Dáil debates

Tuesday, 13 May 2014

Discretionary Medical Cards: Motion [Private Members]

 

8:40 pm

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I move:

That Dáil Éireann:noting the:
— continuing dramatic fall in the number of persons granted or retaining discretionary medical cards;

— persistent refusal of the Minister for Health and the Government to recognise the reality of this reduction and the hardship it is causing, despite numerous representations from the public, representative groups and Oireachtas Members;

— last-minute pre-election acknowledgement by the Minister for Health, prompted by a meeting of the Fine Gael Parliamentary Party, that a problem exists;

— statement by the Minister that he has asked Fine Gael TDs to give him a list of ‘hard cases’; and

— Minister’s floating of the vague notion of a ‘third tier’ of services; and
calls on the Government to:
— reverse the cuts to discretionary medical cards imposed in the Health Service Executive (HSE) 2014 Service Plan;

— 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;

— consult with all Oireachtas Members, and not on a selective party political basis, on the effects of the cuts on citizens;

— extend free general practitioner (GP) 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; and

— clearly set out in legislation entitlements to healthcare and, in line with the recommendation of the Constitutional Convention, provide for an amendment to the Constitution to recognise the right to healthcare.
I wish to share time with Deputies Ellis, Colreavy and O'Brien.

Photo of Michael KittMichael Kitt (Galway East, Fianna Fail)
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Is that agreed? Agreed.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Sinn Féin makes no apology for returning to the issue of medical cards, as well as once again urging the Minister for Health and the Government to listen to and act upon the voices of thousands of people who are being adversely affected by medical card cuts. We in Sinn Féin, and others in the Opposition, have repeatedly brought this to the attention of the Minister for Health and his junior colleagues only to be met with a stonewall. Up until recently, the Minister and his colleagues refused to recognise there was even a problem with discretionary medical cards, even to the point that, at one stage, they denied that such a category of card exists.

The current widespread review and extensive culling of medical cards is causing huge distress and worry to thousands of people. That is undeniable. All Members of the Oireachtas, if they are honest, will testify to the truth of this statement because they know it from the representations they are receiving from constituents and representative groups. The numbers holding discretionary medical cards has fallen dramatically. The Minister's own figures for the number with full medical cards and general practitioner visit cards on a discretionary basis in March 2011 was 97,120. By March 2014, that had fallen to 78,310, a drop of nearly 19,000.

It was only after a recent Fine Gael Parliamentary Party meeting that the Minister grudgingly recognised there is a problem. He was reported as stating, “We’ve asked the TDs to give a list of any of the hard cases they have, the ones that they feel should have been given cards”. This request was confined to his own party colleagues. Did it extend to back bench Labour Deputies? It certainly did not reach me or any of my Dáil party colleagues. The Minister also spoke vaguely about some sort of third tier of services. We found out from the media at the weekend that he has since written to his Fine Gael Party colleagues stating he will not be creating a so-called third tier of medical cards.

Significantly, he also stated unemployment has fallen under the current Government but that there are far more medical cards in circulation now than when the Government came into office. What is not often pointed out, certainly not by the Minister, is that the number of medical cards in circulation is an indicator of income across the population while a great many of the jobs created are low-paid or part-time or are schemes concocted by this Government to disguise the jobless figures. Real, decently paid jobs would indeed see more people earning over the income threshold for the medical card, and thus fewer income-based cards in circulation. That, however, is not the situation in the Government's boasted recovery that is only a recovery for some.

Our focus in this motion is the discretionary medical card. We are calling on the Government to reverse the cuts to discretionary medical cards imposed in the Health Service Executive 2014 service plan. It should ensure the HSE treats with due respect and compassion all applicants for medical cards, taking fully into account not only incomes but the burdens imposed by medical conditions, illnesses and disabilities. The Minister should consult all Oireachtas Members, not just his own party as he has done, on the effects of the cuts on citizens.

In budget 2014, a figure of €113 million of medical card cuts was announced by the euphemism “probity measures”. The Minister for Health has been unable to give us any account of how this figure was arrived at. It was apparently dictated by the Department of Public Expenditure and Reform. When the 2014 HSE service plan was published, the figure had magically changed to €23 million. This surely calls into question the entire management of health funding and health services by the Minister and the Government.

While the Cabinet's juggling with figures is shrouded in mystery, there is no mystery about the effects of the cuts on real people with real illnesses and medical needs. The Minister knows those effects very well. As recently as last Friday, 9 May, he received a letter from the Jack and Jill Foundation's specialist children's nurses. I wish to read some of that letter into the Dáil record:

Dear Minister Reilly,

As the team of nationwide specialist children's nurses responsible for designing and managing home care plans for the 300 precious children under the Jack and Jill Foundation's wing, we are compelled to write this letter to you to outline our serious concerns in relation to the allocation, or rather non-allocation, of discretionary medical cards to our patients. Medical cards have always been an issue since the establishment of Jack and Jill in 1997. However, the situation has become particularly vicious over the past two years. The situation is critical.

It is only a matter of time before somebody, most likely a stressed out parent, is pushed over the edge by this unjust system. We see the danger signs already. Parents worn out, reduced to tears, not sleeping, not coping and worried out of their minds in relation to their child's medical card. The "lucky" ones who have a temporary six or 12 month medical card live in dread of the next review and the whole torturous process of form filling, rejection letters, more visits to GPs for supporting evidence etc. etc. etc. which starts all over again.

We are particularly worried about the parents who suffer in silence. The parents who have given up already. Depressed and beaten into submission by a system that is just too hard, where parents have to fight for every little support for their child.

The medical card system in Ireland is broken. It lacks humanity. Is unjust. Inconsistent. A hellish lottery.

We know it is a real issue on the doorstep for local and European election candidates. We know the pressure coming to bear on you from backbenchers unhappy with the medical card complaints from their constituents. However, it is for the sake of the children, rather than any election process that this system must be radically overhauled. And quickly. Time is something the families of children with life limiting and life threatening conditions don't have.

We will make ourselves available to you to show you the reality of medical cards and the stress being subjected on our families in every community in Ireland. It's time to diagnose the true extent of the problem with medical card allocation in Ireland and to come up with a timely and cost effective solution to the benefit of all, especially the children we support.

Our call to action is simple Minister. Review, refresh and redesign this system of discretionary medical cards. Recognise the child in his or her own right. The system is broken and we need you to fix it.
The Jack and Jill Foundation and other representative groups, such as the charity Aoibheann's Pink Tie, which works with children with cancer and their families, have repeatedly pointed out the significant problems they encounter with the medical card system. This includes the excessive bureaucracy, the distress of parents not knowing where to turn, and the worry that a card has been refused or an existing card will be discontinued. They point to the massive savings to the State when families look after their very ill children at home rather than in a hospital bed.

During this debate, we will hear many examples of what the Minister has called hard cases.

These are by no means exceptional. They are far too common. I quote one experience of many posted on social media by the Jack and Jill Foundation:

Having spent months filling in forms in an attempt to get a medical card for my 3 year old who had a stroke (which she didn't get) I often thought if the HSE cut out a lot of the red tape and bureaucracy and staff repeatedly telling me to send more and more forms etc there would be a lot more money for medical cards for the people who need them. I knew my income was over the limit and was applying for my daughter's card based on her medical needs (I couldn't get a splint for her leg without one and couldn't buy one either it seems) yet I had to send endless information about my financial status (which is by no means excessive) over 4 months ... waste of time and money which could have paid for several splints! ... And don't get me started on the stupidity of having to reapply yearly for children with lifelong conditions.
We, in Sinn Féin, support the principle of free GP care for all, but this Government has undermined public support for that principle by its skewed policy and mismanagement of the health services. People are rightly asking why a healthy child of five will automatically qualify for a free GP card but an older sister or brother with a severe disability, with a rare disease or with cancer will not.

