Health (Alteration of Criteria for Eligibility) Bill 2013: Second Stage

Minister of State at the Department of Health (Deputy Alex White)

I move: "That the Bill be now read a Second Time."

The maintenance of health services is a priority in 2013 for the Government despite the need for significant and difficult financial savings in the health area. It has been our intention that front-line health services would be protected to the greatest extent possible. As part of budget 2013, over €13.6 billion in current funding has been made available to the Health Service Executive for the provision of services. This amount represented an increase of €150 million over the original expenditure targets for 2013, as set out in the comprehensive expenditure review published in 2011. However, despite the extra funding provided, just over €750 billion in savings must be made during 2013. This represents a major challenge for the health services.

The budget strategy has been to achieve savings through efficiencies and reorganisation under the public service agreement, curtailing the growing cost of pharmaceuticals and increasing income generation. The aim of this budgetary strategy is as far as possible to cut the cost of the services and not the services themselves. By way of example, significant savings have been targeted in the cost of prescribed drugs and medicines.

Last year's agreement with the Irish Pharmaceutical Healthcare Association, IPHA, will provide savings in excess of €400 million over a three-year period. The agreement also means significant reductions for patients in the costs of drugs, as well as a reduction in the drugs bill to the State. Separate legislation aimed at reducing the costs of drugs is making its way through the Oireachtas at present - it passed Committee Stage yesterday - and it will introduce a system of reference pricing and generic substitution which will deliver further significant savings in the costs of medicines for the health service.

Budget 2013 set out a wide range of savings that were required, which are made up of a €323 million reduction in the cost of primary care schemes; €308 million pay-related savings; €65 million in increased generation of income by public hospitals; €60 million in net savings on the Department's Vote; €20 million savings on procurement; and €5 million in other savings. Nonetheless, the achievement of €781 million in savings in 2013 remains difficult. The majority of savings have been designed not to impact on front-line activity. However, we have previously acknowledged that it has been necessary to take a number of difficult measures to ensure that the most vulnerable are protected.

The General Medical Services scheme comprises the GP service and prescription drugs, as well as some other services, where such services are provided to holders of medical cards or GP visit cards. Over recent years, there has been a significant expansion in the GMS scheme. At the end of 2007, there were 1.28 million medical cardholders, while by the end of 2012, there were 1.85 million medical cards in circulation, an increase of almost 600,000 cards, or approximately 45%, over a five year period.

The total cost of the GMS scheme is about €2 billion per year. At the end of 2012, there were approximatelt 1.986 million qualifying people under the GMS. Medical cards make up the majority of this number, amounting to about 93% of the total. Medical cards for persons aged 70 years and over account for about 360,000 individuals, or about 20% of all medical cards. The total cost of services provided to over-70s medical cardholders is approximately €750 million per year, which represents about 38% of the total cost of the GMS scheme.

Under the Health Act 2008, special eligibility rules applying to persons aged over 70 years were put in place which are more generous than those applying to the standard means-test medical cards. Under the 2008 framework, a single person over 70 years old with a gross income of up to €700 per week, equivalent to about €36,000 per year, qualifies for a medical card. A couple over 70 years old with a gross income of up to €1,400 per week, equivalent to about €72,000 per annum, also qualifies for a medical card. There are approximately 370,000 people aged over 70 years in the State. Given that there are currently about 360,000 medical cards issued to people aged over 70, medical card coverage of the over 70s population is about 97%. In comparison, the medical card coverage of the under 70s population is about 35%.

In the recent budget, two interrelated changes to the over 70s eligibility arrangements were announced to deliver €12 million in savings during 2013 from the €750 million expenditure on over-70s medical cards. The income limit for an over-70s medical card is to be reduced and people who no longer qualify for a medical card will continue to receive a free GP service. In addition, they will qualify under the drug payments scheme to have some of the cost of their prescription drugs met by the HSE. More specifically, the income limit for an over-70s medical card is to be reduced to €600 per week, equivalent to about €31,000 per year, for a single person. For a couple, the income limit for the over-70s medical card is to be reduced to €1,200 per week, equivalent to gross income of about €62,000 per year.

As I stated, those who no longer qualify for an over-70s medical card will qualify for an over-70s GP visit card. A single person over 70 years old with a gross income of up to €700 per week, equivalent to about €36,000 per year, qualifies for a GP visit card. A couple over 70 years old with a gross income of up to €1,400 per week, equivalent to about €72,000 per year, also qualify for a GP visit card. In addition, under the drug payments scheme, the HSE will meet the prescription drug costs of these people in excess of the DPS threshold of €144 per month. It is estimated that about 20,000 people will have their medical card replaced with a GP visit card under the new income rules. Therefore, it is important to note that about 95% of the over-70s population will not be affected by these new rules; 92% of over-70s that qualified for a medical card will continue to have a medical card; 3% of over-70s that did not qualify for a medical will continue not to have either a medical card or a GP visit card; and 5% of over-70s that did qualify for a medical card will now qualify for a GP visit card instead.

The new legislation is specific in that it is only meant to affect a small number of people aged over 70 years of age: single individuals earning more than €31,000 per year or couples earning more than €62,000 per year. The new income limit for a single person of €600 per week is, for comparison, more than two-and-a-half times the single person's basic State pension of €230 per week. The new income limit for a couple of €1,200 per week is, for comparison, more than two-and-three-quarter times the basic State pension for a married couple of €436 per week.

The Civil Partnership and Certain Rights and Obligations of Cohabitants Act was enacted in 2010 to introduce certain rights and obligations for civil partners and cohabitants. It is important that these rights and obligations are also reflected in the legislation relating to the over-70s medical cards and the new over-70s GP visit cards. The necessary amendments to achieve this are also included in this Bill to ensure that spouses, civil partners and cohabitants are treated in a similar manner.

A primary objective of public service reform is to integrate services with a view to providing better service to citizens and greater efficiency for the State. Co-operation between public bodies at national and local level is one of the key pillars to the achievement of this objective. In this context, the Department will continue to support the HSE in its exploration of opportunities to exchange data with public bodies with a view to ensuring that public services are delivered as efficiently as possible to those who have an entitlement to such services.

One of our intentions under the new over-70s arrangements was to avoid having to unnecessarily contact as many over-70s individuals as possible. Contacting all over-70s would be a very wasteful and time-consuming task, as well as disturbing for the individuals themselves, given that 95% of the over-70s population are unaffected by the new rules. One of the benefits of greater co-operation between the HSE and the Revenue Commissioners is that the HSE will be able to prioritise contacts with higher-income over-70s medical cardholders.

However, the exchange of personal information is more general than just the changes to the over-70s arrangements. The prevention of fraud and abuse of the health service is a very important element of the work of the HSE, even more so in the time of severely limited resources. One of the most effective and efficient ways of targeting cases for review is to electronically match data from other relevant Government Departments and public bodies against the HSE's computer systems. The purpose of this is to identify people who may be holding a medical card to which they are not entitled. In carrying out these data matching exercises, the HSE is obliged to be mindful of its responsibilities to protect the rights and privacy of individuals in accordance with the Data Protection Acts 1988 and 2003.

As I stated at the outset, it is a Government priority during 2013 that health services are to be maintained despite the need for significant and difficult financial savings in the health area. The majority of savings have been designed not to impact on front-line activity. However, it has been necessary to take a number of targeted measures, such as this proposal, to ensure that the most vulnerable continue to be protected.

I commend this Bill to the House and look forward to hearing the views of Deputies.

Deputy Billy Kelleher

The Minister of State might be looking forward to hearing our views but we cannot express any confidence in this Bill.

First and foremost, on the aspect of the Bill being published last week, Deputies have been unable to get a copy of it and we are now in the Dáil Chamber discussing Second Stage. Quite clearly, this is an unpopular measure the Government is bringing forward. Let us be under no illusions. Nobody in the broader public is embracing this measure. Nobody in this Chamber is supportive of it, but the Government has an overwhelming majority and will ram it through. There has been no discussion on this legislation. It was published last week. There has been no time for stakeholders, advocacy groups and others who represent those in the community who will be directly affected by this legislation. It is inherently a nasty piece of legislation.

The Minister of State, Deputy Alex White stated that the legislation is about protecting the vulnerable, that the Government had to make difficult decisions. The Government had to wrestle with its conscience. It had to look deep into its heart. The problem is that the Government did not wrestle with its conscience. In particular, the Labour Party did not wrestle with its conscience in the context of the formulation of the last budget. There was an easy way to avoid all of this, in terms of targeted cuts. The cuts to date have been targeted at the most vulnerable. They have been targeted at the over 70s, in this legislation, at home help and at special needs assistants. They have been targeted at all of the areas where people are most vulnerable. The mobility allowance is another such area where they were targeted. Quite clearly, those who have been targeted most by this Government have been the elderly, those with disability and those who require State supports. Any perusal of the budgetary strategy would indicate that. If the Government really wanted to be fair and equitable and ask those who have most to carry most, it would have had a completely different budget arithmetic brought to this House last year. For example, the universal social charge would have been increased for those earning more than €100,000. That would have realised a major increase in tax receipts and the Government would not have had to bring about some of the insidious and nasty cuts that have been announced.

