Jerry Buttimer (Cork South Central, Fine Gael)
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Amendment Nos. 1 and 2 in the name of Deputy Kelleher have been ruled out of order because they involve a potential cost to the Exchequer.

Billy Kelleher (Cork North Central, Fianna Fail)
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It is difficult to accept this ruling simply because a case has been made by the Minister of State and his party and the Taoiseach and his party and the current Minister of Health, when he was in opposition, to the effect that introducing eligibility criteria for the over 70s would impose a cost on the Exchequer because people would be discouraged from accessing primary care. The commentary relating to this matter for some time indicated that universality of entitlement was both of benefit and a cost-saving exercise in terms of people being in a position to access health care. How amendments Nos. 1 and 2 involve a cost to the Exchequer is beyond me. I am trying to ensure that as many people as possible will be eligible for medical cards because all of the evidence cited by the Minister of State and others indicates that access to primary care is the cheapest option in the context of the provision of health care. It would actually benefit the State if more people had access to primary care services rather than the opposite, which is what the Minister for Health is seeking to achieve by means of the Bill before us. I thought that the amendments would be roundly endorsed, particularly as they would lead to the Exchequer saving money rather than losing it. I do not accept the ruling.

Jerry Buttimer (Cork South Central, Fine Gael)
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As the Deputy is aware, the ruling comes from a higher being. Let me add, however, that said being is not the Minister. The Deputy has been a Member of the Houses for long enough to know how the system operates.

Billy Kelleher (Cork North Central, Fianna Fail)
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I accept that but I felt I had to put-----

Jerry Buttimer (Cork South Central, Fine Gael)
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To clarify, amendments 1 and 2 in the Deputy's name propose a higher gross income rate to be set as the threshold for eligibility for a medical card for over 70s from 1 January 2014 than is currently in force or than is proposed by the Bill. This could result in increased levels of eligibility for medical cards among this cohort, which could impose a charge on the Exchequer. An amendment to a Bill which could have the effect of imposing or increasing a charge upon the revenue may not be moved by any Member, save a member of the Government - a Minister or Minister of State.

Billy Kelleher (Cork North Central, Fianna Fail)
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Yes. However, the arguments put forward over many years indicate that increasing access to primary care and GPs is a cost-saving measure. That has been identified-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am not going to enter into a debate on the matter.

Billy Kelleher (Cork North Central, Fianna Fail)
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I wish to place on the record the fact that I am of the view that the ruling in this case is incorrect, particularly if one examines the evidence as outlined by the Minister for Health.

Jerry Buttimer (Cork South Central, Fine Gael)
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I suggest that the Deputy, who is a long-standing Member of the House, take the matter up with the Bills Office rather than with the Chair, whose hands are tied.

Billy Kelleher (Cork North Central, Fianna Fail)
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That is fine. I just wanted to place my views on record.

Jerry Buttimer (Cork South Central, Fine Gael)
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I appreciate that.

Billy Kelleher (Cork North Central, Fianna Fail)
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The difficulty I have with the legislation before us is that it will lead to the numbers of those over 70 years of age who qualify for medical cards being reduced. There is no way around that. All of the evidence the Minister for Health has cited in respect of free GP care for the under fives indicates that it will be a cost-saving measure. Logic dictates that if the latter is true, then it should also be a cost-saving measure in respect of the over 70s.

Proposing a reduction in the number of people over 70 who will quality does not make economic sense if one follows the Minister's basic argument on free GP care for children under five. I do not like going back too far, but three years ago when an eligibility threshold of €1,400 a week was introduced it was described by those now in government as a damning attack on older people. If €1,400 per week is a damning attack on elderly people surely a reduction to €900 is a complete assault on them and their ability to access health care. I supported the introduction of the €1,400 threshold and we were vilified for it, perhaps, one could argue, rightly so. I cannot understand how the Minister can state this will not impact on many people. It will impact hugely and significantly on people who are over 70. The Health Insurance (Amendment) Bill is before the Dáil today. This is with regard to changes in the budget on tax relief for private health insurance. What will arise next year, and there is no point in us saying otherwise, is some elderly people will be unable to afford private health insurance.

Jerry Buttimer (Cork South Central, Fine Gael)
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I ask the Deputy to deal with this Bill as opposed to the Health Insurance (Amendment) Bill which will be taken later today.

Billy Kelleher (Cork North Central, Fianna Fail)
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They will lose their private health insurance because they will not be able to afford it and they will find they will not qualify for a medical card. The people who are slightly over the threshold of €900 a week are those who possibly could afford private health insurance until recently but will no longer be able to do so. They will not be able to access medical care through the medical card system. The Minister has not thought this through. I cannot square the circle of the idea a threshold of €1,400 per week was bad for people over 70 but one of €900 per week is good and I would like an explanation.