At the conference of the Irish Council of General Practitioners, ICGP, last weekend, a County Wicklow GP, whose disabled patient was the subject of a discretionary medical card removal, told the meeting that the removal of these cards was the "single most evil thing our society is standing over". She stated if the discretionary medical card issue was not addressed she would have no stomach for taking part in the planned free GP care scheme for children under six. Mr. John Hennessy, the HSE's national director of primary care, - one should heed this particular contribution - stated that the way some had been treated was indefensible and described one case as an example of "how we should not be doing things". A GP from Galway told the ICGP meeting his medical card patient list had been reduced, from 800 to 600.

We, in Sinn Féin, are calling for a clear, time-tabled and transparent roll-out of free GP care for all. Anything short of that will only serve to increase inequality. We also need to see this done in such a manner that at 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.

I have tabled a parliamentary question for answer tomorrow in the course of Minister's questions on the process and formula used by the HSE to assess financial hardship in the case of discretionary medical cards. I have asked, in the interest of transparency, for the precise nature of this analysis for new applicants or those seeking to retain their medical cards and who have been diagnosed with motor neurone disease, MND. There can be no doubt that those with MND face significant financial hardship as a result of their progressive and terminal illness. As the PQ lottery has placed this question at No. 42 and beyond reach in tomorrow's brief engagement, I invite the Minister to share the detail of his answer this evening when he rises to respond.

Would the Minister like to further comment on the most disturbing and insensitive practice of the medical card managers who repeatedly require those with life-limiting illnesses and permanent disabilities to respond to review after review, despite the ongoing progression of their illness and that they accept the reality that there is no recovery from their disablement? This compounds their hurt and pain and enrages their loved ones and carers.

What of those over 70, over 80 and beyond who, despite their range of infirmities and the steady deterioration of their general health, are regularly subjected to review after review, despite the false assurance on their card that it expires in 2016 or 2020? Why do this to our senior citizens? Why subject them to this constant worry and stress? Why subject them to the distress of having their medical cards taken from them? GP-only cards only go so far. The real issue for them is their medication supply and for many, it becomes a choice between their essential prescription drugs or heating in their home.

This morning I received a copy of a HSE client registration unit letter of the past two weeks. It advises that a couple and their dependent child who have had a GP-only card was being withdrawn because the calculation of their circumstances showed they exceeded the threshold for qualification by €3.17. The consequence of this decision for this family already shows in the strain in their faces and the fear that now occupies so much of their daily and nightly thoughts. Why do this to those who, across the board, have suffered so much from cuts and the austerity agenda of this and the previous Government?

We do not accept the Fianna Fáil amendment as it omits our call for a reversal of the cuts, as well as our call for people's entitlements and rights to health care to be clearly outlined in law. The previous three Fianna Fáil-led governments promised to do this in legislation, with a Bill listed for years but never published. They failed to deliver. The Minister's self-congratulatory amendment is a sad reflection of the ostrich approach to the crisis in health care delivery, especially the hardships being borne by tens of thousands of citizens across the State who have had their medical card withdrawn or their application refused despite their undoubted need.

We believe it is vital that we clearly set out in legislation people's entitlements to health care and, in line with the recommendation of the Constitutional Convention, we call on the Government to provide for an amendment to the Constitution to recognise the right to health care. Is ceart é an curam sláinte. Tá sé bunúsach. larraim ar gach Teachta ar gach taobh den Dáil seo tacú leis an run.

8:50 pm

Photo of Dessie EllisDessie Ellis (Dublin North West, Sinn Fein)
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Táim an-bhuíoch labhairt ar son an PMB seo.

The past few years has seen chronic and constant confusion with regard to medical cards. Many of the cases that I have come across in my constituency have defied imagination in terms of the reasons given for the refusal to grant their medical cards. We are witnessing a startling fall in the number of persons who are granted or retaining discretionary medical cards. My constituency office has been inundated with medical card refusals over the past year and each one of these refusals not only comes with a heart­breaking story but places a considerable amount of trauma and pressure on an increasingly vulnerable section of the community. The Fine Gael- Labour Government is now implementing the policies of Fianna Fáil which those parties so vehemently opposed when they themselves were in opposition.

The Government must immediately reverse the cuts to discretionary medical cards and ensure that the HSE begins to treat all those who apply for medical cards with the respect and compassion that they deserve. Burdens imposed by medical conditions, illnesses and disabilities must all be taken fully into account, with qualification not simply based on income. We are calling on the Government, in extending free GP care to all, to do so on a programmed, time-tabled and transparent basis and in such a way that 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.

Many who have depended on discretionary medical cards have not retained their cards, and many others who were hoping to receive their cards will not be doing so during the course of this year. In our alternative budget, Sinn Féin provided for the extension of free GP care to all children aged five and under without depriving anyone else of their medical card entitlement. This is the fair thing to do. The current medical card eligibility system is in urgent need of replacement. It, like so many other aspects of the State, is not fit for purpose.

I am a proud republican and I believe in a real republic. As republicans, equality is at the heart of all that we believe in and we strive for this every day in the course of our work and activism. We believe in a new republic, a republic where all citizens are equal regardless of the colour of their skin, their religious beliefs, their sexual orientation, where they live or what they do, and in which all citizens have equal access to the services that they need. Any genuine republic will be judged upon how it treats the most vulnerable and those who are most in need of being helped and for this sitting Government, the conclusion reached will not be a good one.

The withdrawal of medical cards from the sick and the elderly is a stain on this State. I would like to cite a number of examples of cases that have come to the attention of my office recently.

A cancer sufferer, a multiple sclerosis sufferer or a person with Parkinson's disease will not get a medical card if their income exceeds the threshold. The current threshold is €184 for a single person and €201 for a couple. The basic rate of social welfare is €188 for jobseekers. A discretionary card may be granted where one can prove that the absence of a card is unduly burdensome or will cause hardship. This is difficult to prove, however, as there are many debts and bills that are not taken into account such as the household charge, utility bills, debts and loans. In addition, there are extra costs to do with illness that are not on prescription, specialist food one may need for an illness, wheelchairs, stair-lifts and physiotherapy.

I wish to mention a number of examples of cases I have dealt with recently. An 82-year-old woman living alone with huge debts due to personal family circumstances, with a medical card valid until 2016, was sent a review form last week. This woman will now lose her card as she has a private pension. Over 70s medical cards are assessed on gross income, not net income, so the tax she pays to Government on her pension is assessed as income so this puts her over the threshold of €500. This woman worked from the age of 14 to 78. Over 70s are assessed on their gross income so what they pay in tax, pension levies and USC are all assessed as income, even though they are not income but outgoings paid to the Government.

A man who worked for 40 years in a factory, reached 65 years and got a pension of €18 a week from the factory now has to pay €750 per annum for hospital visits and €144 per month for medication purely because he was unfortunate enough to get a pension from his job, which he cannot return or cash in. I have a hundred of examples like this.

