Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the Minister for Health, Deputy James Reilly. What is happening in the provision of discretionary medical cards is simply deplorable and something must be done to alleviate the burden being imposed on families. Those affected include individuals who are very ill, some of whom are terminally ill, and many facing huge challenges and difficulties in their everyday lives. The Government, however, continues to insist there has been no change in policy. If there has been no change in policy, there certainly has been a change in practice. The numbers speak for themselves when it comes to the culling of discretionary medical cards, with a reduction of more than 30,000 since 2009.

To any fair-minded person, the idea that the probity exercise of €113 million announced in the budget would not in some way impact on people is beyond belief. At this stage, if we could get the Government to accept that the policy or practice it is pursuing is having a detrimental impact, we would at least have achieved something. The issues that arise day in and day out in constituency clinics throughout the country and which have been repeatedly raised in the House in the past two years by Members of all parties and none must surely resonate with the Minister. There has to be a reversal of policy in this regard.

The Government has chosen to prioritise the provision of free GP care for all children aged five years and under. I have said time and again in the House that the easy, populist choice for me would be to endorse that proposal without criticism. The difficultly, however, is that the resources which will be applied to fund free GP care for the under sixes are being taken from children and older people facing the gravest challenges on a daily basis. For many of them, it is a challenge just to get through one day. Universal provision of free GP care is a noble idea; the problem arises when there are scarce resources. By my analysis and that of many commentators, this proposal is being funded by depriving those who need a medical card simply to get by on a daily basis.

We on this side of the House have consistently maintained that there must be a prioritisation of need in this matter. The Minister has spoken about being a proud citizen of this republic. Any genuine republic should be judged on how it treats those in most need of the state's support. It is not in the vein of true republicanism to ask a very sick seven year old, a very frail 90 year old, a person with motor neuron disease or a child with Down's syndrome to fund general practice cards for healthy children of five years and under, some of whom are from affluent backgrounds. That is simply wrong. I urge the Minister to reverse the cull of discretionary medical cards which is in nobody's interests, least of all those who need them most.

James Reilly (Dublin North, Fine Gael)
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I thank the Deputy for raising this issue. To clarify, an additional €37 million in funding was made available in the budget for the specific purpose of providing free GP care for children aged six years and under. We are not taking money from anybody else to fund the initiative.

Under the Health Act 1970, persons who are unable, without undue hardship, to arrange GP services for themselves and their families can qualify for a medical card, having regard to their overall financial situation and reasonable expenditure. The Health Service Executive can only award medical cards in accordance with the Health Act and, therefore, must assess the overall financial situation of the applicant and his or her spouse or partner. The HSE gives effect to this legislation through its medical card national assessment guidelines. "Undue hardship" is ascertained through an assessment of financial means.

It is not legally possible to award a medical card by virtue of an illness or a disease. However, where an applicant or a member of his or her family has an illness or disease, medical costs and necessary expenses arising from that condition are taken into account in the assessment process for a medical card. Thus, people whose means are above the income limits but who face genuine hardship in providing GP care for themselves and their dependants may qualify for a medical card.

Recent media reports have referred to the reduction in the number of discretionary medical cards. I reiterate that there is no policy to abolish the awarding of medical cards on discretionary grounds or target any patient group.

The medical card scheme continues to operate in such a way that those who suffer undue financial hardship as a result of a disease or an illness are awarded medical cards. Last year I insisted on a medical team being put in place to review the position on discretionary medical cards in order that people's medical conditions would be taken into account in the context of the financial hardship to which they gave rise. While the number who hold medical cards on discretionary grounds has fallen in recent years, many individuals who previously were marginally over the normal qualifying guidelines have been granted medical cards. Only a small proportion of people with discretionary medical cards have been found to be ineligible for medical cards. While the number in this regard may be small, I in no way underestimate the difficulties caused for those who are considered ineligible.

We know that even where medical expenses have been taken into account, there will be some who are not eligible because their net income remains in excess of the guidelines, sometimes by as much as €1,000 a week. Some of the households in question include people with ongoing medical conditions and, in that context, I have asked the HSE to consider how best we can ensure such households receive all the supports available to them from the health system, within the relevant legislative parameters. The clear intention is to ensure people's entitlements to health services will be maximised to the fullest extent possible, especially where individuals may be facing significant medical expenses. This process is ongoing and I hope it will come to a conclusion in the near future.

Billy Kelleher (Cork North Central, Fianna Fail)
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My difficulty is that we have been raising this issue for over two years. In that time we have drawn a complete blank in obtaining an admission that there is a difficulty in respect of those with discretionary medical cards. Last week, however, there was some semblance of a response from the Minister when some 20 of his colleagues in Fine Gael raised this issue at a parliamentary party meeting and he acknowledged that we at least had to consider it. We must do more than this. In good times and bad, the process of governing involves establishing priorities and making choices. In that context, the Minister has, unfortunately, got caught in a bind between the commitments made in respect of free GP care and trying to fund a health service which, for many reasons, is inadequately resourced. I accept all of the responsibility my party bears in that regard and which the Minister outlines on a continual basis. In this instance, however, the difficulty has arisen on foot of a choice made by him initially. It is echoed in similar choices being made on a daily basis by the Department of Health and the HSE and under his watch. As a result of the choices to which I refer, resources are being transferred from those who need them most to persons who may not need them at all. That is clearly wrong.

As a result of a television interview on Saturday night last, people have been made aware of the case of Alex Coyle. There are hundreds of similar cases. Organisations which represent and advocate on behalf of people with profound intellectual and physical disabilities and life-limiting illnesses have stated it is inherently more difficult for people to retain discretionary medical cards or access full medical cards than it was some years ago. Regardless of whether the Minister likes it, there has been a change in practice. I urge him to amend this by introducing a policy initiative in order to ensure vulnerable people will be protected.

James Reilly (Dublin North, Fine Gael)
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During 2013 the HSE issued 644,858 review notices. As of 27 February 2014, assessments of eligibility had been concluded of 482,000 medical card holders and continuing eligibility was confirmed in respect of 465,000, or 96.4%, of these individuals. Some 17,258 medical cards, or 3.6%, were not renewed because the eligibility criteria, that is, the income thresholds, were not met. In a further 52,000 cases medical cards were not renewed because the card holders did not respond in the review process. On the date in question, assessments of eligibility were ongoing in respect of 102,000 medical cards and in 6,736 cases the card holders were deceased. I could supply the Deputy with much more information, but I will not do so at this time.

There must be probity within the system as a result of the continually changing dynamic. From discussing the matter with the primary care reimbursement office, PCRS, I am aware that the vast majority are not written to at all, except to be informed that they will be keeping their medical cards. This is because we know, on foot of the information in our possession, that they are entitled to them. Another large group are only required to tick a box to indicate that their circumstances have not changed. We are required to examine a small percentage of cases in order to ensure those involved are still entitled to medical cards. As Minister for Health, my role is to ensure the system retains the compassion it is supposed to possess in the first instance. I am also obliged to ensure there is more focus on ensuring people have access to the support and care they require as opposed to medical cards. The HSE is seeking to find the best way to achieve that to which I refer in order to ensure families will receive the support they need.