We initially had thresholds of €700 per individual and €1,400 for a couple. Last year the thresholds were €600 for an individual and €1,200 for a couple, and we now find it will be €500 for an individual and €900 for a couple. I would like clarity on this issue. What is the logical reason for this? This is just about saving money in a short-term process and there is no point in pretending otherwise. The Bill is contrary to everything stated by the Minister, the Minister of State and the programme for Government, and I cannot accept the Bill. What rings in my ear day in and day out are phrases such as "the cheek of them" and "shame on them". I do not like to be overtly political on Committee Stage because we are going into the detail of the Bill, but it beggars belief we are now discussing a further reduction in eligibility for those aged over 70 when the stated policy of the Government is that eligibility should be extended to everybody. This is problematic for me.

Another area which is not in the Bill but which has an impact is the prescription charge.

Jerry Buttimer (Cork South Central, Fine Gael)
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I ask the Deputy to stick to the Bill.

Billy Kelleher (Cork North Central, Fianna Fail)
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My point is this is an attack on older people. The increase in the prescription charge further undermines the ability of older people to access medical care in primary care settings. Older people will have to pay for their GP, medical care and prescription costs and some will lose their health insurance. For all these reasons, the Bill is distasteful to say the very least because it will reduce the number of people who will qualify for medical cards. It is contrary to every stated policy of the Minister of State, the Minister and the programme for Government. I would like explanations as to why I should support it.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I oppose not only this section but each of the two subsequent sections. I am absolutely opposed to the legislation in its entirety. It is not amendable in any shape or form. It was a great disappointment to me because I was very happy to record my support for the provision of free GP care for all children aged five and under as announced in the recent budget. This was something I commended, and I indicated I was willing and happy to support it as long as it was part of a programme to introduce free GP care across the board and that we had a plan. I have not heard the plan, but the proposition entailed in the Bill undermines the credibility of the measure. Not only are we looking at a situation where €37 million has been provided with regard to the roll-out of free GP care to children aged under five, but €149 million in total is being taken out of the medical card budget. This is absolutely massive and the Bill relates to a significant part of this with regard to those aged over 70 whose income thresholds exceed €500 per week for a single person or a person living alone and €900 per week for a couple together. It beggars belief why this approach has been taken and has already demonstrated very serious consequences for ordinary decent people who had the reasonable expectation they would be able to continue to have the comfort and assurance of their medical card entitlement.

On its introduction we had universal over 70 entitlement. The previous Government wanted to restrict this and the Minister went ballistic when he was sitting beside me in the Opposition benches a very short period of time past. As a result of public demonstration, and great commendation to all of the older people who mobilised at the time, the former Government capitulated and introduced thresholds. Again, Deputy James Reilly showed, as I did, strong opposition to a particular cut off, wanting to see universal access as the cornerstone of our respective party policies as I would have understood it. Now he is in government the Minister, and the Minister of State as one of his support Deputies, has proposed not one but two further significant reductions in these thresholds, reducing them first to €600 and €1,200 from €700 and €1,400 respectively and now, in this particular instance, with regard to the budget for 2014, a further reduction of €100 for a single person and a reduction of €300 for a couple, in terms of entitlement, from €1,200 to €900, which no longer keeps the equilibrium with regard to the entitlement of a couple together being twice that of a single person. It is most disappointing and has caused huge disquiet.

There is no doubt people are battle weary. They have taken so much over recent years in a succession of austerity budgets. Do not take any comfort from the fact there has not been a replication of the huge demonstrations which presented a short number of years ago, and that in some way this is an indication of acceptance.

It is not. People are beaten down. While there has been significant mobilisation and protest on what the Bill seeks to do, that in no way reflects what I know to be the reality of thinking on the issue, not only among those directly affected, namely, those within the over-70s cohort of our respective communities, but people across the board of all ages. The Minister should make no mistake - I am within a decade of such an age myself, and we all aspire to reach those august ages - the measure has created great disquiet. It will impose significant hurt and pain on many people who are being hit by a variety of measures contained in budget 2014.

Older people and younger people have been specifically targeted by the measures contained in the recent budget. A Government Deputy I know and respect was very happy to boast to me that the centre ground had been left intact and that the Government had not hit too hard a particular body of people in terms of age and income. That is not entirely true but it is true that they have been less affected than those of senior years and young people who find it difficult to secure work in this country.

There is no meeting of minds or centre ground in this regard. That is why I chose not to offer any amendment. I am absolutely opposed to what is entailed. It runs totally contrary to the Minister of State's stated intent on the roll out of universal health care. It is a most regressive measure. This is not a proud moment for the Minister of State in political life nor for his colleagues in government. It will have a hugely injurious impact on the fortunes of both Fine Gael and the Labour Party in the upcoming county council and European parliamentary elections.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Ó Caoláin should speak on the Bill rather than the elections.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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A Chathaoirligh, make no mistake, it will have such an effect.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is not in the Bill.