There are many situations where people are no longer taking their medication as they simply cannot afford it. They are cutting back on inhalers, they are not paying their house insurance, they do not have enough to eat, or do not eat the proper food with ailments such as diabetes.

The lack of a medical card will have huge consequences for health services in future as people are not taking their medication and their health is deteriorating as a result. They are not eating properly and are suffering from huge stress and worry. Old people are living in fear of getting sick. Doctors say there is little point in prescribing medication as people can no longer afford it. Worst of all, people are dying with stress and worry due to the absence of a medical card.

We want to see GP care for all. The provision of a public health care system is a principle we hold dear.

9:00 pm

Photo of Jonathan O'BrienJonathan O'Brien (Cork North Central, Sinn Fein)
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I am sure the Minister of State, more than anyone else in this Chamber, has people coming into his constituency office about medical card issues. No Deputy can say that in the last three years nobody has attended their constituency offices to inquire about a medical card application or the withdrawal of a card as part of the review process.

I turned on the radio while driving yesterday and got the end of an interview. I am not sure whether the speaker was a departmental official or a journalist speaking about discretionary medical cards. At the end of the interview the speaker said that, according to the Department of Health, anyone who is in receipt of a discretionary medical card and is currently undergoing a review process will not have that card withdrawn as long as they are in correspondence with the Department. The Minister of State might be able to clarify whether or not that is the case. If that is the official policy from the Department, it is not what is happening on the ground. I know of cases where people are in receipt of a discretionary medical card and were asked to take part in a review. The review went on for so long, however, that they received a letter stating that their medical card was being withdrawn at the end of the month.

One case that has come to the attention of my office concerns a woman with spinal cancer. She had a medical card but was called for a review. She submitted documentation on her condition, outlining all the expenses associated with it. When she went back to her consultant last month, she was informed that she now has brain cancer. She returned from the hospital having got that devastating news, only to find the letter from the HSE stating that the medical card was no longer valid from the end of this month. I will forward the Minister of State those details. I have already forwarded them to the medical card section and the Minister himself for review.

I have another case of a young girl whose parents are both teachers. While they exceed the income limits, they have a young child with severe difficulties. One of the issues I find disturbing is that when one applies for a medical card or is in receipt of a discretionary medical card because one is over the income limits and it is based on medical needs, and when one takes part in a review, they take into account one's income but not all of the expenditure associated with a particular disability, illness or sickness.

In some cases people are spending enormous amounts of money caring for loved ones, including children and parents, who are sick. I will give an example from my constituency office, which I will pass on if the Minister of State's officials want it. These are the facts concerning a young girl with a rare genetic condition. She is almost three years old but cannot walk, talk or crawl. She cannot sit up unaided and cannot feed herself. She is unable to chew food or drink from a cup. She is completely non-verbal, does not cry and has no way of expressing her own basic needs. She is attending numerous doctors and specialists, including neurologists, eye specialists, respiratory specialists, paediatricians, dieticians, physiotherapists, occupational therapists and speech and language therapists.

Given that list, the Minister of State will be aware that her care needs are extremely high. She also has other issues concerning her arm and hip joints in particular. Any slight increase in body temperature can lead to seizures of up to 40 minutes for that young girl. Because of all those conditions and the ongoing nature of her illness, it is impossible for her parents to ascertain the future medical costs of caring for that child. However, that particular child lost her medical card. She is not up for review and the card was withdrawn before Christmas on the basis that her parents exceeded the income limit.

I know of another young girl, aged 11, who has CP. Her case has been raised here publicly in the past. She is one of only six people in the world with this particular type of syndrome. She is severely intellectually delayed in addition to being visually impaired to the extent that she is blind. She is deaf in one ear, non-verbal and has movement delays. At the age of 11, she is still in nappies.

Doctors have issued letters of support concerning her ongoing medical requirements. In one such letter, the doctor stated that the medical requirements for this young girl are over and above that experienced in the normal population. She had a medical card for ten years, from June 2002 to 2012, but it was then withdrawn. Her parents appealed it but the appeal was denied. If anything, that child's condition has worsened, yet the medical card has been withdrawn from her on the basis of income and that there was not enough medical evidence to support the application to grant a medical card on discretionary grounds.

Her father submitted payslips stating that he was over the income limit. He earns €636 a week.

The mother receives a carer's allowance of €900 per year. I spoke to them today and although the child's total annual medical costs alone exceed €10,000, they cannot get a medical card. It is beyond belief. I do not think the Department knows the true story of the issue on the ground. There are stories and evidence, and I am sure the Minister of State has them in his party. The Fine Gael backbenchers recently raised it with the Minister for Health, Deputy Reilly, at a parliamentary party meeting. People rely on discretionary medical cards to provide proper care for their loved ones.

Some people with terminal illnesses cannot get medical cards or have had their medical cards withdrawn. There is no such thing as recovering from a terminal illness. If anything, one's condition will worsen until one passes away. I do not know whether the Minister of State has ever cared for a terminally ill person. I have, and many other people have. The last thing a carer needs is to worry about how he or she will cover the cost of caring for the loved one. A carer does not want to run up and down to doctors getting letters outlining his or her loved one's condition to support a medical card application because the medical card assessor's letter has said the patient's medical condition does not merit a discretionary medical card.

We have come through a very difficult period economically during which the State lost not only its economic sovereignty, but its compassion and respect for the most vulnerable in our society, particularly our sick people. If anybody needed evidence of that, it is in the withdrawal of discretionary medical cards. The Government cannot justify the revocation of discretionary medical cards from people who clearly need them. That is a damning indictment on our society and this Government.

9:10 pm

Photo of Michael ColreavyMichael Colreavy (Sligo-North Leitrim, Sinn Fein)
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I will take up the point raised by my colleague, Deputy O'Brien. When speaking in the Dáil, I have had occasion to wonder why this Parliament seems to have lost more than its economic compass in recent years. The Government parties seem to have lost all decency, humanity, empathy and compassion. While I have no doubt the Minister and Government backbenchers are decent, humane, compassionate people, we must ask what sort of sick society takes medical cards from children with severe disabilities or life-threatening and sometimes terminal illnesses. What sort of sick society will tell the parents of a young child with such disabilities and illnesses that the continuation of the child's medical card depends on the parents jumping through bureaucratic hoops to prove they do not earn too much? Why are we removing discretionary medical cards from children and adults who received them some years ago, whose medical conditions have deteriorated rather than improved and whose disposable incomes are lower than they enjoyed when the cards were originally granted? How have we sunk low enough to penalise sick and vulnerable adults and children to further subsidise the wealthy and powerful in our society?

Have the Minister of State, the Government and the Department so lost touch with humanity and basic societal decency that they do not understand the very great challenges facing these people and their families? Do they not understand that the parents and families of the very ill children and adults devote their very lives and every bit of their energy to trying to ensure the best possible outcome for their loved ones? Do they understand the sleepless hours parents spend nightly wondering and worrying where the Government axe will fall next? Do they understand that those who care for their very ill family members, whether children or adults, are terrified that any small domiciliary care allowance or carer's allowance they receive will be removed from them as ruthlessly and suddenly as their medical cards were?

Access to quality health care should be a right, not a concession to be granted or withheld by any government, Minister or civil servant. People believed the Minister for Health, Deputy Reilly, when he said, before the general election, that he aimed to end the two-tier health care system and that every Irish person who needed health care would have that need met, and that medical needs, not ability to pay, would be the determining factor. How does that pre-election objective sit with the practice of withdrawing medical cards from the most sick and vulnerable adults and children in our society?

