The Path to Universal Healthcare: White Paper on Universal Health Insurance – Statement by Dr James Reilly, TD, Minister for Health to the Dáil


  • The current health system is both unaffordable and unfair – and it is therefore unsustainable.
  • This government has embarked on an ambitious programme of health service reform – and we are already seeing positive impacts from those reforms. But deputies should be clear – there are limits to what reform of a fundamentally flawed system can accomplish. If we want to realise the health service we want, radical reform is the only option.
  • Some have questioned whether we can afford this kind of reform. My answer is simple: we cannot afford not to. Without this kind of radical reform the pressures on a dysfunctional system will become overwhelming.
  • The profound inequality at the heart of the current health system is most obvious in relation to access to acute hospital and consultant services. Although the public health service provides universal access to acute hospital services, the fact is that individuals – who choose to and can afford to – buy private health insurance mainly because it gives them faster access to certain hospital services.
  • This is what an unfair, two-tier health system means in practice – those who can afford it can get faster access to hospital services, those who cannot must wait. And they must wait because the high costs that make our current system unaffordable are at the root of the unfairness: high costs mean services must be rationed and this means long waiting lists.
  • This Government made a commitment to the kind of radical reform that we need to tackle one of the most profound inequalities in Irish society. We committed to introducing a system of Universal Health Insurance so that everyone is has health cover from their choice of insurer, so that everyone has access to high quality care on the basis of their medical needs, rather than their ability to pay.
  • The publication earlier this month of the White Paper on Universal Health Insurance underpins the Government’s determination to deliver on that commitment. We were clear from the start that achieving this goal would require at least two terms of office. The job of this government is to put in place the building blocks so that a fair and cost-effective system of UHI can be delivered by 2019.

Overview of the UHI Model for Ireland

  • The White Paper sets out the model of UHI for Ireland. In designing this model, we were acutely aware of the opportunity we have to learn from the experience of other countries – both from the good practice they have developed, and from their mistakes.
  • We did not want to import the model of another country, but to learn from countries such as the Germany and the Netherlands, so that we could develop a system that best fits the needs of the Irish system, in line with our commitments in the Programme for Government.
  • With that objective in mind, my Department undertook detailed policy analysis of various multi-payer models, the design of the future health basket of services and financing mechanisms for UHI.
  • I would, at this stage, like to express appreciation to the members of the UHI Implementation Group that I established in early 2012, for their contribution in terms of the support and advice provided to my Department. I value too the advice the Group provided in relation to some of the core building blocks for UHI, including the introduction of a Money Follows the Patient funding system and the creation of Hospital Groups.
  • But what will the Irish model of UHI mean for people?
  • Everyone will be insured for the same standard package of services. Broadly, this package will include core primary care as well as acute hospital services, including acute mental health services.
  • Under UHI, there will no longer be any distinction between ‘public’ and ‘private’ patients. As set out in the Programme for Government, everyone will have health cover from their chosen insurer. The health insurance market will include a number of private health insurers as well as maintaining the choice to be covered by the publicly owned VHI.
  • Insurers will commission health services for their customers from healthcare providers, who will compete for business in a well regulated market.
  • While people will buy their UHI policy directly from their chosen insurer, a system of financial support will ensure that cover is affordable. Those on the lowest incomes will have their costs fully paid for by the state, and the state will subsidise the costs of others on the basis of their ability to pay. These subsidies will be paid directly to insurers.
  • Government is determined that people on low incomes who currently qualify for a Medical Card will not lose out on benefits under UHI.
    • But all individuals – whether they pay all, some, or none of the cost of the UHI premium – will be able to access the standard package of health services on a fair and equitable basis, that is their health needs.
    • Our system of UHI will be founded on principles of social solidarity, by which I mean that:

–    the right to be accepted by their chosen insurer, and the right to switch health insurer annually (open enrolment);

–    the right to renew their UHI policy (lifetime cover);

–    the right to the same policy, for the same price, regardless of their age or risk profile (community rating);

  • These are fundamental protections that currently apply in the private health insurance market and will continue to apply under UHI.
    • It is intended that the standard package of UHI will cover a comprehensive suite of core health services. Under this single tier system, neither insurers nor providers will be allowed sell faster access to services in the standard UHI package. I am firmly committed to this fundamental aspect to reform, so that everyone will be able to access the health services they need in a timely manner.
    • I know that some are concerned that the introduction of UHI could mean that waiting lists grow even longer. I agree that this would be wholly unacceptable. We have already achieved great progress in reducing waiting times – and we’re not finished yet. That’s why I will shortly bring forward a strategy to bring waiting times in Ireland in line with European norms, in advance of the introduction of UHI.
    • There are some health services that are unlikely to be included in any standard package of services under UHI, for example, surgery that is purely cosmetic (rather than, for example, reconstructive surgery after medical treatment).
    • People will still be able to pay privately for those kind of services not included in the standard UHI package or purchase supplemental health insurance cover for these. However, these supplemental policies will not be subject to community rating, and therefore supplemental health insurance premium costs may take into account risk factors such as health status and age.
    • Certain services – such as social care, public health and wellbeing services – will continue to be funded by the Exchequer through general taxation. They will not be included in the standard UHI package, and people will not have to buy supplementary insurance to access these. However, let me stress that these will be delivered in an integrated manner and around the needs of the individual.


