Discretionary Medical Cards: Motion (Resumed) [Private Members]

The following motion was moved by Deputy Billy Kelleher on Tuesday, 8 October 2013:
That Dáil Éireann:
notes that:
- the number of discretionary medical cards fell from 80,524 at the start of 2011 to 63,126 at the end of 2012;
- in the first seven months of 2013 there was a further reduction of 8,142 such cards to 54,984, a monthly average reduction of 1,163;
- the Health Service Executive, HSE, set a target for 2013 to reduce the number of discretionary medical cards;
- this deliberate targeting was approved by the Minister for Health in the 2013 HSE service plan; and
- the targeted reduction to 55,328 in 2013 has already been exceeded;
agrees that the discretionary medical card is essential for those with serious illnesses, the treatment of which can cause major financial hardship;
deplores the decision to deliberately target people in clinical need of such cards;
and calls on the Government to:
- discontinue the targeting of those with discretionary medical cards; and
- ensure that no one in clinical need is denied such cards where it can cause significant financial distress.
Debate resumed on amendment No. 1:
To delete all words after "Dáil Éireann" and substitute the following:
"notes that:
— there has been no change to the manner in which discretionary medical cards are awarded;
— there is no target set in the Health Service Executive, HSE, national service plan to reduce the number of discretionary medical cards;
— of the 24,000 reduction in discretionary medical cards from the start of 2011 to July 2013 almost 23,000 of these persons have been awarded medical cards on the basis of their financial means;
— the HSE has produced national assessment guidelines to provide a clear framework to assist in making reasonable, consistent and equitable decisions when assessing applicants;
— these guidelines facilitate the application of discretion by decision makers in responding to the needs of the applicant when additional or exceptional circumstances exist;
— the Health Act 1970, as amended, provides that persons who ‘are unable without undue-hardship to arrange general practitioner’ services for themselves and their family qualify for a medical card;
— in accordance with the Health Act 1970, as amended, the assessment for a medical card must ‘have regard to the overall financial situation’ of an applicant and dependants; and
— the centralisation of the processing of medical cards at a national level, rather than at a local level as was the case before mid-2011, facilitates the assessment of applicants for medical cards in a consistent and equitable manner;
commends the Minister for Health on directing the HSE to set up a clinical panel to assist in the processing of applications for discretionary medical cards, where there are difficult personal circumstances;
further notes that:
— between mid-March 2011 and end-August 2013, the number of individuals who had eligibility to a medical card increased by 214,244, some 13 per cent, to 1,863,062; and
— the HSE is facing significant challenges in 2013 and in 2014 given the need to set expenditure levels within the parameters of the national recovery plan; and
acknowledges:
— the significant reductions in financial and staffing resources which the health sector has experienced over the last three years; and
— the range of measures being actively progressed by the HSE to manage its financial resources to ensure that services are provided to persons entitled to receive them; and
commends:
— the Minister for Health and the Government on providing resources to meet the increase of over 200,000 medical cards since March 2011;
— the Minister on the passing of legislation to abolish restrictions on general practitioners wishing to become contractors under the medical card scheme;
— the Minister on the implementation of legislation to achieve savings under the medical card scheme through the use of generic drugs and reference pricing; and
— the Minister on the savings being made in the cost of drugs for the medical card scheme through negotiations with pharmaceutical drug suppliers."
-(Minister of State at the Department of Health, Deputy Alex White).

Deputy Catherine Murphy is in possession and has two and a half minutes remaining.

I would like to change the sharing arrangement as Deputy Halligan will not be here and I would like to share the timeslot with Deputies Finian McGrath and Tom Fleming.

There are ten minutes remaining in this timeslot.

I am pleased that this motion is on the agenda as it is timely. I want to highlight two cases as doing so makes the case for this motion better than any other way of dealing with matters. The first case relates to a young man in his mid-30s who is married and has two children. He is working. He is on an interest only payment but is working with the bank to restructure his mortgage and, hopefully, he will get a split mortgage, but that issue is stressful for him. Unfortunately, this young man has kidney disease and is avoiding dialysis by virtue of a concoction of medication that he is taking. When I met him about 18 months ago regarding this issue he had been assisted by his family in meeting some of his bills, his mortgage and the cost of his medication but that could only continue for so long. It was after he had run out of rope that he came to see me. It may be easy to say that nobody pays more than €144 per month for medication, but a problem arises, as in the case of this young man who is already financially stressed, if one has to pay that amount for medication every month, which would amount to almost €2,000 a year after tax.

It took that young man a long time to get a medical card. We made many arguments to support his application, there were exchanges back and forth and it took him the best part of a year to get it. It was granted with an expiry date of 28 February 2014. He has since been written to and advised that the expiry date has been brought forward to 30 November this year. Taking account of that date, he will have got it for fewer than nine months.

He is not looking for a medical card for the rest of his family. He has very specific needs and only wants it for himself to cover the cost of his medication. He needs his prescription. When I met him he had not got his prescription filled for two months and was very unwell. I questioned in whose interest was it that he would not get a medical card. If he stops taking his medication he will almost inevitably end up on dialysis. That will cost him his job and it will cost the State to maintain him on a very expensive system that is less than ideal. He is now paying part of his mortgage and his family are managing. I do not see the logic if it was decided not to renew his medical card. Dealing with his case in that way would be a silo-based approach. When he has to renew his request for a medical card it will cost him money to get medical evidence because invariably consultants will charge and I am aware of instances of that. Therefore, not renewing his card does not make economic sense or medical sense. Furthermore, it is inhumane.

It states on the website that medical card applications take 15 days to process but routinely the processing of an application takes six weeks. When a person is making the case for a medical card on medical grounds, the person's financial position is considered first and it is only at that point that medical grounds are considered. Given that it is taking six weeks to deal with an application, the manner in which that process happens needs to be examined. If a person is making an argument on medical grounds, the person is not making the argument that he or she fits in with the guidelines.

We all have lists of cases and the second one I wish to highlight is the case of one of my constituents. He is 69 years of age and has had a medical card for the past 13 years. His condition is deteriorating. He needs to see his cardiologist and he suffers from numerous conditions, including rheumatoid arthritis and dementia and he wears a pacemaker. He was on 13 tablets a day but has now stopped taking his medication.

The two cases that I referenced highlight the circumstances of two human beings. There is something wrong here. It is not in the State's interest to have a medical system when the medical card system is failing people who need a medical card and where it makes complete sense for them to have one.

I welcome the opportunity to speak on this Private Members' motion on the medical card issue. I welcome the motion and I will be supporting it in the vote tomorrow night.

The vote will take place tonight.

I commend my colleague, Deputy Billy Kelleher, for bringing forward this motion. We cannot have a situation where seriously ill patients are denied a medical card. It is difficult and tough enough for sick people to cope with their illness while at the same time have to fight, scrap and scrape for a medical card. It is wrong. It is inhumane and above all it is a gross attack on vulnerable people. It also shows the kind of society that some people want in this country.

I got elected three times to the Dáil on a strong health and disability platform and in this debate I am standing by that commitment. Health, disability and education are very important issues to me. I will always fight for a quality health and disability service. In any society these matters have got to be top of the political agenda and, as we all know, they are a matter of life and death.

Focusing on the details, the number of discretionary medical cards fell from 80,524 at the start of 2011 to 63,126 at the end of 2012. In the first seven months of 2013 there was a further reduction of 8,142 such cards to 54,984, a monthly average reduction of 1,163. The HSE set a target for 2013 to reduce the number of discretionary medical cards and this deliberate targeting was approved by the Minister for Health in the 2013 HSE service plan. The targeted reduction of 55,328 in 2013 has been exceeded.