Alex White (Dublin South, Labour)
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Does that aspect of it please Deputy Ó Caoláin?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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No, that is not the case.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are speaking on the Bill.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I am speaking on the Bill. Make no mistake about it, a Chathaoirligh.

Jerry Buttimer (Cork South Central, Fine Gael)
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The local elections are not in the Bill.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Chairman, you cannot just pick what you like about what I have to say, although I am sure that is damn little in terms of what I have put on the record so far, but the fact of the matter is-----

Jerry Buttimer (Cork South Central, Fine Gael)
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The Chair is independent.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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-----I would far prefer, as I have indicated to the Minister already on the floor of the Dáil, that I would be able to say that I welcome such a step, proposal or measure. I have shown and demonstrated time after time that I am an Opposition Deputy willing and prepared to do that when it is merited. That is what disappoints me most of all. I would like to be in that situation. The current situation is absolutely unacceptable and runs totally contrary to everything I would have hoped from the Minister and his party’s particular input into the coalition.

Jerry Buttimer (Cork South Central, Fine Gael)
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I call Deputy Healy to speak on the Bill. We are on section 1. We are straying a bit from it. Deputy Healy has not spoken yet so he cannot be accused of straying.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The Bill is a short piece of legislation. It is essentially a legislative piece of hypocrisy at variance with all Government policy. It goes back to a 2008 decision by Fianna Fáil to introduce a similar regime. We all recall the current Minister’s position at the time. He used the term “terrorism” to describe the proposal by the Fianna Fáil and Green Party Government at the time. The Taoiseach was equally strong in his condemnation. The words, “shame, shame, shame” come to mind. The Tánaiste said something like “How dare Fianna Fáil do this to the elderly people of Ireland?” Those two parties – Fine Gael and the Labour Party – went on to make even more extensive commitments in the 2011 general election and in the programme for Government. The thrust of the approach was to be universal health care and free access to GP services for all. The Bill rolls back on that. It is part of the targeting of elderly people by the Government. I refer also to such measures as prescription charges, the abolition of the telephone allowance, the reduction in the heating and energy allowances and the recent abolition of the bereavement grant.

The cuts are effectively cost-saving measures. It is unnecessary to take this step as there are other areas that could be tackled, for example, the significant number of wealthy people in the country. The Minister of State, Deputy Costello, told us recently that this is the seventh wealthiest country in the world. In a reply I received from the Minister for Finance, Deputy Noonan, the top 20,000 earners have an average annual income of €476,000. The income and assets of significant numbers of people in this country have increased during the recession. I would have expected that the Government would have looked to them for savings if such savings were necessary.

It is also part of the overall attack on medical card holders. There has been a reduction of €149 million and that is affecting 170,000 medical card holders. Of those, 35,000 are in the over-70s age group and 22,000 have lost cards due to a return to employment and then there is the so-called €113 million of probity. I will not support the legislation. I agree wholeheartedly with Deputy Ó Caoláin in that regard.

I wish to make one other comment on services for the holders of medical cards. I wrote to the Minister about it on a number of occasions and I raised it last week in the Dáil. I refer to the situation that is now arising countrywide where GPs charge for services that were heretofore free for people with medical cards.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are on section 1. Could Deputy Healy stick to the Bill?

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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It is an important issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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I know but it is not in the Bill.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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It is related.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are on section 1.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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It is related to the Bill and the services that are available to holders of medical cards under the terms of the Bill.

Jerry Buttimer (Cork South Central, Fine Gael)
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I appreciate that but as the Deputy is well aware it does not relate to section 1.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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It started with charging for blood tests and there are now charges for dressings, minor surgery and letter writing. The Minister must take up those issues directly with the Irish Medical Organisation, IMO, and GPs. It appears that GPs are attempting to pass on cutbacks to medical card holders. It is not acceptable to say that medical card holders must complain directly to the HSE because it is very difficult for people who are availing of services from their GPs to make a formal complaint at the same time to the HSE. I call on the Minister of State to ensure the Department takes up the issues directly with the IMO and GPs around the country.

Alex White (Dublin South, Labour)
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Deputy Kelleher is correct. Colleagues also made the point that these measures are proposed to the Dáil in the context of the necessity to make significant financial savings in the health area. This is where the proposal has come from and I do not for one moment deny that such is the case. Regrettably, there is a need. Colleagues, in particular, Deputy Kelleher, will be aware why that is so and why the economic position is such that we must make savings, including in the health system.