Earlier, I asked what sort of sick society would withdraw medical cards from children with severe disabilities or life-threatening or terminal illnesses. My question was wrongly targeted. I do not believe Irish society is sick but that governance in this country is sick. That confuses me. I believe we live in a democracy. Government spokespersons daily tell us we live in a democracy and that the people are paramount. However the actions, choices and decisions of this Government and its predecessor give the lie to this. Does democracy apply only on polling day? What happens after the elections?

A democratic government should reflect the values, vision and aspirations of the people of the nation. If this is true, and the Irish people were asked the very simple question whether they agree that children and adults with terminal or a life-limiting illnesses should have access to health care and adequate personal support irrespective of means, I know how they would respond. They would say we should do whatever is necessary to support their neighbours in need. They would say we should forget about getting P45s, P60s, PAYE balancing statements, bank statements, evidence of mortgage payments, social welfare searches, etc. They would say that once a person's illness or disability has been credibly confirmed, the State should do all in its power to help and support the person.

However, we saw how this Government and the Minister responded when we first raised the wholesale withdrawal of discretionary medical cards from vulnerable children and adults. For several months the Minister and Government spokesperson were in denial. They said there was no change of policy on eligibility for discretionary medical cards. When the evidence became so overwhelming that denial was no longer credible, the Government changed tack. Now the story runs that medical cards that were granted in previous years should not have been granted in the first place. Apparently, eligibility decision-makers in local offices were too humane, generous and decent in granting these cards and we must have consistency, even if it is based on inhumanity, lack of generosity and indecency in the new, improved, centralised system. Rules are rules, according to the Minister, and everybody must abide by the same rules. The number of children and adults losing discretionary medical cards continues to rise, as does the level of hopelessness and despair for those losing their cards and for their carers.

The latest stunt to get the Government past 23 May is that HSE staff will phone people whose discretionary medical cards have been refused or withdrawn to tell them about all the other wonderful services that might be available to them.

They will have to pay for GP visits and prescribed pharmaceuticals, although they will know about other services for which they have not asked and which will prove to be of little, if any, benefit. That is how I see it.

We have an island of decent, caring people who would choose to help vulnerable children and adults as much as possible but the Government's vision only extends to the end of the financial year. It pays lip service to those most in need of care while it bluffs and blunders through governance, promising everything while delivering nothing. The worst part is that choices could have been made. Such choices were put forward by Sinn Féin in its pre-budget submission last year. Shame on the Government and shame on all of us if we cannot fix this problem.

9:20 pm

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I move amendment No. 2:

To delete all words after “Dáil Éireann” and substitute the following:“notes that:

- under the Health Act 1970, eligibility for the medical card scheme is primarily means-based and that the means basis for eligibility has been subsequently re-confirmed in legislation by the Oireachtas;

- the Health Act 1970 (as amended) provides that persons who ‘are unable without undue hardship to arrange general practitioner’ services for themselves and their family qualify for a medical card;

- the Health Service Executive (HSE) is obliged to operate in accordance with the health legislation with respect to each individual and that the HSE’s assessment for a medical card must ‘have regard to the overall financial situation’ of an applicant;

- the centralisation of the processing of medical cards at a national level, rather than at a local level as was the case before mid-2011, facilitates the assessment of all applicants for medical cards in a consistent and equitable manner irrespective of where they reside in the State;

- the HSE has produced National Assessment Guidelines to provide a clear framework to assist in making reasonable, consistent and equitable decisions when assessing each applicant;

- there has been no change in the policy, whereby the HSE continues to apply discretion to grant a medical card where a person’s income exceeds the income guidelines; and

- the HSE’s National Assessment Guidelines facilitate the application of discretion by decision makers in responding to the needs of the applicant when additional or exceptional circumstances exist;commends the Minister for Health for directing the HSE to set up a clinical panel to assist in the processing of applications for medical cards involving discretion, where there are difficult personal circumstances;

further notes that there is no target to reduce the number of medical cards granted where discretion was applied; and

commends the Minister for Health:- and the Government for providing resources to meet the increase in the number of medical cards and general practitioner (GP) visit cards since March 2011, which now stands at over 1.9 million or 42 per cent of the population;

- for the passing of legislation to abolish restrictions on GPs wishing to become contractors under the medical card scheme;

- on the implementation of legislation to achieve savings under the medical card scheme through the use of generic drugs and reference pricing;

- on the savings being made in the cost of drugs for the medical card scheme through negotiations with pharmaceutical drug suppliers;

- for directing the HSE to examine how it can best assist patients and families to access the full range of supports and entitlements from the health service so that individuals, who are not entitled to a medical card, could still receive services that meet their needs;

- for commencing the most radical reform of the Irish health system since the foundation of the State, where access to health services will be based on need and not on ability to pay;

- for the publication of the White Paper on Universal Health Insurance, which underpins the Government’s resolve to deliver on the Programme for Government commitment to end the inefficient and inequitable two-tier system and establish a single-tier health service, whereby everyone will be insured for a standard package of primary and acute hospital services under a universal health insurance system, which will be founded on the principle of social solidarity; and

- and the Government for commencing the introduction, on a phased basis, of a universal GP service without fees for the entire population within its term of office, as set out in the Programme for Government, with the initial phase to provide a universal GP service to all children aged five and under."
I wish to share time with Deputy Tom Barry.

Photo of Michael KittMichael Kitt (Galway East, Fianna Fail)
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Is that agreed? Agreed.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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It is not the first time it falls to me to put on the record of the House that with regard to medical cards allocated on the basis of discretion, there is no policy to abolish such cards. There is no deliberate so-called targeting to reduce the number of these cards. There is no targeting of any patient group holding these cards, nor would this even be possible, as I have explained before. I accept that some individuals have lost eligibility. We have not denied that although the suggestion has been that we have. However, cards are not being arbitrarily withdrawn or refused. There has been no change in the rules governing the awarding of medical cards where discretion is involved. On the contrary, I can tell Deputies that the medical card scheme continues to operate so that those who suffer undue financial hardship, as assessed under published guidelines, in the arranging of GP services are awarded a medical card in accordance with the legislation passed by this House.

For ease of discussion in our debate, I am going to use the term "discretionary medical card" but it is important to be clear that medical cards are awarded by the HSE, in accordance with the legislation, on the basis of means assessment or where the HSE exercises discretion in circumstances where a person exceeds the income guidelines. I repeat what I have stated in the past in that there is no separate entity of a so-called discretionary medical card, as there is no distinction between any medical cards in terms of eligibility for services and all medical cards are identical in terms of coverage for services. That is irrespective of the route which a person has travelled, in a matter of speaking, to obtain a medical card.

The motion before the House calls on the Government to "reverse the cuts to discretionary medical cards imposed in the Health Service Executive ... 2014 Service Plan". I must respectfully ask where these cuts, or any target for such cuts, is to be found in the national service plan. I searched the plan to find a reference to discretionary cardsand no such reference is to be found therein. Of course, discretion is referred to in the plan, but discretion is not a stand-alone exercise. Rather, the exercise of discretion has been and remains an integral element of the assessment process for a medical card. The Deputies will be aware that medical cards are awarded on a number of grounds which are set out in the HSE national assessment guidelines. However, it is important to be clear that neither the Department nor the HSE has in place differentiated targets for the awarding of medical cards, such as the allocation of so many in this or that category. It would simply not be possible to stipulate or to prescribe in advance the number of medical cards in circulation based on the income guidelines, the number of medical cards based on entitlements under EU legislation or the number awarded on the basis of having income solely from the Department of Social Protection or the HSE. In the nature of a demand-led scheme, the HSE forecasts the overall number of all medical cards it anticipates will be in circulation at the end of the year in order to facilitate its financial planning over the course of the year, but it simply cannot fix in advance the number in any particular category.