I deplore the decision to deliberately target people in clinical need of such cards. I call on the Government to discontinue the targeting of those with discretionary medical cards and to ensure that no one in clinical need would be denied such cards where it can cause significant financial distress.

I attended a launch by Down Syndrome Ireland, Inclusion Ireland and Irish Autism Action today who were campaigning for people with disabilities. Some 763 children are waiting six months or more for an assessment of need under the Disability Act. Some €325 was cut to the annual respite care grant in 2012. The annual reduction in disability allowance since 2008 is €847. There are 1,900 children awaiting assessment by a primary care occupational therapist and 34,617 people are awaiting speech and language therapy. This is the reality of what is happening under this Government. I challenge the Minister of State and all the Members present in this regard; the reality is that we need to support people who are sick and people with a disability. St Michael's House and Prosper Fingal are crying out for support. I urge the Minister of State to adopt a common sense approach tonight. I urge all my colleagues in this Chamber to support the motion at 9 p.m. and to support in particular those seriously ill people who are looking for a medical card.

I welcome and support this Private Members' motion. Hopefully, it will refocus and allow for a re-examination of the inhumane and harsh adjudication on patients who formally would have been granted discretionary medical cards on compassionate grounds but who now are being turned away.

As indicated during this debate, there is anecdotal evidence in abundance to suggest that discretionary medical cards are more difficult - if not almost impossible - to obtain. The move to deprive non-terminal cancer sufferers of such cards is imposing further terrible anguish and stress on these individuals. Such people must deal with the psychological impact of losing their medical cards in addition to trying to cope with their ongoing conditions.

In the past, people with long-term or lifelong illnesses such as cystic fibrosis, multiple sclerosis, motor neuron disease, cerebral palsy and cancer were granted discretionary medical cards on compassionate grounds in circumstances in which there was undue hardship. Now, however, those who suffer with such conditions are asked about their incomes and means and receive repeated requests for further information. The application process is long and drawn out. Reviews are carried out and people may eventually be obliged to lodge appeals on the basis that they have rapidly progressive illnesses which may eventually prove terminal. The latter is not taken into account during the process. Taking away discretionary medical cards is not cost-effective because it means that fewer patients can be cared for in their homes and communities and that they eventually end up in hospital.

I recently dealt with a couple of cases involving people who have extremely serious health conditions. The first involves two elderly cancer patients who are married, who are old age pensioners and who have limited incomes. The wife will travel from Dingle to Cork University Hospital tomorrow for a mammogram. It will be a round trip of 250 miles. The woman is continually monitored by her GP, in various hospitals, etc. The couple in question are only just above the income limit. The husband is due to undergo treatment for prostate cancer. The second case to which I refer relates to three children from a middle-income family who all have cystic fibrosis. One of them has been chosen to take part in drug trials and will be obliged to make a round trip of 130 miles in order to attend for these in Cork University Hospital. I ask the Minister of State to take note of serious cases of this nature. I could provide him with details of several more if I had time to do so.

The next speaker is Deputy Jerry Buttimer, who is sharing time with Deputies Maloney, Ann Phelan, Regina Doherty, Nash and Connaughton. The Deputies will each have five minutes.

I welcome the opportunity to contribute to this debate. As Chairman of the Oireachtas Committee on Health and Children, I am aware, as the Minister indicated, that there is an issue with regard to how the HSE communicates with people in writing and how it determines eligibility.

It is a pity Deputy Finian McGrath has left. Anyone can shout, roar and play to the gallery. However, what I want to do is to put some figures on the record. Deputy Finian McGrath referred to how a society values its people. Let us use that as the measure in the first instance. Forty percent of citizens have access to medical cards and a further 2.7% have GP-only cards. In addition, the Government will spend between €13.2 billion and €13.5 billion on health this year. That is a measure of how we value our people. It also attests to the reform of the health system in which the Government is engaged. I welcome the statements from both the Minister, Deputy Reilly, and the Minister of State, Deputy White, that those with discretionary medical cards are not being targeted.

The motion before the House is the classic old-style Punch-and-Judy approach of Fianna Fáil. When the leader of Fianna Fáil, Deputy Martin, served as Minister for Health and Children there were overruns in the health budget, but not a word has been said about that by the members of his party. Where are Fianna Fáil's suggestions with regard to how we might make health care more accessible and available to the population? The motion contains is a litany of figures but no solution. Never before in the history of the State have so many people had medical cards or GP-only cards.

On foot of the motion before the House and discussions that have taken place at meetings of the Joint Committee on Health and Children, we must challenge the HSE to indicate the basis on which people can qualify for medical cards and how they might apply for them. At one of the meetings of the joint committee, I made the point to the Minister of State that people are petrified when they receive letters indicating that their cases are being reviewed. Very often there is nothing to worry about; these are merely reviews. As a result of what was said at the meeting to which I refer, the HSE changed the language used in the letters it sends people. I take this opportunity to compliment the staff of the primary care reimbursement service, PCRS, for being prepared to be available to and engage with people. We must remove fear from the equation. I welcome the decision taken by the Minister and the Minister of State to establish the clinical review panel.

The State has a duty and a responsibility to provide people with access to health care, which it is doing. Those who are vulnerable need to continue to have access to health care. That is the test we must pass. If we fail in this regard, we will undermine the process of reform in which the Minister and the Minister of State have engaged by creating the hospital groups, restructuring the HSE, reconfiguring the health service, reducing the cost of pharmaceutical products, promoting the use of generic medicines and improving work practices in hospitals. All of these developments have occurred on foot of the Minister's reform agenda and the level of buy-in from health care staff.

The staff of the PCRS can only do so much. The management of the HSE must invest time and energy in communicating properly with medical card holders, with the Joint Committee on Health and Children and with Members of this House. The centralisation of the HSE medical card system was a welcome development. People might ask why that was the case. I am of the view that it exposed the nod-and-wink culture which obtained under Fianna Fáil whereby people whose incomes massively exceeded the thresholds were given medical cards to which they were not entitled.

Those to whom I refer received a clap on the back and voted for Billy, Seán, Mick, Batt or whomever was running for election at the time. We now have a level playing field. However, I agree with Deputy Finian McGrath that we must consider how to ensure those with disabilities are not adversely affected when it comes to the awarding of medical cards.

I welcome the opportunity to contribute to the debate on what is a fundamental issue for all of our constituents. I wish to preface my remarks by observing that just because people sit on the Opposition benches does not mean they have a monopoly on concern. I am equally concerned about the people I represent in my constituency. Just because those to whom I refer are sitting on the benches opposite does not mean everything they do is good. I am of the view that this matter is so important that people should not try to score political points in respect of it. We are discussing people's health and I do not like individuals to play politics with that issue. I thank the Minister for acknowledging the fact that people are not being deliberately targeted. This matter is being spun in such a way as to make it appear that we are deliberately trying to take away people's medical cards. Nothing could be further from the truth.

I admit that some people are falling through the cracks. There is no doubt about that. However, the majority of those with whom I deal have their medical cards returned if they supply the information requested by the PCRS. I also admit that work must be done in respect of certain individuals who find themselves in extreme ill health. I communicated this fact to the Minister and he has replied that he is intent on resolving the matter.

There are some facts that cannot be ignored. The population of this country is a mere 4.5 million.

Some 1.8 million people are now in receipt of medical cards. That is a fact no matter what way one does the sums and it is an astounding figure. Medical cards are not free and a certain amount of money has to be paid to GPs for servicing them. People tend to ignore facts but I tend not to do so.

I agree with Deputy Buttimer who said that the PCRS ensures all applications are assessed in a fair, equitable and transparent manner and that it is not under political patronage. I welcome the fact it does not involve what he described as the nod and the wink of perhaps a Fianna Fáil person. It did not matter how sick one was or what one's income was but who one voted for was what mattered, which was a disgrace.