The savings that have been put forward this year in the context of the health budget have been designed as far as possible not to impact on front-line activity and to ensure that the most vulnerable are protected, and that is how the Government has proceeded.

As members will be aware, the GMS is one of the areas that has been identified under budget 2014 for the savings that are required to be made. Over recent years there has been a significant expansion in the GMS scheme. The total cost of GMS services provided to over 70s medical card holders is approximately €750 million per year, which represents over one third of the total cost of the GMS scheme. In circumstances where, regrettably, savings must be achieved, there is no reality to the suggestion that we could not look to this area as providing some of those savings, and that is what we have done.

There are approximately 350,000 individuals aged 70 years and over who currently hold a medical card. It is estimated that the budgetary measure proposed here will move approximately 35,000 persons from a medical card to a GP visit card. In response to Deputy Kelleher, I have not stated that this would have no impact. The Government has not stated that it would have no impact. It would be nonsensical for the Government to state that a measure would have no impact. We have not said so. What we stated is that it will affect one in ten of over 70s medical card holders who are - the term "better-off" is a relative term - the better-off 10% of current over 70s medical card holders. As a consequence, the overwhelming majority of over 70s medical card holders will be unaffected by this Bill.

It would be preferable not to have to make these changes. There is nobody coming in here celebrating this proposal. It is being put before the Oireachtas as a necessary saving, but it will affect only the higher income over 70s, if I may describe them as such, who currently hold a medical card.

I will address this issue that is raised consistently by Deputies Kelleher, Ó Caoláin, Healy and others, namely, that this runs contrary to the Government's plan in respect of universal access to GP care. Deputy Healy made the point that it was at variance with Government policy and that it constituted a roll-back on free GP services for all. It does no such thing because nobody, not a single individual, is losing free access to his or her GP from this measure.

Measures proposed by Government are open to criticism from the Opposition. The Opposition must do its job in that regard. I do not challenge the members in that respect, but we must get the facts straight. It is not contrary to the plan for universal access to GP care without fees because nobody is losing free access to his or her GP as a consequence of this measure because every individual who is moved from a full medical card will have a GP card. There is no separate test, or anything else, for it. It is automatic that any individual who loses out as a result of this change will have a GP card.

The plan is universal access to GP services without fees. That is the proposal that we are bringing forward. That is the proposal with which Deputy Ó Caoláin states he agrees, and I thank him for that. That is the proposal that many think is the correct way to proceed in terms of how we adjust our health care services into primary care, that we do not charge persons for attending their GP. Nothing that we are doing today undermines that. Members should stick to the facts of the matter. There are many other measures for which we can be criticised but we have not taken away free access to a GP from any individual, neither in this measure nor in the measure that we brought in last year. Everybody retains a GP card. There is much that we can debate and much on which we can disagree, but we cannot disagree on that because those are the plain facts of the matter. I would appeal to colleagues to note that such is the case.

On the over 70s who will be affected by this measure, I remind colleagues that under the drugs payment scheme the HSE will meet the prescription drug costs of those persons without a medical card who face drugs costs higher than the DPS threshold of €144 per month. This means that a single person aged 70 with a gross income of over €500 a week or a couple with an income of over €900 a week will have their expenditure on prescription drugs capped at approximately €33 per week. It is true that they will lose out on the free drugs if they move from the full card to the GP card, but they will still have coverage from the DPS, which sees their drugs capped at approximately €33 per week. Those are the facts of the matter.

When Deputy Kelleher spoke earlier about the long-term benefits of universal access to GP services, he made the point about the cost and asked how this could be regarded as a cost when we all are trying to move towards universal access. I welcome his support for universal access to GP services, if that, in fact, is his position. However, as I stated previously in this committee, it will not be possible for us to change overnight a system that we have had for so long which is based on means testing and section 45 of the 1970 Act. We must change this system gradually, particularly given that we face such financial constraints.

We are faced with a situation which, perhaps, is paradoxical. In some ways, maybe it can be described as contradictory that we must make savings in the current system that we are managing but we must look to the future, plan and resource as best we can, even in a modest way, the kind of changes that we need to make a fundamental change to the way the health system is managed and its services are allocated. That is why I support and have brought forward the proposal on universal access to GP care without fees. That is why I say this is not contrary to that. If any of the individuals affected by this measure was losing free access to his or her GPs, the case could be made that the measure would be contradictory to our plan but that is not what is happening.

We are faced with a situation where we must make savings. We are doing that in the best way possible consistent with having to make these savings. It is affecting the top 10% of over 70s medical card holders. They all will still keep their GP cards. They will still have access to the DPS scheme meaning that their drugs will cost no more than €33 per week. It is not contrary to what we are trying to do in terms of the universal roll out. For those reasons, I would commend the Bill to the House.

