Dáil debates
Thursday, 16 January 2014
Topical Issue Debate
Medical Card Eligibility
5:00 pm
Finian McGrath (Dublin North Central, Independent)
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I thank the Minister for attending to reply to this issue, which is medical cards for children with Down's syndrome. I must declare a vested interest in this matter. I am a parent who has a daughter with Down's syndrome who, incidentally, has a medical card. I am also a former chairperson and former treasurer of the Dublin branch of Down Syndrome Ireland.
Today, I wish to highlight the children with Down's syndrome who do not have a medical card. What is going on here and why are some children with Down's syndrome included in this scheme while others are excluded? Almost 100 children with Down's syndrome have lost their discretionary medical cards in the last year. The survey carried out by Down Syndrome Ireland showed that many lost their cards despite having various conditions which leave them with very big medical bills. Half of all people with Down's syndrome are born with a heart defect. There are also gastrointestinal conditions commonly associated with Down's syndrome, as are certain types of hearing loss, cancer, cervical spine instability and visual impairment. Most children with Down's syndrome attend weekly speech and language therapy sessions as well, a cost which doubles with the loss of medical cards. Weekly occupational therapy sessions also cost approximately €50 each. Many parents of children with Down's syndrome are also obliged to visit a general practitioner almost weekly to manage their children's medical conditions. This usually costs approximately €65 each visit.
That is the reality for these families and children. Each year approximately 120 children are born in Ireland with Down's syndrome. There are 2,000 children under 16 years of age with the condition, so approximately 1,000 children are at risk and many of them are concerned. Will the Minister of State support these children and their families who are at risk of losing their discretionary medical cards? Will the Minister of State accept the basic principle that all children with Down's syndrome and all children with a recognised disability should have a medical card? Let the Minister of State start his vision of a universal health service today, and start it with these children.
I urge the Minister of State not to make parents jump through hoops. They have enough problems in their lives dealing with these issues. I encountered an example today when a family with a case of very severe physical and intellectual disability contacted me. They have to fight, beg and scream to get their medical card back. This is not acceptable in 2014. Many Government backbenchers share my concerns. Children from Dublin, Cork and Limerick have taken major hits in recent weeks. The Minister must listen to the voices of the parents and advocates of children with Down's syndrome. There are additional costs on doctors as well in respect of fees and prescriptions.
A total of 150 parents have already contacted Down Syndrome Ireland on this issue and appeals are ongoing. On the broader issue, how many of the recent 6,324 discretionary medical cards that were withdrawn were taken from children with Down's syndrome? I ask the Minister of State to support the provision of medical cards to all children with Down's syndrome, as well as other children with disabilities, as a start in implementing his vision of a universal health service.
Alex White (Dublin South, Labour)
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I thank Deputy McGrath for raising this issue. Recent reports have stated that approximately 1,000 children with Down's syndrome - the Deputy said 100 but that might have been a mistake on his part or perhaps he was referring to a different report - have lost their medical card. I assure the Deputy that there is no policy or practice, in the context of medical card renewals, to target children or adults who have Down's syndrome.
The primary care reimbursement service, PCRS, which now processes all medical card applications and renewals, does not have any indicator on its clients registers that would identify people with Down's syndrome. That is the reason it is simply not possible to answer one of the Deputy's questions, which was how many people with Down's syndrome had lost their medical card in the last period. It is impossible to ascertain that. The way the records are kept in the PCRS does not categorise applicants in accordance with their medical condition. Even if the PCRS or the HSE wished to target people with particular illnesses or conditions for the removal of the medical card, they would be unable to do so. I can arrange for a briefing for the Deputy in this regard because this is something I was very anxious to ensure I understood. In fact, I was at the PCRS in Finglas a few days ago for a general meeting and briefing.
The applicants and those who have whole medical cards are not categorised in the system in accordance with their illness or condition. Even if somebody wanted to target people with particular conditions, which would be perverse, they could not do so because the system is not set up in a way that categorises people in accordance with a particular illness or condition.
I might add that this situation obtains to other medical conditions, including diseases and disabilities. There is no system in place that would enable people with particular disabilities or diseases to be targeted for review or discontinuation of medical card eligibility. The reason for that is that medical cards are provided to persons who, in accordance with the provisions of the Health Act 1970, as amended, are in the opinion of the HSE unable without undue hardship to arrange GP services for themselves and their dependants. Therefore the 1970 Act established a financial means assessment. The legislation has been in place for over 40 years. No Minister can override that decision of the Oireachtas that medical cards are essentially issued on the basis of financial means. They are issued to people on the basis that if they did not have a medical card they would suffer undue hardship in arranging for GP services for themselves or their dependants. That is the law under the Health Act 1970. The only way the situation can be changed would be for the legislation to be changed.