All applications are assessed in adherence with the HSE national assessment guidelines which ensure the €2 billion spent annually on the medical card system is as cost-effective as possible. I do not believe anyone would argue with that. It must be cost-effective in that we must know we are getting value for money. There have been significant improvements in the system in terms of efficiency and overall delivery of service, in particular in respect of the delivery of service on an emergency basis and on discretionary grounds where undue financial hardship is involved.

There are still some people who fall through the cracks, which I admitted earlier. Currently, the system dictates that where an individual and-or his or her family is experiencing undue financial hardship as a result of an ongoing medical condition, he or she may qualify for a medical card on a discretionary basis. While this is commendable, we could go one step further. Why should financial hardship take precedence when assessing an individual for a discretionary card? Personal hardship should also be taken into account as it certainly applies in some circumstances. We all have examples of such people.

I do not envy the Minister of State. This situation is not of his making. We inherited a very difficult situation. As a result of the economic situation, people are coming into the medical card system all the time. There is a cost to that, which must be met. Perhaps we could do some re-balancing of the medical card system in respect of young healthy individuals aged between 18 and 25 years of age who become unemployed but who never need to go to the doctor.

The Government's overarching goal is to ensure medical cards are issued to people who need them most. All factors are taken into account, in particular outcomes in regard to their medical condition. If somebody is terminally ill and the HSE, through the PCRS, learns about it, he or she will have confirmation of the granting of an emergency card within 24 hours. The cards are issued to people with serious illnesses, regardless of their incomes. Panels of doctors are now assessing applications for discretionary cards as opposed to the wink and the nod culture, to which Deputy Ann Phelan referred.

This motion is a complete puff of smoke by Fianna Fáil. It talks about the reduction of discretionary medical cards from 80,000 to 63,000 last year and a further 8,000 this year but what it fails to recognise is that of the 24,000 discretionary medical cards issued in that time, 23,000 of those people now have a medical card because of their entitlement and not because of the wink and nod culture where a Fianna Fáil person telephoned the PCRS or the former health boards instructing them to give the card. This Government is acting with probity.

It is no surprise that we have seen a reduction in the number of medical cards in recent months - probably more so than in previous months - and the return of medical cards to which people were not entitled. The money we are spending on our health service needs to be directed to the people who most need it. Those people who have incomes in excess of the threshold are not entitled to get medical cards.

The State cannot afford to pay for a medical card for everybody, regardless of means. Currently, almost half the population has access to free medical care funded by the State. According to HSE figures, in excess of 2 million people, or 45% of the population, have a means-tested medical card or GP visit medical card.

This Government's aim, which it will probably not achieve in its lifetime but please God it will do so in the future, is to give everybody access to universal health insurance, so there will be a one-tier medical service and not the current three-tier service or the two-tier service promulgated by the previous Government.

Medical services need to be delivered on the basis of the people's means, so that the money being spent by taxpayers follows the patient and their needs and not the way it was done in the past with a wink and a nod. This motion is a puff of smoke.

The awarding of medical cards on discretionary grounds is a fraught issue and is probably one of the most familiar to Members of all political persuasions. We have all been asked at one stage or another by our constituents to make representations on their behalf. In an ideal world, I would like to see a system of universal health care where all citizens have free and ready access to primary health care provision, a system which would be self-sustaining in the long run by avoiding later more serious or prolonged medical intervention for conditions which could have been treated simply and cheaply with early action. We are making some inroads in that regard. Unfortunately, we do not live in such an ideal world currently and we must try to make do with the limited resources we have available to us in a fair and equitable manner. Even under such constrained circumstances, it is important to remember that almost half our population has access to a medical card.

In general, the system of issuing cards based on an individual's financial circumstances is very clear and quite well understood. The problems arise where people do not meet the income criteria but may have large medical bills due to long-term illnesses or disabilities. There are groups of people with conditions who may rarely need to see a doctor but who would need the security of ready access should it be needed. One group is children with congenital heart defects, some of whom may not need regular visits to a GP but obviously would need ready access should it be needed. It is my belief and that of most Members that parents of such children should not have to worry about finding the money to visit the doctor nor should the parents of children with Down's syndrome have to share that burden.

Other groups which should not be refused medical cards include patients undergoing oncology treatment. Surely the non-renewal of cards for such people can only add to stress and lessen their chances of a full recovery. We are all aware of certain examples where the system does not necessarily work to their benefit.

Having said all of that, I know the Minister of State is aware of these problems and I commend him and the Minister, Deputy Reilly, for directing the HSE to set up a clinical process to assist in the processing of such applications. However, it is important when dealing with such cases that not only is the system fair but that it is seen to be fair. In cases where a refusal to grant a discretionary medical card on medical grounds is being reviewed or appealed, the HSE issues a simple "Yes" or "No" decision at the end of its deliberations. This is fine where a review or an appeal has been successful but it is, as the Minister of State knows, deeply frustrating in unsuccessful cases where people are sometimes left in the dark, to a degree, about the basis for that decision. As I have mentioned previously to the Minister of State, it is not unreasonable for the HSE to provide even a basic summary of its findings and the rationale behind why certain decisions are not in somebody's favour. The HSE will only provide these reasons on foot of a freedom of information request which can be very time-consuming and frustrating.

As I said, I raised this with the Minister of State last week and in fairness to him, he has agreed to take a look at that particular process. I take the opportunity to urge him to continue in that vein and to ensure we have an even fairer and more transparent system.

As I said previously, I cannot see how any costs would be incurred by such a change. If anything, savings could well result from it. Such transparency would also bring more consistency to decisions made in relation to medical cards issued on a discretionary basis. The perceived and sometimes real lack of consistency can sometimes be a bit of a bugbear for people.

It was mentioned earlier that 1.8 million citizens have full access to medical cards. That is not an insignificant number. There is clear evidence that approximately half of the population benefits from medical cards. Given that so many demands are being placed on the system, there is no doubt that there can be problems in getting decisions right all of the time. As public representatives, we often hear about some of the challenges people encounter in their dealings with the medical card system. While I acknowledge that there can be problems with the administration of the system, I think it is improving and changing. We should not be blind to the improvements that are being made to a system that was not renowned for the transparency of its decision-making process. Some of the interventions made by this Government, the Minister for Health and the Ministers of State in the Department of Health to ensure there is greater openness and transparency in this area are to be commended. Much more can be done to make sure we are all satisfied that the situation is much clearer and much more transparent for all citizens.

I am grateful to have an opportunity to speak on Private Members' business. Many people are affected by this issue. We all have our own stories in this regard. It is important to acknowledge the motion we are discussing. No attempt has been made to remove mass amounts of medical cards. The problem lies with the changes that have been made in the process. I will talk about the small number of people who have been affected by these changes, which have had a significant effect on their lives. That is where the problem is coming from.

Like many other Deputies, on a daily or weekly basis I meet constituents who are affected by the reduction in the number of discretionary medical cards. I have identified three problems with the manner in which this reduction has been implemented. I refer to the timing of the decrease, the manner in which it was communicated or not communicated to people and the dire position many acutely ill people are now in. We are all aware of the pressure the HSE is under as it tries to find savings and help enable this country to balance its books. I appreciate the major part the health budget plays in the context of overall expenditure. Therefore, it is clear that when Government budgets are cut, there must be commensurate reductions in the health budget.

When savings are made, it is important that the manner of the cuts does not add to the difficulty being experienced by people. We believe this was the case recently when the number of discretionary medical cards was reduced. I am aware that people who were granted discretionary medical cards in the spring had them removed just three months later, necessitating their re-entry into the application and appeals process. Surely this is a gross waste of resources within the medical cards office and the HSE appeals office. I suggest that the reduction in the number of medical cards should be effected gradually as they fall due, rather than in one fell swoop as appears to have been the case.

