Denis Naughten (Roscommon-South Leitrim, Independent) | Oireachtas source

I welcome the opportunity to speak to the Bill and raise a number of pertinent issues, as previous speakers have done. It is important the legislation would address a number of anomalies. However, a number of other anomalies which I will bring to the attention of the Minister of State are not addressed. These gaps in the system deny people, especially people with incomes slightly above the threshold, the right to a medical card. The working poor are highly aggrieved because they believe they are not entitled to anything but must pay for everything. They are not entitled to a medical card or general practitioner visit card, while others, who have more disposable income and, in some cases, greater gross income, are legitimately entitled to a medical card under the current rules.

I will provide one example of the type of an anomaly that affects older people. The income limit for a medical card for an older couple aged more than 70 years is €298 per week. A couple who are in receipt of the maximum contributory old age pension, which is €230 per week each, in addition to the half rate of carer's allowance, will have a total weekly income of €562 per week. A couple in this position will receive a medical card because all of their income comes from the social welfare system, even though it exceeds the €298 income limit. However, the position is different for a person with a similar income if part of it is provided by the social welfare system in the United Kingdom.

Since the pension is coming from the United Kingdom it is calculated as income and not disregarded, as it would be for an Irish social welfare recipient. Such a person's income could be below the threshold and their sole income could be from social welfare but they are denied a medical card because some of the income comes from a contributory social welfare payment in another jurisdiction. That anomaly probably contravenes EU law and needs to be clarified and addressed.

A more frustrating anomaly relates to the working poor in this country. The purpose of family income supplement is to support low income families and encourage them to stay in work. The family income supplement element of their income is disregarded in the means test for the medical card but the supplement could push their total income over the income threshold and cause them to be denied the medical card. Meanwhile, someone who is considerably over the income limit but whose income comes solely from social welfare will qualify. The system is being turned on its head. It penalises people who are in work in favour of others whose sole income comes from social welfare and discourages people who are on social welfare from going back into employment. I accept that there is a transition period, the purpose of which is to iron out anomalies. Nevertheless, consider two neighbours living side by side. Both are on, pretty much, the same income but one gets up every morning and goes to work, if they are lucky enough to get employment, while the other does not even attempt to find employment. What is the incentive to either of those neighbours to go to work? They may get a few extra euro but they will lose their medical card in three years time, or the law could change in the intervening period. The ethos of the medical card needs to be addressed.

Consider another example. A single person in receipt of disability allowance of €188 per week as well as the half-rate carer's allowance is entitled to a medical card. Someone in employment and earning €290 per week, which is less than the first person's income, is denied a medical card. The system is wrong. Some people who are just over the income threshold get nothing while others who are significantly over the income threshold, because their sole income is from social welfare, are entitled to a medical card.

I am also frustrated by the roundabout way we have doctored the income threshold for the medical card over the past number of years. The income threshold has not increased but, because of budget changes, the cost of attending hospital has gone up and the payments people have to make until the drug refund scheme kicks in have increased. The medical card system allows no formal recognition of that. More and more people are being pushed into this poverty trap. This needs to be addressed. The Bill, while it deals with anomalies, does not deal with several genuine anomalies which incentivise people to give up employment and go into social welfare system.

When the Minister of State replies to the debate, I hope he will deal with the issue of granting only GP visit cards for the long-term illness scheme. The original Government announcement was that those covered by the long-term illness scheme would receive medical cards. That has been watered down and they are to receive doctor only, or GP visit, cards. Can the Minister of State give us a timeline for that change?

When the Minister brings forward that legislation, I suggest that it be extended to other long-term illnesses, such as haemochromatosis, that are not now covered by the scheme. Policy decisions were taken by a series of Governments not to entertain any extension of the long-term illness scheme. Illnesses such as haemochromatosis should be included in the scheme. This disease does not involve any additional costs, other than the out-patient charge, so sufferers would benefit from having the GP visit card. They are a significant proportion of the population. Other long-term illnesses, including colitis, have been mentioned by Deputies on this side of the House. Recognition should be given to them.

The vast majority of children with life limiting conditions will never see their 15th or their 18th birthdays. There is a small number of these children, approximately 1,500 per annum, and many are probably in receipt of the medical card, either on means grounds or because of their medical condition. A small cohort do not have the medical card. It would be some recognition of these families if they were included in the scheme. I will raise this matter with the Minister when the legislation comes to the House in the next number of months. This needs to be addressed.

