligibility who avail of the service under section 59(1).

(4) The Minister may, following consultation with the Health Service Executive, by regulation prescribe—

(a) the form and manner in which the Health Service Executive shall reimburse a pharmacy provider who has dispensed menopause products in accordance with this section,

(b) the form and manner in which a pharmacy provider shall claim for reimbursement from the Health Service Executive for the dispensing of menopause products in accordance with this section,

(c) such forms as may be necessary for the purposes of paragraphs (a) and (b), and

(d) such additional, incidental, consequential or supplemental matters as the Minister considers necessary or expedient for the purposes of giving effect to this section.

(5) Every regulation made under this section shall be laid before each House of the Oireachtas as soon as may be after it has been made and, if a resolution annulling the regulation is passed by either such House within the next 21 days on which that House has sat after the regulation is laid before it, the regulation shall be annulled accordingly, but without prejudice to the validity of anything previously done thereunder.

(6) In this section—

‘Act of 2011’ means the Nurses and Midwives Act 2011;

‘Act of 2013’ means the Health (Pricing and Supply of Medical Goods) Act 2013;

‘enactment’ has the same meaning as it has in section 2(1) of the Interpretation Act 2005;

‘menopause’ means, in relation to a woman, the various stages related to menopause and includes perimenopause, post menopause, early menopause, premature menopause and medically induced menopause;

‘menopause products’ means hormone replacement therapy drugs, medicines and surgical and medical appliances used to alleviate the symptoms of menopause, which are for the time being on the Reimbursement List;

‘pharmacy provider’ means a retail pharmacy business (within the meaning of section 2(1) of the Pharmacy Act 2007) which has entered into or agreed to enter into an arrangement with the Health Service Executive for the dispensing of menopause products to women referred to in subsection (1);

‘registered medical practitioner’ has the same meaning as it has in section 2(1) of the Medical Practitioners Act 2007;

‘registered midwife’ has the same meaning as it has in section 2(1) of the Act of 2011;

‘registered nurse’ has the same meaning as it has in section 2(1) of the Act of 2011;

‘Reimbursement List’ has the same meaning as it has in section 2(1) of the Act of 2013.”.”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 5:

In page 3, between lines 10 and 11, to insert the following: “Amendment of Health (Pricing and Supply of Medical Goods) Act 2013

5. The Health (Pricing and Supply of Medical Goods) Act 2013 is amended—

(a) in section 20—

(i) in subsection (1), by the substitution of “section 59, 62A, 67E or 67F” for “section 59, 62A or 67E”,

(ii) in subsection (2), by the substitution of “section 59, 62A, 67E or 67F” for “section 59, 62A or 67E”, and

(iii) in subsection (3), by the substitution of “section 59, 62A, 67E or 67F” for “section 59, 62A or 67E”,

and

(b) in section 23, by the substitution of “section 59, 62A, 67E or 67F” for “section 59, 62A or 67E”.”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No.6:

In page 3, to delete line 12 and substitute the following:

“6. In this Part, “Act of 1994” means the Health Insurance Act 1994.”.

David Cullinane (Waterford, Sinn Fein)
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I move amendment No. 7:

In page 3, between lines 12 and 13, to insert the following: “Amendment of Section 7F of Principal Act

2. Section 7F is amended in section 4A by the deletion of paragraph (c) and the insertion of:

“(c) In respect of each of the following applicable 3 year periods—

(i) the 3 year period from 1 January 2023 to the end of 2025, and

(ii) the 3 year period from 1 January 2026 to the end of 2028,

the reference in paragraph (a) to 6 per cent per annum shall, as respects the applicable 3 year period referred to in subparagraph (i), be read as a reference to 5 per cent per annum and, as respects the applicable 3 year period referred to in subparagraph (ii), be read as a reference to 5 per cent per annum, and paragraph (a) shall apply accordingly.”.”.

I spoke about this proposed amendment previously and I raised this issue last year too. This amendment is intended to limit the reasonable profit for providers to 5%, which is similar to the rate of reasonable profit from 2016 to 2020, when this Government increased it to 6% and higher. I made the point that families are struggling with all sorts of costs now. Unfortunately, private health insurance premiums have gone up considerably over the past two years, as the Minister knows. In recent months, we have had announcements of further increases, all of which add to the pressures families are under. We did have a lower rate of 5% before, but it was dropped. I would like to see this reinstated and this is the intended purpose of this amendment.