The lack of communication in relation to what has been happening has caused great confusion for the public. People deserve to know what is happening. The HSE communications office is well able to publicise good news, so it is only right that the withdrawal of medical cards from the population should be explained in a similarly forthright fashion. The staff in that office should have been obliged to share this information with the general public. Instead, very ill people had their lives thrown into turmoil when a letter arrived stating that their medical cards had been cancelled but failing to provide a reason or context for that decision.

Communication continues to be a problem, especially when it comes to the allocation of medical cards to the chronically ill. Three examples come easily to mind. A lady who was paralysed in an accident last year was granted a medical card in early 2013 following a mammoth battle. She had been rendered tetraplegic after the accident and required extensive rehabilitation in the National Rehabilitation Hospital. She was informed in July of this year that the medical card was cancelled. An application to have the card reinstated was turned down. The matter is now under appeal. In the meantime, she has been left without a card.

The second case I would like to mention is quite similar. It relates to a man who suffered an accident over 30 years ago which left him paralysed and in a wheelchair. He has always held a medical card. He was informed in July without warning that his card was cancelled. He faces the prospect of cutting back on the number of colostomy tubes and bags he uses because the cost of those items is prohibitive in the absence of a medical card. There is no doubt that this will increase the likelihood of infection. This man may well have to present himself to his local accident and emergency department before the winter is out. To add to his difficulties, he has developed high blood pressure since his card was withdrawn. His family believes this is due in no small part to his worries about the medical bills that may accrue if he is hospitalised. To add insult to injury, the last time he was granted a medical card - on discretionary grounds due to his disability - his wife received a GP visit card. They took the time to ring the medical card office to say she did not need the GP visit card, and had not sought it, but they were told it had been granted and they should keep it.

The third case to which I would like to refer is just as surreal. It relates to a man who is on the transplant list as he awaits a kidney transplant and attends dialysis three days a week. Now that he does not have a medical card, the cost burden on his family is proving great. Surely it does not take weeks for a medical assessor to determine that someone on the transplant list has exceptional medical needs. In addition to his health concerns, the man is now worried that if his transplant operation comes through, he will be faced with astronomical medical bills. Why did the HSE once again use a sledgehammer to crack a nut? Is there absolutely no common sense in the allocation of medical cards? Surely someone on the transplant list is defined as having an exceptional medical need. Can a programme not be put in place whereby the medical card office can refer to the current transplant list so that these ill people can be spared the stress of waiting for weeks to see whether their applications are successful? Details of all these cases have been provided to the Minister. I have already been in contact with the medical card office in relation to all three cases.

It is quite obvious to me that there are problems in the assessment of medical evidence. Surely it is not impossible for the primary care reimbursement office to provide guidelines to people on what can be said to constitute "exceptional medical circumstances" which warrant a discretionary medical card. Equally, people should be given guidance on how best to prove their medical evidence. I understand that the HSE service plan for this year included a plan to reduce the number of discretionary medical cards from 63,000 to 55,000 and replace them with the full medical card. I believe the manner in which this has been conducted is nothing short of a disgrace, especially given that the people worst affected are those with the greatest medical needs. I accept that a small number of people in possession of discretionary medical cards might not have merited them. The manner in which the HSE has handled this has ensured the greatest burden and stress has been placed on those most in need.

I would like to share time with Deputies Seán Ó Fearghaíl, Éamon Ó Cuív and Michael Moynihan.

I commend Deputy Kelleher on tabling this motion. I am glad I made it back to the Chamber in time for this debate. I was on the run. Deputy Kelleher has made it clear that the number of discretionary medical cards decreased by approximately 17,000 in the 12-month period from the start of 2011 to the start of 2012. He has accepted that discretionary medical cards are for sick people with serious illnesses. As the Minister knows, those who have to deal with serious illness can face major financial hardship. All Deputies are aware of what is happening as people lose their medical cards. This issue has been raised in many parliamentary questions and on Topical Issues.

One of the points that has been made about discretionary medical cards is that it used to be possible for one to be granted such a card in respect of a serious illness for a temporary period until one recovered. This does not seem to be happening at the moment. Indeed, the former Ombudsman, Emily O'Reilly, has suggested that health cutbacks are being implemented by applying "the letter of the law" and discarding the element of discretion that formerly existed. She gave the example of people with motor neurone disease who are now finding it hard to qualify for medical cards. The chief executive officer of the Irish Motor Neurone Disease Association has said that she has tried many avenues in her search for answers in this regard, but she has failed to get any. I am sure the newly appointed Ombudsman will encounter the same issue when the issue of medical card applications is raised with him.

The Jack and Jill Foundation has warned that the cutbacks being imposed are making it increasingly difficult for seriously ill people to access discretionary medical cards. The Irish Medical Organisation has reported that the HSE has unilaterally cancelled certain medical cards without advising patients. I agree with the organisation that patients should not have to find out from their general practitioners that their entitlements have been withdrawn. I think that is an appalling situation. We have been told that the HSE is considering a three-year period of eligibility rather than a one-year period. This is also very worrying. It is obvious that from an administration point of view, people have to gather a huge amount of information every year to reapply for a medical card.

Like other Deputies, I can give many examples of cases that highlight the sort of issues that are arising for our constituents. I have been told by a man who has cancer and is undergoing two types of chemotherapy and radiation that it took more than six months for his application to be approved. He sent in various medical reports from his doctors. He was initially refused because his means exceeded the limit. He was not granted the card until his sick pay from his employment ceased and his only income was illness benefit.

As the card was issued for six months, from June to November 2013, he is due for review again next month. This is a very difficult situation for a man who is still on treatment. Another constituent who has multiple sclerosis had a medical card valid up to 2015. He was reviewed under the 2013 guidelines and issued with a GP visit card. After further medical evidence was submitted by the general practitioner, he received a full medical card. In another case, a person in receipt of a social welfare payment plus an income of €600 per year from land was issued with a GP visit only on review. He appealed the decision and received a full medical card. A huge number of appeals are being dealt with. A person with diabetes and high blood pressure was told he had been refused a GP visit card because his means exceeded the limit by less than €5. On appeal, this man, who is almost 70 years of age, was granted a full medical card. There is great anxiety, concern and grief throughout the country at what is happening. As one who is interested in this area, I hope the Minister of State will ensure nobody in clinical need is denied a medical card where there is significant financial distress.

I compliment Deputy Billy Kelleher on tabling the motion. I agree with Deputy Ann Phelan who said we do not have a monopoly of concern on this side of the House so far as these issues are concerned. I respect the acknowledgement of the fact that problems were cited by Deputies Paul J. Connaughton, Deputy Gerard Nash and even Deputy Jerry Buttimer has accepted, through his committee work, that there is a particular problem. However, Deputy Regina Doherty described the whole thing as a puff of smoke. The concern we have across all benches in the House about people who are in receipt of these particular medical cards is not a puff of smoke. It is something that is very genuine and very real.

I think she said the motion was a puff of smoke.

The motion is about an issue.

For the sake of accuracy.

The difficulty we face is not so much that there is a problem but that there is denial on the part of the Taoiseach that there is a problem when his own backbenchers indicate there is a problem. We accept that 22,000 people who had discretionary cards now have full medical cards. We will have to look back over the history of the medical card process to see the transition from discretionary to full medical card. I have seen in my constituency a little girl in the care of the Jack and Jill Foundation who has a very serious heart condition and who had a discretionary medical card for about four years from the date of her birth but which was withdrawn. The case was appealed and she got the medical card back, but it took 13 months. I raised with the Minister of State the issue of a young couple where the husband has multiple sclerosis and serious kidney disease, both of which conditions are progressive. The husband had a discretionary medical card because of his medical condition, and although his family income went down progressively from 2009 to 2012, his medical card was withdrawn. Any number of appeals to the Minister of State and to the HSE-----

No, appeal to the Minister.

