Alex White (Dublin South, Labour) | Oireachtas source

Okay. I wish to address the broad issue of the Government's policy on the development of a universal GP service. I would also like to respond to the suggestion that has been made during this debate that the legislative measure we are discussing is somehow contrary to the Government's policy on the universal GP service. As I have said previously in this Chamber, I do not accept that the provisions of this Bill, however they may be criticised, are contrary to the Government's policy on the universal GP service. I am not saying they cannot be criticised. The Government is protecting access to GP services for the over 70s. It is expanding access to GP services for young children. By the end of next year, almost half the national population will have access to a GP, as the first point of contact with the health system, without the financial barrier of fees in their way.

The Government is committed to introducing on a phased basis a universal GP service without fees within its term of office, as set out in the programme for Government and the future health strategy framework. The introduction of a universal GP service that will be free at the point of use constitutes a fundamental element in the Government's health reform programme and the ultimate introduction of universal health insurance. A universal GP service will underpin the delivery of health care close to people in their communities, at the lowest levels of complexity and at the lowest levels of cost. This is a critical step on the road to introducing universal health insurance and eliminating the two-tier health system that bedevils our health services.

As the Minister for Health outlined when he introduced this debate, the State's economic and budgetary situation means it has been necessary to take a number of difficult decisions to secure the savings required. Most of these savings have been designed to ensure they do not have an impact on front-line activity and protect the most vulnerable. I will come back to that point. Approximately 350,000 individuals aged 70 and over currently hold a medical card. It is estimated that the budgetary measures provided for in this Bill will move approximately 35,000 people from a medical card to a GP visit card. Deputy Calleary asked about the precise numbers involved.

The overwhelming majority of medical card holders over the age of 70 will be unaffected by this Bill. The budgetary measure we are dealing with will affect medical card holders over the age of 70 who have the highest incomes. Each and every one of the 35,000 people - 10% of the total - who will be affected by this measure will continue to have access to free GP services without quibble and without needing to go through an application process. Their medical cards will be replaced by GP-visit cards. As has been mentioned, a person over the age of 70 with a weekly income of €500 will continue to qualify for a medical card. Similarly, a couple over 70 years of age with a weekly income of €900 will continue to qualify for a medical card.

Given that the new income limits are more than twice the level of the basic State pension of €230 per week for an individual or €436 per week for a couple, it is clear the majority of over 70s medical card holders will not be affected. I am not trying to suggest that no one will be affected. Deputies have been very straight and I have listened very carefully to what everybody has said. I will not misrepresent any of the Bill's provisions. Some 35,000 people will be affected by the Bill and will lose an entitlement to a full medical card and have it replaced by a GP-visit card. I do not try to suggest in any way that is not occurring; it is occurring. It is important to understand that the new income limits are more than twice the level of the basic State pension. I believe Deputy Clare Daly said that 80% of pensioners live on the State pension alone. While I am not sure if she is right in that figure, if it is the case, it is important to point out that the State pension is approximately half the new income limits for the over 70s medical card.

Under the drug payments scheme, the HSE will meet the prescription drug costs of these older people without a medical card who face drugs costs higher than the drugs payment scheme threshold of €144 per month. This means that a single person aged over 70 years with a gross income in excess of €500 per week, or a couple with an income in excess of €900 per week, will have their expenditure on prescription drugs capped at approximately €33 per week. The people affected will still have access to the DPS threshold, meaning that they cannot be required to spend more than €33 per week on drugs. I do not underplay or make any value judgment or suggest that would never be a difficulty for anybody in the State. I simply lay the facts before the House in order that we have a sense of proportion and clarity about what is happening. By the end of 2014, in the region of 93% of the over 70s population will continue to have access to GP services without fees through either a medical card or a GP-visit card.