I do not want to go back over the history of eligibility for those over 70s, but it is interesting. The first one to put a cap on eligibility was the previous Government made up of Fianna Fáil, the Progressive Democrats and the Greens. Previously, it was a Fianna Fáil-led Government that brought in automatic entitlement for those over 70. When, in January 2009, we brought in a more liberal regime in terms of assessing eligibility for medical cards for those over 70, the parties opposite were apoplectic with rage. The Government parties, then in opposition, were beside themselves with anger, indignation and sheer determination that they would campaign to the end to take away the inherent unjust proposal that was being brought forward. The Minister, Deputy Reilly, was furious in opposition at the time when we were bringing in an eligibility income threshold, but a more generous one than that being proposed in this legislation. He stated that those were the people who made this country what it is today, that they raised us, nursed us when we were sick, protected us from violence, grew our food and ran a proud Civil Service.

I find it hard to believe that the Government is bringing this in as it stands. First, there has been no consultation whatsoever. It was announced as a budgetary matter, but one would have thought that the legislation would be published and that there would have been time for Deputies to collect it and read it before it was rammed through the Dáil so that there would be no dissent from Government backbenchers. One would have thought also that there would have been an opportunity for engagement with the broader community and society because this will impact on people's lives.

What I cannot understand is that while the Government speaks about universal health insurance and getting rid of the two-tier system, every policy it has adopted since has provided the opposite and created more difficulty for people. The policy of charging private insurance companies the full cost for patients in public beds will increase the price of private health insurance dramatically to subscribers who are put to the pin of their collar to retain private health insurance. Previously, subscribers have responded to the Government's suggestion that they take out private health insurance to lighten the burden on the public health system and to enable them to access care. Here we have a Government, that is promising to bring in health insurance for everybody while at the same time loading private health insurance against those who are trying their best to lighten the burden on the State in terms of the provision of health care. A total of 67,000 people gave up their private health insurance last year. Any assessment or actuarial analysis of the figures shows that this is quite alarming because it is the younger subscribers, those who are healthiest, who are leaving private health insurance and the burden will fall further on those who retain private health insurance, and there will be a price spiral.

One need not be an economist or actuary to assess the impact of this. One need only listen to Mr. Donal Clancy. He represents a private health insurance company, but he, along with many others such as VHI, GloHealth and Aviva, was quite adamant in his evidence to the Joint Committee on Health and Children. All of the insurers state that this will have a devastating impact on the ability of the private health insurance market to grow, prosper and develop. At the same time, week in and week out, I get a lecture from the Minister for Health that he has a mandate to bring in universal health insurance. He has a mandate, but he certainly did not seek a mandate to inflate private health insurance and drive families, who are put to the pin of their collar making decisions on whether they will fill the oil tank or whether they will buy essential services and supplies for their house, to decide not to pay their private health insurance. That is what people are doing. The Minister of State should go out to Dunshaughlin or Stamullen. If he goes anywhere in County Meath, he will hear this on the doorsteps. Residents are saying they simply have not got it. Now they are getting a letter through the letterbox. That is a separate issue, but it shows that people simply do not have disposable income. Are we now viewing private health insurance as a luxury? Is this now considered a luxury that one can do without? It is fine. If they do without it, they will fall into the public health system.

My point is the Minister is making decisions that go against everything of which he speaks when he refers to universality. On universal GP care, the problem is this legislation makes it more expensive for people to access their GP and medicines. That simply is the case and there is no way around it. Listening to the opening statement from the Minister of State, who has responsibility for primary care, it is quite evident that a U-turn of massive proportions is being done in terms of the legislation the Minister has presented to the Dáil. At the same time, the Government is promising free GP care for everybody. If we cannot afford to look after those who, as the Minister stated, made this country what it is today, how does he expect us to believe that the Government could afford to provide free GP care to everybody? It simply does not add up.

It is time that the Government stopped this delusional approach and had a rational debate on how we fund the health services. I am the first to accept there are budgetary constraints on the Government. We all realise the difficulties the country faces, but the critical issue is how we apportion funding and taxpayers' money, who we decide are vulnerable and who we decide we should care for. As a member of the Labour Party, I am amazed the Minister of State, Deputy White, is coming forward with this legislation. He should have fought tooth and nail with the Minister in the corridors of Hawkins House not to present this legislation in terms of the budget arithmetic because it is inherently unfair, if we are talking about universality.

All the statistics on the number of GP visits show clearly that older persons will visit their GP more, will access medications more, will have higher incidence of chronic diseases and need chronic illness management. This legislation will impact disproportionately on older persons. It will have a profound impact on those who built this country, and I quote none other than the Minister for Health.

When one goes through the legislation, there is another little nasty nugget in it.

We talk about democratic accountability in this Chamber, but I do not believe anybody believes that anymore. The Bill will allow a Minister without ever having to come into the House again to decide to change the eligibility criteria for those on medical cards. Up until now a Minister had to come into here - brazen and with a brass neck possibly - and explain to the House why he or she was changing the eligibility criteria and reducing people's entitlements and rights. However, with one fell swoop this legislation takes that democratic accountability away. If we pass the Bill, we will allow the Minister, whoever it might be, to decide without any further approval to change criteria and reduce medical card eligibility. Most people inside and outside this Chamber could not accept that. It simply gives a Minister too much power to decide without having to explain the rationale behind it to a democratic assembly.

The Bill is contrary to stated Government policy as outlined in the programme for Government and is a U-turn of massive proportions. Just as importantly, it denies public representatives the opportunity to speak on changes to eligibility to medical cards and GP-only cards. We will be opposing the Bill and urging everybody else to oppose it. As the Minister of State well knows, its provisions can and will be abused. There is more mention of the Minister for Public Expenditure and Reform than anything else with phrases such as "with the consent of the Minister for Public Expenditure and Reform". Where are we going? We are giving a carte blanche for responsibility for budgetary matters. Removing accountability of any form must be genuinely reconsidered. We will be opposing the Bill on Second Stage. The Government may make its case for changing eligibility. However, the democratic deficit will be forever enshrined in the legislation if passed and is a shameful exercise in itself regardless of the attack on the older people. Equally, there is an attack on the ability of democratically elected public representatives to at least have an opportunity to speak and defend those who are vulnerable and for the Minister of the day to come into the House and explain his or rationale for changing eligibility criteria. The Minister of State knows in his heart and soul that is wrong for many reasons.

Deputy Alex White

It is based on the CPI.

Deputy Billy Kelleher

While the Minister of State may say it is based on the CPI, the Minister can still decide at any time he likes to change the criteria. It does not need to be based on the CPI at all.

Deputy Alex White

The Minister has to act rationally. The Deputy should read out the section.

Deputy Billy Kelleher

He can decide to change eligibility criteria without any legislative change, which is simply unacceptable.

On the broader issue of access to our health services, the GMS costs approximately €1.9 billion a year and is clearly a drain on resources. However, at the same time the Minister has told us - as a Minister and as a GP - that access to a GP is critical. The first port of call is to a GP and should go unhindered as much as possible.

Deputy Alex White

We are not taking that away.

Deputy Billy Kelleher

He previously said that access to medicines is critical. He expressed serious concern when we applied a 50 cent charge on prescriptions. He vehemently opposed that and said it was an appalling attack. He said that measure alone could discourage people from going to their GP and on to a pharmacist to get their medicines on the medical card. He said the 50 cent charge was a barrier to people accessing possibly life-saving medicines. My problem is that charge is now €1.50 and is a bigger barrier to accessing life-saving medicines. What has changed between March 2011 and March 2013? In two years it has gone from 50 cent to €1.50 and the monthly ceiling has been raised to €19.50 so people have to pay that much in prescription charges prior to being exempted. What was promised and what has happened are at variance in many cases. It is hugely at variance in the context of free GP care for everybody. Universal health insurance and all the Government legislation and proposals that come to this House are simply not credible when one considers the commitments in the programme for Government. The health care commitments in the manifestos prior to the general election are fundamentally at variance with the programme for Government.

Last week, the Minister for Health waved at me an interim document on universal health insurance the Government had published. There is nothing in that.

Deputy Alex White

Did you read it in the meantime?

Deputy Billy Kelleher

I read it initially.

Acting Chairman (Deputy Seán Kenny)

It would be better if we spoke through the Chair.