Fair enough. During a Topical Issue debate, the Minister of State at the Department of Education and Skills, Deputy Ciarán Cannon, advised me to write to the Minister of State, Deputy Alex White, in order that we might solve the problem. The Minister of State, Deputy Ciarán Cannon, said we had been able to solve some of these issues in the past. We did not get that particular issue solved.

I was struck today by the press release issued by an extraordinary individual who is known to all of us in the House, Mr. Jonathan Irwin, who, at more than 70 years of age and not in the best of health, has devoted his life, and continues to do so, to working for children who are severely medically challenged. He referred to the Taoiseach's comments in the House today by stating:

The heartless letters being sent out to the families of children with severe disabilities as a result of brain damage, precious children under our wing, are an absolute disgrace. The Taoiseach must challenge the HSE and call a halt to this system which is torturing already stressed parents. Remember these are parents who simply want to care for their sick child at home, which makes sense medically, financially and morally. The HSE should be embracing these parents and supporting them to look after their child.

Instead, parents are receiving cold letters from the HSE in relation to applications for medical card-GP visit card; letters that make no mention of the child, and boldly state that "Your application will be considered closed unless information is received to support your application within 21 days from the date of this letter.

He went on to state:

My call to the Taoiseach today is simple. Please do the right thing on behalf of these sick children and their parents. Do what the UN Convention on the Rights of Children recommends in relation to sick children and their entitlement to medical cards. Fix this broken system so that Ireland's children in most need are granted their medical card in their own right. If you cannot do that immediately, fast track their applications in the meantime. This issue needs the immediate clout and the commitment from the Taoiseach to address it head on and I believe that Enda Kenny is the man to make this happen.

I do not know whether the Taoiseach will get directly involved. The Minister of State is the man who is charged with solving it. I do not believe the Minister of State would stand over the disgraceful treatment of many people with serious illnesses. This is what we are talking about. It is not a puff of smoke and I ask the Minister of State to take immediate action.

I am delighted to have an opportunity to speak on the motion and also on the Government's amendment. We are asked to note that there has been no change to the manner in which discretionary medical cards are awarded. That does not stand up. I have cases in my constituency of people with very severe disabilities who have had medical cards for many years and who suddenly find they have been withdrawn. I had one extreme case - I do not wish to go into the details because it might identify the person - where I was utterly shocked that the medical card had been withdrawn. A colleague of mine from the Minister of State's party in my constituency and I worked on this issue. When we became aware of the circumstances of the case we contacted the medical card section and were advised to appeal. This has been going on for many months and no card has been granted.

If the Minister of State is interested in the case, I will provide, on a confidential basis, the circumstances of the case and he can check out what I have said. If anything, he will find that I am understating the position. I can understand on a review how a mistake might be made. However, I cannot understand, given that the evidence we have provided was so thorough and overwhelming, the reason, months later, the card still has not been granted. I checked today with my assistant in the office if it was her impression and clear understanding that cards are being withdrawn where they had been granted in the past on medical need. She said that is what is happening.

It is correct in some cases when one makes the case and goes through the process that one wins the appeal. This is happening in many cases but it is putting a huge strain on people to get evidence that is already available to the HSE.

It seems to be a pattern with this Government so there is no point in blaming the HSE for this. The Minister of State's party colleague, the Minister for Social Protection, is constantly throwing people off invalidity pension who have been on it for years. Where we produce all the medical evidence and go to appeal, in the vast majority of cases and after a slow process - the process is slow rather than there being a lack of evidence - the person then wins the appeal and gets the invalidity pension back. There seems to be a process of believing that people who have been given either an invalidity pension or a medical card based on medical need for a long time no longer need them. It seems to be hitting people who often find it quite difficult to get the evidence together - not because it is unavailable but because it means going to doctors and getting a lot of paperwork together. Due to their disability, these people can find difficult what we do as our daily work. This puts a lot of pressure, including mental pressure, on them.

I do not understand the logic behind this approach. If one takes all the people off invalidity pension and puts them on jobseeker's allowance, the saving is minimal. In a very competitive work market, the chances of those people getting employment if they have been on invalidity pension for 15 years are next to nothing when we already have a market that is overcrowded. What seems to be happening with the medical card is not just an isolated "one issue" matter but a pattern that is being followed by the Government and Labour Ministers to try to make savings. It is not a fair way of doing it.

There are rumours circulating that the Minister of State will give every child in the country under five a medical card, which is very attractive. It does mean that parents earning €200,000 per year will be granted medical cards and at the same time, there is a vendetta against those who most need them based on medical grounds. This is a very serious issue. It is a matter of hitting the weak and vulnerable and putting huge strain on people because it is creating uncertainty about the future. I accept that the previous Government made a mistake when we granted medical cards to everyone over 70 because of the cost factor. However, it was right of us to say that once a person reached 70 and received a medical card, there should be no further review of the card. There is an argument that in straitened times, one cannot give cards to people of very great means - unless one is to give cards to everybody in the country - and have families struggling on low means and no card. I have always been of the view that somewhere in the higher echelons, there is an argument for saying that the universal provision of anything like a medical card must be at the expense of somebody else because there is only a finite amount of money and it inevitably is at the expense of struggling families who are earning a bit of money and are just over the threshold.

Where somebody with a significant disability is given a card and their income is very unlikely to change significantly if they are a pensioner, it should be left and not reviewed. Before the general provision of medical cards for older people was introduced, the problem was not with taking the card from them, rather, it was the review and the strain, stress and worry the person suffered in trying to get the bits of paper together to deal with the review and in wondering whether they would get the card back. Even when somebody like myself would have said on looking at their circumstances that they would inevitably get it back and that there was no need to worry that did not take away the worry.

There needs to be a change of attitude. We need to go back to the much more humanitarian processes that were in place in the past where we dealt with real people who had a good idea about the people to whom the cards were granted rather than these so-called fair procedures that are so far removed and that try to judge everything on a bit of paper without ever having met the person about whom a judgment is being made.

I compliment Deputy Kelleher for tabling this motion. I have had considerable amount of experience over the past 12 months, particularly this year, in dealing with discretionary medical cards. In one case, I set about getting a medical card for a person who had been diagnosed with terminal cancer and who needed immediate hospital care. Documentation came back to us about a small private pension of some €67 per month. As we were working through it, the cancer was found to be more serious than had been anticipated and the person died without the medical card being approved, even with a letter from the consultant stating that the cancer was terminal. I got on the telephone over several days to explain how serious the case was to the medical cards section and yet we still received what I can only describe as tripe from the section. I remember when another e-mail came back looking for some form of clarification. At that stage I knew how serous the situation was for the family. I had to go look again at the process and ask relatives to go through paperwork to find what the medical cards section was looking for.

The simple notion that there is no change in policy is irrelevant. I do not think there is a Deputy, Senator or public representative in any part of this country who would not accept privately, although maybe not publicly, that there is a change in direction in respect of the medical card. We have seen people, particularly children with special needs. I have met an adults their thirties with special needs. There is always concern on the part of parents about long-term care. The medical cards section questions a woman who may never have had earned income for herself and checks the income of retired parents.

There is a change in policy in this area. The basic human effort from the medical cards section must relate to where there is overriding medical need. I am talking about the cancer patient, not about somebody who is way over the limit financially. I am also talking about retired people of modest means who have not yet reached the age of 70. The only thing that should be accepted here tonight by all sides of the House is that there has been a change in the policy that must be reversed.