Some of the Deputies, including Deputies Calleary and Terence Flanagan, raised the issue of the differential between the gross income threshold for an individual, which is €500 per week, and that for a couple, which is €900 per week. Heretofore, the single threshold was half the couple threshold. The Government recognises that the living costs of an individual living alone are more than half the living costs of a couple living together and that expenditure does not necessarily diminish relative to the number of people in the household. This differential concept is not new and is evident in other areas of public policy to which I will briefly allude. Examples include the State pension, which is €230 per week for an individual and €436 per week for a couple; the provision of the living alone increase - an extra payment for people on social welfare pensions who are living alone; differential income limits between individuals and couples which apply for medical cards for persons aged under 70 years; the assessment for supplementary welfare allowance where a differential applies whereby the rate for a dependent qualified adult is not half the personal rate of the applicant; and various items under the Insolvency Service of Ireland guidelines, where a significant extra sum is not allowed per month after tax, PRSI, and so forth for a couple compared with a single person.

I will reply to some of the points made in the debate. Deputies touched on the issue of the discretionary medical card. I believe Deputy Timmins expressed the view, which is often expressed, that there should be an entitlement to a medical card for medical reasons. Other Deputies continue to assume a person can qualify for a medical card for a medical reason. I know there is a lot that divides us and this debate is a difficult one. Many Deputies said we need to remember the humanity and ensure the system is applied and administered in a humane fashion, with which I entirely agree. However, the system is the one that has been in place since the 1970 Act. That Act does not allow a medical card to be allocated on the basis of a medical condition.

Deputy Healy Rae pressed me on the issue of doctors versus consultants. The involvement of a doctor, consultant or any medical person in the assessment of entitlement to a discretionary medical card is not to give a medical report as to a person's illness or a diagnosis. That does not arise in the case of a medical card. Deputy Timmins suggested that should be the case. He may be right and I can come back to that in a minute. However, that is not the position. The involvement of the doctor is to give a view or help in the assessment of the application of a person who is over the income limits but has extra expenses associated with a particular medical condition, which could include attendance at a doctor or the need to travel, for example. The doctor's involvement is essentially to help the HSE to judge whether that is fair and whether the medical condition or illness would reasonably give rise to those kinds of expenses. However, it is still an assessment of needs. We can have a discussion on whether that is right or wrong. I reiterate to colleagues that there is no medical diagnosis involved in the decision to give a medical card, discretionary or other. It is not done on the basis of a medical condition.

Deputy Timmins developed the point and suggested it should be where there is a need, which I understand. We are all human beings and can all see that where an immediate need is presented to us, the health service should react to such a need that is current and present. I understand that. It is the humane response anybody would have. As well as being humane people, I hope, we are also legislators. We need to work out what sort of system we would need to have and what kind of law we would need to introduce if we were to give medical cards on the basis of medical conditions or illnesses. First, we would need to change radically the 1970 Act. We would need to define that a person with a medical condition diagnosed in a particular manner would be entitled to a medical card. We would need a list of medical conditions to which it would apply. The diagnostic basis would need to be set out in legislation or in regulations.

I know people's eyes glaze over when we go into this part of the discussion, which I can understand. When we looked at the issue of universal access to GP services last year, people asked why we changed course given that the programme for Government contained long-term illness. We also had the other route we had proposed taking, after which we discussed chronic illness. It would have meant we would have needed to legislate in considerable detail for the awarding of medical cards to people with particular illnesses. We would have needed regulations to govern the diagnostic basis, whether it was for asthma, diabetes or various cardiovascular conditions. We would have needed very complicated legislation to allocate medical cards on the basis of a medical condition. That is why we took a different view of how we should reach the ultimate aim of universal access to GP care.

People would need to think twice about the idea of doing it through a particular illness or condition. That is not to say I disagree with people who say the humanity of the situation must constantly be before us. We have the discretionary card precisely so that it is not just the strict case of either satisfying the means test or not, resulting in either being in or out. That is why we have taken the approach to allow an extra discretion to facilitate people who, even though they do not satisfy the income limits, have a particular medical situation that is impacting on their financial situation. We cannot do it in any other way. Neither the Minister for Health or I or the HSE can override the legislation. We cannot say that from now on we will give a medical card on the basis of a medical illness or condition. We simply cannot do it and we would need to change the law to do so. If people come forward and say that is what we should do, that is fine, but unless or until we decide to do that-----

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