Deputy Billy Kelleher

If the Acting Chairman read it, he would be amazed. It was basically a press release that got a little bit longer and he had to keep filling things into it - timelines, commitments made, 2016, etc. It is utterly farcical that we are discussing small hospital frameworks, the establishment of hospital groups and universal health insurance when the Minister has not even a notion of what he is doing. The Labour Party's proposal was for a social insurance model for universality. The Minister for Health, on the Fine Gael side, is proposing that private health insurers would fund health cover in the years ahead. If we are to change fundamentally how we are to fund our health services, one would think the Minister for Health would have an idea as to what he is doing. He should have been able to publish some form of vision of where he is going. We are two years on and are still awaiting a White Paper on universal health insurance and I do not know how close we are to it being published. In the meantime we have a health service that is being dragged from pillar to post in terms of the Minister's whims about how it is to be funded and the direction it is being taken, which is simply not credible.

For all its faults and ills, the Health Service Executive was established on the premise of having a centralised system giving strong governance to health and removing it from political interference. Every day of the week something else comes out about political interference in the delivery of health care. These are not allegations but statements of fact - primary care centres, hospitals in Wexford and Kilkenny, etc. These are things happening on a continual basis. While we have limited resources, we need absolute certainty that decisions on the basic provision of health care are not being made for political reasons. I accept Ministers always make representations - nobody is denying that. However, when resources are scarce and decisions are being made to prioritise hospitals, we need clear accountability and clear criteria laid out to ensure they are awarded on the basis of need as opposed to political decisions or whatever goes on behind closed doors at Cabinet.

The Health Service Executive (Governance) Bill also gives the Minister significant powers. I cannot understand why the Government is doing this. It beggars belief that it is now introducing legislation to give sweeping powers to the Minister in the governance of the new health structure. It provides that the Minister may decide on many issues. I accept the Minister should have accountability to the House here but he should not be able to direct where health services should go.

This is a dangerous road to go down, one in respect of which Fianna Fáil was criticised in the past. To introduce legislation in this Chamber which will give a Minister more power in terms of the running of the health services is fraught with danger. This Bill also gives the Minister extraordinary powers to, if he or she so wishes, reduce people's rights and entitlements. For all those reasons, I urge caution.

Older and Bolder and many other organisations representing people at the coalface also have difficulty trusting what the Government says. Only last year the Government launched an all-out assault on home helps. It withdrew home help hours from those who most needed them, and in an arbitrary way with promises of reviews and instructions to the HSE regarding the process of reducing hours. The Minister of State, Deputy White, and I know that people's lives were turned upside down during the time home help hours were reduced dramatically, in some cases without prior notice. I know of an 85 year old who was told by way of letter that his home help hours were being reduced from eight to four. There was no consultation with the man concerned. This type of behaviour is unacceptable.

I am concerned about the implementation of policy decisions by the Department and how they impact on people on the ground. During the past two years, Members of the Opposition have been highlighting and pinpointing the difficulties in the medical cards process. I accept there have been some improvements. The Minister of State's predecessor, Deputy Róisín Shortall, gave a commitment in January 2012 to address the issues people were experiencing in accessing emergency medical cards. There have been some improvements. However, on the broader issue of medical cards, there is a lot to be desired.

On eligibility, during the 20 years I have been a Member of the Oireachtas I always assumed, obviously wrongly, that a person diagnosed with cancer was entitled to a discretionary medical card on health grounds. Following representations which I made previously to the former health boards, patients were awarded a card on discretionary health grounds. I have received representations from a woman diagnosed with cancer who, despite having had a double mastectomy, cannot get a medical card. I have previously brought this to the attention of the Taoiseach in the Dáil and have, at his request, forwarded the information to him. I have also raised this issue by way of parliamentary question, the response to which has been that the woman concerned does not qualify for a medical card because she does meet the income criteria. However, I did not ask if she met the income guidelines, rather I asked if a medical card could be provided on discretionary health grounds. This situation is repeated throughout the country.

The Government should, following this debate, and having endured the whims of the Opposition in highlighting these issues, seek to rectify the situation whereby people with life-threatening and often life-limiting illnesses are being refused discretionary medical cards because they are over the income qualifying criteria. Like many other Deputies, I had always assumed such people were entitled to a medical card. The reason this was assumed is because previously people were given discretionary medical cards on health grounds. This entitlement has been reduced dramatically. There has been much mention from Government and others of the increase in the number of medical cards granted. The reason for this increase is the downturn in the economy, which means more people qualify on income grounds. The Government needs to give serious consideration to the issue of discretionary medical cards on health grounds. It needs to undertake deep analyses of the blockages and the reason people diagnosed with bowel cancer and so on, who are over the limit by only a few euro, are being refused cards. I have outlined many instances in this regard in the Dáil and have, as stated earlier, forwarded the information to the Taoiseach, at his invitation.

Why can such people not get a medical card? Why is it that in this day and age, taking account of all our difficulties, people with serious life-threatening and in many cases life-limiting illnesses cannot because they are a few euro over the income criteria obtain a medical card? The power to grant medical cards on a discretionary basis has all but been abolished. There is no doubt but that this is the result of a policy decision by the Department of Health to save money. The bar, in terms of eligibility on health grounds, has been raised so high people cannot qualify, resulting in their having to not only suffer the difficulties of their illness, but the financial vagaries of life in terms of dealing with it. It is shameful that this Government has chosen to make it almost impossible for people to qualify for medical cards on a discretionary basis. This is being said not alone by me, but by Deputies on all sides of the House and advocacy groups.

On the Government's comments around changes in eligibility, income guidelines, fair budgets and having looked deep into its heart to ensure there would not be an attack on the vulnerable, in my view a person who has been diagnosed with cancer and has had a double mastectomy is vulnerable, as is the person diagnosed with bowel cancer and the person with a life-limiting illness, yet they are being refused medical cards. The Government should be addressing this issue in this legislation. It should also address therein the issue of eligibility for people with life-limiting illnesses.

There were alternatives in terms of how the health services and government services in general could be funded. The Labour Party almost walked out of Government. Labour Party Ministers walked out of the discussions, down the corridor and then went back in again. I am still puzzled as to the reason they went back in. I have asked myself on numerous occasions what it is they went back in for. It has been said that the reason they walked out is the Labour Party wanted an increase in tax on those earning over €100,000 and that they fought very hard for it, including walking out of the discussions. However, when the budget was presented, the only change in terms of income revenue raising measures was a reduction in eligibility for people over 70. There was no increase in tax for people earning over €100,000.

What changed? Why did the Labour Party Cabinet Ministers turn around and run back to the Cabinet table? I would like an answer to that question. I will never get it because of Cabinet confidentiality, safety in numbers, running back to the herd and taking cover in the flock. What I do know, however, is that the budget did not address fairly the imbalance in our society. It disproportionately affected those on low incomes. The Minister of State, Deputy White, need not take my word for that. The ESRI has said the last two budgets were the most regressive in recent years. While Fianna Fáil in government introduced fairly tough budgets, they were not as regressive as were the last two budgets introduced by this Fine Gael-Labour Party Government.

This issue is another indication of this Government targeting groups as opposed to showing genuine solidarity by ensuring those with the widest and broadest shoulders bear most. As I said, the ESRI stated that the last two budgets were regressive. This legislation is further proof that when it comes to making decisions this Government chooses to hit people with disabilities, older people and other vulnerable groupings in society as opposed to standing up, being brave and making decisions that will ensure that those who have most pay most. This Bill is not part of any such measure and I reject it.

Deputy Caoimhghín Ó Caoláin

Citizens could be excused for believing this Bill is more accurately named than most legislation which presents in these Houses. The Health (Alteration of Criteria for Eligibility) Bill is not about the medical card in one's pocket; it is about the eligibility for health. This is what it comes down to in real terms for real people, citizens throughout the land.

The Minister of State, Deputy White, must hand it to his senior colleague at the Department of Health for sheer brass neck. The Minister, Deputy Reilly, has it all. We saw evidence of it here earlier this afternoon, with the nakedly obvious efforts he and his associates employed to close down ministerial accountability to the Dáil and the people. This was the Minister who made much of his stated intent to restore ministerial accountability on taking office, but this afternoon we saw a flagrant effort to stymie the opportunity for Opposition voices to hold him to account here in the Parliament of the land. There are buckets full of evidence from which to choose with regard to the Minister and brass neck.

In 2001 and 2002, he was head of the Irish Medical Organisation's GP section. He spoke publicly against the decision of the then Fianna Fáil and Progressive Democrats Government to extend the medical card without means test to people aged over 70. He then negotiated a hugely lucrative deal for general practitioners to provide care for these new over 70s medical card holders. Fast forward to 2008, when the Fianna Fáil and Green Party Government tried to row back on universal over 70s medical card entitlement, they quite rightly met a huge wave of opposition from older people.