A person who is aged 70 or over and is no longer within the income threshold can apply for the ordinary medical card. Other issues, which are not taken into account for the over 70 medical card, will be considered. However, the discretionary medical card, which traditionally was given in cases of medical hardship, has been greatly curtailed since the primary care reimbursement service, PCRS, took over the provision of the service. I have significant experience of such cases over a long number of years. The HSE took a pragmatic approach to them and took into account the genuine costs involved in attending medical appointments and so forth. It is now nearly impossible to get any movement from PCRS. When we do get movement, in the vast majority of cases people are issued with a GP visit card rather than a medical card. In many of these instances the additional hardship relates not just to medicines, but to frequent visits to hospital and to consultants in Galway or Dublin. Additional financial costs are associated with that, especially since the withdrawal of transport support from the HSE. The closure and downgrading of hospitals such as Roscommon County Hospital, is forcing more people to travel to avail of services.

With regard to Roscommon County Hospital, I must dispute claims that Roscommon hospital is busier today than it ever was. This is load of rubbish, as the mathematics show. That is all I will say on that matter. I do not want to get involved in that debate because it is not relevant to what is in front of us today.

The discretionary medical card is, slowly and surely, being withdrawn. Where there are cases of genuine need a GP visit card only is issued. I ask the Minister of State to look at that situation. Families who suffer significant financial hardship need a medical card.

In many cases, having free access to a general practitioner will not deal with their financial hardships in a substantial way. It is probable that they also see a number of consultants, which incurs additional costs - consultants' fees, inpatient costs, transport, lost earnings, etc.

I hope that the Minister of State will consider my point on the long-term illness scheme.

A proposal has been put to the Minister regarding the establishment of a national fund for sick children with life-limiting conditions. It would save money for the local offices of primary, community and continuing care, PCCC, services. The HSE is spending approximately €47,000 per annum per child through its various local offices. This figure could be reduced by half if there was a national office to control services. It would provide consistency in the provision of services for children with life-limiting conditions across the country. In my county, a white line in the middle of the road is the provincial dividing line. A child on one side gets access to a certain level of services while a child on the other side has a different entitlement.

I hope we can deal with the anomalies in the system across the country. The primary care reimbursement service, PCRS, in Dublin is doing so in respect of medical cards, but the same cannot be said for children with life-limiting conditions. Everything depends on the local budget, the attitude of the local health office manager to a particular case and families' persistence in pushing their cases. Sometimes, parents whose children are sick do not have enough energy or time to push as hard as they need to. A child with a lower level of dependency can get a higher level of support purely because a family has access to someone who can do the pushing or who has the wherewithal to articulate their case well. This is not right, particularly given our limited resources.

HSE offices spend approximately €8.2 million per annum. At a launch in the Mansion House on Monday of last week, however, it was estimated that a budget of €5 million would provide the necessary services. I have provided the details to the Minister for Health. After today's debate, I will send a copy to the Minister of State, Deputy White. By taking this service out of local offices and centralising it in Dublin, a significant amount would be saved and a better quality of service could be ensured for children, some of whom will live for a week, a month or one, two or three years.

As public representatives, each of us has encountered heart-wrenching cases. We must roll up our sleeves and try to fight for them. Deputy Connaughton has entered the Chamber. He and I dealt with a case in which we wanted to get a child home before last Christmas. A parent should not need to ask one, two or three public representatives to obtain these rights, particularly when the overall national pool of funding is adequate to deal with the issue. How the money is distributed and the lack of consistency across the country seem to be causing problems. I urge the Minister of State to consider this matter.

A further issue arises in respect of the analysis of this legislation, namely, the substantial number of older people who have private health insurance. Many also possess the over-70s medical card. At a time when the private health insurance system is haemorrhaging families - 64,000 people left last year and, according to a recent survey, one in three families plan to give up health insurance this year - it is bizarre that more older people are buying it for the first time. If we keep going as we have been, those who can afford insurance - the wealthy - and those who cannot afford not to have it - the very sick - will be the only ones left in the system. There has been a failure to recognise the crisis. This trend will place an additional burden on the public health system, which is already creaking.

The problem is not the treatment that people receive once they enter the system. Rather, the problem is accessing that treatment in the first place. While it must be recognised and welcomed that waiting lists for inpatient procedures have shortened, the waiting lists for outpatient appointments have grown longer. This crisis is worsening. If we force people out of private health insurance and into this system, the problem will be compounded.

Will the Minister of State consider the legislation passed by the Houses in the early 2000s to introduce lifetime community rating? It would be a step in the right direction and would provide young families and people with an incentive to join health insurance schemes for the first time instead of waiting until they are 55 or 60 years old, which is currently the case.

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