I am aware of recent media reports referring to the alleged plan to reduce the number of discretionary medical cards. The HSE's figures clearly indicate that the number of medical cards issued where discretion was involved has fallen in recent years, and I am not disputing that. However, this reduction is not as a result of a change in policy or a deliberate targeting of discretionary cards, which my Opposition colleagues have persistently claimed. Rather, it is attributable, in the main, to the fact that many people who previously were marginally over the qualifying means thresholds have subsequently been granted medical cards because they comply with those means thresholds.

Of the discretionary medical cards in circulation in 2011, approximately 6% have subsequently lost their medical card following review. On any reasonable account, this could not be described as indicative or reflective of a policy to remove discretionary cards over a period of three years. Of course, whereas the numbers who have lost their discretionary medical cards may be relatively small, let me assure the House that I do not for a moment make light of the difficulties that may arise for people who are found to be ineligible, especially where they may have relied on the medical card for a period, as some Deputies have alluded to during the course of this debate. It is important the facts are clear for the record, and in the region of 80%, or four fifths, of those who held a discretionary medical card in 2011 held a medical card in 2014 on the basis of either a means assessment or with HSE discretion. Approximately half of all individuals who held a discretionary card in 2011 went on to retain the card under the basic means assessment, so that they transferred from a card granted on discretion to one granted under the basic means assessment. Approximately one third continued to hold the card following the exercise of discretion by the HSE. The balance, approximately one eighth of the 2011 cohort, is mainly made up of people who did not respond to the HSE renewal notice, did not complete the review process or are deceased, or cases where other family members were awarded a card. I repeat that approximately 6% of those who held a discretionary card in 2011 have lost that card following review. That is between 5,500 and 6,000 who have lost discretionary medical cards in those three years.

I have listened very carefully to what the Deputies said and this discussion will continue over the two days of debate. Far from targeting people who need our support, this Government has provided very substantial funding to meet the increase in the number of medical cards and GP visit cards required by individual citizens. Of the national population, 42% of people currently have access to GP services without any charges under the General Medical Services scheme. Of these, 39.2% of people have medical cards and 2.6% of people have GP visit cards. As the Deputies will be aware, the HSE is responsible for assessing an individual's entitlement to a medical card and a GP visit card. In this regard, the HSE has produced national assessment guidelines to provide a clear framework to assist in making reasonable, consistent and equitable decisions when assessing each applicant. These guidelines are available for review on the HSE website.

The relevant legislation is the Health Act 1970, as amended. Under the provisions of the Act, persons who are unable, without undue hardship, to arrange a general practitioner service for themselves or their family qualify for a medical card. In accordance with the legislation, the assessment for a medical card is determined primarily by reference to the means, including the income and expenditure of the applicant and his or her partner and dependants.

It is a fact that under the health legislation, there is not, nor ever has been, an entitlement to a medical card for a person with a particular illness or medical condition. In accordance with the legislation, it is not possible for the HSE, and the HSE has no authority, to award a medical card by virtue of an illness or a medical condition.

I listened carefully to what Deputy O'Brien said. He made a compelling contribution to the debate. If I understood him correctly, however, he referred to circumstances in which persons who had applied for a medical card and were outside the income limits ought to, or should have been considered on the basis of his or her illness or medical condition. It is not possible for the HSE to do that. All the HSE is expected to do, and does, is take into account the medical expenses, or expenses associated with the medical condition or illness of a person who is above the income threshold and therefore does not qualify under the income limits. That is where the doctor is involved in the assessment for a medical card. The doctor does not give a medical report on the severity of the illness. This may sound harsh but I feel it necessary to state the position clearly. The doctor and panel are involved in assessing the expenses that are reasonably associated with that illness or condition. It is not the illness or medical condition that qualifies a person for a medical card. That is not the position. People may believe that we should migrate to that system. There may be a case for allocating medical cards on the basis of an illness or medical condition but that is not how the system has operated since 1970.

9:30 pm

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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If the Minister of State revisits what Deputy O'Brien said he will find that he based it absolutely on the financial situation.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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He made a very good speech and I will deal with it if I get a chance.

Under Section 45(2) of the Act the HSE is obliged, in deciding on an individual's eligibility, to have regard to the person's overall financial situation, including the means of the spouse, if any, in view of the reasonable expenditure on him or herself and his or her dependants. Different criteria apply for assessment of eligibility for a medical card for those persons aged 70 years and over. That assessment is on a gross income basis. A person over 70 does have the option of choosing the net income assessment, should he or she wish not to be assessed on the gross income basis.

The HSE has discretion to grant a medical card where a person's income exceeds the income guidelines. This discretion must be exercised by the HSE in accordance with the legislation. The fundamental provision in the 1970 Act, however, is that a person is assessed on the basis of undue hardship in arranging a GP service having regard to his or her means. In that context, the HSE takes into consideration social and medical issues when determining whether undue hardship exists for the individual in accessing GP or other medical services. Discretion will be applied automatically during the processing of an application where additional information has been provided by the applicant which can be considered by staff or a medical officer, where appropriate. Several Deputies have asked about the extent to which a person is told when he or she applies that he or she can or should submit further information in respect of medical expenses. While an applicant may be denied eligibility for a medical or GP visit card, if the person has referred to a medical condition which is causing undue hardship a medical officer may review his or her eligibility, if the person's GP completes a medical report which is furnished together with a prepaid envelope.

Having completed a full assessment of an application or review, a letter issues to the applicant advising of the decision thereon. If a review is assessed as ineligible or eligible for a GP visit card only, the letter issued informing the applicant of this decision will include an explanation of how the application was assessed and the details of the means assessment calculated on the application. If this is not happening I want to know about it. Some people have interpreted what I have said as meaning that the Minister has a role in deciding on the merits of individual applications. The Minister has no role in this regard. If I am wrong when I state in this House what happens or should happen in the mechanics of an application, and solemnly say that I am advised by the HSE this or that process is applied, and if somebody can give examples of my being wrong I want it drawn to my attention. I will then immediately draw it to the attention of the HSE that something we say happens in the mechanics of applications is, in fact, not happening. I have taken these points up when Deputies have raised them.

Applicants will be advised that they can request a review of the HSE decision if they believe their financial or other circumstances have not been correctly assessed. They will also be requested to provide any additional relevant information or details of any change in circumstances since their original application. In addition, the letter will notify the applicant of the option to appeal the decision and the contact details of the appeals office. Where applicants submit an application without any additional medical documentation and are refused, they will receive a letter giving a calculation of the guideline thresholds and where these have been exceeded. At this stage, they are also informed of the option to furnish further medical documentation to support their application.