The Deputy will be aware that under the legislation, since 1991, the assessment for a medical card is determined primarily by reference to the means, including the income and reasonable expenditure, of the applicant and his or her partner and dependants. In the case of a child, the parents' income and reasonable expenditure is assessed. Under the legislation, determination of eligibility for a medical card is the responsibility of the HSE.
The HSE has produced national assessment guidelines to provide a clear framework to assist in the making of reasonable, consistent and equitable decisions when assessing an applicant for the general medical services or GMS scheme. These guidelines are publicly available and can be downloaded from the HSE's medical card website. They include the net after-tax, after-expenses income guidelines for the awarding of medical cards.
While there is no automatic entitlement to a medical card for persons with specific illnesses or with a disability, the HSE has discretion to award a medical card to avoid undue hardship, having regard to a person's or family's overall financial situation, even where the person's income exceeds the income guidelines. It is important to correct any impression circulating that medical cards are issued automatically or irrespective of means, even if an applicant is suffering from a serious medical condition. The Deputy will be aware that the GMS scheme is a means-based scheme, rather than one based on having a specific illness, as a reading of the legislation makes clear.
The HSE has established a panel of community medical officers to assist in the processing of applications for medical cards on a discretionary basis, where the income guidelines are exceeded but where there are difficult personal circumstances, such as an illness or physical disability which would impact on the applicant's financial situation.
I see my time has run out but perhaps I can return to this later.
5:10 pm
Finian McGrath (Dublin North Central, Independent)
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When I referred earlier to about 100 children I was talking about one particular survey that was done. However, I agree with the Minister of State that the broader national figure would be in the region of 1,000 children with Down's syndrome who are at risk of losing their medical cards.
We must re-examine the categorisation issue and the system that has been set up. I take the Minister of State's point on the legislation but we must ensure that legislation protects the rights of children and adults with disabilities. I am concerned that we are taking our eye off the ball as regards how the 1970 Act deals with a person's financial means.
I am also concerned that the Minister of State does not seem to agree with the principle that a child with Down's syndrome or another recognised disability should have the right to a medical card. There are severe personal situations such as, for example, the cases I have to hand. One case concerns an eight year old who has Down's syndrome, asthma, sight difficulties, thyroid problems and hearing loss. His discretionary medical card was withdrawn in recent months. That is wrong, regardless of who may have made the decision.
Another case concerns an eight year old girl who was granted a discretionary medical card at the age of five. She has asthma, juvenile arthritis, a heart condition and hearing problems. In 2013, the HSE wrote to the family about its plan to withdraw the young girl's card.
I am asking the Minister of State to talk to his colleagues, the Minister of State, Deputy Kathleen Lynch, and the Minister, Deputy Reilly, about this matter. Earlier today I submitted the details of a case to the Minister's office concerning a young person with a severe physical and intellectual disability. The family is very upset about the loss of that person's medical card.
Alex White (Dublin South, Labour)
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The Deputy mentioned the survey and whether the figure was 100 or 1,000 but I was referring to reports I had seen in recent days of 1,000.
Finian McGrath (Dublin North Central, Independent)
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Yes.
Alex White (Dublin South, Labour)
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I am not saying that there are 1,000 children concerned but I have seen those reports. I am not seeking to argue with the Deputy about numbers but I do not know what are the statistics. I am not being in the least bit facetious with the Deputy but it is not possible for me to establish the numbers, formally or otherwise, because the system does not include such information.
The Deputy seeks to urge me to accept the principle that somebody with Down's syndrome should automatically have a medical card, but the 1970 Act does not provide for that. I am interested in universal access to health care and, in the first instance, to GP services. That is what the Government is doing as regards the interim roll-out in respect of under six year olds. That is not a stand-alone project, it is the first instalment of a project in the programme for Government.
Finian McGrath (Dublin North Central, Independent)
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Which I support.
Alex White (Dublin South, Labour)
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The Government is committed to extending universal access to the whole population within the lifetime of this Government. That is not the full medical card because, as the Deputy will say, there are other services as well. In recent days, the Minister for Health acknowledged that there are other services to which many people need access that they do not have with a GP-only card but would have with a full card. We may need to examine innovative ways of ensuring that those kind of services are available to people who need them, without necessarily doing so through the full medical card system.
I am in favour of the universality system but I cannot override the 1970 Health Act. Neither the Minister, Deputy Reilly nor I, nor anybody else can extend medical cards to people other than in accordance with the law. The law refers to "undue hardship" which can only be ascertained through an assessment of financial means, with the extra discretionary effect where somebody's condition or illness is affecting their financial situation. That is the position.
I understand the case the Deputy is making and I appreciate his support for the universality principle. We have some distance to go on this but the more support we have across the board politically, and in the broader society, for universal access to GP services the better.