Sinn Féin supported the over 70s non-means tested medical card because we consistently support the principle of universal eligibility for health care free at the point of delivery for all. Therefore, when the threat to withdraw it was made, we stood with older people in opposition. So too did the former Irish Medical Organisation negotiator, by then Fine Gael and Opposition health spokesperson, Dr. James Reilly. The then Deputy Reilly did not mince his words, as he rarely ever did on these benches over that time. He stated the threat to withdraw the over 70s card was a vicious attack and a savage assault on the elderly. I spoke from the Opposition benches also, as my party's health spokesperson, and I heard his words as I did at protest events organised by Age Action and others. When the Fianna Fáil and Green Party Government was forced to back down and introduce the current over 70s medical card scheme based on an income limit, then Deputy Reilly stated it was a desperate climbdown, that their efforts were tinkering with income limits and that it was nowhere near good enough.

The Minister, Deputy Reilly, championed Fine Gael's fair care health policy with its promise of universal primary care. The Fine Gael and Labour parties achieved a record mandate in the general election of 2011 on the basis of manifestoes which promised to greatly extend, and make universal, entitlement to free primary care. This is a laudable objective. In the Fine Gael and Labour parties' programme for Government we are told universal primary care will remove fees for general practitioner care and will be introduced in the Government's term of office. We are also told access to primary care without fees will be extended in the first year to claimants of free drugs under the long-term illness scheme at a cost of €70 million; access to primary care without fees will be extended in the second year to claimants of free drugs under the high-tech drugs scheme at a cost of €15 million; access to subsidised care will be extended to all in the next phase; and access to care without fees will be extended to all in the final phase.

The Minister, Deputy Reilly, promised the first phase, including the extension of free primary care to claimants of free drugs under the long-term illness scheme, would be in place by the summer of last year, but it was not as we well know. The explanation given was drafting difficulties because of the change from entitlement based on income to entitlement based on forms of illness. In the autumn of last year we were told by the Minister it was still on track and that there would be a Bill. Here we are today, 20 March 2013, and there is no Bill yet presenting to extend free primary care in any way whatsoever. On the contrary, we have this legislation, the Health (Alteration of Criteria for Eligibility) Bill 2013 which is designed to reduce the number of citizens entitled to free primary care under the medical card scheme.

Deputy Alex White

But not to GP visits.

Deputy Caoimhghín Ó Caoláin

The Minister for Health, Deputy Reilly-----

Deputy Alex White

Does the Deputy accept this?

Deputy Caoimhghín Ó Caoláin

We know very well what it says about entitlement to the medical card and the care this entails. We must remember it is all about health. The Minister for Health, Deputy James Reilly - I do not need to remind Minister of State, Deputy White, of the picture I painted which is absolutely accurate - has come full circle, from IMO opponent of universality for over 70s, to IMO beneficiary of it, to vociferous Dáil opponent of change to it, and now to imposing a further restriction on the scheme leading to thousands of older people losing their medical cards. This is some journey.

Again and again in opposition, the Minister, Deputy Reilly, quite rightly pointed out that restricting action to primary care was penny wise and pound foolish, because older people would suffer poorer health outcomes and require more hospital visits, inpatient care and residential nursing home care. Time after time these were his words, yet now in the very same manner as the people he condemned time and again, namely, his Fianna Fáil predecessors, he brings forward a Bill to restrict medical card access, a so-called savings measure which will undoubtedly, as the Minister believed when in opposition, adversely affect the health of our older citizens, a view I still hold.

Just as the Fianna Fáil row-back on the over 70s did in 2008, this Bill will cause confusion and distress to many older people. The question is what other categories, based on income or otherwise, are to follow. That is a valid question to ask. Heretofore we have been told that it will be the category of over 70s with an income in excess of €600 and others. Who are these others?

Already we know that the HSE is tightening up on the issuing of discretionary medical cards. I learned today of a mother with a young child who has Down's syndrome and a serious heart condition. He is entitled to a long-term illness card but also had a discretionary medical card based on medical need. The mother has now been told that her child is no longer entitled to the medical card, even though his condition and circumstances have not changed and will not change in any way through his lifetime.

Another mother with a child who has a rare condition decided not to fight what is for many a long and weary battle for a discretionary medical card. She chose instead to await the promised extension of free primary care to long-term illness patients. She is still waiting and, sadly, will continue to do so.

The main provisions of this Bill will reduce the income threshold for assessment for an over 70s medical card from €700 per week to €600 per week for a single person and from €1,400 per week to €1,200 per week for a couple. Those in the €600 to €700 weekly income bracket will be assessed for an over 70s GP visit card, as the Minister of State indicated.

This Bill does not implement the programme for Government, but rather the will of the troika as interpreted by this Government in the contents of its budget for 2013 and in the HSE's so-called national service plan for 2013. It is not a service plan but could be more accurately described as a plan for slashing services. Of the total of €721 million in cuts in this plan, a massive €383 million - not the €323 million as suggested earlier - is being cut from primary care. That is a huge cut which, in the minds of any reasonable person, makes a mockery of the Government's so-called reform programme which it claims has primary care at its centre. That incredible claim holds no water any more.

The Minister, Deputy Reilly, signed off on a plan that will deprive some 40,000 people of medical cards in 2013. How many more people will be similarly deprived thereafter as the income criteria for receiving a medical card are changed? This is a further attack on people on low incomes. In his reply, perhaps the Minister can indicate how many people the Department of Health estimates will lose medical cards as a result of this Bill. If it falls short of the 40,000 figure that has been signalled repeatedly, including in the HSE's national service plan, where will the others come from? Will they include that young child I described earlier who rightly had succeeded in securing a discretionary card based on medical need?

No doubt we will be told that the numbers of people with medical cards is increasing and is at an all time high. We are all aware of that but I understand the reasons. It is because people's incomes have plummeted with mass unemployment and a prolonged economic recession brought on, I acknowledge, by the last government and prolonged - all too sadly and despite all the promises - by the current Fine Gael-Labour coalition. Even at the current low income threshold for a medical card, the numbers are increasing. This Bill and other measures no doubt being contemplated by the Government are designed to restrict access where possible. What cards are they still holding to their chests? This is exactly the opposite of what was promised by this Government when it took office. It is nothing but a further health cutback from a Government whose health policy is in total disarray.

We still do not know what shape the Government's proposed universal health insurance scheme will take or how it is to be funded. We know it will be based on competing private, for-profit insurance companies. I find it incredible that Labour would even countenance that. Far from bringing us fundamental reform, this Government is continuing the regime of health cuts and health privatisation of its predecessors.

The other provisions in this Bill relate to cohabitants to bring the law into line with the provisions of the Civil Partnership and Certain Rights and Obligations of Cohabitants Act 2010. These are necessary and welcome. We do not have a difficulty with the other provisions in the Bill regarding the exchange of personal data information between Departments and the Revenue Commissioners, nor with the data protection provisions. These latter provisions could easily have been made in a separate Bill and are essentially extraneous to the main purpose of this Bill. They are not a neat fit. The main purpose of this Bill is, without question, to further restrict access to the medical card entitlement. On that basis, Sinn Féin will oppose the Bill's passage at every Stage.

Deputy Richard Boyd Barrett

I wish to share time with Deputy Seamus Healy.

Acting Chairman (Deputy Seán Kenny)

Is that agreed? Agreed.

Deputy Richard Boyd Barrett

I am implacably opposed to this move to erode further universal health care to the over 70s. A brass neck attitude seems to abound in this House both on the Government side and on the main Opposition party benches when it comes to this issue.

As the saying goes: "By their deeds and words you shall know them." If one was to state a case against what the Government is doing, one would not have to do more than cite the motion tabled here by the current Minister for Health, Deputy James Reilly, on 21 October 2008.

One need only consider the arguments he made against Fianna Fáil's effort to remove universal health care for pensioners, that is, for all those over 70. Indeed, what Fianna Fáil at the time was trying to do was even worse. Initially it planned to remove completely automatic entitlement to a medical card for those over 70. That was its initial proposal, which was met with utter outrage by the pensioners of the nation and many others who came out on the streets and, like the people of Cyprus, showed the effectiveness of mass protest. Within days, they had terrified the Fianna Fáil Government into backtracking on its atrocious plan to do away with automatic entitlement to medical cards. I certainly hope that in response to this effort, the pensioners will do the same again and, if they are alerted to what is going on, will come out onto the streets.