That is universally accepted. The official line may be that nothing has changed but the simple fact of the matter is that the policy has changed and it is causing undue hardship to families facing serious illness. Most families have come face to face with illness at some point. Such families are extremely vulnerable and they will accept whatever help they can get from the State. The illness may involve a child, someone with profound disabilities since birth or a person who has recently been diagnosed with cancer. The Government should simply accept the motion. We can have our spats but people are suffering unnecessarily because of this change in policy. They have enough to contend with already.

This morning reference was made to a letter from a consultant. This is what the HSE requires at present. A GP's letter counts for nothing. Some of the people in the medical cards section are doing an exceptional job in communicating with us and trying to help people, but they are constrained by policy. They are telling people a GP's letter is no good and that a consultant must write the letter. It can take a long time to get such a letter, however. To public representatives it may appear to be a simple task, but for families that are already under stress because of illness, it is a mountain to climb. We need to be honest with each other and admit that the policy has changed and is causing hardship to those who are most in need of the State's support.

I recently dealt with the case of a 60 year old man who has suffered from progressive multiple sclerosis since he was 32 years old. He had a medical card since his early 40s and he is confined to a wheelchair. Thankfully, his multiple sclerosis has been in remission for the last year to 18 months, but he still needs support for his daily needs. He was accused out of the blue of having a private pension from some mysterious company even though he retired on an invalidity pension. This man and his wife and two adult children would dearly love to have a private pension but they do not know where the HSE got such a notion. This family sacrificed everything to survive on an invalidity pension. If he had been able to work there is no question that he would have done so.

Earlier this year one would have been forgiven for thinking that the changes were being applied on an area-by-area basis. In one part of my constituency people were being asked for further information as part of a review of medical cards. We can discuss the reviews elsewhere but the main reason I speak tonight is the discretionary medical card. It is nonsense for anybody in Government to say the policy has not changed. We have seen cases in which people are over the limit in respect of financial need, but I dealt with a case earlier this year in which the HSE refused to sanction a medical card, even though a consultant had written a letter stating that the individual's illness was terminal, because a private pension worth peanuts had to be examined or a box had to be ticked.

How often does the body established to examine this issue meet? Is it simply a case of carte blanche for the policy? I urge the Government to reflect on the motion in a humanitarian and realistic way and reverse the policy. It is causing hardship for those with terminal illnesses and profound disabilities. Children have also been targeted on the basis that their parents might have incomes above the limit. Those who have held medical cards for lengthy periods due to the severity of their conditions have suffered enough. Every Member of this House has received representations on this issue. I urge the Government to examine this issue and to tell us the truth about it. The only line I would accept is that the policy has fundamentally changed. It should be changed back.

The Government rejects the notion that persons who were issued with medical cards on a discretionary basis are being deliberately targeted where their incomes exceed the HSE's income thresholds. Despite what Opposition Deputies have stated, there is no target to reduce the number of discretionary medical cards in the HSE's national service plan for 2013. It did not form part of budget 2013 and it is not Government policy. During the course of the debate last night and again tonight, there have been numerous references to automatic medical cards and medical cards awarded on the basis of medical need. As my colleagues stated last night, this is not the case. There is not, and there never has been, an entitlement to a medical card for a person with a specific disease or on the basis of medical need. Under the Health Act 1970, persons who are unable to arrange GP services for themselves or their families without undue hardship qualify for medical cards. Deputy Kelleher is familiar with that Act.

Applications for medical cards are considered by the HSE on the basis of an assessment of the applicant's means by reference to the HSE's national assessment guidelines, which set out the income thresholds. Where a person's income is within the guidelines, a medical card or a GP visit card will be granted by the HSE for three years in most cases. However, the HSE has discretion to grant a medical card where a person's income exceeds the income guidelines. The discretion must be exercised by the HSE but the fundamental provision in the 1970 Act is that a person is assessed on the basis of undue hardship in arranging a GP service, having regard to his or her means. I accept that the interpretation of that provision has changed over the years. Social and medical issues are considered when determining whether the individual faces undue hardship in accessing GP services.

The Deputies point out in their motion that the number of discretionary medical cards has decreased. The documentary evidence shows this is correct but, rather than its being a deliberate targeting as suggested by the Deputies, there is a valid and, indeed, logical and rational explanation. The HSE has indicated that there has been a decrease of approximately 24,000 in the number of discretionary medical cards between the start of 2011 and July 2013. Of these 24,000 people, nearly 23,000 have qualified for medical cards on the basis of their means assessment alone, with no need for discretion to be considered.

I can further clarify the figures. At the start of January 2011, there were more than 80,000 discretionary medical cards. In July 2013, there were more than 56,000 discretionary medical cards out of a total of almost 1.9 million medical cards. This shows a reduction on paper in the region of 24,000. However, of that 24,000, almost 23,000 have been awarded medical cards on the basis of their means assessments. As such, they have not lost their medical cards. The number of people who hold medical cards on discretionary grounds has fallen in recent years, largely because more people who previously were marginally over the normal qualifying income limit became eligible for medical cards under the normal qualifying scales. It is important to note that medical cards provided on the basis of means or where discretion is involved are identical and provide access to the same set of health services.

There is no target for reductions in discretionary medical cards in the 2013 HSE national service plan. Last night, it was stated that the service plan set a target to reduce discretionary medical cards by 40,000. This is incorrect. The plan reads: "Policy changes will reduce eligibility for approximately 40,000 people currently in receipt of medical cards, giving an anticipated net growth in 2013 of 60,000 medical cards." Note that I stated "medical cards" and not "discretionary medical cards". Due to the current financial climate, it was necessary to identity measures to mitigate the escalating costs of the medical card scheme. However, I assure the House that discretionary medical cards were not targeted in this regard. There has been no change to the qualifying criteria for discretionary medical cards in the past year and the scheme continues to operate in such a way that those who suffer undue financial hardship as a result of a medical condition receive the benefit of a medical card.

Contrary to the suggestion that we are targeting people who need our support, the Government has provided funding to ensure that an additional 220,000 people are covered by the general medical services scheme, GMS, since entering office. This means that more than 43% of the population has access to general practitioner, GP, services without any charge under the scheme, comprising 40.6% with medical cards and 2.7% with GP visit cards.

The HSE continues to issue medical and GP visit cards, with nearly 2 million people currently having access to free GP care. In fact, the number of people with medical cards has increased by approximately 45% since the start of 2008 when the current economic crisis began. This commitment to meet the additional financial costs of a greatly expanded medical card scheme makes light of any contention that this Government is targeting certain people.

I call Deputy Troy, who is sharing time with Deputies Kirk and Kelleher. Deputy Troy has five minutes.

I welcome the opportunity to contribute on this important motion. It is clear to anyone with an ounce of intelligence that there is a cynical campaign to reduce the number of discretionary medical cards. At the beginning of 2011, there were more than 80,524 discretionary medical cards, a figure that reduced to 63,126 by the end of 2012. This year has witnessed a further reduction.

Listening to Government Deputies last night as well as to the Minister of State a few moments ago, one would wonder in what type of parallel universe they were living. They believe that there has been no deliberate attempt to reduce the number of discretionary medical cards. Are they holding clinics at all or engaging with their constituents? The anecdotal evidence presented at my clinics and those of my colleagues tells of a deliberate attempt to withhold discretionary medical cards. This is not just being asserted by Deputies on this side of the House. Consider the comments of the outgoing Ombudsman, Ms Emily O'Reilly, in this regard. She stated that health cutbacks were being implemented by applying the letter of the law and removing an element of discretion that had previously applied. She is not only renowned in this country, but also on the European stage.