Stephen Donnelly (Wicklow, Fianna Fail)
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I thank the Deputy. We have probably discussed this aspect on a few occasions in the context of this Bill. The 6% rate was a recommendation from the Health Insurance Authority. A report was done and a range recommended between 5.5% and 8.6%. The 6%, therefore, is right down at the lower end of the range. The Deputy's question is a very fair one, why not bring it down further. The report looked around Europe and, essentially, we have to balance two things. We want more competition in the market here. We know what happens when there is a monopoly, a duopoly or an oligopoly here. It is the customer who ends up paying too much. This rate, therefore, is at the lower end of what was recommended in trying to achieve a balance of a reasonable but not an extortionate rate of return for the providers while still having a suitably attractive market to have suitable competition in the country.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I am just going to comment briefly. I would bring the rate down to zero to be honest. I just do not see why these providers should make a profit. We are probably not going to get into this debate, but I cannot understand how a Government committed to universal, single tier healthcare can think it is acceptable these companies are making any profit at all. I cannot see how they are anything other than parasitical on the health service. There is no good reason to have these people, other than the inequity that exists in the provision of healthcare and the fear we discussed earlier, which they are profiteering from. They have no good purpose here at all. Is there any intention really to get these parasites out of the health service ultimately? When I use that phraseology, I want to be clear that I am not talking about ordinary workers working in those places, whom I am sure are ordinary decent people who could probably play an important role. Administrators are often attacked by various people in the House . Administration is actually necessary in the health service, but I do not actually think sending out bills to people to make profits for private companies has anything useful to contribute to the provision of healthcare. I do not, therefore, see why these companies should be allowed to make any profit at all out of health.

David Cullinane (Waterford, Sinn Fein)
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People before profit.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Absolutely, and in healthcare more than anything. I am just using this opportunity to say this, because unless there is an intention to get rid of that at some point, the Government is perpetuating a fundamentally iniquitous situation where these companies are, essentially, exploiting people's vulnerability for profit.

Stephen Donnelly (Wicklow, Fianna Fail)
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I thank the Deputy for that contribution. If we were to move the margin down to zero, any sector would then fold up its tent.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Excellent

Stephen Donnelly (Wicklow, Fianna Fail)
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I think there are two sides to this point. As discussed earlier, there is the side where we have people in Ireland who have health insurance out of fear. Everything we have been doing for the past four and a half years has been to move away from that and provide a public health service we can be incredibly proud of and that gives people brilliant care when they need it. At a simple level, this is behind everything we are doing. Success for this would be seen in a reduction in people feeling the need to take out private health insurance. One of the reasons it has gone up, and it might have been Deputy Cullinane or another Deputy who referred to the number of people with private health insurance having gone up, which it has, is that the former Minister, James Reilly, brought in the rule whereby if people did not take up health insurance, they would be penalised in later life. Many people ended up taking it up for this reason. Nonetheless, even if we get to where we all want to get to in respect of having a phenomenal public healthcare service that gets people the care they want when they need it, I think people will still take out private health insurance. There are people who will want whatever it is they will want. It could be fancier foyers; I do not know. It should, however, become a nice-to-have rather than something people feel they have no choice other than to take out. I fully accept that.

Another point was raised by Deputy Shortall that is linked to the points being made here, which was that the public health service, to an extent, has been subsidising private care in our public hospitals. This is not the case in the private hospitals, obviously, because these are self-contained entities, but in the public hospitals, that is true. We typically do not charge the fully loaded cost to private patients in public hospitals in terms of health insurance. I hope the Deputies will accept that the public-only consultant contract is a major step in the right direction. It is a fundamental and structural shift that is moving private healthcare provision out of our public hospitals.

The public-only consultant contract is a major step in the right direction. It is a fundamental and structural shift that is moving private care out of our public hospitals. I hope the Deputy will accept my bona fides that I am fully committed to our public hospitals being for public patients.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I accept that.

Stephen Donnelly (Wicklow, Fianna Fail)
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I think there will always be private hospitals. To be honest, from a public healthcare perspective it can be useful to be able to dip into additional capacity from time to time when it is needed and if there is a shortage. However, it should be the exception rather than the rule.

I hear what the Deputy is saying but I do not agree with the Deputy's language. It is a little unfair. I have met people who are providing health insurance - the State owns the main health insurer, VHI - from the chair of the board and the CEO down, and I would not accept the Deputy's charge.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I am not talking about them.

Stephen Donnelly (Wicklow, Fianna Fail)
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The people I have met at the VHI are doing their very best to try to provide the best possible care.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 8:

In page 3, line 14, to delete “Principal Act” and substitute “Act of 1994”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 9:

In page 4, line 32, to delete “Principal Act” and substitute “Act of 1994”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 10:

In page 4, line 35, to delete “Principal Act” and substitute “Act of 1994”.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 11:

In page 3, to delete lines 5 to 9 and substitute the following: “An Act to provide for the making available for supply, without charge, to certain women, of certain products used to alleviate the symptoms of menopause; and, for that purpose, to amend the Health Act 1970 and the Health (Pricing and Supply of Medical Goods) Act 2013; to amend the Health Insurance Act 1994 to specify the amount of premium to be paid from the Risk Equalisation Fund in respect of certain classes of insured persons from 1 April 2025; to amend the definition, in that Act, of high cost claim; to amend the Stamp Duties Consolidation Act 1999; and to provide for related matters.”.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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The Bill will be sent to the Seanad. Congratulations to all involved in that piece of work.