Additional information can be used for consideration on a discretionary basis, following receipt of a letter indicating an unsuccessful application. Additional information that may be relevant to the exercise of discretion includes illness or medical circumstances which result in financial hardship; the cost of providing general medical and surgical services; the cost associated with the provision of medical, nursing and dental treatment; or the cost of medical aids and appliances. Where discretion is exercised with regard to an applicant with an illness or disease, it is the effect of reasonable expenditure related to that condition on a person's financial situation that is relevant.

The processing of medical cards at a national level, rather than at a local level as was the case before mid-2011, ensures that all people are assessed in a similar and fair manner when applying for a medical card, irrespective of where an applicant lives. Concerns have been raised in this House that an individual may or may not, or would be more likely to, get a medical card depending on where he or she lived. I listened to what Deputy Colreavy said about this and must respectfully disagree with the impression he gave that it was in some way acceptable. I do not think it is at all acceptable. We all would share the view that everyone should be treated in the same fair and consistent manner. I have seen figures relating to early 2013 showing that some counties, such as Cork, Limerick and Tipperary, at one stage had three or four times the proportion of discretionary medical cards per head of population compared to other counties, such as Louth or Meath. In previous years, there was a local assessment process, which, although it might be seen as desirable from one point of view, actually led to there being real inequities throughout the country. Bluntly, it meant that a person may have been awarded a discretionary medical card in one part of the country that he or she would not have obtained in another because of the lack of a centralised standardised approach.

That said, I acknowledge that the transition to a nationally consistent standard system of assessment has caused difficulty at renewal stage for households with incomes above the HSE threshold, even where an illness or disability is involved. Shortly after the introduction of the new system the Minister for Health, Deputy Reilly, requested the HSE to set up a clinical panel to assist in the processing of applications for discretionary medical cards, where income guidelines have been exceeded, but where difficult personal circumstances exist, such as an illness that would affect a person's financial circumstances.

In addition, at the behest of the Minister, the HSE is examining how individuals, who are not entitled to a medical card, could still receive services that meet their needs. This issue is being addressed in a manner that includes all of the services and supports provided by the HSE, with as much flexibility as possible, and at a local level. Notwithstanding what Deputy Colreavy said, it is a very real and important opportunity for people to be able to access services in circumstances where they perhaps no longer have the medical card but although in some cases they are above the income limits, even substantially so, they still need access to services for themselves or their child. We must move the system forward to ensure we provide that and put in place protocols for quick access to services that people need in their communities where they have a medical condition or illness.

It is intended that improvements will be made, and it has been brought to my attention that they are needed, to the level and extent of information published by the HSE and local information points will be established at major health centres around the country, where members of the public can obtain comprehensive information and support in accessing their full range of supports and entitlements from the health services. I have seen examples of cases where people with a medical card who lost their eligibility were entitled to the long-term illness, LTI, scheme but were not aware of that. It is not acceptable that a person would be coldly refused continued eligibility to a medical card where it is not drawn to their attention, or there is not some way of their knowing, that they could have access to the LTI scheme, which could cover their medications, equipment, medical devices and other services that they need. Appropriate notice is also being considered as part of this review for existing medical card holders who may no longer be eligible on renewal but where serious medical conditions or disability continues to exist. In that way people would have a decent level of notice where eligibility has been found not to exist. The Government is fully aware of the difficulties that arise for persons who are deemed ineligible, particularly after a period where they have held a medical card.

As the House will be aware, one of the key goals of the reform of our health system is to ensure that people receive health care according to their particular needs, rather than based on their income. It is an anachronistic and inappropriate basis for a 21st century health system and it is far from any comparable modern health system in any other European country where we continue to assess people on the basis of their means to determine their eligibility to access health services. It seems essential that we move towards a health system that is based on universality of access. The concept of eligibility has been amended by legislation passed by the Oireachtas in 1991 and 2005 and the House did not depart from the principle of means testing in terms of access to health services. One result has been that the means based legislative framework has produced a very complicated eligibility system, with all of the difficulties, anomalies and contradictions that exist throughout our system.

Some members have criticised the bureaucracy involved in the system and Deputy Colreavy referred to the forms required to be completed. Others have said to forget about the forms, that the humanity of the situation should always win through. However, as legislators, we must also have regard to the fact that we should have clear entitlements. People should be clear on what their entitlements are and they should be either entitled or not entitled to a particular service. It should not be the case that people have to come begging or go to politicians to make a personalised case to be treated as an exemption. Their entitlements should be clear and they should be consistent across the country. We do not have that type of system. The only way we will achieve that is by working together in order to create the kind of reformed health system that we need where we have proper equality of access for all our citizens based on need and not based on their income.

It has been suggested - though perhaps not in this House - that in the meantime we should consider moving from eligibility based on means to a system where people are eligible on the basis of their having a particular medical condition. I have thought long and hard about this, as I am aware other Members have. On the face of it, it is clearly right that if one has an illness one should be able to access the health service. That is what we want and what I passionately believe - as I think we all do - we need to achieve in terms of the reform of the heath system, but we cannot simply shoehorn the new system into the old one. We have to continue to manage the existing system fairly and transparently while moving as quickly as we can to introduce a new system. We are trying to do two things at the one time. If we were to try to replace in the interim our current inadequate system with an illness based system, that would have very significant unintended consequences that we would need to address. The first question that comes to mind is which illnesses or conditions should enable a person to access health services and which should not? Our immediate reaction to that question would be "any and all illnesses". Which of us will be the first to stand up and say "we would exclude a particular illness or condition"? Would eligibility extend for the duration of an illness or condition or once a person had that illness or condition would they retain their medical card permanently? How would we choose one illness over another? Would we be acting in an arbitrary manner or excessively impairing the right to equal treatment? How would we even define an illness? It has become more difficult in the modern age sometimes to define a disease or an illness. Would we set clinical criteria in the legislation or leave it open to medical practitioners or the HSE to interpret? Similarly, who would determine if those criteria or conditions w;ere met? Would we rely on the opinion of a GP, who would be placed in the invidious position of determining if his or her patient can use the health system while at the same time potentially benefiting financially from that decision? There are many examples of anomalies that would arise in that situation which I do not believe would bring about the fair and transparent system that we want to have.

On the issue of constitutional rights covered in the motion, I strongly believe we should have robust constitutional rights but the allocation of resources, particularly to the health area, is a political question and there are political differences as to how best to allocate resources. We could place rights in the Constitution but we as politicians would still have to argue and resolve in this House how best to allocate resources. Even the argument between universality and another system is a political issue that requires to be resolved, as does the issue of resources and how much we allocate to health versus other areas of public expenditure.

I agree that our system is not fit for purpose, as Deputy Ellis said. We need to work together to reform and change it. There is much that we could discuss on this issue but I want to hand over to Deputy Barry.

9:40 pm

Photo of Tom BarryTom Barry (Cork East, Fine Gael)
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I welcome the opportunity to contribute to this Private Members' motion on medical cards. We need to be cognisant of the fact that this discussion is taking place against the background of our health service which is already costing this country approximately €14 billion. It shows that the Government is committed to health. However, it does not mean that we have a perfect health service - far from it. I deal in my offices in Mallow and Fermoy with medical card applications and reviews for people on a weekly basis, as do all of the other Members present. Dealing with those is not the preserve of any one party; they are an issue and we all deal with them. Currently, medical cards are given on the basis of financial hardship. The primary care reimbursement service is tasked with this job. I must acknowledge their help and engagement because they have a very difficult job to do. The time has come to properly define what a discretionary medical card is because I am not quite sure that I know what it is. We need to address the lack of clarity in this area.