It is never especially palatable to change eligibility in this way. It is necessary in order to achieve the savings that the Government must achieve. On that basis, I would ask the committee to support it.

On Deputy Healy's point about the doctors, I wish to reassure him, as I did in the House the other day. There have been some complaints raised by the Deputy and others. The HSE has raised this issue with the IMO. The rules are clear. There is no basis for some of the charges that one has heard about.

If somebody requires a blood test as part of the normal diagnostic process, he or she cannot and should not be charged. If it is happening, we need to know about it. We have raised the issue with the IMO. In more general terms, it points to the need for a new contract with doctors. This is another job in which I am very much engaged. In so far as there is a lack of clarity in this area, there should be clarification in a new contract, to which the Government is committed to achieving.

Billy Kelleher (Cork North Central, Fianna Fail)
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We could be going around in a circle for the day. The Minister of State said I, more than anyone else in this room, should be aware of cost savings. I should be, to say the very least, but the fact is that the current programme for Government was drafted in February and March 2011.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are discussing the Bill, not the programme for Government.

Billy Kelleher (Cork North Central, Fianna Fail)
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One should consider its impact.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy is straying from the Bill.

Billy Kelleher (Cork North Central, Fianna Fail)
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The legislation runs contrary to everything in the programme for Government. I can go through it line by line. It states:

Where—(a) a person—

(i) was married to another person until that other person’s death,
(ii) was living with another person as husband and wife until that other person’s death, or
(iii) was a civil partner as respects another person until that other person’s death...

The last line of the provision states: "their combined gross income limit is €900 per week, not including the income from the portion of their savings or similar investments whose capital value does not exceed €72,000”. People over 70 years are resilient and resourceful. The Tánaiste said previously that they had marched for civil liberties, women's rights, pay equality and, only a few years ago and also a few weeks ago, for the entitlement to a medical card. We now find their income threshold is being reduced. On top of this, there are issues that will obviously have a detrimental impact on their health. If one does not have a medical card, one receives a GP card, but the GP refers a person to hospital, where he or she will be charged €80 per night up to a maximum of ten nights in the year, totalling a maximum of €800. There are charges being imposed all the time by stealth on persons who will have to gain access to health care without a medical card. This will have an impact on their health. The prescription-only charge will have an impact.

I am speaking to the Bill. I tabled amendments that were ruled out of order, but I have conceded that the concept of universality has been breached by us previously. To be consistent, I am asking the Government to raise the threshold to the original €1,400 per week per person. That is fair and rational and it would, in some way, be constructive. The idea that a figure of €1,400 was terrible for people, while €900 is not so bad rings very hollow.

The 35,000 people affected have a fixed income at their stage in life. Their earning capacity is no longer such that extra income can be generated. Their savings' capital value must not exceed €72,000 and they now have a property tax on their house. Therefore, their disposable income is greatly diminished already, yet we are asking them to pay €80 per night when they go to hospital. If one considers the profile of those over 70 years, one realises very many of them have private health insurance. The cost of private health insurance will go up for the average family by €350 to €360 next year. Many of the people in question, therefore, will not be able to afford private health insurance and will enter the public hospital system. This runs contrary to what one would expect. I cannot accept the Minister's arguments, primarily because I do not believe he believes in them himself and also because they run contrary to everything that was stated policy as recently as the time of drafting of the programme for Government.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Not everyone over 70 years is retired. There are those over 70 in paid employment who are taxpayers. They may not comprise a large number, yet the position on their medical card entitlement under the terms of this and previous legislation is such that they are being evaluated on the basis of their gross pay, not their net pay. I use the term "pay" certainly-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Since there is a vote in the Dáil, I ask the Deputy to conclude in order that we can suspend the sitting.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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There will be those over 70 years in paid employment who are tax contributors and who will be treated differently from those under 70 on the basis of gross rather than net income. I heard this referenced in the consideration of the Bill on Second Stage. I listened carefully to the Minister's reply on that occasion.

It is a question of understanding why the Minister lowered the qualifying threshold for a couple by a greater percentage than that applying to a single person. It could encourage a couple to break up. I am not suggesting that might happen in many cases, but it could apply in some. If the couple were earning over €900 or had that gross income stream, they would qualify for a medical card if they were living separately rather than together. Some might scoff or laugh at that idea, although the Minister of State has not. The fact of the matter is that it is a by-product of what is being provided for in the legislation. It is another weakness and, accordingly, merits being highlighted again today.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are now resuming in public session. I wish to convey to the Minister of State that Deputy Ó Caoláin has to attend the Dáil for the debate on the Child and Family Agency Bill. It is a pity that a spokesperson is supposed to be in two places at once. None of us has been able to master the art of bi-location but this situation is disappointing. It is unfair to spokespersons and other members of this committee to have two health Bills being dealt with simultaneously - one on our clár and one in the Dáil. Health spokespersons want to contribute to both debates but they cannot be in two places at once. I wish, however, to record Deputy Ó Caoláin's apology. It is not a slight or discourtesy to the Minister of State, but he has to attend the Dáil debate.