At the time, both Fine Gael and the Labour Party stood with the pensioners at the demonstrations and expressed the same outrage at what Fianna Fáil was proposing to do. Not only did they express outrage at the original drastic proposal to remove automatic entitlement for all those over 70, they also expressed outrage at the revised position Fianna Fáil adopted as a result of the protests. They, and specifically the now Minister, Deputy Reilly, asserted that even in the face of considerable backtracking on the part of the Government, which conceded that only those over the threshold of €36,000 per year would not be entitled to the medical card, this was neither acceptable nor good enough. The then Deputy Reilly then tabled a motion in the Dáil demanding "immediate reversal of the Government decision to withdraw the automatic entitlement to a medical card from citizens aged over 70". He made the point that his policy and that of Fine Gael was there should be universal entitlement. He made this point without qualifications or buts or thresholds or eligibility criteria. He stated there should be universal entitlement to medical cards for all those over 70 and that "Fine Gael supports the policy of universal health care for all". While I will quote further from his contribution in a moment, the Minister for Justice and Equality, Deputy Shatter, stated: "To suggest that an individual with €36,500 gross is among the super rich is such a warped view of income as to defy understanding." The threshold that Government proposed was €36,000 but yet the current Administration proposes to reduce it to €31,000. I will quote further from the Minister, Deputy Reilly, who, commenting on the motion he tabled, stated:

The principle is simple; universal health care for everyone over the age of 70. Those are the people who made this country... They raised us, nursed us when we were sick, protected us from violence, grew our food and ran a proud Civil Service. Are we to repay them by taking away something which was freely given?

He continued that "with the loss of their medical cards, many of those affected... may not take their medicines regularly. If they end up in hospital as a result, one day’s care will negate any saving made to the Exchequer". He stated that "for the sake of €20 million", which is the same figure this Government projects will be saved by the measure under discussion, "we are sacrificing the principle of universality in health care for the over 70s". He then asked, "What is next?", thereby pointing to the slippery slope once one begins down this road. He stated:

It makes no sense to remove the medical card from the over 70s. It is important to point out that the removal of the card is in direct contradiction to the stated aim of the Minister... of supporting people at home and in the community, thereby avoiding hospitalisation.

One really could not put it any more clearly and he was absolutely right. I have nothing to add to that but this measure is an utter betrayal of those words. It reveals those words to have been hollow and cynical and as another ruse to fool the people. It was a ruse to fool the pensioners and to gather in the votes of those who rightly took to the streets against the outrageous plans of Fianna Fáil to take away their automatic entitlement to medical cards. It was a case of cynically saying what those people wished to hear before going into government to do the exact opposite. Moreover, the Government is doing even worse than the action to which Fianna Fáil fell back as a result of those protests. It really is outrageous and as I have indicated in the aforementioned quotes, someone who is earning more than the threshold being proposed, namely, €31,000, was not super rich. Such people were nurses, doctors or teachers, that is, ordinary people and there should be no threshold which would debar them from automatic entitlement to a medical card.

In response to all these points, Members opposite of course will note that they will get a GP visit card, which mitigates against the unfairness and injustice and many of those points the Minister, Deputy Reilly, rightly made at the time. However, even if one gets a free visit to a GP, one still may be obliged to pay out a lot of money for medication and for items such as 'flu vaccines, public health nurses, community nurses, hearing aids, physiotherapy, dentistry or services for one's eyes, namely, for all those items that people are far more likely to need as they move into their elder years. Moreover, all those items are before one counts the possible costs of ending up in hospital. This was the point the Minister, Deputy Reilly, made himself at the time. It is the point he made to Fianna Fáil when its members referred to the thresholds in an effort to justify them. He noted there were significant potential costs for elderly people, above and beyond the cost of going to a GP, and, therefore, there should be no question of eligibility criteria, thresholds or anything else but it should just be a straightforward and simple principle in respect of the people over 70, who have made a massive contribution to the State. As the Minister then pointed out, the generation to which I refer are those who paid 60% tax for most of their lives and who were obliged to put up with interest rates of 15% on their mortgages. This generation has already made significant sacrifices but now the Government intends to ask them to pay again and to take away this entitlement, which they deserve richly as a reward for the lifelong contribution they have made to the State and society. However, the Government intends to take that away from them, which is absolutely outrageous. As the Minister, Deputy Reilly, pointed out at the time, what next? Once one takes away the principle of universality, he asked, "what is next?" We are on the slippery slope. At the time, he asked about the €20 million in savings and I must read out this classic quotation on the savings. He stated "Some €20 million, and much more besides, could have been secured from the bankers who got off very lightly." He went on to state:

An additional €100 million or €200 million from that source would not have gone astray. Instead, however, the Government went after the elderly whom it perceived as the soft option.

This is extraordinary as one simply could not put it better, more succinctly or more accurately. Was he right then or was he simply playing people?

Was this just another cynical trick pulled on the elderly in this country or did he mean it? There is no doubt that his words were correct, yet now he has simply torn up those promises. That was a promise. Fine Gael and the Labour Party said that their policy was universal entitlement to all health care, and all costs of health care, for all pensioners. They put down motions to that effect in the Dáil. That was a promise to the people of this country whose votes those parties were seeking. Then they go and do this to them, the exact opposite of what they said, and try and justify the very things they railed against when in the Opposition. That type of stuff is not just a cruel kick in the teeth for the pensioners of this country, but it has brought politics into disrepute. The reason people are so utterly alienated from the political system is that politicians think it is okay to play fast and loose with the truth and with their supposed principles, manifestos and so forth to cynically secure votes and then just abandon those policies completely and do the reverse. Really, it is shameful.

Incidentally, the Minister, Deputy James Reilly, went further at the time. It was not just pensioners. He said: "My personal belief is that once Irish citizens [not just Irish citizens over 70 but all Irish citizens] have adequate food, clothes on their backs and roofs over their heads, they should be entitled to proper access to health and education regardless of their status, creed, race or religion." That is absolutely right. However, now we are establishing eligibility criteria for pensioners and reducing the eligibility and rights of those pensioners. It is not just all the citizens that the Minister referred to, but the pensioners. It is simply unacceptable.

How does it make sense to do this against the background of this Government having committed itself to universal health cover and free general practitioner care for everybody? I do not understand how it can square this, and all for €20 million. At that time the Members opposite asked the Fianna Fáil Government about the €20 million which it said it would save through that measure. That Government could never show the savings. Can this Government show the savings?

Deputy Alex White

We are not removing the GP visit card from anybody.

Deputy Richard Boyd Barrett

No, but the Minister is saying that the saving that will result from changing the eligibility criteria will be approximately €20 million. The Fianna Fáil Government used the same figure at the time as a result of reducing the income to €36,000. The Minister is saying that reducing it from €36,000 to €31,000 will save €20 million.

Deputy Alex White

I will get the numbers for the Deputy.

Deputy Richard Boyd Barrett

Coincidentally, it is the same figure. The Minister condemned that Government for that-----

Deputy Alex White

It is €12 million this year.

Deputy Richard Boyd Barrett

It is even less.

Deputy Alex White

It is €24 million in a full year. I am not chiding the Deputy, just drawing his attention to the figure.

Deputy Richard Boyd Barrett

I have no problem with that. The figure is about the same as the saving that the then Government claimed, and the current Minister, Deputy Reilly, railed against it. He told that Government that it was doing away with the principle of universal health care for the sake of a miserable €20 million, which it could have got from the bankers. Now, this Government is doing the same thing. It is an utter betrayal of the principles the parties in this Government expounded, and there is no justification for it.

I hope the pensioners will rise up against this. We will oppose the Bill, but words in this House seem to count for little, whether one is in opposition or in government. The only thing that made any difference on the last occasion was the fact that the pensioners took to the streets and forced Fianna Fáil to backtrack. I suspect the only thing that will force this Government to backtrack on this attack on the concept of universal provision is doing the same thing.

What is the alternative to this? It is what the Minister of State, Deputy White, and the Minister, Deputy Reilly, said at that time, universal health provision. How should it be funded? This is the same argument as applies to the issue of removing child benefit. If the aim is to take from those who can afford it, it should not be done at the price of the principle of universal health care. The same amount of money, indeed much more money, could be raised through having higher levels of taxation on higher earners. The Government could achieve in a fairer way the savings or the extra revenue it seeks without sacrificing that critical principle, which the Minister upheld until he took office. I appeal to him not to betray yet another principle. There cannot be another principle that is more important than the principle of universal health care, particularly for pensioners and the elderly who have contributed and done so much and who deserve to be rewarded with at least the security that they will be looked after and all the costs of their health care will be provided.

I hope the Minister will reconsider this, but I doubt it. Nevertheless, hope springs eternal.

Deputy Seamus Healy

I object and draw attention to the manner in which this legislation has been brought before the House. It was published late last week. Deputies scarcely had time to read the legislation and certainly did not have time to consider it properly or to consult with stakeholders. The Minister and the Department were absolutely unreasonable in the manner in which this legislation was put before the House. We were told that the last general election was a democratic revolution. Any revolution is based on information. It is another U-turn on the part of this Government that it would bring legislation before the House at such short notice, giving both Opposition and Government Deputies little or no time to consider or consult about it. It is absolutely outrageous behaviour and is, again, another U-turn by the current Government.