One million medical cards were to come under review for 2014 but this might be a little too ambitious. However, I do not disagree with the principle of a review. We need to review but we need to do it in a manageable fashion. We need to examine new legislation which would allow a third tier of provision for people with grave illnesses. This is not the current position. This is the area where the discussion is developing and I welcome that. Nobody wants to see people suffer, especially people who have grave illnesses such as people on the transplant lists. How can one face a person who is on a multiple transplant list and tell them they cannot have a medical card? I certainly could not do it. We need to have a discussion on where these guidelines should be drawn. We have a duty to explore this area. There will be anomalies but change is always challenging. Transplant patients should be given the support of a medical card, as should living donors, who have donated organs. We are trying to encourage organ donation and it is a very sensitive are. The quality of life enjoyed by people who have received organ transplants is fantastic.

We need to expand the long-term illness scheme to cover other conditions. As the Minister of State said, awareness of this scheme needs to be heightened as many people are not fully aware of it. We must also recognise that we are approaching a threshold with regard to affordability. Some 40.8% of the population have medical cards and 8.8% have GP visit cards. Of the 644,000 reviews last year, 482,000 were dealt with and 96% of those people continue to be eligible. Very few were not found to be eligible. However, with regard to the other 161,992, which is a sizeable number, those people either did not respond or some of them passed away during the term of review.

I disagree with medical cards being tied to other issues such as exemption from exam fees. They have nothing to do with each other and should not be there to muddy the waters - they could be dealt with in other ways.

There are issues with dealing with medical cards at a centralised site. It has removed local knowledge and I am not necessarily a fan of this. However, taking up to eight months to deal with people's reviews is certainly not good enough and it needs to happen in a proper timeframe. If they are not dealt with within that timeframe action needs to be taken. There are also issues with considerable amounts of data being lost and being lost multiple times. I spoke to a lady last week who told me of her data being lost five times. This cannot continue.

With medical cards that were granted recently and are not due to expire for a while, there is no point in reviewing them immediately again, which would be wasting time and delaying the process. Some of these reviews are counterproductive. We are in a demand-led scheme and the applications are complicated. Confusion exists and people need help. They come to Deputies, but we need a better portal to deal with these people.

I welcome this discussion. Health care needs to follow the needs of the patient and the citizens need to feel they are valued and protected especially at vulnerable times when their health is failing.

9:50 pm

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I thank the party next to me for tabling the motion which gives me an opportunity to speak on the issue. At the outset of his speech the Minister of State said:

It is not the first time it falls to me to put on the record of the House that with regard to medical cards allocated on the basis of discretion, there is no policy to abolish such cards; there is no deliberate "targeting" in order to reduce the number of these cards; there is no targeting of any patient group holding these cards; and nor would this even be possible ... I accept that some individuals have lost eligibility ... but cards are not being arbitrarily withdrawn or refused. There has been no change in the rules governing the awarding of medical cards where discretion is involved.
We immediately have a difficulty with that. Even in the HSE service plans up until last year there was in the accounting exercise a targeting of discretionary medical cards. It was identified and highlighted in the HSE service plans that there would be a reduction in the number of medical cards. That is an obvious targeting of discretionary medical cards. For the Minister of State to suggest at the outset of his speech that there was no such policy does not cut ice given that it is stated in the HSE service plans up to last year. This year the Government decided not to include the word "discretionary" in the HSE service plan because it made a deliberate attempt to erase the word "discretion" from official policy.

Even in the responses to some of the parliamentary questions I and other Deputies tabled, the Minister of State informed us that there was no such thing as discretion. There were more than 80,000 entities in terms of-----

Photo of Alex WhiteAlex White (Dublin South, Labour)
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I wish to make a correction. There is no such thing as a discretionary medical card. I never said there is no such thing as discretion.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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The Minister of State said there is no such entity as a discretionary medical card.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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That is right.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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The point is that more than 80,000 people had such an entity for a number of years and had been granted a medical card on discretionary grounds based on their illness.

Deputies who have already spoken on this Sinn Féin motion have outlined some terrible examples and every Deputy in the House has come across it. Time and again people's discretionary medical cards are being withdrawn and people who are applying for one on a discretionary basis because of an illness are not being granted them. That is a fact of life and that is what is happening. My difficulty is that there seems to be this official wall that has decided to brazen this out and I cannot understand why.

The former Ombudsman, Ms Emily O'Reilly, stated clearly that while there was not substantial change to the policy, the issue of discretion was being shrunk to the point where medical cards were not being awarded. I have frequently quoted her report in the House with regard to the discretionary element.

What is most bizarre is that the Minister, Deputy Reilly, the Minister of State present, the HSE and others have decided to ring-fence €35 million for children aged under six. Although the Minister of State has not said it, he is ring-fencing €35 million away from people who genuinely need medical cards in terms of the illnesses, or physical or intellectual disabilities they have in order to fund this project.

As my party's spokesman I have said repeatedly in this House that of course universality is something to which most of us subscribe. However, when we have limited finances we must cut our cloth according to measure. Any measure of a decent society would suggest that we should give a medical card to a person who has an illness, disability or congenital disease before giving a GP-visit card to a child aged under six who may come from an affluent background and does not need it in the first place. That is a decision the Government has made. The Minister of State can dress it up whatever way he likes, but until such time as he can come into the House and convince me that the Government is not taking the medical cards that have been awarded on a discretionary basis to fund the GP-only medical cards for children aged under six, then I have a difficulty in supporting the Government's project for universality for GP-only medical cards for children aged under six because it is inherently and deeply unfair.

The Minister, Deputy Reilly, has told me that he is a republican and that he lives in a republic. We have seen that word abused many times, but in this context nobody could stand up in this Parliament and say it is right to apply universality to children aged under six when we are taking medical cards away from people while undertaking a review of their medical evidence, people with Down's syndrome, congenital heart disease and people who are 90 years of age and are incontinent and blind. Where are we going? Any fair rational assessment of what we stand for as a people would suggest at the very least that we should first look after those people. If resources are then available, of course we should spread it out to ensure that as many people as possible have access to GP services. However, it defies belief for the Minister of State to come in here and try to convince me that there is not a problem.

If the Minister of State does not want to believe me, he should believe the replies he gave to parliamentary questions which show that the number of medical cards awarded on a discretionary basis has reduced from roughly 90,000 at one stage down to fewer than 50,000, which indicates there must be a targeting and culling of medical cards.

People who were previously granted a discretionary medical card based on certain types of illnesses can no longer get them. Deputy Ó Caoláin referred to motor neuron disease. By and large people who contracted motor neuron disease in the past would have been awarded a discretionary medical card regardless of means. This is a disease for which there is no cure. They will die from it and yet we drag them through a system that is heartless, bureaucratic and is set up purposely to discourage people from applying for a medical card on a discretionary basis.

The word coming back from the PCRS appeals process is that they are outside the income guidelines. We all know they are outside the income guidelines, but people have genuine illnesses, some of them terminal and some very serious and they still cannot get a discretionary medical card. The Jack and Jill Children's Foundation has repeatedly stated that some of their clients have reached crisis point with regard to the application of the discretionary card.

We have had it with terminal illness, including cancer. I have highlighted these on numerous occasions. We have been raising the issue on this side of the House for two years. I have sent on details to the Taoiseach on numerous occasions. I do not expect the Taoiseach to be involved in every particular application for a medical card, but I wanted to highlight what is happening in our society. The Minister of State has told us we will have a universal health system but the difficulty is that those who need it most will have universal access to a GP if they are aged under six.