Health reform

  • The delivery of a single tier health system, supported by universal health insurance, is a central pillar of the Government’s overall health reform programme.
  • Since coming into office I, along with my colleagues, Ministers Lynch and White, have been working on a range of reforms which will result in a fundamental shift in the way our health services are funded, organised and delivered, to

–    Improve health outcomes;

–    Develop our health services;

–    Making the best use of limited resources; and

–    Lay the foundations of the future universal health insurance system.

  • Our aim is to ensure more efficient and effective delivery of services, so that we can move away from a hospital-centric model to one that provides the most appropriate care in the most appropriate setting.
  • The introduction of UHI is the most radical reform of the Irish health system since the foundation of the State. It requires both time and careful planning to implement. It is my goal to put in place the essential groundwork to underpin UHI in the lifetime of this government, so that UHI can be implemented by 2019.
  • The White Paper identifies and outlines progress to date on the key structural, regulatory, financial and information-related building blocks that will pave the way for the introduction of universal health insurance. I will briefly mention some of the key building blocks.

Free GP care for all children under age six

  • As deputies will be aware, universal primary care is at the very core of this government’s goals in relation to universal health insurance.
  • Today, government approved the Health (General Practitioner Service) Bill, 2014, which provides the basis for every one of the 420,000 children in Ireland aged 5 and under to access a GP service without facing the barrier of fees. At present, the parents of about a quarter of a million children under 6 years of age must pay if they need to attend a GP.
  • This legislation will bring Ireland into line with health systems in Europe that ensure that all children can access a family doctor when they need to. Government has provided new, additional funding of €37million to meet the cost of this measure.
  • This represents the first step in introducing a universal GP service for the entire Irish population. Under UHI, every member of the population will have a universal entitlement to the core primary care services provided by GPs.
  • The Bill will be distributed to Deputies in the coming days when publication is completed.
  • My colleague, Alex White TD, Minister for State for Primary Care has invited the representative bodies for GPs to meet him in connection with the draft GP contract for the under-6’s service, which the HSE recently published for public consultation, and I would encourage GP bodies to take up that offer.

Hospital Groups

  • The transformation of public hospitals into independent, not-for-profit hospital trusts is a key commitment in the Programme for Government. As a first step in this process, seven hospital groups have been established. The creation of Hospital Groups is a critical step in improving hospital performance and, ultimately, patient outcomes.
  • Chairpersons have been appointed to all seven hospital groups, and Board members have been appointed to three out of the seven hospital groups (West/North West; UL Hospitals Group; Childrens Hospital Group) – appointment of the remaining four is imminent.
  • Group CEOs have been appointed to five hospital groups, and the HSE is working to appoint Group CEOs to the remaining two groups. After this, management teams will be appointed.
  • The Strategic Advisory Group to oversee implementation of hospital groups, developing policy direction and guiding reorganisation of acute services is in place and has already had productive meetings.
  • On the 1st of January this year we began phased implementation of a Money Follows the Patient funding system for acute hospitals. This will bring to an end inefficient block grants, and deliver funding on the basis of the number of patients treated. While the initial focus of the new funding system is on hospital care, the aim is to extend the system to care in primary and community settings.


  • Effective regulation of the safety and quality of health services is important in protecting and safeguarding people’s health. The approval of national healthcare standards and ongoing work in relation to licensing legislation are central to achieving good governance, patient safety and quality of care.  Draft legislation to support the new licensing regime is currently being prepared. It is my intention to have the new licensing system up and running in early 2015.

Private Health Insurance – reform as we move to UHI

  • Competing health insurers will form the backbone of the new purchaser/provider split: they will be the commissioners of a wide range of primary care services, acute hospital services and acute mental health care.
  • Even before UHI, we need an affordable, competitive market that meets consumers’ needs. I want to create the best possible environment within which more people will want to take out and keep health insurance cover.
  • I would particularly like to encourage younger people to join as early as possible, and to that end from 2015 in relation to Lifetime Community Rating and discounted rates for young adults.
  • Lifetime Community Rating is designed to encourage people to join health insurance schemes early.  Late entry loadings are applied to those who join later – but there would of course be a grace period to allow people take out insurance and a strong communications campaign to give everyone adequate notice of the change.
  • The second initiative I will be announcing is some discounted rates for young adults, while protecting the important principle of community rating. This is to help address the sharp increase in the cost of insurance faced by young people – or their parents – around age 21, when child discounts cease, which can lead to young adults downgrading their cover or leaving the market altogether.
  • Subject to the appropriate legislation, I intend that these two initiatives will operate from 2015, allowing for an appropriate notice period for both customers and insurers.
  • I am also committed to making further improvements to Risk Equalisation for health insurance.  In January 2013 I introduced a new permanent risk equalisation scheme designed to takes greater account of the extra cost of treating older and sicker patients, compared with younger and healthy ones.  Last December, I introduced further improvements to the Scheme’s effectiveness, and this process will continue.
  • I am committed to improving the extent to which we take the health status of patients into account, so that the extra costs of sicker patients of all ages are more fully reflected in the scheme.  My Department is working with the Health Insurance Authority to develop a more refined measure of health status as part of the RE Scheme.
  • Insurers have been making submissions to the Health Insurance Authority on the issue, and I intend to set out my overall plans very shortly for the scheme that will operate from 2016-2018.

