Mary Harney (Dublin Mid West, Progressive Democrats)

The Health Bill 2008 gives effect to recent Government decisions to end the automatic entitlement to a medical card, irrespective of income, for people aged 70 years and over and to introduce new arrangements in order that the vast majority of people aged 70 years and over will continue to have medical cards under a new income threshold.

With the enactment of this Bill, people aged 70 years and over will have three gateways to a medical card. First, under the new gross income limits, we expect 95% will qualify because their income will be below the new limits of €700 a week for a single person or €1,400 for a couple. Second, people whose gross income is above the limits may still apply for a medical card using the standard net income means test which applies for people aged under 70 years. This takes account of personal circumstances, such as high outgoings on nursing home fees. Third, a person may still apply for and be granted a medical card if his or her health circumstances cause undue hardship, under the discretionary medical card arrangements. Many people who have terminal illnesses, for example, are granted medical cards even if they do not qualify under the means test.

For those who are now aged 70 years or over — or become so by the end of this month — there will be no new means test. For those who turn 70 years in the new year, there will be a much simplified means test, designed to show that their gross income is below the new limits. These new arrangements will improve the sustainability of financing of medical card services for older people and allow resources to be targeted to those most in need. In particular, they enable the ending of the specially high capitation fee for general practitioners which has been paid since 2001 only in respect of over 70 year olds who received a medical card by virtue of age rather than means. This payment had the distinction of being discriminatory, inequitable and financially unsustainable. It was paid in respect of about 38% of people aged 70 and over. A wide range of people, including general practitioners, is pleased that the perverse incentive that this special fee created between different general practices is being ended. I welcome again the recommendation of Mr. Eddie Sullivan of a single fee capitation level of €290, which we intend to implement from 1 January next.

Under existing legislation, the objective of the general medical services scheme is to ensure the medical card benefit is available to those who are unable, without undue hardship, to meet the cost of health services for themselves and their dependants. People aged 70 years and over are more likely to require regular access to health services and it is appropriate that additional support is put in place to enable their access to medical care. At the same time, it is consistent with the general approach of the GMS for many years and the need to provide for financially sustainable schemes, that the medical card should be provided to all but the top 5% of income earners among the over 70s. There are and will continue to be pressing calls on scarce resources to meet the needs of many people across the whole range of health services. Fundamentally, it is better that we devote taxpayers' funds to meet those needs rather than pay for access to medical services for those who can, in any event, have full access to general practitioner services using their own resources.

Fortunately, people in Ireland are living longer and healthier lives. This is due in no small part to better health services and the higher living standards as a result of economic growth. We also have the youngest population in Europe, with only about 11% of people aged over 65 years. This will change in the years ahead as our population ages and lives longer. We we should welcome and prudently plan for the development in every respect, including Exchequer commitments.

The number of people over 70 years is projected to increase to 363,000 by 2011, 433,000 by 2016 and to 535,000 by 2021. We need to plan for and provide many health services for the people now aged 55 years and over who will form the over 70 age group at that time and use public resources in the most effective and fairest way to provide these services. In that context, the continuation of the automatic medical card and the specially high capitation fee paid for it does not represent prudent or fair financial planning. Resources should be used for those with the greatest medical and financial need. While some people counter this basic principle with a call for universalism in all services, it is highly relevant that our primary care services, in particular, GP practices, provide the same service to all, irrespective of the basis of payment. That is a universal service. A quality service that is accessible by all, with different rates of contribution or payment, based on means, is one that is equitable and fair.

I now propose to briefly outline the main provisions of the Bill. Section 3 provides for the replacement of section 45(5A) of the Health Act 1970 which provided, since 2001, for an automatic entitlement to a medical card for all persons aged 70 years and over who are ordinarily resident in the State, irrespective of their means. The old section 45(5A) is replaced by this new section 45(5A) which provides that those people who are aged 70 years or over before 1 January 2009 and who had full eligibility on age grounds will continue to have full eligibility provided their gross income from all sources does not exceed the specified limits. These limits, which are set out in section 45A, are €700 per week gross in the case of a single person, excluding any income from savings or similar investments whose principal value is €36,000 or less, and €1,400 per week gross in the case of a couple, excluding any income from savings or similar investments whose principal value is €72,000 or less. A person who was automatically entitled to a medical card, and therefore had full eligibility by virtue of the old subsection 45(5A), will continue to have full eligibility until 2 March 2009. Consequently, all persons can continue to use their medical card as normal until 2 March 2009 even if their gross income exceeds the relevant income limits set out in this Bill.

Section 4 provides for the insertion of a new subsection, 45(A), in the 1970 Act dealing with the eligibility of persons aged 70 and over, and their dependants, for a medical card from 1 January, 2009. It provides that people reaching 70 on or after 1 January will have to make an application to the HSE and provided they meet the income and other criteria of age and ordinary residency, they will receive a medical card.