The Irish Cancer Society has cited concerns about the removal of medical cards from cancer patients. At an Oireachtas health committee in July, the Minister for Health, Deputy Reilly, confirmed that this was being done. Professor Orla Hardiman, the neurologist who deals with the most cases of motor neurone disease, rubbished claims that applicants were provided with emergency medical cards within 24 hours as being untrue.

I will provide examples from my area. I have tabled a parliamentary question on the case of a 13 year old boy. When he was diagnosed with autism at four years of age, he received a medical card. It was renewed every two years until August of this year when, despite there being no change in his medical condition - if anything it had worsened - or in his parents' financial position, something else that had worsened, his application was refused. That refusal is being appealed.

In the case of a one year old child who was diagnosed with cancer, three and a half months have been spent toing and froing with the medical card office to secure a card. What a thing to put that child's parents through. Are they not going through enough trying to look after their sick child without having to worry about the financial hardship that their family was incurring?

I am not pulling these cases from the sky. I can provide the Ministers of State with the details of each. A gentleman has been diagnosed with cancer for the third time. On the two previous occasions, he was awarded a discretionary medical card. He applied for a medical card in September 2012. On 23 November, his application was refused. He appealed and was further refused. He appealed again. He was refused again. After appealing once more, he was finally granted a card on 19 September 2013. For 12 months, a man who was critically, if not terminally, ill with cancer had to battle with an arm of the State to get his entitlement.

Do not come in here and tell me that there has been no change to the conditions applying to people who try to obtain discretionary medical cards. The clear tactic is to refuse and delay as much as possible. This is causing unnecessary anxiety and is having a severe negative impact on persons who are critically ill and cannot afford to suffer such anxiety and pressure.

I compliment Deputy Kelleher on introducing this important motion. For God's sake, will the Ministers of State and the Government take on board the fact that this is a real issue and take the foot off the drive to withhold discretionary medical cards? It is unfair, inhumane and beneath them.

I thank Deputy Kelleher for the opportunity to contribute briefly on this important debate. The number of discretionary medical cards has decreased from 80,524 in 2011 to 63,126 in 2012, with a further reduction in the first seven months of this year to less than 55,000. These statistics illustrate what we are discussing. Clearly, the HSE's service plan is targeting discretionary medical cards.

Two Ministers of State at the Department are present.

Over the past 18 months, everyone in this Chamber will have had cause to make representations to the HSE about medical cards being withdrawn or not being granted in particularly heart-rending situations. In some circumstances one or two members of a family may be under treatment for cancer but they are told that a medical card will only be granted if evidence can be provided that the illness is terminal. In heaven's name, how can one expect a local GP or consultant oncologist to provide evidence that the illness is terminal and that the medical card will be granted only in those circumstances?

That is for emergency medical cards. The Deputy is mixing up two things.

Those are the circumstances. I have dealt with an individual case where I had to go through it line by line to get it processed. That is what I was told at the end of the day.

The Deputy is talking about the emergency situation.

Not at all. We are talking about discretionary medical cards. People with pressing clinical needs are being put under undue or severe pressure. In many circumstances where an illness is life-threatening, people simply do not have the cover or finances to meet the exceptional medical expenses involved. Such expenses could include travelling for treatment at one of the centres of excellence, or the increased financial pressure on a family circle due to such a situation. If one combines that with significant outgoings for adult children in third level institutions, it all adds up to very difficult circumstances for far too many families.

The Minister of State should review this decision. Given the number of discretionary medical cards granted compared to those withdrawn, the statistics graphically illustrate the difficulties involved. The situation needs to be addressed urgently because there are too many families under severe stress. They are under stress due to attending an oncology unit or suffering from motor neurone disease. They are on the financial margins in terms of eligibility for a medical card. Such circumstances lead to undue and unfair stress on too many people.

I welcome the contributions from Deputies on both sides of the House. We do not claim to have a fount of wisdom on this side, but we know there is a difficulty concerning the granting of discretionary medical cards. The review process is laborious and takes a long time.

The Minister of State says there has been no change to how discretionary medical cards are awarded. However, a profoundly disabled child with intellectual disabilities and many other medical complications may have been awarded a discretionary medical card based on the medical evidence presented at the time. If that card is withdrawn at a later date, there has obviously been a change in how the awarding of such a card is assessed. Such children should be entitled to the continuance of that medical card because there has been no change in their medical circumstances. Regardless of the family's financial circumstances, the person was granted the card in his or her own right because of their medical condition.

Discretionary medical cards are now being withdrawn. Mr. Jonathan Irwin of the Jack and Jill Children's Foundation has stated that parents are receiving cold letters from the HSE in relation to applications for medical cards and GP visit cards. The letters make no mention of the child involved and boldly state: "Your application will be considered closed unless additional information is received to support your application within 21 days of the date of this letter." The HSE letters seek evidence of fire and contents insurance, mortgage payments and expenses incurred. The Minister of State knows the form.

The bottom line is that these people are applying for a medical card based on their extreme medical needs. That is the basis for awarding a discretionary medical card. Quite clearly, the HSE is looking at existing discretionary medical cards and is applying the financial guidelines in assessing them. That is what is happening. There is no change in the guidelines, but the financial guidelines under the Health Act 1970 are being applied to assess eligibility for discretionary medical cards. That is how they are being withdrawn.

There is no point in trying to convince Deputies, who have made contributions in this debate as well as having tabled numerous parliamentary questions on the difficulties involved in securing discretionary medical cards for people with profound medical needs, that this is not the position. That is why I have kept the motion's wording tight and specific, targeting the issue of discretionary medical cards.

There is a disconnect between what Ministers have said and what is being said by Government backbenchers, even though they used couched language with phrases like "issues of communication" and "difficulties in informing families". What they are really saying, however, is that discretionary medical cards are being withdrawn for no valid reason other than that there has been a deliberate change of policy in how such cards are assessed, granted, reviewed and appealed. There can be no other reason that such children would have discretionary medical cards withdrawn. If the Minister of State can explain that to me, I would like to hear it because, unfortunately, their medical conditions have not changed one bit. The incontrovertible evidence is there in black and white in case after case, so I urge the Minister of State to review the process quickly.

My major concern is that this is a budgetary exercise. Next week, the Minister of State will expect applause from Labour Party Deputies about granting free GP care to children under five. Is the Government asking a profoundly disabled child to fund free GP care for under fives? If so, we have a major problem in this country in terms of our priorities. The Minister is saying he will give a free GP card to every child under five, but at the same time a person who is profoundly disabled, with major medical conditions, and who may have life-limiting illnesses, will not be granted a discretionary medical card based on their individual needs. If so, that would simply be shameful. Whatever is announced next week, I hope the Minister is not taking discretionary medical cards from thousands of people in order to fund his pet topic.

I wish to thank every Deputy who has spoken on this motion. I know the vote will be lost but I urge the Minister of State to re-examine this matter. The Government amendment states that "the HSE has produced national assessment guidelines to provide a clear framework to assist in making reasonable, consistent and equitable decisions when assessing applicants". That is the change of policy.

9 o'clock
Amendment put:
The Dáil divided: Tá, 75; Níl, 46.