I now call Deputy Seamus Healy to contribute.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The Minister of State has been honest in his contribution by confirming that this Bill is all about cutbacks, savings and targeting elderly people for those savings. He indicated that he does not have any other options, but there are choices. This is a wealthy country, although some people would have us believe that it is broke. In October 2012, the Minister of State, Deputy Costello, told us that Ireland is the seventh wealthiest country in the world. Independent CSO evidence indicates that the top 10% of people in this country have increased their income and assets during the course of this recession. There is also clear information that the top 5% of wealthy people in this country have assets in the order of €239 billion.

The Government could have chosen to raise income from these areas, but it chose not to implement a tax on wealth or assets. It also chose not to introduce a third rate of PAYE for higher earners. Some months ago, the Minister for Finance, Deputy Noonan, told me that the top 20,000 earners in the country have an annual average income of €476,000 each. These are areas that could have been targeted by the Government for increased taxation. Had that choice been made, it would have obviated the need to target elderly people's savings.

The loss of a medical card does not simply mean the loss of free attendance at one's GP. Medical card holders are entitled to access other services, including home help, appliances, day care centres, physiotherapy and occupational therapy. Such services allow elderly people to remain in their homes for as long as possible. They ensure that significant savings are made by the State since older people can remain in their own communities.

The Minister of State referred to issues I raised about charging for services to medical card holders.

That is a reasonably new development. He has indicated that the GP contract needs to be addressed in that context. I am sure he is correct but that will take time. I ask the Minister of State to deal with this matter urgently. I am sure every Deputy is getting complaints from constituents about GPs charging for services that were previously free. It is not good enough to say we will deal with that matter under the contract. We all know the contract will not be agreed today or tomorrow, or possibly even next year.

Alex White (Dublin South, Labour)
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On Deputy Healy's last point, I did not say the matter would have to await the negotiation of a new contract.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I did not claim you said that.

Alex White (Dublin South, Labour)
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In that case we are not disagreeing.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I am asking you to deal with the matter urgently.

Alex White (Dublin South, Labour)
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Absolutely. Deputy Healy raised a fair point in the Dáil recently and he has repeated it today. In the circumstances he and others have outlined, there is no basis for doctors to impose extra charges. The position is clear and it has been communicated to the IMO. To the extent that it is necessary to do that again, it will be done. If there are doubts about any of these areas, the time for them to be addressed is during the negotiations on a new contract. The issue is being addressed by the HSE and I have no difficulty with the Deputy raising it and drawing it to my attention.

In regard to savings, he addressed the broader political point in respect of the economic adjustments and the possibility of finding a fairer way. It is interesting and important to debate who has been most affected by the economic downturn and the measures introduced by the Government. I respect his refusal to accept that savings have to be made in the GMS but if he did accept our argument, he would agree this is the fairest way to do so. Approximately 85% of those aged over 70 years will retain the full medical card. The change is not affecting the overwhelming majority of citizens aged over 70 years.

Deputy Ó Caoláin raised the issue of gross assessment as opposed to net assessment for the over 70s. Perhaps he was suggesting this may throw up anomalies in respect of people who are working. It is open to persons over the age of 70 years to be assessed through the net system that applies to the rest of the population. There are slightly different schedules for applicants aged over 65 years. In respect of the €900 and €500, I pointed out on Second Stage that the Government realises the living costs of an individual living alone are more than half those of a couple. Expenditure does not necessarily diminish relative to the number of people in a household. That was the rationale behind the thresholds.

With respect to what Deputy Kelleher said in his rejoinder, nobody disagreed with me when I said that the change is not contrary to the policy of universal GP access without fees because the GP card is not being removed from anybody. As is his entitlement, the Deputy is fond of pointing out what people said prior to the election. I recall that the previous Government intended to make fundamental changes to medical cards for the over 70s.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are speaking on the Bill.

Alex White (Dublin South, Labour)
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As the Deputy was given latitude to make his political point, it is no harm to remind members what his party wanted to do to people aged over 70 years. The changes it proposed were more fundamental than what was ultimately implemented, namely, an income threshold of €1,400. The 3% of people who lost their medical cards through that decision did not get GP cards. Anyone who has lost a full medical card under our measure received a GP card as a replacement. We spend a considerable amount of time looking back but it is better to look forward.

Jerry Buttimer (Cork South Central, Fine Gael)
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I would be happy if the Minister of State looked at the section.

Billy Kelleher (Cork North Central, Fianna Fail)
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There will be embarrassment for lots of people in looking forward.