Deputy Boyd Barrett outlined the history of the hypocrisy surrounding this issue on the part of the Minister, Deputy Reilly, the Minister for Justice and Equality, Deputy Shatter, and others. Everybody also recalls the grandstanding and outrage of the Leader of the Labour Party at the time, the Tánaiste and Minister for Foreign Affairs and Trade, Deputy Eamon Gilmore. He did his usual grandstanding and outrage act in the Dáil. Now there is a U-turn on that. It is a fact that both the Tánaiste, Deputy Gilmore, and this Government have again reneged on the positions they held and promises they made in that election and, indeed, in the programme for Government. Politicians, politics and political parties are being brought into disrepute on a daily basis because solemn promises and commitments made to the electorate in the course of a general election are being reneged on.

Young people can no longer trust or believe statements made by politicians.

The Minister of State trotted out the old, dishonest argument that cutbacks are needed. It is especially dishonest of the Labour Party to make this argument which must be rebutted at every opportunity. The Government continues to have choices. This is a very wealthy country, with significant numbers of wealthy individuals who do not pay their fair share of taxation. In recent days, we learned that the chief executive officer of the Bank of Ireland receives an annual salary, excluding additional payments, of approximately €690,000. Last week, the Minister for Finance informed me that 10,000 individuals have a combined income of almost €6 billion per annum, giving an average annual income of €595,000. Moreover, a further 20,000 individuals have a combined annual income of €8.742 billion per annum, giving an average income of more than €400,000. These extraordinarily wealthy people do not pay their fair share of taxation, yet the Government refused to impose any tax increases on them in the previous budget. We were told the Labour Party was prepared to walk out of government on this issue, but it did not do so. Even if we were to take 10%, 15% or 20% of the incomes of the wealthiest individuals in Ireland, they would remain extremely rich.

The Central Statistics Office informs us that the top 5% of earners made a profit from the recession, both in terms of income and assets. Last Sunday week, the Sunday Independent reported that in the past two years the richest 300 individuals in the country had increased their wealth from €50 billion to €66 billion. Despite this, we do not have a wealth or asset tax. There are, therefore, choices. We could, for example, take on the rich and powerful and properly tax their income, assets and wealth to properly fund the health service. The Government, specifically the Labour Party, should have made this choice.

On the basis that it expounded a policy of universality and free general practitioner care for all during the general election campaign, people expected the Government to introduce a Bill to implement its policy commitments. We could have at least expected it to implement some reasonable measures, for example, the provision of free general practitioner cards for people with long-term illnesses. The Government told us such a scheme would be in operation by June 2012, yet there is no sign of the relevant legislation. It is clear that legislation to reduce eligibility can be introduced at the drop of a hat, whereas there is always a problem with drafting or some other aspect of legislation when one wishes to extend eligibility.

In addition to a provision implementing its promise to introduce free GP visit cards for people with long-term illnesses, we could have expected the Government to abolish prescription charges given that it was ostensibly opposed to the charge when it was introduced. Rather than abolish the 50 cent charge, however, it chose to increase it to €1.50 per item. It now costs people in poverty, including those on an income of €188 per week, up to €19.50 per month for medicines.

We could also have expected income limits for medical cards to be increased given that they have not increased since 1 January 2006. The only reason for the large increase in the number of medical cards issued in recent years has been the increase to 430,000 in the number of people who are unemployed and, as such, automatically entitled to a medical card.

The current income limits for medical cards are out of date. A person with income in excess of a social welfare payment will not be eligible for a card. For instance, the current limit for a single person aged up to 65 years is €184 per week, which is below the minimum social welfare rate. The figure for a married couple is €266.50, which is also below the social welfare rate. One would have expected the Government to increase these income limits.

Members, in particular, members of the Joint Committee on Health, have consistently made the case to the Minister and Health Service Executive that people suffering from serious illnesses such as cancer should receive a discretionary medical card. Prior to the centralisation of the medical card system, people with serious illnesses were able to obtain a discretionary medical card. Unfortunately, that is no longer the case. I am informed that applicants in this category have been told the only way they will obtain a medical card is if their general practitioner certifies they are terminally ill, which is outrageous.

I ask the Minister to consider the issues I have raised. We expected and should have been given some amelioration of the position in regard to the issues to which I have referred.

Deputy Liam Twomey

A previous speaker indicated that the legislation is rushed and stakeholders were not given an opportunity to discuss it. This is a pity because no mention has been made of the ongoing debate outside the House on the issues of eligibility and universality.

Instead, we have heard tit-for-tat commentary, point scoring and remarks about what the Minister, Deputy Reilly, stated or did not state. Were we to hold this debate up to ourselves like a mirror, we would see that we did not have much to say about future eligibility and entitlements.

I expected the figures to be discussed further. Some 42% of patients over the age of 70 years have private health insurance, 47% of patients under the age of 70 years have private health insurance, 90% of patients over the age of 70 years have medical cards and 36% of patients under the age of 70 years have medical cards. Approximately 70% of people aged less than 70 years must pay for their own health care costs. Surely the House should debate this issue. People with young families are not being looked after as they should be, yet this debate has been focused on people aged over 70 years.

For this reason, primary care reform is important. Not only must we continue to look after the health care needs of elderly patients, but we must make resources available to those under the age of 70 years to prevent the types of health problems that have exploded in recent years. When I qualified as a doctor 20 years ago, the issues of obesity, diabetes, blood pressure, cholesterol and a lack of exercise were discussed, but they were not central concerns. Now, some schoolchildren are significantly obese. The cholesterol plaques that lead to heart disease begin to form in one's teenage years. We will see an explosion in the incidence of heart disease among younger people. Diabetes is being diagnosed in people in their 30s and 40s. Some 20 years ago, cases were only seen in people in their 50s and 60s.

More people need medical cards and should be able to access general practitioner, GP, services, yet we have not held a discussion on eligibility for health care services or on universality. We should not be discussing elderly people alone. We must debate the available resources. There is no point in discussing what we should be doing in terms of health or education without referencing the available resources or how resources can be shifted. To do so would be to continue with our silly arguments and tit-for-tat rubbish. It is easy to see why no one has any interest in paying the House's proceedings attention, given the ráiméis that I have had to put up with in this debate.

Deputy Alex White

Hear, hear.

Deputy Liam Twomey

Many resources are aimed at people aged over 70 years, but no one has suggested giving a medical card to every child under the age of five years. What about the young parents who are unsure about whether their children are sick because the latter cannot express what is wrong with them? No one believes that there is a need to discuss such people. Sinn Féin has its usual approach - give everyone whatever he or she wants.

If anything has come through in this discussion, it is the fact that a blatant political stroke was pulled when a medical card was given to everyone aged over 70 years without there being any policy to support the move or any view of what the ideas of eligibility and universality constituted in a health care, educational or other setting. We are now hearing the usual commentary that we heard during the past decade, for example, whether that measure was right. It does not matter.

No one has mentioned the suggestion of a patient safety authority. Most democracies have such authorities. We are in the process of developing one. I raised the issue a number of years ago. The former Minister, Ms Mary Harney, established a commission to get the idea off the agenda. The current Minister, Deputy Reilly, is considering the idea seriously. Such an organisation would look after patients.

Much of what has been mentioned about the Minister being able to change eligibility and universality under this legislation is not technically true. It is a question of how these parts of the legislation work. After a bad week, the Minister will not change everything on a whim or because someone annoyed him. We need a better approach, for example, a patient safety authority. Such an approach would work. For example, the Mental Health Commission has revolutionised how the health service perceives patients with mental health issues. It has removed the paternalistic view that the doctor always knows what is best for people with mental health issues. Those people know their illnesses well, but they are also vulnerable. The commission has made a difference.

If we are to be progressive in how we manage health, we should establish a patient safety authority that would consider questions of eligibility for accessing services. The medical card is not just about GP care. It also determines whether a person gets to see a public health nurse. One's entitlement to a range of services is automatic when one has a medical card. If one does not have a medical card, one is not entitled. For example, if a retired schoolteacher happens to have some savings and presents to me for bad leg ulcers, getting a public health nurse to see him or her is difficult, as he or she is not entitled to that service. We should discuss issues such as this and determine how to move them forward.

Maternity care is a free service for every woman. One is entitled to free GP and hospital care while one is pregnant and for up to six weeks after one's child is born. If we are really discussing how to move the concept of eligibility onwards, let us consider extending this service in the next budget so that the child is protected for up to one year after birth. In the following budget, change that to two years. In the subsequent budget, change it to three years.

Let us start considering what "universality" means. We can put income limits on that provision if, for example, the view is taken that Deputies with young families are too prosperous to have it extended to them, but we should consider how to provide services for everyone else in society.

All of the commentary in this debate has been reactive on the issues of the elderly, people with long-term illnesses and the Minister's remarks a number of years ago. Nothing new has been added to our considerations. The parties' representatives should meet the many societies that are considering this issue and are suggesting that legislation should be put in place to underpin service delivery for patients, albeit not necessarily free GP care for everyone. We should consider what we can do for our citizens at all times.