  • Bannon, James.
  • Barry, Tom.
  • Bruton, Richard.
  • Burton, Joan.
  • Butler, Ray.
  • Buttimer, Jerry.
  • Byrne, Catherine.
  • Byrne, Eric.
  • Carey, Joe.
  • Coffey, Paudie.
  • Conaghan, Michael.
  • Conlan, Seán.
  • Connaughton, Paul J.
  • Conway, Ciara.
  • Coonan, Noel.
  • Corcoran Kennedy, Marcella.
  • Coveney, Simon.
  • Creed, Michael.
  • Daly, Jim.
  • Deasy, John.
  • Deering, Pat.
  • Doherty, Regina.
  • Donohoe, Paschal.
  • Doyle, Andrew.
  • Durkan, Bernard J.
  • English, Damien.
  • Farrell, Alan.
  • Feighan, Frank.
  • Fitzpatrick, Peter.
  • Flanagan, Charles.
  • Griffin, Brendan.
  • Hannigan, Dominic.
  • Harrington, Noel.
  • Harris, Simon.
  • Heydon, Martin.
  • Humphreys, Heather.
  • Humphreys, Kevin.
  • Keating, Derek.
  • Kehoe, Paul.
  • Kenny, Seán.
  • Kyne, Seán.
  • Lawlor, Anthony.
  • Lynch, Ciarán.
  • Lynch, Kathleen.
  • Lyons, John.
  • McCarthy, Michael.
  • McEntee, Helen.
  • McHugh, Joe.
  • McLoughlin, Tony.
  • McNamara, Michael.
  • Maloney, Eamonn.
  • Mitchell O'Connor, Mary.
  • Murphy, Dara.
  • Murphy, Eoghan.
  • Nash, Gerald.
  • Nolan, Derek.
  • Ó Ríordáin, Aodhán.
  • O'Donnell, Kieran.
  • O'Donovan, Patrick.
  • O'Mahony, John.
  • O'Sullivan, Jan.
  • Perry, John.
  • Phelan, Ann.
  • Rabbitte, Pat.
  • Ring, Michael.
  • Ryan, Brendan.
  • Shatter, Alan.
  • Spring, Arthur.
  • Stagg, Emmet.
  • Stanton, David.
  • Tuffy, Joanna.
  • Twomey, Liam.
  • Wall, Jack.
  • Walsh, Brian.
  • White, Alex.

Níl

  • Adams, Gerry.
  • Broughan, Thomas P.
  • Browne, John.
  • Collins, Joan.
  • Collins, Niall.
  • Colreavy, Michael.
  • Crowe, Seán.
  • Daly, Clare.
  • Donnelly, Stephen S.
  • Dooley, Timmy.
  • Ellis, Dessie.
  • Ferris, Martin.
  • Flanagan, Luke 'Ming'.
  • Fleming, Sean.
  • Fleming, Tom.
  • Grealish, Noel.
  • Halligan, John.
  • Healy, Seamus.
  • Keaveney, Colm.
  • Kelleher, Billy.
  • Kirk, Seamus.
  • Lowry, Michael.
  • Mac Lochlainn, Pádraig.
  • McDonald, Mary Lou.
  • McGrath, Finian.
  • McGrath, Michael.
  • McGuinness, John.
  • McLellan, Sandra.
  • Martin, Micheál.
  • Mathews, Peter.
  • Moynihan, Michael.
  • Murphy, Catherine.
  • Nulty, Patrick.
  • Ó Caoláin, Caoimhghín.
  • Ó Cuív, Éamon.
  • Ó Fearghaíl, Seán.
  • Ó Snodaigh, Aengus.
  • O'Dea, Willie.
  • O'Sullivan, Maureen.
  • Pringle, Thomas.
  • Ross, Shane.
  • Shortall, Róisín.
  • Smith, Brendan.
  • Stanley, Brian.
  • Troy, Robert.
  • Wallace, Mick.
Tellers: Tá, Deputies Emmet Stagg and Paul Kehoe; Níl, Deputies Michael Moynihan and Seán Ó Fearghaíl.
Amendment declared carried.
Question put: "That the motion, as amended, be agreed to."
The Dáil divided: Tá, 76; Níl, 45.

  • Bannon, James.
  • Barry, Tom.
  • Bruton, Richard.
  • Burton, Joan.
  • Butler, Ray.
  • Buttimer, Jerry.
  • Byrne, Catherine.
  • Byrne, Eric.
  • Carey, Joe.
  • Coffey, Paudie.
  • Collins, Áine.
  • Conaghan, Michael.
  • Conlan, Seán.
  • Connaughton, Paul J.
  • Conway, Ciara.
  • Coonan, Noel.
  • Corcoran Kennedy, Marcella.
  • Coveney, Simon.
  • Creed, Michael.
  • Daly, Jim.
  • Deasy, John.
  • Deering, Pat.
  • Doherty, Regina.
  • Donohoe, Paschal.
  • Doyle, Andrew.
  • Durkan, Bernard J.
  • English, Damien.
  • Farrell, Alan.
  • Feighan, Frank.
  • Fitzpatrick, Peter.
  • Flanagan, Charles.
  • Griffin, Brendan.
  • Hannigan, Dominic.
  • Harrington, Noel.
  • Harris, Simon.
  • Heydon, Martin.
  • Humphreys, Heather.
  • Humphreys, Kevin.
  • Keating, Derek.
  • Kehoe, Paul.
  • Kenny, Seán.
  • Kyne, Seán.
  • Lawlor, Anthony.
  • Lynch, Ciarán.
  • Lynch, Kathleen.
  • Lyons, John.
  • McCarthy, Michael.
  • McEntee, Helen.
  • McHugh, Joe.
  • McLoughlin, Tony.
  • McNamara, Michael.
  • Maloney, Eamonn.
  • Mitchell O'Connor, Mary.
  • Murphy, Dara.
  • Murphy, Eoghan.
  • Nash, Gerald.
  • Nolan, Derek.
  • Ó Ríordáin, Aodhán.
  • O'Donnell, Kieran.
  • O'Donovan, Patrick.
  • O'Mahony, John.
  • O'Sullivan, Jan.
  • Perry, John.
  • Phelan, Ann.
  • Rabbitte, Pat.
  • Ring, Michael.
  • Ryan, Brendan.
  • Shatter, Alan.
  • Spring, Arthur.
  • Stagg, Emmet.
  • Stanton, David.
  • Tuffy, Joanna.
  • Twomey, Liam.
  • Wall, Jack.
  • Walsh, Brian.
  • White, Alex.

Níl

  • Adams, Gerry.
  • Broughan, Thomas P.
  • Browne, John.
  • Collins, Joan.
  • Collins, Niall.
  • Colreavy, Michael.
  • Crowe, Seán.
  • Daly, Clare.
  • Donnelly, Stephen S.
  • Dooley, Timmy.
  • Ellis, Dessie.
  • Ferris, Martin.
  • Flanagan, Luke 'Ming'.
  • Fleming, Sean.
  • Fleming, Tom.
  • Grealish, Noel.
  • Halligan, John.
  • Healy, Seamus.
  • Keaveney, Colm.
  • Kelleher, Billy.
  • Kirk, Seamus.
  • Lowry, Michael.
  • Mac Lochlainn, Pádraig.
  • McDonald, Mary Lou.
  • McGrath, Finian.
  • McGrath, Michael.
  • McGuinness, John.
  • McLellan, Sandra.
  • Martin, Micheál.
  • Moynihan, Michael.
  • Murphy, Catherine.
  • Nulty, Patrick.
  • Ó Caoláin, Caoimhghín.
  • Ó Cuív, Éamon.
  • Ó Fearghaíl, Seán.
  • Ó Snodaigh, Aengus.
  • O'Dea, Willie.
  • O'Sullivan, Maureen.
  • Pringle, Thomas.
  • Ross, Shane.
  • Shortall, Róisín.
  • Smith, Brendan.
  • Stanley, Brian.
  • Troy, Robert.
  • Wallace, Mick.
Tellers: Tá, Deputies Paul Kehoe and Emmet Stagg; Níl, Deputies Michael Moynihan and Seán Ó Fearghaíl.
Question declared carried.
The Dáil adjourned at 9.20 p.m. until 10.30 a.m. on Thursday, 10 October 2013.