Alex White (Dublin South, Labour)
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Certainly for Deputy Kelleher.

Robert Dowds (Dublin Mid West, Labour)
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Like the Minister of State, I regret that the medical card situation for the over 70s has to be changed but if we are required to make savings in this area, it is better to impose cuts on those who are most able to bear them. This legislation will have that effect. It is important to highlight two other issues - or perhaps three given that Deputy Kelleher has reminded me of his past. Some 43% of the population have medical cards, many of whom have qualified because of the collapse of the Celtic tiger over which Deputy Kelleher's party presided. The Government rightly decided to focus its attention on providing GP access to children aged five years and younger. That was a wise decision -----

Jerry Buttimer (Cork South Central, Fine Gael)
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Please speak to section 1.

Robert Dowds (Dublin Mid West, Labour)
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----- because most people's health care needs at old age are dealt with at that stage of their lives. The €900 threshold protects those who are least able to look after their own needs.

Jerry Buttimer (Cork South Central, Fine Gael)
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I think we have had a fair discussion on section 1.

Billy Kelleher (Cork North Central, Fianna Fail)
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We had a discussion but I do not think it has been fair.

Jerry Buttimer (Cork South Central, Fine Gael)
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I appreciate that Members have busy schedules but Deputy Ó Caoláin is standing in the Dáil speaking on another Bill as part of our committee work. The scheduling is disappointing and I hope we will write to the Whip's office and talk to the chair of chairs regarding the scheduling of committee business clashing with the Dáil. It is unfair on spokespersons and committee members who want to participate in the Dáil.

Billy Kelleher (Cork North Central, Fianna Fail)
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I do not want to delay because I know I will inevitably be crushed by a massive majority. At the risk of being accused of being repetitive, we have already discussed the eligibility. Under this section a person who has been notified that he or she is eligible for a medical card shall "at any time after such notification, furnish to the Health Service Executive such information regarding that person’s income and assets as the Health Service Executive considers necessary for it to establish if that person has or continues to have full eligibility." This is the assessment process that will be put in place and the notification obligations of an individual.

I must be very careful here because I do not wish to reflect on the individuals working in the primary care reimbursement centre working very diligently to try to assess people's eligibility but there are major difficulties and every Deputy would accept that. Individuals are being randomly selected for a review process and they could be in their 80s or 90s. Some time ago I raised the case of a 96 year old from Cavan who was being assessed after random selection by the computer. I accept that if the legislation is passed there is a primary obligation to enforce it because the Parliament will have decided and it must be followed through. However, would the Minister not think that profiling would be a better way of assessing people for eligibility than random selection?

The idea that a 90 year old who is under huge pressure physically, bed bound and in full-time care would be randomly selected to furnish details that would invariably allow him or her to retain his or her medical card is bizarre. Am I missing something here? The Minister of State will have to examine this process of reviewing and requesting information because the random selection process is bizarre. The Department's Estimate provides for the generation of €113 million through the probity audit and there is no doubt it will be vigorously enforced through the review process. Medical card reviews should be undertaken on a profiling basis and on the basis of high risk as opposed to random selection through which people will be picked out who invariably will retain their medical card. It would be fine to randomly select if there was a quick assessment made of whether a person was high risk. Surely a 90 year old man is unlikely to be at high risk of being in breach of criteria for a medical card. I hope the Minister of State understands what I am driving at.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I support Deputy Billy Kelleher. These elderly persons have medical cards that are valid until 2020 and their applications were assessed and the cards granted by the HSE. At the time, officials obviously felt their circumstances would not change significantly in the next period of years, which was a reasonable and common-sense position to take. I question whether this is being done on a random basis, as I suspect it is being done on a blanket basis, given the number of reviews taking place. These medical cards are being reviewed, even though the persons concerned are in their 80s and 90s. For instance, the day before yesterday I was contacted by the daughter of an 85 year old lady who lived alone. She has a medical card until 2020, but she received a review form in July. She was in hospital at the time and did not see the form. As a result, she did not return it, but she did not realise until she had to obtain medication that she no longer had a medical card without even the reasonable notification of a reminder. If the review form is not returned for whatever reason, card holders do not even receive a reminder that they have not returned their forms and if they do not do so, they will lose their medical cards. That is the least that could be done. In 95% of cases there is no need to, or point in, reviewing the applications because, as Deputy Billy Kelleher said, they will retain their medical cards. The HSE assessed them and took the view that they had a fixed income which would not change in the next number of years unless they won the lotto, which we cannot all win. This issue needs to be examined.

Assessments on medical grounds as opposed to those relating to general discretion where applicants exceed the income thresholds are taking weeks on end and, in some cases, the medical evidence provided by people with serious health conditions and who are slightly over the limit is sitting in a queue. I am aware of one case that took more than three weeks to decide and this is happening on an ongoing basis. This issue also needs to be examined.

