Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein) | Oireachtas source

The debate on this Bill is timely because the cutting of discretionary medical cards was undoubtedly one of the key issues in the local and European Parliament elections and in the two by-elections just concluded. This issue was presented at door after door to canvassers across the political spectrum.

The effective removal of discretion as a category of medical card has had a devastating impact on many families, especially those with seriously ill or disabled children. During the final week of the last Dáil sitting before the elections Sinn Féin tabled a Private Members' motion calling on the Government to reverse the cuts to discretionary medical cards imposed in the Health Service Executive 2014 service plan. Now, with an even stronger mandate from the people, we make that call again here in this debate.

The Government must ensure that the HSE treats with due respect, consideration and compassion all applicants for medical cards, taking fully into consideration not only incomes but the burdens imposed by medical conditions, illnesses and disabilities. It should consult with all Oireachtas Members, and not on a selective party political basis, on the effects of the cuts on citizens. It should extend free general practitioner care to all on a programmed, timetabled and transparent basis and in such a manner that, at the least, no one entitled to a full medical card under the current rules will lose any of the services provided under the card in the context of a free-GP-care-for-all system. It should clearly set out in legislation entitlements to health care and, in line with the recommendation of the Convention on the Constitution, provide for an amendment to the Constitution to recognise the right to health care. I urge the Minister of State to note that and act on it.

This is not about tweaking the current system, or providing a kinder voice on the telephone or a more nicely worded letter. This is about ensuring that those most in need receive the health care they require and when they require it. The State is failing to do that at present.

As I have stated repeatedly in this House and outside it, we need to set our aim higher and work towards universal health care, including primary care, delivered free at the point of delivery. It must be based on medical need not on ability to pay or geographic location and it must be funded on the basis of fair and reformed general taxation.

The principle of universality is fundamental, a view I believe we share. It is the best guarantee - the only guarantee - that no one is denied the medical care they need. It is deeply regrettable that the Government has undermined the principle of universality in two important ways. First, it has set in train a system of privatised universal health insurance as the way to fund and organise health care. This is to be based on competing private for-profit health insurance companies. We do not know what the so-called basic basket of care will be, which immediately begs the question as to what is covered by the term universal? What type of care or types of conditions may be excluded?

Second, the Government has undermined the principle of universality by its treatment of medical card patients. On the one hand it brings forward this Bill to provide free GP care to children aged five and under. On the other hand it has cut discretionary medical cards and last year it enacted two Bills designed to remove medical-card coverage from more people over 70 years of age. These are real and stark contradictions.

We have moved from having in place universal medical-card coverage for over-70s under the previous Fianna Fáil-led Government to that Government’s attempt to end universal over-70s coverage altogether. This was followed by huge protests by older people leading to a partial U-turn with provision for the over-70s being made subject to a higher income limit. Under the present Government, that income limit was lowered once in budget 2013 and was lowered again in budget 2014.

At that time the Minister for Public Expenditure and Reform, Deputy Howlin, defended the taking of discretionary medical cards from children with disabilities by asking if it was right that such children from wealthy families should have them.

Simultaneously, however, the Government signalled its intent to provide GP cards for all children aged five and under regardless of income or wealth and as provided for in the Bill before us. Since then I have inquired on many occasions where the consistency is to be found in these policies, if one can refer to them as policies at all. A Fine Gael-Labour Party Government which states that it is committed to the provision of GP care for all at the point of delivery is actually moving in the opposite direction. Discretionary medical cards are being cut back even for some of our most needy citizens, young and old. I know some of those people personally and I have given voice to their specific needs.

Under the Health (Alteration of Criteria for Eligibility) (No. 2) Act 2013, more people over 70 years of age lost their cards and fewer will qualify when they reach the age of 70. Prior to 2008, people over 70 received medical cards without a means test. When the then Fianna Fáil-led Government decided to end that entitlement, the current Minister for Health, Deputy Reilly, who was then the Fine Gael health spokesperson, described this move as a "vicious attack" and a "savage assault on the elderly". Then came the Fianna Fáil-led Government’s climb-down - to which I have already referred - in the face of mass protest by older people. The 2008 legislation set the income limit for over-70s medical card qualification at €700 per week for a single person and at €1,400 for a couple. What did Deputy Reilly, then in opposition, say in response? Here in this Chamber he stated it was a "desperate climb-down" that represented nothing but a "tinkering with income limits" and was "nowhere near good enough". In budget 2013 the income limit for medical card qualification for those aged over 70 was reduced from €700 to €600 per week for a single person and from €1,400 to €1,200 per week for a couple. The income limits were cut again last year, this time to €500 per week for a single person and by a whopping €300 to €900 per week for a couple. When this was announced, Age Action Ireland stated, "It is contradictory to be removing means-tested cards from a section of society which has high medical needs, in a budget which is rolling out free GP care for children and heralding it as the roll out of its universal primary care plans."

That brings us to the point we have reached today with this Bill. At the very time when the callous cuts to discretionary medical cards affecting some of the most seriously ill and disabled children are coming to light, we have been presented with this legislation. Quite naturally, this is prompting people to ask why is the Government giving with one hand and taking away with the other - and, most pertinently, taking from those who are most in need and giving to those who are possibly least in need. Citizens are understandably asking where the fairness lies in giving automatic entitlement to free GP access to a healthy child of four but denying it to his or her very ill or disabled sister or brother. Where is the fairness in giving free GP care to a disabled child from birth and taking it away on his or her sixth birthday? These are the anomalies and inequities that are built into a system which does not offer universality of access on the basis of medical need alone and regardless of income, age or - in view of where I live on this fair island - geographical location. The Government will argue that it cannot roll out universal free GP access in one go. That is fair enough. We support universality and, in that context and as I have informed the Minister previously, we will not oppose this Bill and are prepared to regard it as a first step. Where, however, is the timetable and the programme to roll out universal free GP care in a progressive and transparent manner? It is not contained in the Bill. That sounds all sorts of alarms for me.

How will the Bill be implemented? It is clear that the Irish Medical Organisation, IMO, has set its face against this legislation and the proposed new GP contract. That is what I have heard to date. The chairperson of the IMO's GP committee has stated:

This legislation has nothing to do with GP visit cards for children. It is nothing less than a unilateral attempt to replace the long-standing GMS Contract with a new, draconian contract which will destroy the very fabric of the GP service in Ireland and there are very serious concerns as to the future viability of the service.

The individual in question is well known to the two Ministers who are now in situ. The IMO has also pointed out that the proposed contract would penalise whistleblowers with the clause - I ask the Minister and Minister of State to note this - which states that those under contract "shall not do anything to prejudice the name or reputation of the HSE". I note that the Minister of State, Deputy White, has said that the Government is prepared to negotiate all aspects of a new contract with the exception of that relating to fees. This clause should certainly be top of the list for deletion from the contract as now drafted.

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