I hope that the economic crash of recent years will be a blip in our history. It will not crash like that again, 250,000 people will not become unemployed in the course of a few years and 600,000 husbands, wives and children will not need medical cards because a Government made a royal mess. If we debate matters now, put certain principles in place and underpin universality, we could build year on year. I had hoped that ideas such as this would be discussed during this debate.

We know what will occur in terms of primary care. I am not privy to what the Minister or the Minister of State, Deputy White, think on this issue, but I have a fair idea about how primary care works. GPs will be paid less to look after more patients. There is an expectation that practice nurses and other health care professionals will do more primary care work and that GPs will have an overarching role in patient care. There will be greater co-operation and, I hope, value.

Primary care teams and primary care buildings are not the only solution to making primary care work. They are an expensive solution and other options are available. The 300 additional health care professionals who have been promised are vital, particularly because deficiencies have been identified in certain areas. The HSE failed to provide universal health care. Universality does not mean that everyone should have everything. Rather, it means that we should all have the same chance in light of the level of resources that are available. County Wexford should have the same number of speech and language therapists as County Galway. We should have the same level of occupation therapists as County Waterford. That there are seven times more occupational therapists in County Waterford than there are in County Wexford is amazing, given the fact that it is just across the river from us. The HSE failed to do what it was supposed to do.

That was a strong criticism of it. Even though I was very critical of the HSE I am aware it developed its corporate memory and corporate structures to the extent that it was managing to work better than was previously the case.

The Minister of State, Deputy Alex White, is very much in favour of the collation of information. A significant amount of information is generated in primary care. With few changes the Department of Health could access the information. At this stage 90% of general practitioners are computerised. All payments should be made on the Internet. Disease coding should be introduced and applied to every single patient. A chronic disease management programme should be introduced for patients. That would require a new contract with GPs but that is not impossible and has been done previously. There is no reason why it could not be done again. We would get a tremendous amount of information were such a system to be introduced. We could identify pockets of the country where health needs are greatest. We would know about the prevalence of heart disease, diabetes and obesity instead of assuming we know, having the HSE second-guessing or spending large amounts of money to find out such information. The information would be readily available from the 22 million consultations carried out by GPs every year. We are not collating the information in the way we should.

The Minister of State, Deputy White, visited the Caredoc service in County Carlow to see how such a system works there and how the health service could be run like any other business. The service does not need to be erratic or all over the place. One can identify trends in health care but we are not collecting the information. That would add hugely to how we make decisions on eligibility and make medical cards and other services part of universal health care. That is the type of thinking and discussion we should have in the Chamber. That discussion is happening outside of the House. Instead we get nonsense about who said what, who did this and that and who did not do this or that. That is a pity. The argument about private health insurance and what went wrong with it in terms of community rating dates back to 2006 and a court case BUPA took to Europe about the initial legislation that was introduced. We must acknowledge that the issue is tricky and difficult to work out.

Prescription charges were raised and comments were made about the Government being uncaring. I read a report concerning a call by the Irish Pharmaceutical Union for its members to collect drugs its patients had not used that were out of date and lying around in cupboards in people’s homes that should not be there. The campaign was run for three months and three tonnes of unused medication were collected. It would save a significant amount of money if we had a better system of monitoring drug use, patient compliance with taking medication and prescriptions were not given out willy-nilly that are not necessary and are going off in cupboards at home. Rather than having a bog standard political debate about the Government increasing charges and Members quoting back what Government party members said four years ago, let us examine whether there is another way to improve compliance by talking to patients about how to make the system work. That would reduce our drugs bill and thereby reduce the approximately €300 million worth of cuts we must make in the primary care system this year. It would also reduce the €2 billion we spend on primary care. A remark was made by a Member of the Opposition that the €2 billion spent on primary care was just fettled away. A good service is provided. However, it is true that a significant amount of waste is still ongoing in the way medication is used in primary care and the hospital system. A remarkable amount of waste is evident in how we deliver health services to patients. When I began in general practice I had no practice nurse and one secretary. A significant amount of the work I did then is now done by the practice nurse. That change has taken place in a considerable number of general practices so even though there has not been a significant increase in the number of GPs in recent years there is still an increased amount of throughput in general practices because of the improved system of organisation.

If hospitals were to organise themselves as well as the primary care sector significant savings could be made there also. That is not to say there is not scope for further efficiencies and a better use of the expertise of doctors and nurses in primary care, which is still to come. The debate in which we should engage in the House is how we can make the primary care system work better. If we make the necessary changes to primary care it will reduce the amount of cuts that are required elsewhere. We must be efficient in what we do. Some efficiencies are driven by the hospital sector and others are caused by it. Some of the efficiencies were based on a protocol on how patients should be X-rayed so as not to waste X-ray resources. Equally, we could introduce protocols on how we take routine blood samples from patients so that we do not just take a blood cholesterol test because a patient has not turned up for six months or that we carry out a full blood count, FBC, test because a patient looks a bit pale from a hard weekend in Galway. There is a need to examine how we can make the health service work. If we do that it will improve our opportunity to provide more services for patients and possibly at no cost. That is how a free GP care service will be delivered over a number of years.

I accept legislative issues require to be dealt with, but the issues that exist in primary care have not been examined either by this House or any political party. I hear much about the need for free GP care and suggestions by the Opposition on what we should do but nobody has set out a structure for how that is to be achieved. Nobody has provided an action plan. Both the Minister, Deputy Reilly, and especially the Minister of State, Deputy Alex White, share a desire to understand how the system works and to roll out an action plan to make it work. That must be the focus of the debate in this House. In so doing, patients will say we are relevant to what happens in their lives. I urge Members to steer clear of what has passed for debate in the past hour and a half.

Deputy John Browne

I welcome the opportunity to speak on the Bill. I listened with interest to Deputy Twomey, who is also a doctor. I agree with many of the issues he raised, in particular about home help, community nursing and primary care centres. However, I am not in favour of many of the measures being introduced by the Minister. When he was on this side of the House he was critical of what Fianna Fáil did in power. I will not spend my time criticising the Minister, Deputy Reilly, who has done so many U-turns that he has gone beyond criticism.

I wish to bring to the attention of the Minister of State, Deputy White, the issues that require attention. Older people have suffered dramatically in recent budgets due to cuts in ESB allowance, fuel allowance and to many other areas that affect them. Many organisations representing older people are concerned that the Minister is implementing changes to medical card eligibility without any discussion with stakeholders. It is important that the Minister would engage with groups such as Older & Bolder which wish to support and assist him with ideas and suggestions on how to save money without implementing the cuts proposed by him in certain areas.

One area that should always be exempt from cuts to medical card eligibility is cancer care. On a number of occasions in recent months we raised issues relating to cancer patients not being granted medical cards. Serious discussion is required on the issue. Many cancer patients cannot afford their disease treatment and others use their entire savings to pay the associated costs of treatment. Cancer should be treated as a chronic disease in the same way as multiple sclerosis, MS, and other long-term illnesses.

As we know, when people are suffering from cancer it can cause many problems within the home. In many cases people have to hire in home help and child minders to take care of their children. They also incur enormous costs travelling to and from hospital for treatment. In some instances, their spouses have to spend time at the hospital too, paying for overnight accommodation and so forth. I ask that discussions take place with those involved in the treatment of cancer to ensure that it is easier for cancer sufferers to get medical cards. In fairness to the HSE, it must be said that those dealing with medical card applications try, where possible, to help those with cancer to acquire a medical card. However, the delays that sometimes occur can result in major burdens being placed on families.

I do not know what the Minister intends to do with the savings to be made from these changes. This Bill has been rushed in but reference was made to a saving of €12 million for the latter half of this year and €24 million in a full year. Will some of that money be diverted to the home help service, which is particularly important for older people? In Wexford there is no money available for additional home help hours and we are only in March. I was told at a recent meeting with the HSE that a new applicant will only be given home help hours if an existing service user dies or has his or her hours reduced. This is an area that merits serious examination. It is a matter of grave concern that in the month of March there is no budget for home help in Wexford and I am sure it is the same in many other counties.

Deputy Twomey mentioned nurses in the community and perhaps Deputy White could lean on the Minister for Public Expenditure and Reform, Deputy Howlin, to consider releasing community nursing from the current recruitment embargo. Community nursing is very important in terms of keeping older people in the community and out of long-term care or hospital. However, in every area of Wexford - I am sure it is the same in other counties - there has been a reduction in the number of public health nurses. As a result, the remaining nurses are not in a position to provide the services that are needed. Deputy Twomey alluded to that and the fact that people are finding it very difficult to get public health nurses to call to their homes. When older people are discharged from hospital, they are not getting the after-care they need because of the scarcity of public health nurses in the system.

