Eamon Scanlon (Sligo-Leitrim, Fianna Fail)
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It is imperative to ensure that those persons who experience financial hardships due to very serious illness will receive a discretionary medical card. Page 56 of A Programme for a Partnership Government says: "We will maintain a humane approach for discretionary medical card provision." I received a reply to a parliamentary question on 25 April 2018 where I was told it was "neither feasible nor desirable to list medical conditions in priority order for medical card eligibility." This effectively denies cancer patients an automatic entitlement to a medical card. As far as I can find there is nothing about the medical card application process that is compassionate or humane.

I am baffled that there appears to be no political will on the part of the Minister or the Government to extend the medical card to cancer or terminally ill patients.

Patients and their families face a financial crisis while they are going through their treatment. The 2015 report, The Real Cost of Cancer, showed how a significant number of patients face a severe drop in income while at the same time running up extra bills on a range of items such as child care, travel, prescription charges, hospital stays and consultant visits.

We cannot lump on any additional financial stress to medical care by making patients jump through bureaucratic hoops, but this is what is happening currently.

Frank O'Rourke (Kildare North, Fianna Fail)
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I join my colleague Deputy Scanlon in raising this issue and in seeing how it can be made easier. The reality for people who are suffering from cancer or chronic and long-term illness is extremely difficult. These people have a lot of things going on in their lives; they are trying to deal with the illness and trying to live some sort of a life while dealing with other issues outside of their control with their illness. The painful process of making an application for a medical card is absolutely horrific. I know one young girl who has been diagnosed with a terminal illness and she is currently trying to finish her studies and get on with her life. She has made the application for the medical card and has been refused. She was looking for information from external sources, outside of her control. Because her application went outside the three-month window they closed down the application. When I called they said they were sorry but that was it and nothing could be done. This is shocking. I know another young man who has stomach cancer. He is on social welfare and is trying to fight the system to apply for a medical card, an application which is actually getting refused. He has had no success in getting co-operation in this regard. This is wrong. It should be made easier for people who are suffering from cancer or chronic and other long-term illness to access a medical card without going through this horrific process.

Mary Butler (Waterford, Fianna Fail)
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Ireland has an ageing population, but thankfully life expectancy has increased. Some of us, unfortunately, get sick, develop cancer, terminal illness or chronic conditions. This is a time when some people who do not qualify for a medical card need it most. The application process can be quite difficult if one is ill, recently diagnosed, traumatised and vulnerable.

Many Oireachtas Members have staff throughout the State who, at times, assist when people find it difficult to fill in forms, especially those people who are not online. A diagnosis of terminal illness is an automatic entitlement to a medical card, but a diagnosis of cancer, which also has a poor outcome but maybe a longer timeline, does not entitle the patient automatically to a medical card. Some people who apply for a medical card find the process difficult enough in normal circumstances. When one is extremely sick and devastated with a prognosis such as cancer, this can prove very difficult and trying.

Jim Daly (Cork South West, Fine Gael)
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I thank the Deputies for raising this issue. The HSE has a system in place for the provision of medical cards in response to an emergency situation for persons with a serious medical condition in need of urgent or ongoing medical care that they cannot afford and for persons in palliative care who are terminally ill. These cards are issued within 24 hours of receipt of the required patient details and a letter which confirms the medical condition from a doctor or consultant.

With the exception of terminally ill patients, all medical cards granted in an emergency are issued on the basis that the patient is eligible for a medical card on the grounds of means or undue hardship and will follow up with a full application within a number of weeks of receiving the medical card eligibility. It is also useful to note that in July 2015, the Director General of the HSE made a decision to award medical card eligibility to all children under 18 years of age with a diagnosis of cancer with the card to be held for a period of five years. It is undoubtedly important that the medical card application system is responsive and sensitive to people's needs, especially arrangements relating to the issuing of medical cards on a discretionary basis. To that end, the HSE has sought to implement revised processes to provide a more compassionate and more efficient process in the assessment of medical card applications. Such measures include the development of a burden of illness questionnaire which is now being rolled out in selective circumstances where the assessing doctor in the HSE's national medical card unit requires a more comprehensive assessment of an applicant's medical and social circumstances and any resulting undue financial hardship. In addition, in January this year, the new streamlined online medical card application system was launched. This will enable applicants to find out immediately if they are eligible for a medical card and will bring considerable benefits for people in turnaround times, convenience and security. Implementation of the measures above will aid the HSE's national medical card unit in providing an enhanced service to applicants, ensuring that the application process is as efficient and timely as possible.