Structural reform of the health service

  • Finally, significant organisational change is necessary to pave the way for the introduction of UHI. This will involve the abolition of the HSE. It will be replaced with structures that deliver the essential purchaser / provider split – a key building block for UHI that will pave the way for healthcare providers to operate as independent entities in the future market-based health system.
  • These are important initiatives which, individually and collectively, will play a vital role in improving our health service in advance of the introduction of universal health insurance.


Overview of the White Paper

  • As well as providing detailed information on the UHI model for Ireland, the White Paper:

–    Overviews the processes and structures for determining the future health basket. This includes both the services that will be funded under UHI, as well as the on-going management and review of the future basket;

–    Sets out the options for financing UHI; and

–    Clarifies the key regulatory and cost control frameworks governing the UHI system.

Basket of services

  • In designing our future health system we must decide which services should be funded through UHI, and which services should continue to be funded directly by the State, or individuals’ own resources. These questions are of fundamental importance to everyone living in Ireland.
  • The answers to these questions are complex and multi-faceted, involving various technical, economic and ethical considerations.
  • These are deeply value-laden decisions, and it is therefore important that the values underpinning the health basket reflect the values of society.
  • Good practice in other jurisdictions in these decision-making processes involves a critical blend of both technical appraisal and comprehensive consultation with all relevant stakeholders.
  • Therefore, I intend to establish a Commission, comprising all relevant expertise, within the coming weeks. The Commission will be tasked with developing detailed costed proposals on the composition of the future health basket – including those that will form part of the UHI package of care.
  • But these are not considerations that can be solely based on expert analysis – they must also be based on values. In that regard, the Commission will be required to engage in consultation with both the public and system stakeholders.
  • I hope that the Joint Oireachtas Committee on Health and Children will also be centrally involved in this consultation process. The Committee is being invited to conduct hearings and make recommendations on a values framework that will assist in underpinning decisions on the future health basket and to consider the options proposed by the Expert Commission.
  • The responsibility for the final decision on the services to be provided under UHI will of course rest with Government.

Financing and Cost of UHI

  • UHI represents a substantial shift in how we finance and organise the Irish health system.
  • I am determined that total spending by the State on healthcare under UHI should not exceed total spending under the current two-tier system. With this in mind, the White Paper has been prepared with due regard to the fiscal realities and the need for robust cost control.
  • The White Paper sets out a comprehensive cost control framework to ensure affordability and contain costs – these range from price monitoring of insurers, and setting maximum prices for healthcare providers, to more aggressive measures such as capping insurer overheads and profit margins.
  • Ultimately the cost of UHI in Ireland will depend on a number of key decisions, including the basket of services to be covered, and the scope and design of the financial support system.
  • My Department is already working to further develop and refine proposals in relation to cost control mechanisms, the financial subsidy system and, critically, costed recommendations for the basket of services to be provided under UHI.
  • This work will proceed on the basis of the overriding requirement that overall costs remain within overall Government expenditure targets.
  • Before seeking Government’s approval to draft UHI legislation, I will of course revert to Government with all relevant cost estimates..

UHI Implementation Team

  • A dedicated UHI Implementation Team is being put in place within the Department of Health to drive forward all aspects of the UHI project.
  • The Team will be led by the Deputy Secretary General and will include specialist skills in such areas as project management, communications support and actuarial and financial advice – this expertise will be sourced externally as required.
  • The Team will be responsible for managing the consultation process, UHI communications, developing costings for UHI and developing policy options for the provision of financial support for citizens in respect of their UHI policy.


  • Delivering a single tier health system, supported by UHI, is central to achieving our policy vision for the health system – a vision that is far-reaching and ambitious.
  • I want everyone to have an opportunity to contribute to the development of our UHI policy, and help us to ensure that the major changes are put in place in the best possible way for the benefit of everyone. So I urge individuals, local groups, national organisations and other bodies to actively participate in the consultation processes, and make their views known on the future funding and delivery of our health services.
  • Full details of the consultation process are available on my Department’s website at www.health.gov.ie. This consultation process will stay open until 28th May 2014.
  • Thank you