However, once they are over six years of age, they will lose the GP card because of age and will not qualify for a discretionary medical card because of their illness. I cannot reconcile that. If the Minister of State genuinely thinks he will get plaudits for giving a healthy, wealthy five year old a free GP card while taking a discretionary medical card from a child with Down's syndrome, I think we are living in a banana republic. It is unfair and unjust.

When the human papillomavirus vaccine for girls was not brought in one year, the Minister said the former Minister, Mary Harney, was criminally negligent. I would never go that far but the Government is morally bankrupt if it thinks this is a good idea. I have no difficulty looking at the broader issue of universality but we should prioritise according to the need of individuals as opposed to a cohort of people who may not need medical cards at all. I would like to think most people in society with a reasonable income and young children would willingly pay for their GP knowing that if a crisis hit the family, for example, if a child got very sick, contracted a very serious illness or had an accident, the State would support them then. In the meantime, while resources are limited, would they mind going to the GP the odd time and paying? I think most people are fair. The Government has made a decision which is entirely wrong, unjust and should be reversed immediately. We cannot ask the sickest, the oldest and some people who are dying to fund those under six years of age.

There has not been an increase in the budgetary allocation.

10:00 pm

Photo of Alex WhiteAlex White (Dublin South, Labour)
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There has been.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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Year on year the budget has gone down. It is an accounting exercise and that is the difficulty. The Government has transferred €37 million from one paragraph to another subhead.

Photo of Alex WhiteAlex White (Dublin South, Labour)
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Nonsense.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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That is what is happening. It is highlighted in the Government's budgetary arithmetic. It has highlighted the fact it will target €113 million in medical card probity. That is a stealth word for reducing the number of discretionary medical cards. The reason discretionary medical cards are being targeted for a cost-saving exercise is that they are being used all the time because they are awarded to people based on their illnesses. They need these for many reasons. The Government has decided to take them from those who need them most and give them to those who may not need them at all. If a person contracts an illness or a disability, the State should support them through the discretionary medical card process, but the Government has opted to go the wrong way by going down the GP universality route prior to having additional funding in place. Additional funding is the critical issue.

I am not the only one saying this. The advocates of many people in society who are facing very difficult times and huge hardship in terms of illnesses, diseases and disability, both physical or intellectual, are also saying it. The Jack and Jill Foundation, the Irish Cancer Society, people who advocate for people who contract motor neurone disease, Down Syndrome Ireland and other organisations are saying there has been a change in how one is assessed and granted a medical card on a discretionary basis.

Reading through the Minister of State's speech, it is exceptionally disappointing that we are back to square one. There is no acceptance that it has become more difficult to be granted a medical card on a discretionary basis. Mr. Hennessy of the HSE said that some of the ways in which medical cards were handled were indefensible. If they were indefensible, why is the Government defending them? Is it not time to accept that this move towards culling and reducing the number of discretionary medical cards should be reversed and that the precedents set were set for good reasons? It is a shameful exercise that we are now quoting the 1970 Act in its entirety and that the Government is now tying the hands of those who would have been able to grant a medical card on a discretionary basis.

The Minister set up a clinical panel to assess people seeking a medical card on a discretionary basis. I do not know the guidelines under which it is operating but I know one thing for sure-----

Photo of Alex WhiteAlex White (Dublin South, Labour)
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They are published on the website.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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-----and that is that I see no reason a person who contracted motor neurone disease four or five years ago and was granted a discretionary medical card should be contacted again. It is beyond belief that such a person would be asked to furnish new medical information. If there are clinicians on that clinical panel, they should know full well that the disease is incurable but we have a situation where these people are being dragged through a bureaucratic system.

The Minister should accept at this late stage that the discretionary medical card was there for a good and valid reason. It was there to bring humanity and provide support in a very bureaucratic system, which was the case with medical cards. It was there for the right reasons and it should be maintained for the right reasons. The idea the Minister would deny there has been a targeting of discretionary medical cards is indefensible as Mr. Hennessy said himself.

Photo of Maureen O'SullivanMaureen O'Sullivan (Dublin Central, Independent)
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The response of staff of the HSE with whom I am in contact in regard medical cards is very satisfactory and very prompt but I must ask from where this review has come. The review has caused considerable distress and anxiety for people when they are being reviewed. As we know, some of them should never be subject to a review because of the type of illness or condition they have. That stress is added to by the wait to see if they will be successful in holding on to their medical cards.

How much was spent tendering for the private company contracted to carry out the administrative services of the HSE for the review? There are concerns that some of the people in the particular company who are asking the questions do not have any background in this particular area. They do not have access to full records and are only getting names and addresses, which is perhaps why people are being reviewed even though they should not be. They are also getting confidential and sensitive information about people and I wonder if those people have Garda clearance.

The Minister of State said there was no deliberate targeting but he must be aware, because he has been told, of the concerns of doctors and pharmacists in regard to cases of hardship and distress among their sick and elderly patients who have had their medical cards removed. I totally agree with the Minister that they should not have to contact their politicians, but they are doing so. Like others, I have been contacted by people, in particular in their 70s, who have lost their medical cards and they are not people of means. The thresholds are a problem because somebody can miss out ever so slightly as a result of a threshold but could not be considered as a person of means.

Thalidomide sufferers and those who with symphysiotomy have medical cards, which is correct. Those who were given contaminated blood products have the HSAA card. Mr. Justice Quirke recommended that the ladies from the Magdalen laundries would have a health care package similar to the HSAA card but nothing seems to be happening in that regard and I have tabled questions to the Ministers for Justice and Equality and Health. These are elderly ladies and there are deaths all the time. They deserve better treatment than they are getting.

I refer to complementary medicines and whether they could be considered in terms of medical cards. I do not understand the rationale behind giving free health care to people who are healthy while depriving people who are ill of vital and necessary health care.

10:10 pm

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I do not accept the Minister's statement that the rules and policy on discretionary medical cards have not changed, because they have. Every Member of this House, on the Opposition side and the Government side, knows what is happening because they deal with it every day. People who had medical cards for years and whose circumstances have not changed have had their medical cards reviewed and withdrawn. People are being targeted daily. Those with chronic illnesses and other serious illnesses are either not being granted medical cards or are having them withdrawn.

I will refer briefly to two cases. Recently, a gentleman came to me whose medical card was withdrawn because he was 8 cent over the limit, even though he was ill. A 16 year old young man with cerebral palsy who is wheelchair-bound and has serious and frequent epileptic seizures had his medical card withdrawn. He had a medical card for years. Such cases are heard hourly in my office and in the office of every Oireachtas Member in this House and in the Seanad.

Currently, it takes a minimum of two to three weeks for documentation to be registered on the PCRS system. It takes months to process applications. Unless one has a medical certificate that says one has a terminal illness and one is applying on discretionary medical grounds, it can take months to have one’s application assessed. Constituents with diagnoses of cancer have been waiting two, three and four months for a decision. They are waiting in a queue to be looked at by a doctor. That is simply unacceptable but it is a fact. Everything I have said this evening is a fact. Everything I have heard from other speakers reflects what I hear and see daily in my office.

Debate adjourned.

The Dáil adjourned at 9.05 p.m. until 9.30 a.m. on Wednesday, 14 May 2014.