Jerry Buttimer (Cork South Central, Fine Gael)
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The issuance of letters is an issue. The fear of God is instilled in people, particularly the elderly, when there is no need to do so in many cases. We all accept that some people who have medical cards should not have received them. When Deputy Billy Kelleher's party was in government, patronage was ripe. That was the way it was then, but everything has changed.

Billy Kelleher (Cork North Central, Fianna Fail)
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That is what discretion is for.

Jerry Buttimer (Cork South Central, Fine Gael)
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We have driven people completely demented and there is no need for it. It is welcome that at the initiation of the Minister of State and the Minister the HSE now has a communications plan and the letter has been changed but profiling is an issue that should be examined. People in their 80s and older are coming into to our offices petrified. Deputy Seamus Healy has made a good suggestion about issuing a reminder notice. We all know of people who have been in hospital or who have moved to nursing homes or who do not open the post themselves and that it is left on the hall table. Will the HSE consider issuing a reminder, particularly for the over 70s? The committee is supportive of the staff in Finglas who do tremendous work, but the assessments of those aged over 70 years are not user friendly.

Alex White (Dublin South, Labour)
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The amendment to section 48A(1) includes a requirement for a person with full eligibility to provide information on income and assets if so requested by the HSE. It does not make sense, however, to only apply this requirement to existing medical card holders. Therefore, we propose to delete the reference to "prior to the coming into the operation of this section".

Fair points were raised about the reviews, to which I will refer, but the amendment provides for a net change, which is that the power to review will be provided for in legislation in respect of all future medical cards issued. The current provision only provides for this power in respect of existing medical card holders. If this is agreed to by the committee, the same power will be extended to cover all medical cards issued in the future.

There are a number of ways to review eligibility. The first relates to the defined eligibility period - usually three years. The second is risk-based reviews, on which Deputy Billy Kelleher touched, based on specific criteria such as inactive medical cards or where information from other statutory bodies such as Revenue indicates the medical card should be reviewed. The third type is the so-called random review, while the fourth is use of the death event notification system which identifies the deceased and enables the cessation of capitation payments in cases where the GP or family have not notified the HSE.

The policy on random reviews arises from a recommendation of the Comptroller and Auditor General in his most recent report:

The HSE should conduct reviews of random samples of cardholders on an annual basis. This would allow the HSE to develop an estimate of the level of excess payment in the system as a whole. Tracking changes in this estimate of excess payment would allow the HSE to evaluate the effectiveness of its overall control strategy.

Those are the total number of reviews that have taken place on, as it were, a random basis. The other reviews I have mentioned, namely risk-based reviews and reviews based on the expiration of the eligibility period and so forth, are taking place.

Jerry Buttimer (Cork South Central, Fine Gael)
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I must interrupt the Deputy because a vote has been called in the Dáil.

Billy Kelleher (Cork North Central, Fianna Fail)
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Can I make a suggestion? I would like to fight the good fight for as long as possible but we can go through this very quickly if the Government agrees to that.

Alex White (Dublin South, Labour)
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I am just answering the questions put to me.

Billy Kelleher (Cork North Central, Fianna Fail)
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I accept that and am just trying to facilitate the Minister of State. I am trying to facilitate everyone here.

Alex White (Dublin South, Labour)
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I understand the Deputy's point. Will I finish my response?

Jerry Buttimer (Cork South Central, Fine Gael)
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Will we resume after the vote in the Dáil?

Billy Kelleher (Cork North Central, Fianna Fail)
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If the Minister of State concedes-----

Alex White (Dublin South, Labour)
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The Deputy should not expect concessions.

Billy Kelleher (Cork North Central, Fianna Fail)
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Concedes was the wrong term. The Minister of State might agree to go through this quickly.

Alex White (Dublin South, Labour)
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I have listened carefully to what the Deputy has said. Deputy Kelleher is correct. There are other types of reviews, apart from random reviews but we need to be able to conduct each type. Risk-based reviews will also be part of the process. Deputy Healy made the point about cards being valid until 2020 but we must have the power to review eligibility. We must have the power to do that. The Deputy suggested that in many cases the income of the cardholder is unlikely to change, but we cannot know that as a certainty. There is no flag in the system to highlight individuals whose income will never change. We must have the power to review eligibility. I agree with the Chairman that it must be done sensitively. The HSE must ensure that the communication process is sensitive and proper. That is being done and being improved upon as we speak.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will the Minister of State take Deputy Healy's point on the review into consideration too?

Alex White (Dublin South, Labour)
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I will take everything that has been said here into account. I have listened very carefully to what the Deputies have said.