A simplified means test will be arranged to enable people to apply. They will receive confirmation from the HSE that they have full eligibility and will continue to have it so long as their gross income does not exceed the limit. This section also covers people who have already reached 70 prior to the 1 January 2009, but who, for a variety of reasons, may not have applied for a medical card under section 45(5A) of the Health Act 1970, which provided for automatic entitlement to a medical card for all persons aged 70 and over. This section provides that dependants of persons covered in this section and section 45(5A) will also have full eligibility.

The gross income limits which will apply under this Bill from 1 January 2009 for single persons are €700 per week, excluding income from savings or similar investments whose capital value does not exceed €36,000. For couples, the gross income limits are €1,400 per week for people who are married or living together as husband and wife, excluding income from savings or similar investments whose capital value does not exceed €72,000. The couple limit of €1,400 will also apply where the spouse or partner is under 70.

This section requires that I review the consumer price index annually on 1 September and provides that the gross income limits may be increased to reflect any increase in the index. In this Bill I am making provision for the exclusion of income, and interest earned thereon, arising from certain compensation awards payable by the State.

These include compensation awards to persons under the Hepatitis C Compensation Tribunal Acts 1997 to 2006, compensation awards by way of the Residential Institutions Redress Board, established under section 3 of the Residential Institutions Redress Act 2002, prescribed repayments made under section 8 of the Health Repayment Scheme Act 2006 made to a living relevant person, to the spouse or former spouse of a living or deceased relevant person, directly to a living child of a relevant person by virtue of section 9(8) of that Act and ex gratia awards approved by the Lourdes Hospital Redress Board under the terms of the Lourdes Hospital Redress Scheme 2007. It further provides that I may make regulations prescribing further payments made for similar purposes also to be excluded as income for the purposes of this Bill.

This section also gives effect to the Government's commitment not to impute income from property. For the purposes of assessing gross income under this Bill, income will not be imputed from any property, whether it is a family home, a holiday home or any other property, unless it is rented, and only the net rental income, calculated as gross income less any costs necessarily associated with the rental of the property, will be included for this purpose.

Sections 5 and 6 are technical amendments which amend sections 47 and 47(A) respectively of the 1970 Act to provide for the new section 45(A) being inserted in the Act by this Bill. The amendment to section 47 provides that the appeals process available to persons under section 45 of the Act will also now apply to persons over 70 qualifying for a medical card under this Bill. The amendment to section 47(A) provides that guidelines on persons ordinarily resident in the State issued for the purposes of assisting the determination of an appeal under section 47 shall now also apply to persons qualifying for a medical card under this Bill.

Section 7 provides that people who are 70 years of age before 1 January and who hold a medical card on the basis of automatic eligibility under section 45(5A), prior to the enactment of this Bill, shall notify the HSE, no later than 2 March 2009, if they have concluded that their income exceeds the gross income limits. I want to ensure that the process of self-assessment required under this provision will be much simplified compared to that required under the existing hardship-based scheme. Consequently, I have asked the HSE to ensure that any assistance that a person may need in relation to self-assessment will be made available by the HSE on an administrative basis.

Subsection (b) amends section 49(2) of the 1970 Act such that the provisions applicable to a person who knowingly contravenes the requirement set out in subsection (1) to notify the HSE of any change in the circumstances that entitle him or her to a service provided by the HSE under the Health Acts shall also apply to persons qualifying for a medical card under this Bill.

The purpose of section 8 is to amend section 4 of the Health Contributions Act 1979 to provide an exemption from the health contribution for any person who is or reaches the age of 70 on or after 1 January 2009. The amendment will exempt everybody over 70 from paying the contribution regardless of whether they fall into the existing categories exempted under section 11 of the 1979 Act.

Sections 9 and 10 are technical amendments to the Social Welfare Consolidation Act 2005 so that the existing statutory provisions in relation to the sharing of information between public bodies, which already apply to section 45 of the 1970 Act, shall now also apply to section 45(A) of that Act as inserted by this Bill.

Section 11 is a technical amendment to ensure that the existing statutory provision in relation to the sharing of information between the Registrar of Births, Deaths and Marriages and the HSE, which already applies to section 45 of the 1970 Act, shall now also apply to section 45(A) of that Act as inserted by this Bill.

The Government has been concerned at all times in these new arrangements to ensure that a person aged 70 or over would not lose their medical card as an immediate consequence of the death of their spouse. We have explored all possible solutions in recent weeks within the boundaries of what was possible from a non-discrimination point of view as between widowed persons and single persons. I propose to introduce an amendment on Committee Stage to give effect to this objective.

This Bill is designed to give effect to the Government's decision to replace the automatic entitlement to a medical card for persons aged 70 and over with a new arrangement based on gross income limits. Under the new arrangement, the limits are set at a sufficiently high rate to ensure that the majority of people aged 70 and over will continue to qualify for a medical card. I commend the Bill to the House and look forward to hearing the views of Deputies.

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