It is nonetheless important to note that eligibility for a medical card remains primarily on the basis of financial assistance. This position was endorsed by the HSE's expert group on medical need and medical card eligibility which examined the issue of awarding medical cards on the basis of illness. That group concluded that it was not feasible, desirable, nor ethically justifiable to list medical conditions in priority order for medical card eligibility and that a person's means should remain the main qualifier for a medical card. This position remains unchanged. To summarise, I recognise that patients require a responsive and efficient health system to meet their medical needs, which may often be required urgently. The processes in place in the HSE for granting an emergency medical card, the new measures of the burden of illness questionnaire and the online application system are aiding the national medical card unit to provide an enhanced service to applicants, ensuring that the application process is as efficient and timely as possible.

Eamon Scanlon (Sligo-Leitrim, Fianna Fail)
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I am aware of doctors who are not aware of this emergency form that they can apply on. There must be greater awareness. I had a case of a lady who applied online in January. She got her medical card last week despite that she is very ill with cancer and is getting cancer treatment. That is very unfair. There should be people in the medical card office who will look at the applications when they come in and decide whether they need more information on an application or not. Information is being requested two or three weeks later and it is not good enough, particularly in cases where people suffer from cancer.

Frank O'Rourke (Kildare North, Fianna Fail)
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With respect, if the Minister of State's reply was the case, we would not need to be here, raising this with him. He outlined and highlighted a process. I had a constituent who was a patient in hospital with cancer, and applied through the hospital for that emergency fast-track system. That patient was told that the condition was not severe enough to allow the person to apply in this way, although it was signed off by a consultant, and that the patient should apply in the normal way. It was horrific. What about the student who was terminally ill and cannot get the paperwork in in time? Her application was closed down after three months. What should happen here, and maybe the Minister of State will discuss it with the officials, is that when an application is made for someone with long-term terminal illness such as cancer or another diagnosis, and the application is accompanied by a letter from a consultant, that should have some fast-track system to get through to get a medical card awarded. That would be instead of the painful, slow process which happens, where people who are suffering dramatically are tortured by the system for information and asked ridiculous questions and for supporting documentation for a terminal condition. It is wrong. If this was happening as the Minister of State says, we would not need to have this Topical Issue debate.

Mary Butler (Waterford, Fianna Fail)
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The programme for Government commits to a humane approach to discretionary medical cards for patients undergoing cancer treatment. The guidelines used to award discretionary cards for patients undergoing cancer treatment must be more lenient. They must be more caring. They must be patient-focused. The patient has to come first. They have to look at individual circumstances, case-by-case, as opposed to income only. I am disappointed to see that in the third last paragraph the Minister of State said: "It is nonetheless important to note that eligibility for a medical card remains primarily on the basis of financial assistance." I was contacted during the week by a woman whose dad was diagnosed with stomach cancer at 83 years of age. The man had previously applied for a medical card but unfortunately he only qualified for the doctor only card, being €20 over the weekly limit. The doctor only card was sufficient up to then but now he is 83 and has stomach cancer, so it has to change. I put the emphasis on the patient having to come first.

Jim Daly (Cork South West, Fine Gael)
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I accept what Deputy Scanlon says about greater awareness. The burden of illness questionnaire is very new and many people do not know about it. I had occasion to write to the Secretary General of my own Department recently about my concerns with the application of a constituent. We, as politicians, will always come across the bad cases and the cases that were not dealt with properly, while there are almost 1.6 million in the system who have full medical cards and another 500,000 have general practitioner, GP, visit cards, amounting to over 2 million of the population, but we as representatives will always pick up the cases that were wronged by the system. Our view of the world through that can be overly negative but that does not take from every individual having a right to get what they should, and there should be a process that backs it up. I accept the Deputy's point about increased awareness and I will take that up with the Department to make sure that every GP is aware of the burden of illness questionnaire.

Deputy O'Rourke mentioned somebody who is terminally ill and cannot do the paperwork. In that situation, a consultant can write a letter to the medical card section on the part of the patient. I have witnessed these situations. A medical card would be issued immediately without any questions asked if somebody is so terminally ill that he or she cannot do the paperwork. There is a system to deal with that but, as with all systems, it is not perfect and there are always glitches. I welcome the opportunity and attention that people have brought to the issue.

Deputy Butler addressed eligibility and financial means. At the end of the day, the medical card will not make anybody better. It will not assist their treatment if they have cancer. We have to be clear on that. All it will do is ensure that they are not under financial burden and we have to be careful with that. People could be diagnosed, as I was myself a number of years ago, with a skin cancer which is something very mild. I do not need a medical card. I did not need it then and I do not need it now. There is not a need for everybody who has been diagnosed with cancer to be given a medical card. It just does not stack up. While it sounds like it would be a good idea, it does not stack up in all cases. It is still about financial eligibility and making sure that there is no additional financial burden whatsoever on people. That is the role of the medical card as opposed to treating the person.