I have a problem with primary care centres. Many doctors have upgraded their practices in recent years. Others have amalgamated with colleagues and provided their own one-stop-shop for health care. There are often two or three doctors, a nurse and other trained medical staff. In many cases, doctors have provided their own primary care centres without any Government support and in that context, I am not sure that we should be wasting money on the provision of primary care centres. Furthermore, in some areas, doctors are not one bit interested in getting involved in public primary care centres. They want to stay in their own upgraded practices.

I could say that this Bill is shameless, scandalous and that these changes should not happen but they will happen because the Government has a majority. This Bill will be passed and the number of medical cards will be reduced. In that context, I wish to focus on what will happen with the money that is saved. There was uproar recently with regard to the withdrawal of the mobility allowance for people with disabilities. I ask the Minister of State to use whatever influence he may have to ensure that the mobility allowance is restored to people with disabilities as quickly as possible. I know there is a four-month window but many people with disabilities are worried about what will happen at the end of that period. It is important that funds be restored immediately to that particular area to ensure the continued independence of people with disabilities. There are approximately 200 families in Wexford who will be affected if nothing happens at the end of the four months. I am hopeful that the Minister for Health and his Ministers of State will have enough sense and concern to make sure that people with disabilities have their mobility allowance restored.

I have written to the Minister a number of times about a practice which the Minister himself has said should not be happening but which is continuing to happen, namely, doctors charging medical card patients for blood tests. Charges range from €10 to €20. The Minister has told me that this is not allowable under the GMS rules but I know of doctors who are charging their patients. Doctors should be brought to heel in this regard. If they are not entitled to charge for blood tests for medical card patients, they should not be allowed to do so. The practice is widespread in my own county and it is important that it is dealt with forthwith.

I am concerned that the Bill gives the Minister for Health the power to further decrease the income thresholds for medical card eligibility without Dáil approval. In the past, the Minister for Health had to have Dáil approval for changes to income limits and could only increase, rather than decrease, the income limits. This Bill puts the Minister in a very powerful position whereby he or she can reduce the income limits for medical cards whenever he or she feels like it. If the Exchequer is not meeting its budgetary targets for 2014, will the Minister just decide, with the stroke of a pen, to further decrease the income limits for medical card eligibility?

Another area of concern is the data exchange agreement between the HSE, the Department of Social Protection and the Revenue Commissioners. The Revenue Commissioners are becoming the most powerful body in the State. They cause havoc for people in the area of revenue and have recently been given responsibility for the collection of the property tax. Revenue will now also be providing information to the Department of Health on people's incomes. I ask the Minister to explain how this will work and how any data protection concerns will be addressed. What discussions, for example, have taken place between the Department and the Data Protection Commissioner? I am concerned that so much information will be shared and exchanged and I believe that, at the end of the day, older people will suffer as a result.

I am opposed to this Bill in principle but recognise that it will be passed whether I like it or not, because the Government has a majority. However, I would like to see the moneys saved being spent on the areas I have referred to and, in particular, on elderly people. If older people are going to suffer cuts in one area, I would like to see them benefit in other areas. They have already felt the effects of the trebling of prescription charges, the sharp reduction in the income thresholds for the over-70s medical card and the reductions in the value of their household budget packages, all of which is having a serious impact.

I could read out all the things the Minister for Health said in 2008 when he was in opposition, when thousands of people were on the streets protesting about the reduction in the income thresholds for medical cards for those over 70. I will not do it because it might embarrass Deputy Reilly, although he is not easily embarrassed. He did a lot of jumping up and down and that stage, saying the then Government was callous, uncaring, a disgrace and so forth.

The Minister has made great play of the fact that generic drugs will become much cheaper but the cost of such drugs in Ireland is a scandal.

I got a prescription recently that was filled with a generic drug but when I compared prices, the saving in purchasing the generic drug over the branded drug was €1.20. The Minister of State should take that on board and tackle the companies providing generic drugs in this country. The cost of these drugs is way above the cost in England, Spain and other European countries, and we should consider why that is so.

People with disabilities who were in receipt of the mobility allowance should be the priority for the Minister of State, Deputy White. The Government must restore their funding within the four-month timeline set out by the Minister.

Deputy Peter Fitzpatrick

I wish to share time with Deputy Bernard Durkan.

Acting Chairman (Deputy Thomas P. Broughan)

Is that agreed? Agreed.

Deputy Peter Fitzpatrick

The Health (Alteration of Criteria for Eligibility) Bill 2013 seeks to reduce the income limits for medical eligibility for people over 70 and introduce new measures for data sharing between the HSE and the Department of Social Protection, as well as the HSE and the Revenue Commissioners. Overall, nearly 43% of the national population has free access to GP services under the general medical services, GMS, scheme. As of 1 February 2013, there were 1,855,797 medical cards, equating to over 40% of the national population, with 130,301 GP visit cards, representing nearly 3% of the population. Expected activity in 2013 with regard to medical cards and GP visit cards reflects a Government commitment to address rising costs in the medical card scheme and to rebalance medical cards. It also takes account of the roll-out of GP care without fees, as promised by the programme for Government. The expected total number of medical cards at the end of 2013 will be 1,921,245, with the expected total of GP visit cards at the end of 2013 at 265,257.

This Bill will reduce income limits for medical card eligibility for people over 70 to €600 per week or approximately €31,000 for a single person, or €1,200 per week or approximately €62,000 per year for a couple. Those who lose medical cards as a result of this will become eligible for a GP visit card and the HSE will also meet prescription drug costs in excess of the drugs payment scheme threshold of €144 per month. There are approximately 370,000 people over 70 in the State and approximately 360,000 medical cards issued to people over 70, giving medical card coverage of approximately 97%. In comparison, the medical card coverage of those under 70 is approximately 35%. This policy change will leave approximately 92% of the existing medical card holders over 70 unaffected, with approximately 20,000 medical card holders over 70 continuing to receive free GP services instead of a medical card.

The changes proposed in this Bill will happen in the context of a broader health service reform, including the phased introduction of free GP care for all and the introduction of universal health insurance, planned for 2016, which will effectively end the two-tier health system. The Bill allows for data sharing between the HSE and the Department of Social Protection, as well as the HSE and the Revenue Commissioners. The Bill includes provisions for sharing of personal and sensitive data between the bodies for the purpose of assessing and reviewing eligibility, entitlements and liability for taxes and charges. The Data Protection Commissioner must be consulted before data can be shared.

The legislation also proposes to change the manner in which those over 70 who have obtained separation are assessed for eligibility. Those separated over 70, although legally married, will be assessed as a single person. Their assessment will also take account of any maintenance payments. The proposed approach is similar to that used by State bodies like the Revenue Commissioners.

Acting Chairman (Deputy Thomas P. Broughan)

Deputy Durkan has 16 minutes.

Deputy Bernard J. Durkan

Some of that will be used tomorrow. I am glad to have the opportunity to speak to this important legislation. It is particularly distressing for any Minister to have to introduce cuts in health services for older people, and any cut is always felt by this vulnerable group, which is more prone to illness. That is understandable. The Minister and his Minister of State, Deputy White, are clearly very conscious of that. Nevertheless, it should not go unnoticed that the number of medical card holders expected at the end of this year will be 1.9 million, as opposed to the current number of 1.8 million.

I have listened with interest to the heart-wrenching allegations of hardship from the Opposition all evening but I do not understand the comments. This is a corrective measure within the system to try to make the budget meet requirements that will be greater than they were in the year gone by: it is about being able to pay for services until the end of the year. The expected number of GP visit cards being used at the end of 2013 will be 265,000, as opposed to the current figure of 130,000.

I am not sure where the outrageous indignation that has been expressed by some parts of the Opposition in the past hour or so has come from. We are all aware of how difficult it is for people to function now. This Minister of State and others must be watching with incredulity nevertheless. In the past two years, the total cost of motions proposed in this House by the Opposition would have had a total cost of between €12 billion and €15 billion. That would be on top of the current budget deficit of between €12 billion and €15 billion. The grandiose proposals, which appeal to the hearts and minds of the people, would only double our current budget deficit. Nevertheless, it was never mentioned in the House that those actions would create more hardship for the people, including those who currently have medical cards but who would lose them if we continued on that way.

There was a time when the Opposition would be asked what to do but that seems to have gone by the wayside and nobody seems to ask that question now. Those opposite only seek more spending, and not one person from the Opposition has put forward a single proposal to raise revenue. They are only appealing to the public and arguing that everything is all right because we can get more money from banks or another group of individuals. They want to pour more money on so-called troubled waters. It is about time to be honest with the people of this country and we must tell them how it is. When those opposite were in power there was a promise to extend medical cards to everybody over 70. That promise was made just before an election, and such statements served their purpose.

Debate adjourned.

Dáil Éireann debate - Wednesday, 20 Mar 2013

Health (Alteration of Criteria for Eligibility) Bill 2013: Second Stage

Dáil Éireann debate -
Wednesday, 20 Mar 2013